surgery for ne tumors the university of texas m. d. anderson cancer center houston, texas jason b....

Surgery for NE Tumors

The University of TexasM. D. Anderson Cancer Center

Houston, Texas

Jason B. Fleming

Carcinoid / Islet Cell

GI Neuroendocrine Tumors

• Biology of Tumor• Detailed Knowledge of Pertinent Anatomy• Goals of the Operation

Important Variables (assuming patient is suitable candidate)

• Midgut Carcinoid Tumors• Pancreatic Neuroendocrine Tumors

A 63-year-old man has an ulcerated mass at the ileocecal valve identified during routine colonoscopy. Biopsy identifies a well-differentiated neuroendocrine tumor. He is taken to the operating room for planned laparoscopic right hemicolectomy.

Midgut Carcinoid

• Biology of Tumor• Detailed Knowledge of Pertinent Anatomy• Goals of the Operation

Variability in Neuroendocrine Tumors

Low Grade NET– Islet Cell

Carcinoma (pancreas)

– Carcinoid• Forgut (Lung

(typical, atypical), Thymic)

• Midgut (SB)• Hindgut (CR)

Kim do, et al. Genes Chromosomes Cancer. 2008

Genetic Differences of CarcinoidILEAL NON-ILEAL GI

Sur

viva

l pro

bab

ility

Localized Regional

Distant

Months

Sur

viva

l pro

bab

ility

Median survival, months

Color Site Localized Regional Distant Appendix > 360 > 360 27 Cecum 135 107 41 Colon 261 36 5 Duodenum 107 101 57 Gastric 154 71 13 Liver 50 14 12 Lung 227 154 16 Pancreas 136 77 24 Rectum 290 90 22 Sm bowel 111 105 56 Thymus 110 68 40

Survival of NET by Site and Stage

Yao, et al. JCO, 2008.

Carcinoid/islet cell: well-differentiatedCarcinoid/islet cell: unspecified gradeCarcinoid/islet cell: moderately differentiatedNeuroendocrine: poorly differentiatedNeuroendocrine: undifferentiatedNeuroendocrine: unspecified grade

Median survival , months (95% CI) Carcinoid/islet cell: well -diff. 124 (101 -147) Carcinoid/islet cell: unspecified grade

64 (56 -72)

Carcinoid/islet cell: moderately diff.

129 (124 -134)

Neuroendocrine: poorly diff. 10 (9 -11) Neuroendocr ine: anaplastic 10 (9 -11) Neuroendocrine: unspecified grade

10 (9 -11)

Yao, et al. JCO, 2008.

Survival by NET Histology

• Biology of Tumor – Prognosis is favorable – Regional lymph node metastasis likely

• Detailed Knowledge of Pertinent Anatomy• Goals of the Operation

Midgut Carcinoid

Anticipated Lymphatic Drainage

Wang, et al Surgery. 2009 Dec;146(6):993-7

1st

2nd

3rd

Pancreas

D

SMV, ileal br

Ohrvall UWorld J Surg 2000; 24: 1402–1408.

Mesentery Arterial Anatomy

• Biology of Tumor – Prognosis is favorable – Regional lymph node metastasis likely

• Detailed Knowledge of Pertinent Anatomy– Predictable Lymphatic Chain at Risk– Dual Venous Drainage of Mesentery– Redundant Arterial Supply

• Goals of the Operation

Midgut Carcinoid

Palliative Benefits of R0 Resection82% of the patients (n=125) demonstrated complete or partial symptom alleviation

Makridis, World J Surg. 1996

Affect of Surgery on Survival

Hellman P, World J Surg. 2002

Retrospective review of 314 patients

• Biology of Tumor – Prognosis is favorable – Regional lymph node metastasis likely

• Detailed Knowledge of Pertinent Anatomy

– Predictable Lymphatic Chain at Risk

– Dual Venous Drainage of Mesentery

– Redundant Arterial Supply

• Goals of the Operation– Palliative at least– Potentially Curative at best– R0 resection with bowel preservation

Midgut Carcinoid