Role of surgery and transplantation in the treatment of hepatic metastases from neuroendocrine tumor

Abstract

Neuroendocrine tumors (NET) are a heterogeneous group of cancers, with indolent behavior. The most common primary origin is the gastro-intestinal tract but can also appear in the lungs, kidneys, adrenals, ovaries and other organs. In general, NET is usually discovered in the metastatic phase (40%-80%). The liver is the most common organ involved when metastases occur (40%-93%), followed by bone (12%-20%) and lung (8%-10%).A number of different therapeutic options are available for the treatment of hepatic metastases including surgical resection, transplantation, ablation, trans-arterial chemoembolization, chemotherapy and somatostatin analogues. Recently, molecular targeted therapies have been used, usually in combination with other treatment options, to improve outcomes in patients with metastases. This article emphasizes on the role of surgery in the treatment of liver metastases from NET.

The Impact of 68Ga-DOTATATE PET/CT Imaging on Management of Patients with Neuroendocrine Tumors: Experience from a National Referral Center in the United Kingdom

“…Although NETs can metastasize to any organ, published surveys have shown that the liver is the most commonly involved organ when metastases occur (40%-93%), followed by bone (12%-20%) and lung (8%-10%) (3,15).…”

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“…2 On the other hand, surgery is feasible only in fewer than 20% of cases for the bilobar involvement of the liver parenchyma at diagnosis 3 and is generally indicated only if 90% of the tumor mass can be removed. 4,5 In view of the small percentage of patients eligible for resection, considering that the overall 5-year survival rate in case of untreated liver metastases from NET is approximately 30% to 40%, 6 liver transplant can represent the only curative treatment for patients affected by NET bilobar liver metastases.…”

“…[1][2][3][4][5][6][7] We performed a literature review and found 32 articles, from 1989 to 2014 (Table 2), analyzing patient outcomes after liver transplant for NET liver metastases: data on approximately 1188 patients have been collected worldwide. Considering the lack of stringent generally adopted pretransplant selection criteria and of uniform follow-up protocols, which hamper critical assessment of the published results, the 5-year survival rate of liver transplant recipients for neuroendocrine tumors ranges from 0% to 90% (median 50%), resulting in a recurrence of the carcinoid tumors-the main cause of death.…”

Surgical strategy for neuroendocrine liver metastases

“…Another study reported the 10‐year overall survival for patients who had R0, R2 and non‐resected NET–liver metastases (90.4, 51/4, and 19.4 per cent), but these data must be interpreted with caution given the heterogeneity and difference in tumour burden between the three groups . Debulking hepatectomy can improve symptomatic disease in up to 95 per cent of cases, and might be indicated for patients with hormonally active disease who are refractory to non‐surgical treatments …”

“…Ablation can be performed via the percutaneous, laparoscopic or open techniques or at the time of surgical resection . Radiofrequency ablation (RFA) is a frequently used technique, while other modalities, such as microwave ablation (MWA), ethanol injection, laser ablation and cryo‐ablation, have been utilized as effective treatments …”