Surgical management for non-functional pancreatic neuroendocrine neoplasms with synchronous liver metastasis: A consensus from the Chinese Study Group for Neuroendocrine Tumors (CSNET)

Abstract

Pancreatic neuroendocrine neoplasms (p-NENs) are slowly growing tumors with frequent liver metastasis. There is a variety of approaches to treat non-functional p-NENs with synchronous liver metastasis (LM) which complicates the determination of optimal treatment. Based on updated literature review, we discussed the treatment strategy determinants for p-NEN with LM. According to the resectability of primary tumor, the WHO 2010 grade classification and the radiological type of liver metastasis, the CSNET group reached agreements on a number of issues, including the following. Prior to treatment, biopsy is required to confirm pathology. Liver biopsy is important for more accurate grading of tumor and percutaneous core needle biopsy is more available than EUS-FNA. In patients with unresectable primary, surgical resection for liver-metastatic lesions should be avoided. Curative surgery is recommended for G1/G2 p-NET with type I LM and R1 resection also seems to improve overall survival rate. Cytoreductive surgery is recommended for G1/G2 p-NET with type II LM in select patients, and should meet stated requirements. Surgical resection for G1/G2 p-NET with type III LM and p-NEC with LM should be avoided, and insufficient evidence exists to guide the surgical treatment of G3 p-NET with LM. Liver transplantation may be an option in highly select patients. In addition, the optimal time for surgical approach is still required for more evidence.

Hepatic Resection for Non-functional Neuroendocrine Liver Metastasis: Does the Presence of Unresected Primary Tumor or Extrahepatic Metastatic Disease Matter?

“…14,17,18 In turn, the presence of unresectable primary NETs and/or extrahepatic metastasis are still considered a contraindication to surgery by many clinicians. 11,19 However, aggressive onco-surgery has been increasingly advocated, even in the presence of advanced metastatic disease. 20,21 The current study was important as it specifically defined the outcomes of patients with advanced NF-NELM who had unresected primary NETs, as well as extrahepatic metastasis using a large, international, multiinstitutional database.…”

“…[6][7][8][9] Traditionally, the presence of unresectable primary disease and/or extrahepatic metastatic disease was considered advanced NELM. 10 While some investigators have recommended against resection of NELM in the setting of advanced disease, 11 other data have supported surgical debulking as a reasonable treatment of NELM that has yielded improved long-term survival. 12 As most patients with NELM die of liver failure due to intrahepatic tumor progression rather than the primary tumor or extrahepatic disease, liver resection may have a role, even in the setting of advanced disease.…”

Time to think: Selecting patients who may benefit from synchronous resection of primary pancreatic cancer and liver metastases

“…Further studies have identified distinct biological differences between limited metastatic lesions and widely disseminated disease for multiple tumor types, including pancreatic cancer[ 13 - 15 ]. Radical surgery to treat both primary and metastatic sites has been accepted and conducted for an increasing number of tumor types[ 16 - 18 ]. Thus, pancreatic cancer patients with few liver metastases may benefit from aggressive surgical approaches.…”

Carbohydrate antigen 19‑9 as a prognostic biomarker in pancreatic neuroendocrine tumors

“…G3 pNETs are well known for their aggressiveness and poor response to major treatment strategies, including surgery (26). Considering the differing management strategy between G1, G2 and G3 pNETs in clinical practice, the aberrant elevation of CA19-9 may serve as an indication of G3 pNETs for clinicians (26).…”