The Surgical Management of Small Bowel Neuroendocrine Tumors

Abstract

Small bowel neuroendocrine tumors (SBNETs) have been increasing in frequency over the past decades, and are now the most common type of small bowel tumor. Consequently, general surgeons and surgical oncologists are seeing more patients with SBNETs in their practices than ever before. The management of these patients is often complex, owing to their secretion of hormones, frequent presentation with advanced disease, and difficulties with making the diagnosis of SBNETs. Despite these issues, even patients with advanced disease can have long-term survival. There are a number of scenarios which commonly arise in SBNET patients where it is difficult to determine the optimal management from the published data. To address these challenges for clinicians, a consensus conference was held assembling experts in the field to review and discuss the available literature and patterns of practice pertaining to specific management issues. This paper summarizes the important elements from these studies and the recommendations of the group for these questions regarding the management of SBNET patients.

Everolimus in the treatment of neuroendocrine tumors: efficacy, side-effects, resistance, and factors affecting its place in the treatment sequence

“…In recent guidelines, everolimus is generally recommended as second-line therapy behind SSAs[201–203,207–209], because of the low toxicity with high tolerability of SSAs treatment[165]. At present, everolimus is one of the most frequently used second line treatments in patients presenting clinically significant tumor burden and disease progression on SSAs.…”

Challenges Staging Neuroendocrine Tumors of the Pancreas, Jejunum and Ileum, and Appendix

“…13 The goals of surgery are resection of the primary tumor(s), regional lymph nodes, and mesenteric fibrosis, if feasible, maximizing the length of viable intestine. 2 However, large ([2 cm) mesenteric masses or encasement of the proximal superior mesenteric artery and vein may preclude safe resection. Another change to the 8th edition of the AJCC staging system is a new classification of nodal involvement, N2, so information on the prognostic significance of large ([2 cm) mesenteric masses or encasement of mesenteric vessels can be collected.…”

“…9,12,13 Again, digital palpation is critical to identify them. 2 For NETs of the jejunum and ileum, the AJCC TNM staging classification imperfectly provides prognostic information. 3 Death rates remain stable from stage I to III and only significantly differ between stage III and IV.…”

“…9 Because primary tumors are frequently (in 25-44% of patients) multifocal and multifocal tumors often are very small (\1 cm), they can only be found by meticulous palpation. 2 Importantly, if surgeons are performing laparoscopic or minimally invasive surgery, the entire jejunum and ileum should be palpated digitally to identify small primary tumors that are frequently multifocal. 2,9,11,12 This can be done using a hand-assisted laparoscopic device (Gelport; Applied Medical) or a soft-tissue wound retractor (Alexis Wound Retractor; Applied Medical) to exteriorize the jejunum and ileum.…”

“…2 Importantly, if surgeons are performing laparoscopic or minimally invasive surgery, the entire jejunum and ileum should be palpated digitally to identify small primary tumors that are frequently multifocal. 2,9,11,12 This can be done using a hand-assisted laparoscopic device (Gelport; Applied Medical) or a soft-tissue wound retractor (Alexis Wound Retractor; Applied Medical) to exteriorize the jejunum and ileum. 9,12 With the jejunum and ileum outside the abdomen, complete palpation, resection of the mesenteric adenopathy/fibrosis and primary tumor(s), and intestinal anastomosis can be done.…”