surgery for ne tumors the university of texas m. d. anderson cancer center houston, texas jason b....
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Surgery for NE Tumors
The University of TexasM. D. Anderson Cancer Center
Houston, Texas
Jason B. Fleming
Carcinoid / Islet Cell
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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
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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
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• Biology of Tumor• Detailed Knowledge of Pertinent Anatomy• Goals of the Operation
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Variability in Neuroendocrine Tumors
Low Grade NET– Islet Cell
Carcinoma (pancreas)
– Carcinoid• Forgut (Lung
(typical, atypical), Thymic)
• Midgut (SB)• Hindgut (CR)
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Kim do, et al. Genes Chromosomes Cancer. 2008
Genetic Differences of CarcinoidILEAL NON-ILEAL GI
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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.
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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
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• Biology of Tumor – Prognosis is favorable – Regional lymph node metastasis likely
• Detailed Knowledge of Pertinent Anatomy• Goals of the Operation
Midgut Carcinoid
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Anticipated Lymphatic Drainage
Wang, et al Surgery. 2009 Dec;146(6):993-7
1st
2nd
3rd
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Pancreas
D
SMV, ileal br
Ohrvall UWorld J Surg 2000; 24: 1402–1408.
Mesentery Arterial Anatomy
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• 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
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Palliative Benefits of R0 Resection82% of the patients (n=125) demonstrated complete or partial symptom alleviation
Makridis, World J Surg. 1996
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Affect of Surgery on Survival
Hellman P, World J Surg. 2002
Retrospective review of 314 patients
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• 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