Surgical Approach & Techniques of Tumours Reduction€¦ · Organ Transplantation . 2nd...
Transcript of Surgical Approach & Techniques of Tumours Reduction€¦ · Organ Transplantation . 2nd...
Surgical Approach & Techniques of Tumours Reduction
E A Antoniou MD PhD Ass Prof of Gen. Sutgery & Organ Transplantation 2nd Propaedeutic Surgical Department, University of Athens G.H.A. Laiko
NET MASTERCLASS EVGENIDES FOUNDATION ATHENS, 5 July 2014
GI- Neuroendocrine Tumours (GI-NETs)
Relatively rare – complex neoplams
Presenting many clinical challenges Sporadic, multiple, component of a familial syndrome Location assessment- GI-NETs extent : crucial for
management
Yao JC, et al. Clin Oncol 2008 Diez M, et al. Annals of Gastroenterology 2013
GI- Neuroendocrine Tumours (GI-NETs)
Appropriate diagnosis/treatment: Multiple disciplines specialists involvement Novel imaging modalities for micro-metastases detection under evaluation Management strategies: surgery, radiological intervention, cytotoxic chemotherapies, somatostatin analogs, novel biological agents (ERL, Sunitinib, etc)
Yao JC, et al. Clin Oncol 2008
Diez M, et al. Annals of Gastroenterology 2013
GI-NETs: Surgical Approach Background
NETs : family of Neuroendocrine Neoplasms Heterogenus group arising from dispersed
neuroendocrine cells – embryological gut 3 Groups of NETs:
Panceatic Neuroendocrine Tumours Arising from GI tract Arising from Bronchopulmonary system 25.3%
NETs secrete hormones + peptides Secretory products: different clinical syndromes
Modlin IM, et al. Cancer 2003 Vinik AI, et al, Pancreas 2010
67.5%
GI-NETs: Surgical Approach Background
GI-NETs: Surgical Approach
Surgery in localized disease
Surgery of metastatic disease
Liver transplantation (?)
GI-NETs: Surgical Approach
Surgery in localized disease
Only potentially curative therapeutic strategy Radical oncological surgery indicated, except:
<2cm carcinoids of stomach, appendix, rectum Small pancreatic insulinomas (90% benign) –enucleation
No Adjuvant therapy in well-differentiated – R0 Adjuvant in poorly differentiated – R0 resection Surgery: major role in advance disease
Modlin IM, et al. Lancet oOncol 2008.
GI-NETs: Surgical Approach
Surgery in localized disease
Appendical carcinoid
Pancreatic head insulinoma
GI-NETs: Surgical Approach Surgery of Metastatic disease: 39% Liver Mets (LM)
Primary tumour resection at early phase/ <complications LM surgery: if complete resection feasible Major cytoreductive therapy-palliative purposes
Even R0 not achievable, >70% resectable – extensive LM, hormonal syndrome refractory to medical therapy
Tumours reduction: hormone secretion reduction, symptoms improvement
Prophylactic cholecystectomy: GB stones prevention, somatostatin treatment
Regional control of LM: RF-A, MW-A, Laser-Ablation, TACE Öberg K, et al. Ann of Oncol 2012
MW-A
GI-NETs: Surgical Approach Surgery of Metastatic disease
GI-NETs: Surgical Approach
Functioning tumour diagnosed before Surgery Carcinoid crisis risk, during tumour’s operation Prevention: continuous/boluses i.v. Octreotide Avoid drugs releasing histamine or sympathetic
nervous system activation Insulinoma: glucose infusion Gastrinomas: PPI & Octreotide
Roy RC, et al. Anaesthesia 1987 Dougherty TB, et al. Int Anesth Clin 1998
GI-NETs: Surgical Approach Liver Transplantation (OLTx)
NET: slow growth tumours, unlike other tumours Small group of Pts with bilobar liver mets- no
extrahepatic disease concidered for OLTx: Intent to cure, but high rate of recurrence Palliation from life-threatening hormonal disturbances
High rate of recurrence Better survival in mets from SB NETs, than Pancreas Pts <50years, low Ki-67, E-cadherin: can benefit
Pfitzmann R, et al. Liver Transpl 2007 Ahlman H, et al. Ann N Y Acad Sci 2004
Chan G, et al. Curr Oncol, 2012
GI-NETs: Surgical Approach Liver Transplantation (OLTx) OLTx photo
Steeve Jobs
GI-NETs: Surgical Approach Conclusion
1. Surgery in localized disease: Curative resection of the primary tumor and locoregional
lymph node metastases improved patients’ outcomes. excellent 5- and 10-year survivals of 100% in stage 1-2 Pts still favorable outcomes in stage 3 disease with 5- and 10-
year survivals of more than 95% and 80%, respectively. Surgical procedures: small intestinal resection or right
hemicolectomy. Distal pancreatectomy, Whipple, enuclation. Clearance of mesenterial / retroperitoneal LNs metastases by dissection around the mesentery, preserving the intestinal vascular supply.
GI-NETs: Surgical Approach Conclusion
2. Surgery of Metastatic disease Primary intestinal NET/regional LN metastases Resection, in PTs with
LMs: prevention of mesenteric fibrosis, SB obstruction, painful vascular encasement. Survival is prolonged in most studies (retrospective)
Mortality <1%, morbidity <10% Pancreatic NETs: Curative surgery, whenever possible, including
localised LMs, if potentially resectable, Pt can tolerate surgery.
Surgical procedures: small intestinal resection (no large ones) or right hemicolectomy.
Whipple, Distal pancreatectomy, nucleation in combination with LMs. Mandatory LNs Clearance, as frequently malignancy of pancreatic NETs Cytoreductive surgery: when metastatic disease is localized or if >70% of
tumor load is thought resectable
GI-NETs: Surgical Approach Conclusion
3. Liver Transplantation (OLTx) OLTx role for LMs from NET: recognised, still yet undefined Literature review: studies of heterogenus population, wide-range tumour
burdens, variety of operative procedures 5-year survival (4 studies): 67-90%, (UNOS:44-49%), recurrence free:
20-48% Criteria: Unresectable LMs, absence of extrahepatic metastases,
symptomatic disease refractory to medical therapy, low grade tumour with Ki-67 <2%, previous resection of primary disease, previous therapy for metastatic NET, age <50-year.
Surgical procedures: Orthotopic Liver Transplantation: DBD, DCD, Split-graft, LRLD
Treatment Algorithm (ESMO)
Lets go for retrieval now…….
Thank you