Simultaneous resection reduced repeat intervention

ORLANDO – Combining surgical resection of primary carcinoid and neuroendocrine tumors with cytoreductive surgery of liver metastases is safe in select patients and can produce outcomes similar to those seen with surgery and adjuvant therapy, said investigators at the annual Digestive Disease Week.

Among 47 patients with carcinoid and neuroendocrine tumors (CNET), 22 of whom underwent simultaneous resection of primary tumors and surgical reduction of metastatic tumor burden with partial or near-total surgical cytoreduction (CR), and 25 of whom had resection of the primary with additional therapies, the 5-year survival rate was 82%, reported Dr. Nicholas N. Nissen of the Cedars-Sinai Medical Center in Los Angeles.

In addition, no patients who had near-total CR required a repeat hepatic intervention within 1 year of surgery, compared with 18 of 25 patients (72%) who had surgery followed by additional hepatic therapy, Dr. Nissen said.

"While most patients progress over time, overall survival is excellent, and we admit very freely that this reflects the growing and evolving multimodal therapies that are available to these patients," Dr. Nissen said.

"We would propose that simultaneous removal of the primary tumor and liver metastases may in fact be primarily beneficial as it consolidates procedures and allows some patients to delay or perhaps even avoid other locoregional hepatic therapies," he added.

The authors took a retrospective look at records of 51 patients, 47 of whom were available for the overall survival analysis. The patients all underwent resection of hepatic masses simultaneously with surgery to remove either small bowel carcinoid (32 patients) or pancreatic neuroendocrine tumor (15 patients). In all, 27 patients had partial surgical cytoreduction of metastases, and 22 had planned near-total surgical CR.

Of the 19 patients with carcinoid syndrome, all had what Dr. Nissen described as "dramatic improvement," and 11 had complete resolution of symptoms following surgery.

There were no deaths within 30 days of surgery. There were eight complications greater than Clavien grade 2, including two instances of bile leak requiring endoscopic retrograde cholangiopancreatography, and four cases requiring repeat laparotomy.

Overall survival for 47 patients with at least 5 years of data was 95% at 1 year, and 82% at years 3 and 5 of follow-up. Overall 5-year survival among those patients who had near-total CR was 88%, compared with 72% of those who had subtotal CR, but the difference was not statistically significant.

The respective progression-free survival rates were 77%, 37%, and 28%. Broken down by treatment type, 5-year PFS was 40% among patients who had near total CR, compared with 22% for those who had subtotal cytoreduction, but this difference was also not significant.

However, the seven patients who had no additional hepatic therapy had a more-than-threefold risk for progression, compared with either near total CR (hazard ratio [HR], 3.10; P = .044) or partial CR with additional liver treatment (HR, 3.37; P =.029).

No demographic or disease-related variables appeared to predict survival, but progression-free survival was significantly associated with poor differentiation (P = .022) and with large tumors (P = .044).

Dr. Carlos Corvera, a gastrointestinal surgeon at the University of California at San Francisco, who was not involved in the study, commented that the worse progression-free survival seen in the seven patients who did not receive adjuvant hepatic therapies suggested a benefit for additional cytoreduction, regardless of whether the patients are having symptoms.

"What do you tell your medical oncology colleagues who argue that disease-specific survival is really the most important thing, and that we end up predisposing these patients to possible [surgical] complications in situations where there’s really no significant survival benefit shown in asymptomatic patients?" he asked

Dr. Nissen replied that with the availability of new targeted systemic and locoregional therapies, in the near future the question may no longer when to operate and with what additional therapies, but "whether to operate."

The study sponsor was not disclosed. Dr. Nissen and Dr. Corvera reported having no relevant financial disclosures.

ORLANDO – Combining surgical resection of primary carcinoid and neuroendocrine tumors with cytoreductive surgery of liver metastases is safe in select patients and can produce outcomes similar to those seen with surgery and adjuvant therapy, said investigators at the annual Digestive Disease Week.

Among 47 patients with carcinoid and neuroendocrine tumors (CNET), 22 of whom underwent simultaneous resection of primary tumors and surgical reduction of metastatic tumor burden with partial or near-total surgical cytoreduction (CR), and 25 of whom had resection of the primary with additional therapies, the 5-year survival rate was 82%, reported Dr. Nicholas N. Nissen of the Cedars-Sinai Medical Center in Los Angeles.

In addition, no patients who had near-total CR required a repeat hepatic intervention within 1 year of surgery, compared with 18 of 25 patients (72%) who had surgery followed by additional hepatic therapy, Dr. Nissen said.

"While most patients progress over time, overall survival is excellent, and we admit very freely that this reflects the growing and evolving multimodal therapies that are available to these patients," Dr. Nissen said.

"We would propose that simultaneous removal of the primary tumor and liver metastases may in fact be primarily beneficial as it consolidates procedures and allows some patients to delay or perhaps even avoid other locoregional hepatic therapies," he added.

The authors took a retrospective look at records of 51 patients, 47 of whom were available for the overall survival analysis. The patients all underwent resection of hepatic masses simultaneously with surgery to remove either small bowel carcinoid (32 patients) or pancreatic neuroendocrine tumor (15 patients). In all, 27 patients had partial surgical cytoreduction of metastases, and 22 had planned near-total surgical CR.

Of the 19 patients with carcinoid syndrome, all had what Dr. Nissen described as "dramatic improvement," and 11 had complete resolution of symptoms following surgery.

There were no deaths within 30 days of surgery. There were eight complications greater than Clavien grade 2, including two instances of bile leak requiring endoscopic retrograde cholangiopancreatography, and four cases requiring repeat laparotomy.

Overall survival for 47 patients with at least 5 years of data was 95% at 1 year, and 82% at years 3 and 5 of follow-up. Overall 5-year survival among those patients who had near-total CR was 88%, compared with 72% of those who had subtotal CR, but the difference was not statistically significant.

The respective progression-free survival rates were 77%, 37%, and 28%. Broken down by treatment type, 5-year PFS was 40% among patients who had near total CR, compared with 22% for those who had subtotal cytoreduction, but this difference was also not significant.

However, the seven patients who had no additional hepatic therapy had a more-than-threefold risk for progression, compared with either near total CR (hazard ratio [HR], 3.10; P = .044) or partial CR with additional liver treatment (HR, 3.37; P =.029).

No demographic or disease-related variables appeared to predict survival, but progression-free survival was significantly associated with poor differentiation (P = .022) and with large tumors (P = .044).

Dr. Carlos Corvera, a gastrointestinal surgeon at the University of California at San Francisco, who was not involved in the study, commented that the worse progression-free survival seen in the seven patients who did not receive adjuvant hepatic therapies suggested a benefit for additional cytoreduction, regardless of whether the patients are having symptoms.

"What do you tell your medical oncology colleagues who argue that disease-specific survival is really the most important thing, and that we end up predisposing these patients to possible [surgical] complications in situations where there’s really no significant survival benefit shown in asymptomatic patients?" he asked

Dr. Nissen replied that with the availability of new targeted systemic and locoregional therapies, in the near future the question may no longer when to operate and with what additional therapies, but "whether to operate."

The study sponsor was not disclosed. Dr. Nissen and Dr. Corvera reported having no relevant financial disclosures.

ORLANDO – Combining surgical resection of primary carcinoid and neuroendocrine tumors with cytoreductive surgery of liver metastases is safe in select patients and can produce outcomes similar to those seen with surgery and adjuvant therapy, said investigators at the annual Digestive Disease Week.

Among 47 patients with carcinoid and neuroendocrine tumors (CNET), 22 of whom underwent simultaneous resection of primary tumors and surgical reduction of metastatic tumor burden with partial or near-total surgical cytoreduction (CR), and 25 of whom had resection of the primary with additional therapies, the 5-year survival rate was 82%, reported Dr. Nicholas N. Nissen of the Cedars-Sinai Medical Center in Los Angeles.

In addition, no patients who had near-total CR required a repeat hepatic intervention within 1 year of surgery, compared with 18 of 25 patients (72%) who had surgery followed by additional hepatic therapy, Dr. Nissen said.

"While most patients progress over time, overall survival is excellent, and we admit very freely that this reflects the growing and evolving multimodal therapies that are available to these patients," Dr. Nissen said.

"We would propose that simultaneous removal of the primary tumor and liver metastases may in fact be primarily beneficial as it consolidates procedures and allows some patients to delay or perhaps even avoid other locoregional hepatic therapies," he added.

The authors took a retrospective look at records of 51 patients, 47 of whom were available for the overall survival analysis. The patients all underwent resection of hepatic masses simultaneously with surgery to remove either small bowel carcinoid (32 patients) or pancreatic neuroendocrine tumor (15 patients). In all, 27 patients had partial surgical cytoreduction of metastases, and 22 had planned near-total surgical CR.

Of the 19 patients with carcinoid syndrome, all had what Dr. Nissen described as "dramatic improvement," and 11 had complete resolution of symptoms following surgery.

There were no deaths within 30 days of surgery. There were eight complications greater than Clavien grade 2, including two instances of bile leak requiring endoscopic retrograde cholangiopancreatography, and four cases requiring repeat laparotomy.

Overall survival for 47 patients with at least 5 years of data was 95% at 1 year, and 82% at years 3 and 5 of follow-up. Overall 5-year survival among those patients who had near-total CR was 88%, compared with 72% of those who had subtotal CR, but the difference was not statistically significant.

The respective progression-free survival rates were 77%, 37%, and 28%. Broken down by treatment type, 5-year PFS was 40% among patients who had near total CR, compared with 22% for those who had subtotal cytoreduction, but this difference was also not significant.

However, the seven patients who had no additional hepatic therapy had a more-than-threefold risk for progression, compared with either near total CR (hazard ratio [HR], 3.10; P = .044) or partial CR with additional liver treatment (HR, 3.37; P =.029).

No demographic or disease-related variables appeared to predict survival, but progression-free survival was significantly associated with poor differentiation (P = .022) and with large tumors (P = .044).

Dr. Carlos Corvera, a gastrointestinal surgeon at the University of California at San Francisco, who was not involved in the study, commented that the worse progression-free survival seen in the seven patients who did not receive adjuvant hepatic therapies suggested a benefit for additional cytoreduction, regardless of whether the patients are having symptoms.

"What do you tell your medical oncology colleagues who argue that disease-specific survival is really the most important thing, and that we end up predisposing these patients to possible [surgical] complications in situations where there’s really no significant survival benefit shown in asymptomatic patients?" he asked

Dr. Nissen replied that with the availability of new targeted systemic and locoregional therapies, in the near future the question may no longer when to operate and with what additional therapies, but "whether to operate."

The study sponsor was not disclosed. Dr. Nissen and Dr. Corvera reported having no relevant financial disclosures.