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Surgical Management of Hepatic Neuroendocrine Metastases

Surgical Management of Hepatic Neuroendocrine Metastases. Mark Bloomston, M.D. Associate Professor of Surgery Division of Surgical Oncology The Ohio State University OSU Neuroendocrine Symposium December 3, 2011. No disclosures. Surgery for Metastatic NET. Institutional biases

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Surgical Management of Hepatic Neuroendocrine Metastases

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  1. Surgical Management of Hepatic Neuroendocrine Metastases Mark Bloomston, M.D. Associate Professor of Surgery Division of Surgical Oncology The Ohio State University OSU Neuroendocrine Symposium December 3, 2011

  2. No disclosures

  3. Surgery for Metastatic NET • Institutional biases • MSKCC – no resection • Moffitt – selective resection • Mayo clinic – aggressive resection • LSU – aggressive resection • MDACC – selective resection • OSU – no resection  selective resection  aggressive resection

  4. Metastatic NET • Liver most common distant organ • Can result in liver dysfunction • Often results in symptoms • Incurable • Long-term survival still possible

  5. Local Therapies • Surgical resection • Ablation • Regional Therapies • Chemoembolization • Bland embolization • Selective internal radiotherapy • Systemic Therapies • Chemotherapy

  6. Surgical Resection • Only potential cure (rare) • Cytoreduction or debulking • Requires removal of at least 90% of tumor • Effective palliation in nearly 90% • Durable palliation of nearly 2 years • May improve survival • Up to 80% of liver can be removed in healthy patients

  7. Meta-analysis: 1973 – 1999 • Cytoreduction in 212 patients • Hemihepatectomy – 45% • Wedge – 21% • Extended hepatectomy – 14% • 1 – 3 segments – 20% • Morbidity – 14% • Mortality – 2.3% Cancer Control 2002;9(1): 67-79

  8. Symptom response • Complete – 86% • None – 1 patient • No recurrence in 41 • Survival • 71% at 5 years Cancer Control 2002;9(1): 67-79

  9. Cancer Control 2006; 21(1)

  10. 4 institutions • 172 patients • No deaths HPB 2010; 10: 427-33

  11. Overall Survival • Median 9.6 years • 5-year 77% • 10-year 50% HPB 2010; 10: 427-33

  12. 339 patients • 8 institutions: 1995 – 2009 • Outcomes following resection and/or ablation Ann SurgOnc 2010;17(12):3129:36

  13. Ann SurgOnc 2010;17(12):3129:36

  14. Hepatectomy safe ~1% mortality Recurrence universal 94% at 5 years Long-term survival expected Median 125 months Ann SurgOnc 2010;17(12):3129:36

  15. Ann SurgOnc 2006;13(4):572-81

  16. Multi-institutional Study • 753 patients with hepatic NE metastases • 339 had surgery • 414 had intra-arterial therapy (TACE, TAE, DEB, SIRT) • Demographics: similar • Primary location • Pancreas more common in surgical group • Unknown more common in IAT group Ann Surg Oncol. 2011 Dec;18(13)

  17. Group Comparisons IAT = Intra-arterial therapy Ann Surg Oncol. 2011 Dec;18(13)

  18. Overall Survival Ann Surg Oncol. 2011 Dec;18(13)

  19. OS- Propensity Matched Ann Surg Oncol. 2011 Dec;18(13)

  20. Ann Surg Oncol. 2011 Dec;18(13)

  21. Predictors of worse OS • MV analysis of all patients: • IAT only predictor of decreased survival • HR 2.69 [95% CI 1.90 – 3.83], p<0.001 • MV analysis of IAT patients only: • Primary not resected (HR 1.69, p<0.001) • Metachronous disease (HR 0.61, p=0.049) • Extrahepatic disease (HR 1.68, p<0.001) Ann Surg Oncol. 2011 Dec;18(13)

  22. Conclusions • Low tumor burden (<25%)  surgery • High tumor burden (>25%)  IAT • Carcinoid syndrome  surgery • Asymptomatic  IAT Ann Surg Oncol. 2011 Dec;18(13)

  23. Survival Advantage after Transarterial Chemoembolization for Operable Metastatic Carcinoid Reflects Tumor Biology Rather than Efficacy Arrese D, Feria-Arias E, Hatzaras I, Guy G, Khabiri H, Schmidt C, Shah M, Bloomston M The Ohio State University Columbus, Ohio Presented at ACS Clinical Congress 2010

  24. Hypothesis • Following TACE, patients with disease amenable to cytoreductivehepatectomy would have better: • Tumor response • Symptom control • Overall Survival Presented at ACS Clinical Congress 2010

  25. Methods • TACE was undertaken in 200 consecutive patients with NET metastases to the liver • 98 had pre-TACE imaging available for review • Indications for TACE: • poor symptom control • liver tumor progression • large tumor burden Presented at ACS Clinical Congress 2010

  26. Methods • Pre-TACE imaging re-assessed for operability Potentially Resectable (N=28) Inoperable (N=70) Presented at ACS Clinical Congress 2010

  27. Results Presented at ACS Clinical Congress 2010

  28. Results • No difference between groups for: • Complications (10%) • Mortality (3%) • Length of Stay (5 days ± 3.6) Presented at ACS Clinical Congress 2010

  29. Overall Survival Median OS 125 months after resection Presented at ACS Clinical Congress 2010

  30. Progression Free Survival Median 15 months after surgery Presented at ACS Clinical Congress 2010

  31. Response to TACE Presented at ACS Clinical Congress 2010

  32. Conclusions Liver metastases from NET amenable to cytoreductive hepatectomy represent better tumor biology TACE does not result in superior outcomes in these favorable patients We support a multi-institutional trial comparing outcomes in TACE vs. surgical cytoreduction Presented at ACS Clinical Congress 2010

  33. Surgical Approach • Symptomatic (syndrome) • Liver-only disease • Predominately one-sided disease • Low volume (i.e. <25%) • Single operation preferred • Debulking ablation?

  34. Surgical Management of Hepatic Neuroendocrine Metastases Mark Bloomston, M.D. Associate Professor of Surgery Division of Surgical Oncology The Ohio State University OSU Neuroendocrine Symposium December 3, 2011

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