ITALIAN SURGICAL SOCIETY ENDOCRINE SURGERY SCHOOL LIVER METASTASIS FROM NEUROENDOCRINE TUMORS Gennaro Favia
Liver metastasis from NETs Incidence 75% in NETs Knox CD, J Gastroint Surg 2006
.but 28-45% cases Suspicious Liver nodule
Liver metastasis from NETs OTHERS LOCALIZATION 55% Ileus 19% Colon 18% Others 18% PANCREAS 42% Active 18% Not Active 17% Touzios et al. Ann Surg 2005; 141:776-785
PRIMITIVE TUMORS SIZE AND METASTASIS Tumor < 1 cm 12% node and liver metastasis Tumor 1-1,9 cm Tumor > 2 cm 29% node and liver metastasis 70-100% node and liver metastasis
LIVER BIOPSY AND IMMUNOHYSTOCHEMICAL EXAMINATION ARE BASILAR DIAGNOSTIC ELEMENTS Research Ki-67 Sutcliffe R, Am J Surg 2004; 187: 39-46
PROGNOSIS MOLECULAR INDEX MIB-1 CELL PROLIFERATION INDEX MIB-1 LABELLING INDEX (%) = NR. CELLS WITH NUCLEAR ANOMALIES X 100 NR. TUMORAL CELLS MIB-1 < 5% surv >24 mth 37 % MIB-1 > 5% surv >24 mth 16 %
SEROTONINE = TGFβ e Connective GF LIVER FIBROSIS MORBIDITY AND HIGH SCORE OF CHOLESTASIS AND LIVER FAILURE
TC/RMN DIAGNOSTIC PATTERN OCTREOSCAN PET TC
SPECIFIC DIAGNOSTIC PATTERN Angio/Colangio-MR FDG-PET CT Volume Reconstruction
THERAPY SURGERY TACE ABLATIVE LOCOREGIONAL THERAPY RADIOMETABOLIC THERAPY WITH 11 I Landry CS, Journal of Surgical Oncology 2008;97:253 258
RESECTIVE SURGERY WHY? SURGERY TACE+/-RFA 1. Radicality DFS e Survival 2. Symptoms control 3. Quality of life ONLY CT Touzios et al. Ann Surg 2005; 141:776-785
Liver metastasis from NETs 51%-63% Can be treated with Surgical Therapy SURGERY NO SURGERY 28% 5 yrs. Survival rate without any treatment Osborne DA et al. Ann. Surg. Oncol. 2006; 13:4-19 Landry CS, Journal of Surgical Oncology 2008;97:253 258
RESECTIVE SURGERY WHAT THERAPEUTIC OPTIONS?
1. RESECTIVE TREATMENT With radicality intent REV VC
DFS Anatomic surgery Median 50 mth Other Weber AH et al. Arch Surg 2006; 141: 1000-1004
WHAT THERAPEUTIC OPTIONS? 2. ITERATIVE RESECTIVE TREATMENT Landry CS, Journal of Surgical Oncology 2008;97:253 258
RIGHT HEPATECTOMY AFTER LEFT LOBECTOMY
3. EXTREME TREATMENT For quality of life and (?) survival
Pathology Cancer volume Best Outcome Knox D, J Gastroint Surg 2003
WHAT THERAPEUTIC OPTIONS? 4. MULTIMODAL TREATMENT for down staging
WHAT THERAPEUTIC OPTIONS? 5. OVER-/DOWN /DOWN-TREATMENT Not identified treatment for symptoms control
NEO-ADIUVANT CHEMOTHERAPY before after DOWNSTAGING WITH INCREASE OF RESECTABILITY RATE
NEO-ADIUVANT CHEMOTHERAPY Liver injury Impaired regeneration Steatohepatitis Extended R. Hepatectomy plus caudate
PROGNOSTIC FACTORS After liver resection PRIMITIVE TUMOR Appendix, 85.9% Rectus, 72.2% Ileus, 55.4% Colon, 41.6% Pancreas, 34.1% GRADING Ki-67 + STAGING MARGINS % LIVER INVOLVEMENT (N. Of metastasis) Landry CS, Journal of Surgical Oncology 2008;97:253 258 Touzios et al. Ann Surg 2005; 141:776-785
ABLATIVE THERAPY radiofrequency ADVANTAGE Disease control Low morbidity/mortality Adiuvant therapy for Surgery Multimodal therapy LAPAROSCOPIC APPROACH
ABLATIVE THERAPY radiofrequency VERSUS Tumors Size Tumor recurrence???? NOT ALTERNATIVE TREATMENT TO SURGERY
TACE Cisplatinus Adriamicine Mitomicine C Lederfolin Symptoms Control Growth Control Down Staging and Resectability Eur J Surg Oncol 2002
OLTx and NETs
MOUNT SINAI CRITERIA indications 1.Bilobar lesions not indicated to resective surgery 2. No medical therapy 3. Symptoms control after resective surgery 4. No extrahepatic disease Mean follow up 34±40 months Survival at 1-3 yrs 73% and 36% DFS 9% at 10 yrs Schwartz M, J Gastrointest Surg 2004; 8:208-212
Conclusions Liver metastasis have always to be thought also as NETs lesions Today resective indications are more wide than in the past A more aggressive surgery is permitted It is to be defined the laparoscopic role It is to be emphasized the management of this lesions in High Volume Center
GRAZIE!!!