Elsevier

Surgery

Volume 156, Issue 6, December 2014, Pages 1369-1377
Surgery

American Association of Endocrine Surgeons
Expanded criteria for carcinoid liver debulking: Maintaining survival and increasing the number of eligible patients

https://doi.org/10.1016/j.surg.2014.08.009Get rights and content

Background

Cytoreduction of carcinoid liver metastases typically aims for ≥90% debulking in patients without extrahepatic disease. Data on the impact of less-restrictive resection criteria and other clinical and tumor-specific factors on outcomes are limited.

Methods

Records of carcinoid patients undergoing liver debulking from 2007 to 2011 were reviewed. Debulking threshold was 70%, extrahepatic disease did not preclude cytoreduction, and positive margins were allowed. Kaplan-Meier liver progression-free (PFS) and disease-specific (DSS) survival were calculated and compared by log-rank analysis and statistical significance of differences in distributions of factors between patient groups was determined by chi-squared analysis.

Results

Fifty-two patients were identified. Complete resection of intrahepatic and extrahepatic gross disease was achieved in 12 patients. All primaries reviewed were low grade, but one third of patients had at least one intermediate-grade metastasis. Fifteen patients (29%) had liver progression; median PFS was 72 months. Five-year DSS was 90%, with all deaths from liver failure. Only age was an important prognostic factor for PFS and DSS. Five-year DSS for patients <50 years was 73% and was 97% for patients 50 or older (P = .03).

Conclusion

The use of expanded criteria for debulking resulted in 90% 5-year DSS. Although younger age portends a poorer prognosis, the favorable PFS and DSS justify also using expanded criteria in this subgroup.

Section snippets

Methods

Records of patients with carcinoid undergoing liver debulking by a single surgeon for the indications of improving symptoms and/or survival from January 2007 to December 2011 were reviewed. Data collected included age; sex; primary tumor site; functional status of the tumor; preoperative and postoperative use of octreotide; other treatments of liver metastases; number, location, and size of tumors resected; sites of extrahepatic disease; resection of extrahepatic disease; percentage of hepatic

Results

Fifty-two patients were identified. Patient characteristics are shown in Table I. After exploration at the time of liver resection, the primary tumor was localized in all but three patients. Thirty-seven patients received octreotide long-acting repeatable (LAR) as outpatients before resection; 88% of patients were maintained on octreotide LAR postoperatively. Liver-directed therapy had been used in seven patients before liver debulking; three had undergone liver radiofrequency ablation (RFA),

Discussion

Liver debulking criteria for patients with NETs have not been clearly defined. Generally, a debulking threshold of >90% of liver tumor burden has been accepted.10 An important finding within that cohort is that the 5-year survival rate for those with functional tumors who undergo either complete or incomplete resection is indistinguishable from that of patients with nonfunctional tumors who undergo complete resection (60% vs 61%).10 Others have reported 5-year survival rates of greater than 70%

References (20)

There are more references available in the full text version of this article.

Cited by (97)

  • The Evolving Landscape of Neuroendocrine Tumors

    2023, Surgical Oncology Clinics of North America
    Citation Excerpt :

    Importantly, the studies that have evaluated thresholds of cytoreduction for patients with NETLM did not show any improvements in PFS or OS when the threshold of >70% was compared with thresholds of 90% to 99% and 100%.13,61,62 Factors that have been identified as negative predictive factors for PFS and OS in patients with NETLM are age <50, liver metastases ≥ 5 cm, the presence of synchronous disease at the primary site, extrahepatic disease at the time of liver resection, and NF hormone status.10,59,63 Scott and colleagues61 validated the debulking threshold of 70% and showed that aggressive debulking can be achieved even in patients with >10 liver metastases.

  • The prevalence, operations, and outcomes of carcinoid heart disease

    2022, American Journal of Surgery
    Citation Excerpt :

    This makes a strong argument for performing valve replacement operations in patients with CHD and inoperable liver metastases. Surgical cytoreduction of hepatic metastases has emerged as an important advance in the treatment of carcinoid disease.11,13,14 Bernheim et al.23 reported 31 patients with CHD who underwent hepatic cytoreduction.

View all citing articles on Scopus

Sources of financial support: OHSU Carcinoid Research Foundation.

Dr R. Pommier serves as a consultant for Novartis Oncology Pharmaceuticals and Pfizer, Inc.

View full text