Liver transplantation (LT) has been accepted as a treatment in selected cases of neuroendocrine tumors (NETs) with hepatic metastases.
A systematic review of the literature was conducted to evaluate long-term patient survival in the instances of LT for pancreatic NET. Univariate and multivariate regression analyses and survival analysis were performed.
Fifty-three clinical studies were screened. Data from 20 studies encompassing 89 transplanted patients were included in the study. Most primary tumors were endocrine pancreatic tumors (n=69), with gastrinomas representing the most frequent diagnosis (n=21). There were 61 functioning pancreatic NET. Simultaneous LT and pancreatic NET resections were performed in 45 instances. Cumulative 1-, 3-, and 5-year survival was 71%, 55%, and 44%, respectively, with a calculated mean survival of 54.45±6.31 months. Vasoactive intestinal peptide (VIPomas) had the best overall survival. Recurrence-free survival at 1, 3, and 5 years was 84%, 47%, and 47%, respectively. Recipient age more than or equal to 55 years (P=0.0242) and simultaneous LT-pancreatic resection (P=0.0132) were found to be significant predictors of worse survival by both univariate and multivariate Cox proportional hazard analyses. A scoring system was developed, with prognostic points assigned as follows: age more than or equal to 55 years:age less than 55 years=1:0 points and simultaneous LT-pancreatic resection:LT alone=1:0 points. This stratification delineated three separate population samples corresponding to patients with scores of 0, 1, and 2, respectively. The calculated 5-year survival for scores 0, 1, and 2 was 61%, 40%, and 0%, respectively (P=0.0023).
Despite the limitations of this retrospective analysis, good results can be achieved even for pancreatic NET primaries if the above-proposed scoring system is applied.
"In patients >55 undergoing resection of the primary pancreatic lesion at the same time as OLT, there was a 0% 5-year survival. Accordingly, the authors recommended that patient selection for transplant account for age and simultaneous extrahepatic resections . This finding was corroborated in a multicenter French study by Le Treut et al. in 85 cases of OLT for NETs, 34 of the patients underwent concurrent resection of extrahepatic disease, and 7 of whom required upper abdominal exenteration (resection of the pancreas, spleen, stomach, and duodenum, with 3 patients receiving en bloc composite liver-duodenum-pancreas grafts). "
[Show abstract][Hide abstract] ABSTRACT: In the care of patients with hepatic neuroendocrine metastases, medical oncologists should work in multidisciplinary fashion with surgeons, interventional radiologists, and radiation oncologists to assess the potential utility of liver-directed and systemic therapies. This paper addresses the various roles and evidence basis for cytoreductive surgery, thermal ablation (radiofrequency, microwave, and cryoablation), and embolization (bland embolization (HAE), chemoembolization (HACE), and radioembolization) as liver-directed therapies. Somatostatin analogues, cytotoxic chemotherapy, and the newer agents everolimus and suntinib are discussed as a means for controlling intra- and extrahepatic disease, along with peptide receptor radiotherapy (PRRT). Finally, the experience with orthotopic liver transplant for neuroendocrine tumors is described.
"If patients were 55 years old or younger and were not undergoing simultaneous pancreatic resection, then their predicted 5-year survival was 61%. Conversely, a 0% 5-year survival rate was prognosticated for patients older than 55 who were undergoing resection of the primary pancreatic lesion at the same time as transplantation . The largest single-center experience with liver transplantation for NETs reports a 10-year survival rate of 50% among 19 patients. "
[Show abstract][Hide abstract] ABSTRACT: A preponderance of patients with neuroendocrine tumors (NETs) will experience hepatic metastases during the course of their disease. Many diagnoses of NETs are made only after the neoplasms have spread from their primary gastroenteropancreatic sites to the liver. This paper reviews current evidence-based treatments for neuroendocrine hepatic metastases, encompassing surgery, hepatic artery embolization (HAE) and chemoembolization (HACE), radioembolization, hepatic artery infusion (HAI), thermal ablation (radiofrequency, microwave, and cryoablation), alcohol ablation, and liver transplantation as therapeutic modalities. Consideration of a multidisciplinary approach to liver-directed therapy is strongly encouraged to limit morbidity and mortality in this patient population.
[Show abstract][Hide abstract] ABSTRACT: The management of metastatic disease in pancreatic endocrine tumors (PETs) demands a multidisciplinary approach and the cooperation of several medical specialties. The role of surgery is critical, even when a radical excision cannot always be achieved.
A PubMed search of relevant articles published up to February 2011 was performed to identify current information about PET liver metastases regarding diagnosis and management, with an emphasis on surgery.
The early diagnosis of metastases and their accurate localization, most commonly in the liver, is very important. Surgical options include radical excision, and palliative excision to relieve symptoms in case of failure of medical treatment. The goal of the radical excision is to remove the primary tumor bulk and all liver metastases at the same time, but unfortunately it is not feasible in most cases. Palliative excisions include aggressive tumor debulking surgeries in well-differentiated carcinomas, trying to remove at least 90% of the tumor mass, combined with other additional destructive techniques such as hepatic artery embolization or chemoembolization to treat metastases or chemoembolization to relieve symptoms in cases of rapidly growing tumors. The combination of chemoembolization and systemic chemotherapy results in better response and survival rates. Other local destructive techniques include ethanol injection, cryotherapy and radiofrequency ablation.
It seems that the current management of PETs can achieve important improvements, even in advanced cases.
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