1
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Müller PC, Pfister M, Eshmuminov D, Lehmann K. Liver transplantation as an alternative for the treatment of neuroendocrine liver metastasis: Appraisal of the current evidence. Hepatobiliary Pancreat Dis Int 2024; 23:146-153. [PMID: 37634987 DOI: 10.1016/j.hbpd.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/10/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Liver transplantation (LT) for neuroendocrine liver metastases (NELM) is still in debate. Studies comparing LT with liver resection (LR) for NELM are scarce, as patient selection is heterogeneous and experience is limited. The goal of this review was to provide a critical analysis of the evidence on LT versus LR in the treatment of NELM. DATA SOURCES A scoping literature search on LT and LR for NELM was performed with PubMed, including English articles up to March 2023. RESULTS International guidelines recommend LR for NELM in resectable, well-differentiated tumors in the absence of extrahepatic metastatic disease with superior results of LR compared to systemic or liver-directed therapies. Advanced liver surgery has extended resectability criteria whilst entailing increased perioperative risk and short disease-free survival. In highly selected patients (based on the Milan criteria) with unresectable NELM, oncologic results of LT are promising. Prognostic factors include tumor biology (G1/G2) and burden, waiting time for LT, patient age and extrahepatic spread. Based on low-level evidence, LT for low-grade NELM within the Milan criteria resulted in improved disease-free survival and overall survival compared to LR. The benefits of LT were lost in patients beyond the Milan NELM-criteria. CONCLUSIONS With adherence to strict selection criteria especially tumor biology, LT for NELM is becoming a valuable option providing oncologic benefits compared to LR. Recent evidence suggests even stricter selection criteria with regard to tumor biology.
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Affiliation(s)
- Philip C Müller
- Department of Surgery and Transplantation, University Hospital Zurich, Rämistrasse 100, Zurich CH-8091, Switzerland
| | - Matthias Pfister
- Department of Surgery and Transplantation, University Hospital Zurich, Rämistrasse 100, Zurich CH-8091, Switzerland
| | - Dilmurodjon Eshmuminov
- Department of Surgery and Transplantation, University Hospital Zurich, Rämistrasse 100, Zurich CH-8091, Switzerland
| | - Kuno Lehmann
- Department of Surgery and Transplantation, University Hospital Zurich, Rämistrasse 100, Zurich CH-8091, Switzerland.
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2
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Citterio D, Coppa J, Sposito C, Busset MDD, Virdis M, Pezzoli I, Mazzaferro V. The Role of Liver Transplantation in the Treatment of Liver Metastases from Neuroendocrine Tumors. Curr Treat Options Oncol 2023; 24:1651-1665. [PMID: 37882889 PMCID: PMC10643461 DOI: 10.1007/s11864-023-01124-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2023] [Indexed: 10/27/2023]
Abstract
OPINION STATEMENT Transplant oncology is a new field of medicine referred to the use of solid organ transplantation, particularly the liver, to improve prognosis and quality of life in cancer patients. In unresectable, liver-only metastases from neuroendocrine tumors (NETs) of the digestive tract, liver transplantation represents a competitive chance of cure. Due to the limited resource of donated organs, accurate patients' selection is crucial in order to maximize transplant benefit. Several tumor- and patient-related factors should be considered. Among them, primary tumors with a low grade of differentiation (G1-G2 or Ki67 < 10%), located in a region drained by the portal system and removed before transplantation with at least 3-6 months period of disease stability observed before transplant listing, can be considered for transplantation. In case of NET located in the pancreas, extended lymphadenectomy should complement curative pancreatic resection. A number of other features are described in this review of liver transplantation for NET metastases. Comprehensive approach including various forms of non-surgical treatment and detailed planning and timing of total hepatectomy are discussed. Open issues remain on possible expansion of current criteria while maintaining the same long-term benefit demonstrated with the Milan NET criteria with respect to other non-transplant options, with particular reference to liver resection, peptide receptor radionuclide therapy, and locoregional and systemic treatments.
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Affiliation(s)
- Davide Citterio
- General Surgery and Liver Transplantation Unit, Fondazione IRCCS Istituto Nazionale Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Jorgelina Coppa
- General Surgery and Liver Transplantation Unit, Fondazione IRCCS Istituto Nazionale Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Carlo Sposito
- General Surgery and Liver Transplantation Unit, Fondazione IRCCS Istituto Nazionale Tumori, Via Venezian 1, 20133, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Michele Droz Dit Busset
- General Surgery and Liver Transplantation Unit, Fondazione IRCCS Istituto Nazionale Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Matteo Virdis
- General Surgery and Liver Transplantation Unit, Fondazione IRCCS Istituto Nazionale Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Isabella Pezzoli
- General Surgery and Liver Transplantation Unit, Fondazione IRCCS Istituto Nazionale Tumori, Via Venezian 1, 20133, Milan, Italy
| | - Vincenzo Mazzaferro
- General Surgery and Liver Transplantation Unit, Fondazione IRCCS Istituto Nazionale Tumori, Via Venezian 1, 20133, Milan, Italy.
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.
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3
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Palaniappan V, Li CH, Frilling A, Clift AK. Long-Term Outcomes of Liver Transplantation for the Management of Neuroendocrine Neoplasms: A Systematic Review. J Pers Med 2023; 13:1428. [PMID: 37888039 PMCID: PMC10607978 DOI: 10.3390/jpm13101428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/18/2023] [Accepted: 09/18/2023] [Indexed: 10/28/2023] Open
Abstract
Liver transplantation is an uncommonly used, controversially debated therapeutic approach for highly selected individuals with neuroendocrine liver metastases. Synthesising evidence regarding outcomes from this approach is crucial to understand its position within the broad neuroendocrine liver metastases armamentarium. In this narrative systematic review of studies published in PubMed, Scopus and OVID until 1 July 2021, we summarise and critically appraise the existing literature regarding this modality, with a special focus on long-term outcomes data where possible. Fourteen studies were identified that reported outcomes from the use of liver transplantation for metastatic neuroendocrine neoplasms. No randomised trials were identified. Generally, indications and selection criteria were poorly articulated, with the notable exception of studies using the Milan criteria. The median 5-year overall survival was 65% (ranging from 36% to 97.2%, 11 studies), and the median 10-year overall survival was 50% (ranging from 46.1% to 88.8%, 3 studies). One additional study focussed on treatments and outcomes following post-transplant recurrence. No studies reported outcomes past 10 years. Further follow-up of the largest series with explicit selection criteria will deepen our understanding of the role that transplantation has to play in this setting.
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Affiliation(s)
| | - Chun Hei Li
- St George’s University Hospitals NHS Foundation Trust, London SW17 0QT, UK
| | - Andrea Frilling
- Department of Surgery & Cancer, Imperial College London, London SW7 2BX, UK
| | - Ashley Kieran Clift
- Department of Surgery & Cancer, Imperial College London, London SW7 2BX, UK
- Cancer Research UK Oxford Centre, University of Oxford, Oxford OX1 2JD, UK
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4
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Shannon AH, Ruff SM, Schenk AD, Washburn K, Pawlik TM. Updates and Expert Opinions on Liver Transplantation for Gastrointestinal Malignancies. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1290. [PMID: 37512101 PMCID: PMC10383519 DOI: 10.3390/medicina59071290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/12/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023]
Abstract
Transplant oncology is a relatively new field in which transplantation is used to treat patients who would otherwise be unresectable. New anticancer treatment paradigms using tumor and transplant immunology and cancer immunogenomics are emerging. In turn, liver transplantation (LT) has become a potential therapy for certain patients with colorectal cancer (CRC) with liver metastasis, hepatocellular (HCC), cholangiocarcinoma (CCA), and metastatic neuroendocrine tumor (NET) of the liver. Although there are established criteria for LT in HCC, evidence regarding LT as a treatment modality for certain gastrointestinal malignancies is still debated. The aim of this review is to highlight updates in the role of LT for certain malignancies, including HCC, metastatic CRC, hilar CCA, and neuroendocrine tumor (NET), as well as contextualize LT use and discuss controversies in transplant oncology.
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Affiliation(s)
- Alexander H Shannon
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, The James Comprehensive Cancer Center, Columbus, OH 43210, USA
| | - Samantha M Ruff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, The James Comprehensive Cancer Center, Columbus, OH 43210, USA
| | - Austin D Schenk
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, The James Comprehensive Cancer Center, Columbus, OH 43210, USA
| | - Kenneth Washburn
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, The James Comprehensive Cancer Center, Columbus, OH 43210, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, The James Comprehensive Cancer Center, Columbus, OH 43210, USA
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5
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Moradi A, Lamsehchi N, Khaki S, Nasiri-Toosi M, Jafarian A. Liver Transplant for Patients With Neuroendocrine Tumor: A Report of 2 Exceptional Cases and Literature Review. EXP CLIN TRANSPLANT 2023; 21:578-585. [PMID: 37584538 DOI: 10.6002/ect.2023.0110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
Patients with neuroendocrine tumors with unresec-table liver involvement can benefit from liver transplant. There is a specific set of guidelines for neuroendocrine tumors with liver metastasis that involve less than 50% of the liver. However, beyond those guidelines, there are reports of exceptional criteria patients who benefited from liver transplant. Here, we present 2 unusual cases of patients with exceptional circumstances and with neuroendocrine tumors who underwent liver transplant. The first case describes a patient with an extremely rare neuroen-docrine tumor of the proximal common bile duct that caused liver biliary cirrhosis. The patient underwent tumor resection and liver transplant concurrently. The second case describes a patient with a neuroendocrine tumor of unknown primary origin with more than 50% hepatic involvement who received a liver transplant after downstaging. In our center, patients with unresectable hepatic metastases from neuroendoc-rine tumors are currently selected for liver transplant based on well-established criteria. However, these 2 cases did not meet the criteria for consideration of liver transplant; thus, multidisciplinary team sessions were held to discuss these 2 cases. After a period of nonsurgical treatment and evaluation of the tumor behavior, we selected the patients as candidates for liver transplant based on the favorable tumor behavior and favorable response to treatment. For both patients, we did not observe any signs of tumor recurrence during follow-up. The outcomes were acceptable, and the patients tolerated treatment well. Considering the favorable tumor pathology (G1 phase and low Ki67 index), we suggest that more studies should be conducted to evaluate the outcomes of patients with low-grade tumors and that the criteria for patients with low-grade tumors could be extended based on such future data.
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Affiliation(s)
- Alimohammad Moradi
- From the Department of General Surgery Division of Hepato-Pancreatico-Biliary Surgery and Organ Transplantation Surgery, Tehran University of Medical Sciences, Tehran, Iran
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6
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Fernandes EDSM, Kyt CVG, de Mello FPT, Pimentel LS, Andrade RDO, Girão C, César C, Siqueira M, Monachesi ME, Brito A, Tavares de Sousa CC, Andraus W, Torres OJM. Liver transplantation in gastroenteropancreatic neuroendocrine tumors. Front Oncol 2023; 12:1001163. [PMID: 36844922 PMCID: PMC9947829 DOI: 10.3389/fonc.2022.1001163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 12/21/2022] [Indexed: 02/11/2023] Open
Abstract
Neuroendocrine tumors are part of a heterogeneous group of tumors located in organs such as the gastrointestinal tract (GIT), lungs, thymus, thyroid, and adrenal glands. The most prevalent sites are the small intestine, cecal appendix, and pancreas. More than 50% of these tumors are associated with metastases at the time of diagnosis. Neuroendocrine tumors are classified according to the degree of cell differentiation and the histopathological proliferation index of the lesion. Neuroendocrine tumors can be well differentiated or poorly differentiated. G3 tumors are characterized by Ki-67 expression greater than 20% and can be either well differentiated (G3 NET) or poorly differentiated (G3 NEC). Neuroendocrine carcinoma (NEC G3) is subdivided into small-cell and large-cell types. When neuroendocrine tumors present clinical and compressive symptoms, carcinoid syndrome is evident. Carcinoid syndrome occurs when the tumor produces neuroendocrine mediators that cannot be metabolized by the liver due to either the size of the tumor or their secretion by the liver itself. Several therapeutic strategies have been described for the treatment of metastatic neuroendocrine tumors, including curative or palliative surgical approaches, peptide receptor radionuclide therapy, percutaneous therapy, systemic chemotherapy, and radiotherapy. Liver surgery is the only approach that can offer a cure for metastatic patients. Liver metastases must be completely resected, and in this context, orthotopic liver transplantation has gained prominence for yielding very promising outcomes in selected cases. The aim of this study is to review the literature on OLT as a form of treatment with curative intent for patients with gastroenteropancreatic neuroendocrine tumors with liver metastasis.
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Affiliation(s)
- Eduardo de Souza M. Fernandes
- Department of Gastrointestinal and Transplant Surgery, São Lucas-Rede Dasa Hospital, Rio de Janeiro, RJ, Brazil,Department of Gastrointestinal and Transplant Surgery, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil,Department of Surgery, Rio de Janeiro Federal University, Rio de Janeiro, RJ, Brazil,Department of Hepatology, São Lucas-Rede Dasa Hospital, Rio de Janeiro, RJ, Brazil,*Correspondence: Eduardo de Souza M. Fernandes,
| | - Camila V. Garcia Kyt
- Department of Gastrointestinal and Transplant Surgery, São Lucas-Rede Dasa Hospital, Rio de Janeiro, RJ, Brazil,Department of Gastrointestinal and Transplant Surgery, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil
| | - Felipe Pedreira Tavares de Mello
- Department of Gastrointestinal and Transplant Surgery, São Lucas-Rede Dasa Hospital, Rio de Janeiro, RJ, Brazil,Department of Gastrointestinal and Transplant Surgery, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil
| | - Leandro Savattone Pimentel
- Department of Gastrointestinal and Transplant Surgery, São Lucas-Rede Dasa Hospital, Rio de Janeiro, RJ, Brazil,Department of Gastrointestinal and Transplant Surgery, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil
| | - Ronaldo de Oliveira Andrade
- Department of Gastrointestinal and Transplant Surgery, São Lucas-Rede Dasa Hospital, Rio de Janeiro, RJ, Brazil,Department of Gastrointestinal and Transplant Surgery, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil
| | - Camila Girão
- Department of Gastrointestinal and Transplant Surgery, São Lucas-Rede Dasa Hospital, Rio de Janeiro, RJ, Brazil,Department of Gastrointestinal and Transplant Surgery, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil
| | - Camilla César
- Department of Gastrointestinal and Transplant Surgery, São Lucas-Rede Dasa Hospital, Rio de Janeiro, RJ, Brazil,Department of Gastrointestinal and Transplant Surgery, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil
| | - Munique Siqueira
- Department of Gastrointestinal and Transplant Surgery, São Lucas-Rede Dasa Hospital, Rio de Janeiro, RJ, Brazil,Department of Gastrointestinal and Transplant Surgery, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil
| | - Maria Eduarda Monachesi
- Department of Gastrointestinal and Transplant Surgery, São Lucas-Rede Dasa Hospital, Rio de Janeiro, RJ, Brazil,Department of Gastrointestinal and Transplant Surgery, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil
| | - Anderson Brito
- Department of Hepatology, São Lucas-Rede Dasa Hospital, Rio de Janeiro, RJ, Brazil
| | | | - Wellington Andraus
- Department of Gastroenterology, Gastrointestinal and Transplant, São Paulo University Hospital, São Paulo, SP, Brazil
| | - Orlando Jorge M. Torres
- Department of Hepatopancreatobiliary Surgery, Hospital São Domingos-Rede Dasa Hospital, São Luís, MA, Brazil,Department of Gastrointestinal and Transplant Surgery, Hospital Presidente Dutra, São Luis, MA, Brazil
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7
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Updated Principles of Surgical Management of Pancreatic Neuroendocrine Tumours (pNETs): What Every Surgeon Needs to Know. Cancers (Basel) 2021; 13:cancers13235969. [PMID: 34885079 PMCID: PMC8656761 DOI: 10.3390/cancers13235969] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/25/2021] [Accepted: 11/25/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary In this narrative review, we update the surgical management of pancreatic neuroendocrine tumours (pNETs) and highlight key elements in view of the recent literature. These tumours are rare and suffer from a lack of data and randomized controlled trials. The pNETs management is difficult due to their heterogeneity and the risks associated with pancreatic surgery. Innovative managements such as “watch and wait” strategies, parenchymal sparing surgery and minimally invasive approach are emerging. The correct use of all these therapeutic options requires a good selection of patients but also a constant update of knowledge. Abstract Pancreatic neuroendocrine tumours (pNETs) represent 1 to 2% of all pancreatic neoplasm with an increasing incidence. They have a varied clinical, biological and radiological presentation, depending on whether they are sporadic or genetic in origin, whether they are functional or non-functional, and whether there is a single or multiple lesions. These pNETs are often diagnosed at an advanced stage with locoregional lymph nodes invasion or distant metastases. In most cases, the gold standard curative treatment is surgical resection of the pancreatic tumour, but the postoperative complications and functional consequences are not negligible. Thus, these patients should be managed in specialised high-volume centres with multidisciplinary discussion involving surgeons, oncologists, radiologists and pathologists. Innovative managements such as “watch and wait” strategies, parenchymal sparing surgery and minimally invasive approach are emerging. The correct use of all these therapeutic options requires a good selection of patients but also a constant update of knowledge. The aim of this work is to update the surgical management of pNETs and to highlight key elements in view of the recent literature.
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8
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Frey S, Mirallié E, Le Bras M, Regenet N. What Are the Place and Modalities of Surgical Management for Pancreatic Neuroendocrine Neoplasms? A Narrative Review. Cancers (Basel) 2021; 13:5954. [PMID: 34885063 PMCID: PMC8656750 DOI: 10.3390/cancers13235954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 12/14/2022] Open
Abstract
Pancreatic neuroendocrine neoplasms (panNENs) are a heterogeneous group of tumors derived from cells with neuroendocrine differentiation. They are considered malignant by default. However, their outcomes are variable depending on their presentation in the onset of hereditary syndromes, hormonal secretion, grading, and extension. Therefore, although surgical treatment has long been suggested as the only treatment of pancreatic neuroendocrine neoplasms, its modalities are an evolving landscape. For selected patients (small, localized, non-functional panNENs), a "wait and see" strategy is suggested, as it is in the setting of multiple neuroendocrine neoplasia type 1, but the accurate size cut-off remains to be established. Parenchyma-sparring pancreatectomy, aiming to limit pancreatic insufficiency, are also emerging procedures, which place beyond the treatment of insulinomas and small non-functional panNENs (in association with lymph node picking) remains to be clarified. Furthermore, giving the fact that the liver is generally the only metastatic site, surgery keeps a place of choice alongside medical therapies in the treatment of metastatic disease, but its modalities and extensions are still a matter of debate. This narrative review aims to describe the current recommended surgical management for pancreatic NENs and controversies in light of the actual recommendations and recent literature.
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Affiliation(s)
- Samuel Frey
- Université de Nantes, Quai de Tourville, 44000 Nantes, France; (S.F.); (E.M.)
- L’institut du Thorax, Université de Nantes, CNRS, INSERM, CHU de Nantes, 44000 Nantes, France
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l’Appareil Digestif, CHU de Nantes, 44000 Nantes, France
| | - Eric Mirallié
- Université de Nantes, Quai de Tourville, 44000 Nantes, France; (S.F.); (E.M.)
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l’Appareil Digestif, CHU de Nantes, 44000 Nantes, France
| | - Maëlle Le Bras
- Endocrinologie, Diabétologie et Nutrition, L’institut du Thorax, CHU Nantes, 44000 Nantes, France;
| | - Nicolas Regenet
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l’Appareil Digestif, CHU de Nantes, 44000 Nantes, France
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9
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Machairas N, Daskalakis K, Felekouras E, Alexandraki KI, Kaltsas G, Sotiropoulos GC. Currently available treatment options for neuroendocrine liver metastases. Ann Gastroenterol 2021; 34:130-141. [PMID: 33654350 PMCID: PMC7903580 DOI: 10.20524/aog.2021.0574] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 09/10/2020] [Indexed: 12/16/2022] Open
Abstract
Neuroendocrine neoplasms (NEN) are frequently characterized by a high propensity for metastasis to the liver, which appears to be a dominant site of distant-stage disease, affecting quality of life and overall survival. Liver surgery with the intention to cure is the treatment of choice for resectable neuroendocrine liver metastases (NELM), aiming to potentially prolong survival and ameliorate hormonal symptoms refractory to medical control. Surgical resection is indicated for patients with NELM from well-differentiated NEN, while its feasibility and complexity are largely dictated by the degree of liver involvement. As a result of advances in surgical techniques over the past decades, complex 1- and 2-stage, or repeat liver resections are performed safely and effectively by experienced surgeons. Furthermore, liver transplantation for the treatment of NELM should be anchored in a multimodal and multidisciplinary therapeutic strategy and restricted only to highly selected individual cases. A broad spectrum of interventional radiology treatments for NELM have recently been available, with expanding indications that are more applicable, as they are less limited by patient- and tumor-related parameters, being therefore important adjuncts or alternatives to surgery. Overall, liver-targeted treatment modalities may precede the administration of systemic molecular targeted agents and chemotherapy for patients with liver-dominant metastatic disease; these appear to be a crucial component of multimodal management of patients with NEN. In the present review, we discuss surgical and non-surgical liver-targeted treatment approaches for NELM, each complementing the other, with a view to assisting physicians in optimizing multimodal NEN patient care.
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Affiliation(s)
- Nikolaos Machairas
- 2nd Department of Propaedeutic Surgery (Nikolaos Machairas, Georgios C. Sotiropoulos)
| | - Kosmas Daskalakis
- 1st Department of Propaedeutic Internal Medicine (Kosmas Daskalakis, Krystallenia I. Alexandraki, Gregory Kaltsas)
| | - Evangelos Felekouras
- 1st Department of Surgery (Evangelos Felekouras), National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Krystallenia I Alexandraki
- 1st Department of Propaedeutic Internal Medicine (Kosmas Daskalakis, Krystallenia I. Alexandraki, Gregory Kaltsas)
| | - Gregory Kaltsas
- 1st Department of Propaedeutic Internal Medicine (Kosmas Daskalakis, Krystallenia I. Alexandraki, Gregory Kaltsas)
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10
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D'Amico G, Uso TD, Del Prete L, Hashimoto K, Aucejo FN, Fujiki M, Eghtesad B, Sasaki K, David Kwon CH, Miller CM, Quintini C. Neuroendocrine liver metastases: The role of liver transplantation. Transplant Rev (Orlando) 2021; 35:100595. [PMID: 33548685 DOI: 10.1016/j.trre.2021.100595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE OF REVIEW Neuroendocrine tumor (NET) metastasis localized to the liver is an accepted indication for liver transplantation as such tumors have a low biological aggressiveness in terms of malignancy and are slow growing. RECENT FINDINGS The long-term results are comparable with and in some cases even better than those of transplantations performed for primary liver cancer. However, compared with nonmalignant conditions, neuroendocrine liver metastasis (NELM) may result in an inferior outcome of transplantation. In the face of the scarcity of donated organs and recent improved results of non-surgical treatment for NELM, controversy over patient selection and timing for liver transplantation continues. SUMMARY In this review, we provide an overview of the diagnostic work-up and selection criteria of patients with NELM being considered for liver transplantation. Thereafter, we provide a critical analysis of the reported outcomes of OLT.
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Affiliation(s)
- Giuseppe D'Amico
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Teresa Diago Uso
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Luca Del Prete
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Koji Hashimoto
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Federico N Aucejo
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Masato Fujiki
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bijan Eghtesad
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kazunari Sasaki
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Choon H David Kwon
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Charles M Miller
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Cristiano Quintini
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
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11
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A literature-based treatment algorithm for low-grade neuroendocrine liver metastases. HPB (Oxford) 2021; 23:63-70. [PMID: 32448647 DOI: 10.1016/j.hpb.2020.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 03/03/2020] [Accepted: 04/20/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The optimal timing of treatment of liver metastases from low-grade neuroendocrine tumors (LG-NELM) varies significantly due to numerous treatment modalities and the literature supporting various treatment(s). This study sought to create and validate a literature-based treatment algorithm for LG-NELM. METHODS A treatment algorithm to maximize overall survival (OS) was designed using peer-reviewed articles evaluating treatment of LG-NELM. This algorithm was retrospectively applied to patients treated for LG-NELM at our institution. Deviation was determined based on whether or not a patient received treatment consistent with that recommended by the algorithm. Patients who did and did not deviate from the algorithm were compared with respect to OS and number of treatments. RESULTS Applying our algorithm to a 149-patient cohort, 57 (38%) deviated from recommended treatment. Deviation occurred in the form of alternative (28, 49%) versus additional procedures (29, 51%). Algorithm deviators underwent significantly more procedures than non-deviators (median 1 vs. 2, p < 0.001). Cox model indicated no difference in OS associated with algorithm deviation (HR 1.19, p = 0.58) when controlling for age and tumor characteristics. CONCLUSION This literature-based algorithm helps standardize treatment protocols in patients with LG-NELM and can reduce cost and risk by minimizing unnecessary procedures. Prospective implementation and validation is required.
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12
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D’Amico G, Uso TD. Liver Transplantation for Neuroendocrine Metastases. CURRENT TRANSPLANTATION REPORTS 2020. [DOI: 10.1007/s40472-020-00309-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Kim J, Zimmerman MA, Hong JC. Liver transplantation in the treatment of unresectable hepatic metastasis from neuroendocrine tumors. J Gastrointest Oncol 2020; 11:601-608. [PMID: 32655939 DOI: 10.21037/jgo.2019.11.03] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Neuroendocrine tumors (NET) are rare neoplasms with generally indolent growth behavior. The liver is the most common site of NET metastasis. The NET metastatic spread to the liver are usually multiple tumors involving bilateral hemilivers. For patients with isolated NET metastasis to the liver, a complete extirpation (R0) resection of both the primary NET and liver metastasis provide the best chance of tumor recurrence-free patient survival. Orthotopic liver transplantation (OLT) presents a viable treatment option for patients with unresectable liver metastasis from NET. Post-OLT outcomes for the patients of NET with liver metastasis (5-year overall survival rate 47-71%) are comparable to those for other indications. However, the high rate of recurrence after OLT (31-57%) remains a clinical obstacle. As such, it is imperative to consider each patient individually and identify prognostic factors that would impact post-OLT outcomes. This article focuses on the role of OLT in the definitive treatment of metastatic liver NET, review patient selection criteria predictive of survival outcomes and post-OLT outcomes for patients.
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Affiliation(s)
- Joohyun Kim
- Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael A Zimmerman
- Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Johnny C Hong
- Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
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14
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Liver metastases in gastroenteropancreatic neuroendocrine tumours - treatment methods. GASTROENTEROLOGY REVIEW 2020; 15:207-214. [PMID: 33005265 PMCID: PMC7509904 DOI: 10.5114/pg.2020.91501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 11/30/2019] [Indexed: 12/13/2022]
Abstract
Surgical approaches that allow the safe treatment of multiple, bilateral, large tumours, and that combine extirpative, ablative and interventional therapies, have expanded the population of patients with neuroendocrine tumors (NET) liver metastases (LMs) who can benefit from aggressive treatment of their liver disease. Pre-treatment staging often includes the biochemical assessment of serologic markers such as serotonin, insulin, vasoactive intestinal peptide, and chromogranin, even in patients without clinically apparent hormonal excess. Radiofrequency ablation (RFA) is a technique that involves the use of thermal energy to induce coagulation necrosis, thereby destroying tumour cells. Resection plus RFA is increasingly used in patients with bilateral NET LMs. Resection is performed for large or dominant lesions, while ablation is used to treat small lesions. Hepatic arterial embolization, typically termed transarterial embolization, and transarterial chemoembolization have been shown to induce a reduction in tumour size and to ameliorate symptoms of excess hormonal secretion.
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15
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Recent advances in liver transplantation for cancer: The future of transplant oncology. JHEP Rep 2019; 1:377-391. [PMID: 32039389 PMCID: PMC7005652 DOI: 10.1016/j.jhepr.2019.07.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation is widely indicated as a curative treatment for selected patients with hepatocellular carcinoma. However, with recent therapeutic advances, as well as efforts to increase the donor pool, liver transplantation has been carefully expanded to patients with other primary or secondary malignancies in the liver. Cholangiocarcinoma, colorectal and neuroendocrine liver metastases, and hepatic epithelioid haemangioendothelioma are amongst the most relevant new indications. In this review we discuss the fundamental concepts of this ambitious undertaking, as well as the newest indications for liver transplantation, with a special focus on future perspectives within the recently established concept of transplant oncology.
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16
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Phase I Trial of Dose-escalated Whole Liver Irradiation With Hepatic Arterial Fluorodeoxyuridine/Leucovorin and Streptozotocin Followed by Fluorodeoxyuridine/Leucovorin and Chemoembolization for Patients With Neuroendocrine Hepatic Metastases. Am J Clin Oncol 2019; 41:326-331. [PMID: 26886946 DOI: 10.1097/coc.0000000000000276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES We have previously shown that refractory neuroendocrine tumors can respond to moderate doses of chemoradiotherapy. We completed a dose-escalation phase I/II trial combining hepatic arterial (HA) chemotherapy, chemoembolization, and dose-escalated whole liver radiotherapy to determine the maximum safe dose of radiation that could be delivered and to make a preliminary assessment of response. MATERIALS AND METHODS From 2002 to 2009, 19 patients with symptomatic neuroendocrine liver metastases who failed somatostatin analog therapy were enrolled. HA fluorodeoxyuridine, leucovorin, and streptozotocin were delivered, as concurrent whole liver radiotherapy was dose escalated from 24 to 32 Gy in 2 Gy fractions, with a target rate of dose-limiting grade ≥3 radiation-induced liver disease of 10%. Eight weeks later, for patients without grade ≥3 liver or grade ≥4 any toxicity, a 72-hour infusion of HA fluorodeoxyuridine and leucovorin was given, followed by transarterial chemoembolization. RESULTS Eleven patients completed the entire protocol and received 24 to 32 Gy. No patients developed radiation-induced liver disease; 7 had grade 3 to 4 transiently increased liver function tests, and 4 had other grade 4 toxicities. Three patients (14%) had partial response, 16 (84%) stable disease. Median freedom from local progression and overall survival were 35.3 and 54.6 months, respectively. CONCLUSIONS Thirty-two in 2 Gy daily fractions can be delivered safely when combined with HA chemotherapy and subsequent transarterial chemoembolization. However, although objective responses were observed, this combination was not significantly better than our prior approaches. Further treatment intensification strategies, including individualized dose escalation for radiation-tolerant livers, and improved radiosensitization should be investigated, along with improved systemic therapy.
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17
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Shimata K, Irie T, Kadohisa M, Kawabata S, Ibuki S, Narita Y, Yamamoto H, Sugawara Y, Hibi T. Living donor liver transplantation for a patient with a history of total gastrectomy. Biosci Trends 2019; 13:212-215. [PMID: 30982792 DOI: 10.5582/bst.2019.01037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Adhesions due to previous upper abdominal surgery may complicate later liver transplantation. Here we report successful living donor liver transplantation (LDLT) in a patient with a history of total gastrectomy. A 32-year-old Japanese woman developed end-stage liver failure due to alcoholic cirrhosis. She had undergone total gastrectomy, pancreato-splenectomy, and partial colectomy due to rupture of a pancreatic cyst. LDLT was performed using a right lobe graft from her sister. To minimize blood loss and injury to the jejunum, adhesions between the left lobe and nearby organs were dissected without blood flow in or out of the liver. The right liver graft was implanted uneventfully. She was extubated on postoperative day (POD) 1, but then developed septic shock due to aspiration pneumonia on POD 2. She was reintubated and antibiotics and antifungal agents were administered. Administration of tacrolimus was changed to an intravenous route on POD 3. Her condition improved and she was re-extubated on POD 9. On POD 14, tacrolimus was administered orally. She was discharged from our hospital on POD 30 without any other events and is doing well 6 months after LDLT. We believe that careful planning, such as mobilizing the left lobe with the blood flow blocked just before liver explantation, elevating the head of the bed during tube-feeding, and calculating the area under the curve after drug administration will enable liver transplantation for patients with a history of total gastrectomy.
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Affiliation(s)
- Keita Shimata
- Department of Transplantation and Pediatric Surgery, Kumamoto University Graduate School of Medical Sciences
| | - Tomoaki Irie
- Department of Transplantation and Pediatric Surgery, Kumamoto University Graduate School of Medical Sciences
| | - Masashi Kadohisa
- Department of Transplantation and Pediatric Surgery, Kumamoto University Graduate School of Medical Sciences
| | - Seiichi Kawabata
- Department of Transplantation and Pediatric Surgery, Kumamoto University Graduate School of Medical Sciences
| | - Sho Ibuki
- Department of Transplantation and Pediatric Surgery, Kumamoto University Graduate School of Medical Sciences
| | - Yasuko Narita
- Department of Transplantation and Pediatric Surgery, Kumamoto University Graduate School of Medical Sciences
| | - Hidekazu Yamamoto
- Department of Transplantation and Pediatric Surgery, Kumamoto University Graduate School of Medical Sciences
| | - Yasuhiko Sugawara
- Department of Transplantation and Pediatric Surgery, Kumamoto University Graduate School of Medical Sciences
| | - Taizo Hibi
- Department of Transplantation and Pediatric Surgery, Kumamoto University Graduate School of Medical Sciences
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18
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Korda D, Doros A, Piros L, Gerlei Z, Haboub-Sandil A, Mándli T, Fazakas J, Deák ÁP, Máthé Z. Liver Transplant for Metastatic Neuroendocrine Tumors: A Single-Center Experience in Hungary. Transplant Proc 2019; 51:1251-1253. [DOI: 10.1016/j.transproceed.2019.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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19
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Chouliaras K, Newman NA, Shukla M, Swett KR, Levine EA, Sham J, Mann GN, Shen P. Analysis of recurrence after the resection of pancreatic neuroendocrine tumors. J Surg Oncol 2018; 118:416-421. [PMID: 30259518 DOI: 10.1002/jso.25146] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 05/30/2018] [Accepted: 06/04/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND OBJECTIVES Outcomes after recurrence of resected pancreatic neuroendocrine tumors (PNETs) are not well described. We aim to assess the rate and sites of recurrence, and its effect on clinical outcomes. METHODS Retrospective chart review of patients (n = 83) who underwent surgical resection of PNETs at 2 institutions. Patients were treated from September 2002 to July 2010. RESULTS There were 13 (16%) recurrences. The most common site of recurrence was the liver (9 patients, 9.6%). The most common treatment of recurrences was chemotherapy (5 patients, 36%). The 1-, 3-, and 5-year disease-free survival was 90.9%, 82.7%, and 72.5%, respectively. Median recurrence-free survival was 127 months. The median follow-up for all PNET patients was 25.8 months (range, 1-140 months). The 3-year survival was 97%. The median follow-up of patients after the diagnosis of a recurrence was 13.8 months. The overall survival for those with and without recurrence was 96.3% and 100%, respectively (P = .36). The age ( P = .002) and lymph node ratio ( P < .001) were predictors of recurrence on multivariate analysis. CONCLUSIONS Age and lymph node ratio are significant predictors of recurrence after the resection of PNETs with hepatic metastases being the most common. Survival of patients with recurrence is not significantly different from patients without recurrence.
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Affiliation(s)
- Konstantinos Chouliaras
- Department of General Surgery, Surgical Oncology Section, Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston-Salem, North Carolina
| | - Naeem A Newman
- Department of General Surgery, Surgical Oncology Section, Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston-Salem, North Carolina
| | - Mrinal Shukla
- Department of General Surgery, Surgical Oncology Section, Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston-Salem, North Carolina
| | - Katrina R Swett
- Department of General Surgery, Surgical Oncology Section, Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston-Salem, North Carolina
| | - Edward A Levine
- Department of General Surgery, Surgical Oncology Section, Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston-Salem, North Carolina
| | - Jonathan Sham
- Department of Surgery, Section of Surgical Oncology, University of Washington School of Medicine, Seattle, Washington
| | - Gary N Mann
- Department of Surgery, Section of Surgical Oncology, University of Washington School of Medicine, Seattle, Washington
| | - Perry Shen
- Department of General Surgery, Surgical Oncology Section, Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston-Salem, North Carolina
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20
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Frilling A, Clift AK. Surgical Approaches to the Management of Neuroendocrine Liver Metastases. Endocrinol Metab Clin North Am 2018; 47:627-643. [PMID: 30098720 DOI: 10.1016/j.ecl.2018.04.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Surgical approaches to hepatic metastases occupy an important role in the management of patients with neuroendocrine neoplasms and may have curative or palliative intentions. Resection of hepatic disease with curative intent is the only modality offering potential cure for patients with liver metastases; however, only a minority of patients are eligible. Regardless of resection margin, disease recurrence almost invariably occurs and novel adjuvant/neoadjuvant therapies are mandated to be included within multimodal treatment concepts. Liver transplantation in meticulously selected patients may be associated with excellent outcomes, but unfortunately demands on donated organs limit the wider utilization of this approach.
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Affiliation(s)
- Andrea Frilling
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital Campus, Du Cane Road, London W12 0HS, UK.
| | - Ashley Kieran Clift
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital Campus, Du Cane Road, London W12 0HS, UK
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21
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Clift AK, Frilling A. Liver transplantation and multivisceral transplantation in the management of patients with advanced neuroendocrine tumours. World J Gastroenterol 2018; 24:2152-2162. [PMID: 29853733 PMCID: PMC5974577 DOI: 10.3748/wjg.v24.i20.2152] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/03/2018] [Accepted: 05/18/2018] [Indexed: 02/06/2023] Open
Abstract
Orthotopic liver transplantation (OLT) represents a generally accepted albeit somewhat controversially discussed therapeutic strategy in highly selected patients with non-resectable hepatic metastases from neuroendocrine tumours (NET). Whilst there are some exclusion criteria, these are not universally followed, and the optimal set of inclusion parameters for deeming patients eligible has not yet been elucidated. This is due to heterogeneity in the study populations, as well differing approaches employed and also divergences in selection criteria between centres. Recent data have suggested that OLT may represent the most efficacious approach in terms of overall and disease-free survival to the management of NET metastatic to the liver when conducted in accordance with the modified Milan criteria. Therefore, a consensus set of selection criteria requires definition to facilitate stringent and fair allocation of deceased-donor organs, as well as consideration for living-donor organs. In the context of classically non-resectable metastatic tumour bulk, multivisceral transplantation with or without the liver may also be indicated, yet experience is very limited. In this review, we discuss the diagnostic work-up of patients in whom the aforementioned transplantation approaches are being considered, critically analyse the published experience and also anticipate future developments in this field, including a discussion of immediate and longer-term research priorities.
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Affiliation(s)
- Ashley Kieran Clift
- Department of Surgery and Cancer, Imperial College London, London W12 0HS, United Kingdom
| | - Andrea Frilling
- Department of Surgery and Cancer, Imperial College London, London W12 0HS, United Kingdom
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22
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Shimata K, Sugawara Y, Hibi T. Liver transplantation for unresectable pancreatic neuroendocrine tumors with liver metastases in an era of transplant oncology. Gland Surg 2018; 7:42-46. [PMID: 29629319 DOI: 10.21037/gs.2017.12.11] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Patients with pancreatic neuroendocrine tumors (pNETs) very often present with a metastatic disease at the first diagnosis. Liver transplantation (LT) for unresectable pNET with liver metastases (pNETLM) has been described to prolong survival in highly selected patients, although outcomes were worse than those of patients who underwent LT for gastrointestinal NETLM (GI-NETLM). In this review, several proposed criteria are described with their rationale and controversies. Most of the data used to establish these criteria do not reflect the recent improvements of non-surgical treatments that has changed the landscape of treatment for pNETs, including the development of peptide receptor radionuclide therapy and molecular-targeted agents (sunitinib and everolimus). Properly designed studies are necessary to define the role of down-staging and bridging therapy prior to LT incorporating systemic chemotherapy using these molecular-targeted agents. Also, given the indolent nature of low or intermediate grade pNETs, the best endpoint to compare the efficacy of each treatment option for patients with pNETLM has yet to be determined. Lastly, the definition of "unresectable" remains ambiguous. The indication of the conventional technique of two-staged liver resection with portal vein embolization or the new technique of associating liver partition and portal vein ligation for staged hepatectomy to expand the resectability of wide-spread metastatic liver tumors has been controversial. In an era of transplant oncology, LT should be the last resort for patients who are considered unresectable and otherwise untreatable after an exhaustive multidisciplinary team discussion by all experts in the field. In conclusion, although its long-term outcomes have been promising, the role of LT for unresectable pNETLM as a curative or palliative treatment remains unclear. A well-designed randomized control study is required to elucidate the clinical impact of LT for pNETLM.
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Affiliation(s)
- Keita Shimata
- Department of Transplantation and Pediatric Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Yasuhiko Sugawara
- Department of Transplantation and Pediatric Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Taizo Hibi
- Department of Transplantation and Pediatric Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
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23
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Schaefer B, Zoller H, Schneeberger S. Con: Liver transplantation for expanded criteria malignant diseases. Liver Transpl 2018; 24:104-111. [PMID: 29125687 DOI: 10.1002/lt.24975] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 10/04/2017] [Indexed: 12/18/2022]
Abstract
Organ shortage requires policies and guidelines to aid organ allocation along the principles of urgency or utility. Identifying patients with significant benefit and withholding liver transplantation (LT) from patients too sick for transplantation are ongoing challenges, in particular in patients with malignancies. An arbitrary threshold of >50% 5-year overall survival (OS) is broadly considered a minimum standard for LT. In patients transplanted for intrahepatic cholangiocarcinoma (iCC), this was only achieved in select cases and when the tumor had a diameter of <2 cm. In patients with extrahepatic and hilar cholangiocarcinoma (CCC), strict selection criteria and combined preoperative radiotherapy/chemotherapy according to the Mayo protocol showed that acceptable longterm results can be achieved in a single high-volume center but are difficult to repeat elsewhere. Furthermore, only rigorously selected patients with neuroendocrine tumors (NETs) meeting the NET Milan criteria adopted by United Network for Organ Sharing can also have >50% 5-year OS. A prospective study in patients with unresectable colorectal cancer metastases in the liver has shown promising OS rates, but further prospective trials are warranted. Current evidence shows that none of the proposed expanded malignant criteria justify deviation of scarce donor organs to patients with hilar CCC, iCC > 2 cm, metastatic NET beyond NET Milan criteria, or metastatic colorectal cancer (CRC) outside clinical trials. Liver Transplantation 24 104-111 2018 AASLD.
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Affiliation(s)
- Benedikt Schaefer
- Divisions of Gastroenterology, Hepatology and Endocrinology, Department of Internal Medicine I
| | - Heinz Zoller
- Divisions of Gastroenterology, Hepatology and Endocrinology, Department of Internal Medicine I
| | - Stefan Schneeberger
- Visceral, Transplant and Thoracic Surgery, Department of Surgery, Medical University of Innsbruck, Innsbruck, Austria
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24
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Sposito C, Droz Dit Busset M, Citterio D, Bongini M, Mazzaferro V. The place of liver transplantation in the treatment of hepatic metastases from neuroendocrine tumors: Pros and cons. Rev Endocr Metab Disord 2017; 18:473-483. [PMID: 29359266 DOI: 10.1007/s11154-017-9439-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Liver metastases occur in nearly half of NET patients (MNETs) and heavily affect prognosis, with 5-yr. OS around 19-38%. Although it is difficult to show outcome differences for available treatments, due to the long course of disease, surgery for MNETs remains the most effective option in terms of survival and symptom control. Since MNETs frequently present as an oligo-metastatic, liver-limited disease, unresectable in 80% of cases, liver transplantation (LT) has emerged as a potential curative treatment. Nevertheless, experience with LT for MNETs is limited and burdened by highly heterogeneous outcomes and significant recurrence rate, mostly explained by the variability of selection criteria. Several prognostic factors have been identified: extended surgery on primary tumor associated to LT, elderly patients, pancreatic primary (pNET), extensive liver involvement, poorly differentiated tumors, high Ki67 levels and short wait time to LT. A proper patients' selection based on these data (Milan NET criteria) allows a significant survival advantage over non-transplant strategies, with excellent outcomes in recent series (69-97.2% 5-yr. OS) as opposed to patients undergoing non-surgical treatments (34-50.9%). Evidence indicates LT as the best option for selected patients with MNETs. The use of organs for MNETs is therefore justified.
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Affiliation(s)
- Carlo Sposito
- Gastrointestinal Surgery and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori (National Cancer Institute), Via Venezian 1, 20133, Milan, Italy
| | - Michele Droz Dit Busset
- Gastrointestinal Surgery and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori (National Cancer Institute), Via Venezian 1, 20133, Milan, Italy
| | - Davide Citterio
- Gastrointestinal Surgery and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori (National Cancer Institute), Via Venezian 1, 20133, Milan, Italy
| | - Marco Bongini
- Gastrointestinal Surgery and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori (National Cancer Institute), Via Venezian 1, 20133, Milan, Italy
| | - Vincenzo Mazzaferro
- Gastrointestinal Surgery and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori (National Cancer Institute), Via Venezian 1, 20133, Milan, Italy.
- University of Milan, Milan, Italy.
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25
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Abstract
We present a rare case in an elderly Caucasian lady of primary ovarian carcinoid tumor, causing symptoms of the carcinoid syndrome and severe carcinoid heart disease. Carcinoid tumors are the commonest neuroendocrine tumors, the majority of which are found in the gastrointestinal tract and lungs. Ovarian carcinoids represent only 0.1% of all ovarian neoplasms and 1% of all carcinoid tumors. Carcinoid syndrome can present with flushing, diffuse watery diarrhea, wheezing and breathlessness and in advanced cases lead to carcinoid heart disease. This involves damage to the right heart structures and pulmonary hypertension, which can cause significant breathlessness and peripheral edema, and is associated with a worse prognosis. Diagnosis involves multi-modality radiological imaging and biochemical analysis of neuroendocrine tumor markers, and the first line treatment should always be resection of the tumor where possible. Prognosis is generally favorable, except in some cases with metastasis.
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Affiliation(s)
- Karan Saraf
- a Royal Lancaster Infirmary , Lancaster , UK
| | | | | | - Sanjay Sinha
- b Furness General Hospital , Barrow-in-Furness , UK
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26
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Moris D, Tsilimigras DI, Ntanasis-Stathopoulos I, Beal EW, Felekouras E, Vernadakis S, Fung JJ, Pawlik TM. Liver transplantation in patients with liver metastases from neuroendocrine tumors: A systematic review. Surgery 2017. [DOI: 10.1016/j.surg.2017.05.006] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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27
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Clift AK, Giele H, Reddy S, Macedo R, Al-Nahhas A, Wasan HS, Gondolesi GE, Vianna RM, Friend P, Vaidya A, Frilling A. Neoadjuvant peptide receptor radionuclide therapy and modified multivisceral transplantation for an advanced small intestinal neuroendocrine neoplasm: an updated case report. Innov Surg Sci 2017; 2:247-253. [PMID: 31579758 PMCID: PMC6754026 DOI: 10.1515/iss-2017-0025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 08/02/2017] [Indexed: 01/12/2023] Open
Abstract
Small intestinal neuroendocrine neoplasms (SI-NEN) frequently metastasise to regional lymph nodes, and surgery is the mainstay of therapy for such patients. However, despite the possible use of advanced surgical techniques, the resection of both primary and locoregional diseases is not always attainable. Intestinal and multivisceral transplantation has been performed in a small number of patients with conventionally nonresectable, slow-growing tumours threatening the mesenteric root but has remained controversial. The use of donor skin in “sentinel flaps” in transplantation theoretically offers advantages in tailoring immunosuppression and monitoring for rejection. We represent (with extended follow-up) the first case of a patient with inoperable extensive mesenteric metastases from SI-NEN, who underwent neoadjuvant peptide receptor radionuclide therapy before a modified multivisceral transplant with a concomitant vascularised sentinel forearm flap. At 48 months after transplantation, our patient remained at full physical activity with no evidence of disease recurrence on either tumour biochemistry or radiological imaging.
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Affiliation(s)
- Ashley K Clift
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Henk Giele
- Department of Plastic and Reconstructive Surgery, Oxford University NHS Trust, Oxford, UK
| | - Srikanth Reddy
- Oxford Transplant Centre, Oxford University NHS Trust, Oxford, UK
| | - Rubens Macedo
- Oxford Transplant Centre, Oxford University NHS Trust, Oxford, UK
| | - Adil Al-Nahhas
- Department of Nuclear Medicine, Imperial College London, London, UK
| | - Harpreet S Wasan
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Gabriel E Gondolesi
- Instituto de Trasplante Multiorgano, Fundacion Favaloro, Buenos Aires, Argentina
| | - Rodrigo M Vianna
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Peter Friend
- Oxford Transplant Centre, Oxford University NHS Trust, Oxford, UK
| | - Anil Vaidya
- Department of Plastic and Reconstructive Surgery, Oxford University NHS Trust, Oxford, UK
| | - Andrea Frilling
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK,
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28
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Nuñez-Garcia M, Gomez-Santos B, Buqué X, García-Rodriguez JL, Romero MR, Marin JJG, Arteta B, García-Monzón C, Castaño L, Syn WK, Fresnedo O, Aspichueta P. Osteopontin regulates the cross-talk between phosphatidylcholine and cholesterol metabolism in mouse liver. J Lipid Res 2017; 58:1903-1915. [PMID: 28754826 DOI: 10.1194/jlr.m078980] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 07/28/2017] [Indexed: 12/15/2022] Open
Abstract
Osteopontin (OPN) is involved in different liver pathologies in which metabolic dysregulation is a hallmark. Here, we investigated whether OPN could alter liver, and more specifically hepatocyte, lipid metabolism and the mechanism involved. In mice, lack of OPN enhanced cholesterol 7α-hydroxylase (CYP7A1) levels and promoted loss of phosphatidylcholine (PC) content in liver; in vivo treatment with recombinant (r)OPN caused opposite effects. rOPN directly decreased CYP7A1 levels through activation of focal adhesion kinase-AKT signaling in hepatocytes. PC content was also decreased in OPN-deficient (OPN-KO) hepatocytes in which de novo FA and PC synthesis was lower, whereas cholesterol (CHOL) synthesis was higher, than in WT hepatocytes. In vivo inhibition of cholesterogenesis normalized liver PC content in OPN-KO mice, demonstrating that OPN regulates the cross-talk between liver CHOL and PC metabolism. Matched liver and serum samples showed a positive correlation between serum OPN levels and liver PC and CHOL concentration in nonobese patients with nonalcoholic fatty liver. In conclusion, OPN regulates CYP7A1 levels and the metabolic fate of liver acetyl-CoA as a result of CHOL and PC metabolism interplay. The results suggest that CYP7A1 is a main axis and that serum OPN could disrupt liver PC and CHOL metabolism, contributing to nonalcoholic fatty liver disease progression in nonobese patients.
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Affiliation(s)
- Maitane Nuñez-Garcia
- Departments of Physiology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), Leioa, Spain
| | - Beatriz Gomez-Santos
- Departments of Physiology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), Leioa, Spain
| | - Xabier Buqué
- Departments of Physiology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), Leioa, Spain.,Biocruces Health Research Institute, Barakaldo, Spain
| | - Juan L García-Rodriguez
- Departments of Physiology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), Leioa, Spain
| | - Marta R Romero
- Experimental Hepatology and Drug Targeting (HEVEFARM), IBSAL, University of Salamanca, Salamanca, Spain.,Center for the Study of Liver and Gastrointestinal Diseases (CIBERehd), Carlos III National Institute of Health, Madrid, Spain
| | - Jose J G Marin
- Experimental Hepatology and Drug Targeting (HEVEFARM), IBSAL, University of Salamanca, Salamanca, Spain.,Center for the Study of Liver and Gastrointestinal Diseases (CIBERehd), Carlos III National Institute of Health, Madrid, Spain
| | - Beatriz Arteta
- Cellular Biology and Histology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), Leioa, Spain
| | - Carmelo García-Monzón
- Center for the Study of Liver and Gastrointestinal Diseases (CIBERehd), Carlos III National Institute of Health, Madrid, Spain.,Liver Research Unit, Santa Cristina University Hospital, Instituto de Investigación Sanitaria Princesa, Madrid, Spain
| | - Luis Castaño
- Biocruces Health Research Institute, Barakaldo, Spain.,Hospital Universitario Cruces, Barakaldo, Spain.,Pediatrics Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), Leioa, Spain.,CIBERDEM, CIBERER Carlos III National Institute of Health, Madrid, Spain
| | - Wing-Kin Syn
- Regeneration and Repair, Institute of Hepatology, Foundation for Liver Research, London, United Kingdom.,Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC.,Section of Gastroenterology, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC
| | - Olatz Fresnedo
- Departments of Physiology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), Leioa, Spain
| | - Patricia Aspichueta
- Departments of Physiology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), Leioa, Spain .,Biocruces Health Research Institute, Barakaldo, Spain
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Vennarecci G, Mascianà G, de Werra E, Guglielmo N, Levi Sandri GB, Coluzzi M, Ettorre GM. Rectal Carcinoid Tumor With Liver Metastases Treated by Local Excision and Orthotopic Liver Transplant With Long-term Follow-up. EXP CLIN TRANSPLANT 2017; 16:506-510. [PMID: 28350289 DOI: 10.6002/ect.2016.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In patients affected by unresectable liver metastases from neuroendocrine tumor, liver transplant represents currently the only realistic chance for cure. The first attempt to establish selection criteria for liver transplant in patients affected by neuroendocrine tumor liver metastases was made by Mazzaferro and associates in 2007. We report the case of a 46-year-old man who came to our institution in 2006 with right upper quadrant abdominal pain. Diagnosis of rectal neuroendocrine tumor with bilobar liver nodules was made; the patient underwent transanal local resection. A liver biopsy confirmed the metastatic nature of the hepatic lesion, showing a low-grade neuroendocrine tumor (G1, proliferation index Ki-67 <2%). The patient underwent 2 sessions of transarterial chemoembolization that resulted in stable disease. Afterward, the patient underwent a liver transplant, using the piggyback technique without a venous-venous bypass. His postoperative course was uneventful. The patient has been disease-free for 3 years. Posttransplant treatment has played a key role in increasing the overall survival of the patient and assuring him a good quality of life. He died 9 years (102 mo) after liver transplant.
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Affiliation(s)
- Giovanni Vennarecci
- Department of Surgical Oncology and Liver Transplantation, San Camillo Hospital, POIT San Camillo-INMI Lazzaro Spallanzani, Rome, Italy
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30
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Kouri BE, Abrams RA, Al-Refaie WB, Azad N, Farrell J, Gaba RC, Gervais DA, Gipson MG, Kolbeck KJ, Marshalleck FE, Pinchot JW, Small W, Ray CE, Hohenwalter EJ. ACR Appropriateness Criteria Radiologic Management of Hepatic Malignancy. J Am Coll Radiol 2016; 13:265-73. [PMID: 26944037 DOI: 10.1016/j.jacr.2015.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 12/04/2015] [Indexed: 12/18/2022]
Abstract
Management of primary and secondary hepatic malignancy is a complex problem. Achieving optimal care for this challenging population often requires the involvement of multiple medical and surgical disciplines. Because of the wide variety of potential therapies, treatment protocols for various malignancies continue to evolve. Consequently, development of appropriate therapeutic algorithms necessitates consideration of medical options, such as systemic chemotherapy; surgical options, such as resection or transplantation; and loco-regional therapies, such as thermal ablation and transarterial embolization techniques. This article provides a review of treatment strategies for the three most common subtypes of hepatic malignancy treated with loco-regional therapies: hepatocellular carcinoma, neuroendocrine metastases, and colorectal metastases. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Affiliation(s)
- Brian E Kouri
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina.
| | | | - Waddah B Al-Refaie
- Georgetown University Hospital, Washington, District of Columbia, American College of Surgeons
| | - Nilofer Azad
- Sidney Kimmel Cancer Center at Johns Hopkins University, Baltimore, Maryland, American Society of Clinical Oncology
| | - James Farrell
- Interventional Endoscopy and Pancreatic Diseases, New Haven, Connecticut, American Gastroenterological Association
| | - Ron C Gaba
- University of Illinois Hospital, Chicago, Illinois
| | | | - Matthew G Gipson
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | | | | | | | - William Small
- Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
| | - Charles E Ray
- University of Illinois Hospital and Health Science System, Chicago, Illinois
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31
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Jin K, Xu J, Chen J, Chen M, Chen R, Chen Y, Chen Z, Cheng B, Chi Y, Feng ST, Fu D, Hou B, Huang D, Huang H, Huang Q, Li J, Li Y, Liang H, Lin R, Liu A, Liu J, Liu X, Lu M, Luo J, Mai G, Ni Q, Qiu M, Shao C, Shen B, Sheng W, Sun J, Tan C, Tan H, Tang Q, Tang Y, Tian X, Tong D, Wang X, Wang J, Wang J, Wang W, Wang W, Wang Y, Wu Z, Xue L, Yan Q, Yang N, Yang Y, Yang Z, Yin X, Yuan C, Zeng S, Zhang R, Yu X. Surgical management for non-functional pancreatic neuroendocrine neoplasms with synchronous liver metastasis: A consensus from the Chinese Study Group for Neuroendocrine Tumors (CSNET). Int J Oncol 2016; 49:1991-2000. [PMID: 27826620 DOI: 10.3892/ijo.2016.3711] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 09/19/2016] [Indexed: 02/06/2023] Open
Abstract
Pancreatic neuroendocrine neoplasms (p-NENs) are slowly growing tumors with frequent liver metastasis. There is a variety of approaches to treat non-functional p-NENs with synchronous liver metastasis (LM) which complicates the determination of optimal treatment. Based on updated literature review, we discussed the treatment strategy determinants for p-NEN with LM. According to the resectability of primary tumor, the WHO 2010 grade classification and the radiological type of liver metastasis, the CSNET group reached agreements on a number of issues, including the following. Prior to treatment, biopsy is required to confirm pathology. Liver biopsy is important for more accurate grading of tumor and percutaneous core needle biopsy is more available than EUS-FNA. In patients with unresectable primary, surgical resection for liver-metastatic lesions should be avoided. Curative surgery is recommended for G1/G2 p-NET with type I LM and R1 resection also seems to improve overall survival rate. Cytoreductive surgery is recommended for G1/G2 p-NET with type II LM in select patients, and should meet stated requirements. Surgical resection for G1/G2 p-NET with type III LM and p-NEC with LM should be avoided, and insufficient evidence exists to guide the surgical treatment of G3 p-NET with LM. Liver transplantation may be an option in highly select patients. In addition, the optimal time for surgical approach is still required for more evidence.
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Affiliation(s)
- Kaizhou Jin
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center; Pancreatic Cancer Institute, Fudan University, Shanghai, P.R. China
| | - Jin Xu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center; Pancreatic Cancer Institute, Fudan University, Shanghai, P.R. China
| | - Jie Chen
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Minhu Chen
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Rufu Chen
- Department of Biliary-Pancreatic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Ye Chen
- Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P.R. China
| | - Zhiyu Chen
- Department of Medical Oncology, Shanghai Cancer Center, Fudan University, Shanghai, P.R. China
| | - Bin Cheng
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P.R. China
| | - Yihebali Chi
- Department of Medical Oncology, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, P.R. China
| | - Shi-Ting Feng
- Department of Radiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Deliang Fu
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai, P.R. China
| | - Baohua Hou
- Department of General Surgery, Guangdong General Hospital, Guangzhou, Guangdong, P.R. China
| | - Dan Huang
- Department of Pathology, Shanghai Cancer Center, Fudan University, Shanghai, P.R. China
| | - Heguang Huang
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, P.R. China
| | - Qiang Huang
- Department of General Surgery, Anhui Provincial Hospital, Hefei, Anhui, P.R. China
| | - Jie Li
- Department of Gastrointestinal Oncology, Peking University Cancer Hospital and Beijing Cancer Hospital, Beijing, P.R. China
| | - Ying Li
- Department of Radiology, Peking University Cancer Hospital, Beijing, P.R. China
| | - Houjie Liang
- Department of Oncology, Southwest Hospital, Third Military Medical University, Chongqing, P.R. China
| | - Rong Lin
- Department of Gastroenterology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P.R. China
| | - An'an Liu
- Department of General Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, P.R. China
| | - Jixi Liu
- Department of Gastroenterology, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Xubao Liu
- Department of Hepatobiliopancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Ming Lu
- Department of Gastrointestinal Oncology, Peking University Cancer Hospital and Beijing Cancer Hospital, Beijing, P.R. China
| | - Jie Luo
- Department of Pathology, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Gang Mai
- Department of Hepatobiliopancreatic Surgery, The People's Hospital of Deyang, Chengdu, Sichuan, P.R. China
| | - Quanxing Ni
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center; Pancreatic Cancer Institute, Fudan University, Shanghai, P.R. China
| | - Meng Qiu
- Department of Abdominal Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Chenghao Shao
- Department of General Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, P.R. China
| | - Baiyong Shen
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China
| | - Weiqi Sheng
- Department of Pathology, Shanghai Cancer Center, Fudan University, Shanghai, P.R. China
| | - Jian Sun
- Department of Biliary-Pancreatic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Chunlu Tan
- Department of Hepatobiliopancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
| | - Huangying Tan
- Department of Integrative Oncology, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Qiyun Tang
- Department of Gastroenterology, Jiangsu People's Hospital, Nanjing, Jiangsu, P.R. China
| | - Yingmei Tang
- Department of Gastroenterology, The Second Affliated Hospital of Kunming Medical University, Yunnan Research Center for Liver Diseases, Kunming, Yunnan, P.R. China
| | - Xiaodong Tian
- Department of General Surgery, Peking University First Hospital, Beijing, P.R. China
| | - Danian Tong
- Department of Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, P.R. China
| | - Xiaohong Wang
- Department of Radiology, Shanghai Cancer Center, Fudan University, Shanghai, P.R. China
| | - Jian Wang
- Department of Biliary-Pancreatic Surgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China
| | - Jie Wang
- Department of Hepatobiliary Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, P.R. China
| | - Wei Wang
- Department of Surgery, Huadong Hospital, Fudan University, Shanghai, P.R. China
| | - Wei Wang
- Department of Gastric and Pancreatic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, Guangdong, P.R. China
| | - Yu Wang
- Department of Interventional Oncology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou Guangdong, P.R. China
| | - Zheng Wu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, P.R. China
| | - Ling Xue
- Department of Pathology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, P.R. China
| | - Qiang Yan
- Department of Hepatobiliopancreatic Surgery, Huzhou Central Hospital, Huzhou, Zhejiang, P.R. China
| | - Ning Yang
- Hepatobiliary Surgery Department V, Eastern Hepatobiliary Surgery Hospital, Shanghai, P.R. China
| | - Yinmo Yang
- Department of General Surgery, Peking University First Hospital, Beijing, P.R. China
| | - Zhiying Yang
- Department of Hepatobiliary Surgery, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Xiaoyi Yin
- Department of Biliary-Pancreatic Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, P.R. China
| | - Chunhui Yuan
- Department of General Surgery, Peking University Third Hospital, Beijing, P.R. China
| | - Shan Zeng
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Renchao Zhang
- Department of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, P.R. China
| | - Xianjun Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center; Pancreatic Cancer Institute, Fudan University; Shanghai, P.R. China
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Donor-Derived Hepatic Neuroendocrine Tumor: Pause Before Proceeding With Liver Retransplantation. Transplant Direct 2016; 2:e88. [PMID: 27830182 PMCID: PMC5087570 DOI: 10.1097/txd.0000000000000549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 09/22/2015] [Accepted: 09/24/2015] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal neuroendocrine tumors (NET) are rare but the age-adjusted incidence in the United States has increased, possibly due to improved radiographic and endoscopic detection. In advanced NET, hepatic metastases are common. Orthotopic liver transplant (OLT) is currently considered an acceptable therapy for selected patients with limited hepatic disease or liver metastases where complete resection is thought to have curative intent. The development of NET of donor origin is very uncommon after organ transplant, and it is unclear if the same treatment strategies applied to hepatic NET would also be efficacious after OLT. Here, we describe a unique case of an OLT recipient with a donor-derived NET that was treated with redo OLT as the primary therapy. The donor-derived NET recurred in the recipient's second liver allograft suggesting an extrahepatic reservoir. This case describes the natural history of such a rare event. Here, we highlight the treatment options for hepatic NET and challenge the role of OLT for a donor-derived hepatic NET.
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33
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Herden U, Nashan B. Is There a Role for Liver Transplantation in Non-Colorectal Liver Metastases? VISZERALMEDIZIN 2016; 31:400-4. [PMID: 26889143 PMCID: PMC4748779 DOI: 10.1159/000441237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Due to the high blood flow, especially blood from the intestinal tract via the portal vein, the liver is a preferred organ for metastases. In case of advanced, irresectable liver metastases liver transplantation (LTX) remains an attractive option. However, due to high recurrence rates or a lack of data, up to date, metastases from neuroendocrine tumors (NETs) are the only accepted indication for LTX in non-colorectal liver metastases. In this regard, LTX is only justified in patients in which complete tumor resection (R0 resection) of the NET is achievable. A literature review revealed no clear patient selection criteria but transplantation should definitively achieve an R0 resection with complete freedom of tumor. The available data regarding the outcome following LTX for NETs show a comparable short- and long-term outcome for patients transplanted for other malignancies, e.g. hepatocellular carcinoma, or also benign indications in the high MELD (model for end-stage liver disease) era. Thus, most data prove a better post-transplant outcome and a lower recurrence rate in patients with a good differentiation of the tumor, a low proliferation index (Ki67), and a portal drainage of the NET.
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Affiliation(s)
- Uta Herden
- Department of Hepatobiliary Surgery and Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Björn Nashan
- Department of Hepatobiliary Surgery and Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Wells SA, Hinshaw JL, Lubner MG, Ziemlewicz TJ, Brace CL, Lee FT. Liver Ablation: Best Practice. Radiol Clin North Am 2015; 53:933-71. [PMID: 26321447 DOI: 10.1016/j.rcl.2015.05.012] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Tumor ablation in the liver has evolved to become a well-accepted tool in the management of increasing complex oncologic patients. At present, percutaneous ablation is considered first-line therapy for very early and early hepatocellular carcinoma and second-line therapy for colorectal carcinoma liver metastasis. Because thermal ablation is a treatment option for other primary and secondary liver tumors, an understanding of the underlying tumor biology is important when weighing the potential benefits of ablation. This article reviews ablation modalities, indications, patient selection, and imaging surveillance, and emphasizes technique-specific considerations for the performance of percutaneous ablation.
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Affiliation(s)
- Shane A Wells
- Department of Radiology, University of Wisconsin, 600 Highland Avenue, CSC, Madison, WI 53792, USA.
| | - J Louis Hinshaw
- Department of Radiology, University of Wisconsin, 600 Highland Avenue, CSC, Madison, WI 53792, USA
| | - Meghan G Lubner
- Department of Radiology, University of Wisconsin, 600 Highland Avenue, CSC, Madison, WI 53792, USA
| | - Timothy J Ziemlewicz
- Department of Radiology, University of Wisconsin, 600 Highland Avenue, CSC, Madison, WI 53792, USA
| | - Christopher L Brace
- Department of Radiology, University of Wisconsin, 600 Highland Avenue, CSC, Madison, WI 53792, USA; Department of Biomedical Engineering, University of Wisconsin, 600 Highland Avenue, CSC, Madison, WI 53792, USA
| | - Fred T Lee
- Department of Radiology, University of Wisconsin, 600 Highland Avenue, CSC, Madison, WI 53792, USA; Department of Biomedical Engineering, University of Wisconsin, 600 Highland Avenue, CSC, Madison, WI 53792, USA
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Sher LS, Levi DM, Wecsler JS, Lo M, Petrovic LM, Groshen S, Ji L, Uso TD, Tector AJ, Hamilton AS, Marsh JW, Schwartz ME. Liver transplantation for metastatic neuroendocrine tumors: Outcomes and prognostic variables. J Surg Oncol 2015; 112:125-32. [PMID: 26171686 DOI: 10.1002/jso.23973] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 06/13/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patient selection for liver transplantation for metastatic neuroendocrine tumors remains a topic of debate. There is no established MELD exception, making it difficult to obtain donor organs. METHODS A multicenter database was created assessing outcomes for liver and multivisceral transplantation for metastatic neuroendocrine tumors and identifying prognostic factors for survival. Demographic, transplant, primary tumor site and management, pathology, recurrent disease and survival data were collected and analyzed. Survival probabilities were calculated using the Kaplan-Meier method. RESULTS Analysis included 85 patients who underwent liver transplantation November 1988-January 2012 at 28 centers. One, three, and five-year patient survival rates were 83%, 60%, and 52%, respectively; 40 of 85 patients died, with 20 of 40 deaths due to recurrent disease. In univariate analyses, the following were predictors of poor prognosis: large vessel invasion (P < 0.001), extent of extrahepatic resection at liver transplant (P = 0.007), and tumor differentiation (P = 0.003). In multivariable analysis, predictors of poor overall survival included large vessel invasion (P = 0.001), and extent of extrahepatic resection at liver transplant (P = 0.015). CONCLUSION In the absence of poor prognostic factors, metastatic neuroendocrine tumor is an acceptable indication for liver transplantation. Identification of favorable prognostic factors should allow assignment of a MELD exception similar to hepatocellular carcinoma.
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Affiliation(s)
- Linda S Sher
- Department of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, California
| | - David M Levi
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Julie S Wecsler
- Department of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, California
| | - Mary Lo
- Department of Preventive Medicine, University of Southern California, Keck School of Medicine, Los Angeles, California
| | - Lydia M Petrovic
- Department of Pathology, University of Southern California, Keck School of Medicine, Los Angeles, California
| | - Susan Groshen
- Department of Preventive Medicine, University of Southern California, Keck School of Medicine, Los Angeles, California
| | - Lingyun Ji
- Department of Preventive Medicine, University of Southern California, Keck School of Medicine, Los Angeles, California
| | - Teresa Diago Uso
- Department of General Surgery and Transplant Center, Cleveland Clinic, Cleveland, Ohio
| | - A Joseph Tector
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ann S Hamilton
- Department of Preventive Medicine, University of Southern California, Keck School of Medicine, Los Angeles, California
| | - J Wallis Marsh
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Myron E Schwartz
- Department of Surgery, Recanati/Miller Transplantation Institute Icahn School of Medicine at Mount Sinai, New York, New York
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Small intestinal neuroendocrine tumors with liver metastases and resection of the primary: Prognostic factors for decision making. Int J Surg 2015; 20:58-64. [PMID: 26074290 DOI: 10.1016/j.ijsu.2015.06.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 05/13/2015] [Accepted: 06/03/2015] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Patients with small intestine neuroendocrine tumors present with liver metastases in 50-75% of cases at diagnosis. The aim of the present study was to assess prognostic factors in patients with liver metastases from intestinal neuroendocrine tumor after primary tumor surgical removal with or without liver surgery or radiofrequency ablation. The primary endpoint was disease-specific survival. METHODS Data regarding seventy-eight consecutive patients with liver metastases who undergone primary tumor surgical removal between 1996 and 2011 were extracted from the institutional tumor registry and retrospectively analyzed. RESULTS Liver tumor burden was <25% in 43 (55.1%) 25-50% in 30 (38.5%) and >50% in 5 (6.4%) patients. For the whole cohort of patients disease-specific survival at 3, 5 and 8 years was 93.2%, 83.6% and 77.3%, respectively. Fifteen patients who underwent radical liver surgery were all alive with a median survival of 106 months (range 18-152 months). In multivariate analysis the Ki-67 index in a continuous fashion significantly correlate with prognosis (p = 0.021). Liver tumor burden (p = 0.036) and extrahepatic involvement (p = 0.03), were the most powerful prognosticators for patients who underwent only debulking surgery. CONCLUSION The Ki-67 index, the liver tumor burden and the presence of extrahepatic metastases should be carefully considered in the selection criteria for liver debulking in asymptomatic patients.
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37
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Åkerström G, Norlén O, Edfeldt K, Crona J, Björklund P, Westin G, Hellman P, Stålberg P. A review on management discussions of small intestinal neuroendocrine tumors ‘midgut carcinoids’. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2015. [DOI: 10.2217/ije.15.2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
European Neuroendocrine Tumor Society staging, together with the Ki67 grading system, has appeared as superior for classification of neuroendocrine tumors (NET). The management of small intestinal NET (SI-NET) has been overall controversial. Mesenteric metastases occur also with the smallest SI-NET, and the majority of patients risk to ultimately progress with liver metastases. 68Gallium (somatostatin receptor)/PET/CT has appeared as most sensitive for imaging, and fluorodeoxyglucose-PET is recommended to identify lesions with high proliferation. Our treatment policy for SI-NET is to initiate somatostatin analog treatment, and in order to prevent abdominal complications we recommend early intestinal resection for removal of primary tumors and clearance of lymph node metastases. Liver metastases are liberally treated by resection (or ablation), as this can efficiently palliate carcinoid syndrome-associated symptoms.
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Affiliation(s)
- Göran Åkerström
- Department of Surgical Sciences, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Olov Norlén
- Department of Surgical Sciences, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Katarina Edfeldt
- Department of Surgical Sciences, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Joakim Crona
- Department of Surgical Sciences, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Peyman Björklund
- Department of Surgical Sciences, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Gunnar Westin
- Department of Surgical Sciences, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Per Hellman
- Department of Surgical Sciences, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Peter Stålberg
- Department of Surgical Sciences, Uppsala University, SE-751 85 Uppsala, Sweden
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Abstract
Liver transplantation (LT) has become an acceptable and effective treatment for selected patients with hepatocellular carcinoma with excellent outcomes. More recently, LT has been tried in different primary and secondary malignancies of the liver. The outcomes of LT for very selected group of patients with hilar cholangiocarcinoma (CCA) have been promising. Excellent results have been reported in LT for patients with unresectable hepatic epithelioid hemangioendothelioma (HEHE). In contrast to excellent results after LT for HEHE, results of LT for angiosarcoma have been disappointing with no long-term survivors. Hepatoblastoma (HB) is the most common primary liver cancer in pediatric age group. Long-term outcomes after LT in patients with unresectable tumor and good response to chemotherapy have been promising. Indication for LT for hepatic metastasis from neuroendocrine tumors (NETs) is mainly for patients with unresectable tumors and for palliation of medically uncontrollable symptoms. Posttransplant survival in those patients with low tumor activity index is excellent, despite recurrence of the tumor. More recent limited outcomes data on LT for unresectable hepatic metastases from colorectal cancer have claimed some survival benefit compared to the previous reports. However, due to the high rate of tumor recurrence in a very short time after LT, especially in the era of organ shortage, this indication has not been favored by the transplant community.
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Hore T, Poston G. Perspectives on surgical management of neuroendocrine liver metastases. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2015. [DOI: 10.2217/ije.14.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Abstract: Neuroendocrine tumors (NETs) commonly metastasize to the liver. Different treatments are available for the management of metastatic NETs. Both primary tumor and metastases can significantly affect the patients’ quality of life and overall survival (OS). Surgical resection is the only chance for cure and should be considered for every patient. For operable patients, current evidence suggests that liver resection is a safe and effective treatment for neuroendocrine liver metastases. High rates of recurrence are reported following resection of neuroendocrine liver metastases. There is no evidence to support incomplete (R2) resection (debulking) surgery to improve OS or quality of life. When surgery is performed for NETs, other conservative adjuvant treatments should also be considered to prolong symptom-free, disease-free and OS.
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Affiliation(s)
- Todd Hore
- University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK
| | - Graeme Poston
- University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK
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Frilling A, Giele H, Vrakas G, Reddy S, Macedo R, Al-Nahhas A, Wasan H, Clift AK, Gondolesi GE, Vianna RM, Friend P, Vaidya A. Modified liver-free multivisceral transplantation for a metastatic small bowel neuroendocrine tumor: a case report. Transplant Proc 2015; 47:858-62. [PMID: 25689880 DOI: 10.1016/j.transproceed.2015.01.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 01/14/2015] [Indexed: 12/17/2022]
Abstract
Neuroendocrine tumors originating from the small bowel frequently metastasize to the lymph nodes and/or liver. Although surgical extirpation of the primary tumor and locoregional metastases epitomizes the management of patients with such tumors, this is not always possible with conventional surgical techniques. Nonresectable, slow-growing tumors involving the mesenteric root represent a generally accepted indication for deceased donor intestinal and multivisceral transplantation. Furthermore, vascularized sentinel forearm flaps offer opportunities for monitoring graft rejection and tailoring immunosuppression regimens. Here, we report the first documented case of modified liver-free multivisceral transplantation preceded by neoadjuvant 177-lutetium peptide receptor radionuclide therapy in a patient with a small bowel neuroendocrine tumor and extensive lymph node metastases in the mesenterium. At a follow-up of 21 months the patient is biochemically and radiologically disease-free.
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Affiliation(s)
- A Frilling
- Department of Surgery and Cancer, Imperial College London, United Kingdom.
| | - H Giele
- Department of Plastic and Reconstructive Surgery, Oxford University NHS Trust, Oxford, United Kingdom
| | - G Vrakas
- Oxford Transplant Centre, Oxford University NHS Trust, Oxford, United Kingdom
| | - S Reddy
- Oxford Transplant Centre, Oxford University NHS Trust, Oxford, United Kingdom
| | - R Macedo
- Oxford Transplant Centre, Oxford University NHS Trust, Oxford, United Kingdom
| | - A Al-Nahhas
- Department of Nuclear Medicine, Imperial College London, United Kingdom
| | - H Wasan
- Department of Surgery and Cancer, Imperial College London, United Kingdom
| | - A K Clift
- School of Medicine, Imperial College London, United Kingdom
| | - G E Gondolesi
- Instituto de Trasplante Multiorgánico, Fundación Favaloro, Buenos Aires, Argentina
| | - R M Vianna
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Fla., United States
| | - P Friend
- Oxford Transplant Centre, Oxford University NHS Trust, Oxford, United Kingdom
| | - A Vaidya
- Oxford Transplant Centre, Oxford University NHS Trust, Oxford, United Kingdom
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Fan ST, Le Treut YP, Mazzaferro V, Burroughs AK, Olausson M, Breitenstein S, Frilling A. Liver transplantation for neuroendocrine tumour liver metastases. HPB (Oxford) 2015; 17:23-8. [PMID: 24992381 PMCID: PMC4266437 DOI: 10.1111/hpb.12308] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 06/02/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Search and review of available literature were made to define the indications for and timing of liver transplantation for neuroendocrine tumour (NET) liver metastases. METHODS Electronic bibliographical databases were searched. Prospective and retrospective cohort studies and case-controlled studies were used for qualitative and quantitative synthesis of the systematic review. Reports of patients with liver transplantation alone for NET liver metastases of any origin or combined with resection of extrahepatic tumour deposits were recruited. RESULTS The number of patients who have undergone liver transplantation for NET liver metastases is 706. The post-transplant 5-year survival rate from the time of diagnosis was approximately 70%. NET patients with metastases confined to the liver and not poorly differentiated are favourable candidates for liver transplantation. Selection of patients based on evolution of tumours over 6 months is not recommended. CONCLUSION Non-resectable NET liver metastasis resistant to medical treatment and confined to the liver is an accepted indication for liver transplantation.
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Affiliation(s)
- Sheung Tat Fan
- Department of Surgery, The University of Hong Kong, and Liver Surgery Centre, Hong Kong Sanatorium and HospitalHong Kong,Correspondence, Sheung Tat Fan, 102 Pok Fu Lam Road, Hong Kong. Tel: +852 22554703. Fax: +852 28551897. E-mail:
| | - Yves Patrice Le Treut
- Service de Chirurgie Générale et Transplantation Hépatique, Hôpital de la ConceptionMarseille, France
| | - Vincenzo Mazzaferro
- Gastrointestinal and Hepato-Pancreatic Surgery and Liver Transplantation Unit, Istituto Nazional dei TumoriMilan, Italy
| | | | | | - Stefan Breitenstein
- Department of Visceral and Transplant Surgery, Swiss Hepato-Pancreato-Biliary Center, University Hospital ZurichZurich, Switzerland
| | - Andrea Frilling
- Department of Surgery and Cancer, Imperial College LondonLondon, UK
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Barbier L, Neuzillet C, Dokmak S, Sauvanet A, Ruszniewski P, Belghiti J. Liver transplantation for metastatic neuroendocrine tumors. Hepat Oncol 2014; 1:409-421. [PMID: 30190976 DOI: 10.2217/hep.14.21] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Neuroendocrine tumors are a heterogeneous group of rare epithelial tumors. Most of them are metastatic at the time of initial diagnosis. Liver transplantation (LT) has been proposed in selected patients with diffuse liver involvement. Rationale for LT in this indication is based on the frequently indolent nature of neuroendocrine tumors, the propensity for liver-only metastasis and the high rate of intrahepatic recurrence after resection. However, indications for LT for neuroendocrine liver metastases remain controversial, and patient selection criteria is still a matter of debate. The aim of this review is to summarize data regarding LT for neuroendocrine liver metastases by answering frequently asked questions about this issue.
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Affiliation(s)
- Louise Barbier
- Department of HPB Surgery & Liver Transplantation, Beaujon Hospital (Assistance Publique Hôpitaux de Paris), University Denis Diderot Paris 7, 100 Bd du Général Leclerc, 92110 Clichy, France.,Department of HPB Surgery & Liver Transplantation, Beaujon Hospital (Assistance Publique Hôpitaux de Paris), University Denis Diderot Paris 7, 100 Bd du Général Leclerc, 92110 Clichy, France
| | - Cindy Neuzillet
- Department of Oncology, Beaujon Hospital (Assistance Publique Hôpitaux de Paris), University Denis Diderot Paris 7, 100 Bd du Général Leclerc, 92110 Clichy, France.,Department of Oncology, Beaujon Hospital (Assistance Publique Hôpitaux de Paris), University Denis Diderot Paris 7, 100 Bd du Général Leclerc, 92110 Clichy, France
| | - Safi Dokmak
- Department of HPB Surgery & Liver Transplantation, Beaujon Hospital (Assistance Publique Hôpitaux de Paris), University Denis Diderot Paris 7, 100 Bd du Général Leclerc, 92110 Clichy, France.,Department of HPB Surgery & Liver Transplantation, Beaujon Hospital (Assistance Publique Hôpitaux de Paris), University Denis Diderot Paris 7, 100 Bd du Général Leclerc, 92110 Clichy, France
| | - Alain Sauvanet
- Department of HPB Surgery & Liver Transplantation, Beaujon Hospital (Assistance Publique Hôpitaux de Paris), University Denis Diderot Paris 7, 100 Bd du Général Leclerc, 92110 Clichy, France.,Department of HPB Surgery & Liver Transplantation, Beaujon Hospital (Assistance Publique Hôpitaux de Paris), University Denis Diderot Paris 7, 100 Bd du Général Leclerc, 92110 Clichy, France
| | - Philippe Ruszniewski
- Department of Gastroenterology, Beaujon Hospital (Assistance Publique Hôpitaux de Paris), University Denis Diderot Paris 7, 100 Bd du Général Leclerc, 92110 Clichy, France.,Department of Gastroenterology, Beaujon Hospital (Assistance Publique Hôpitaux de Paris), University Denis Diderot Paris 7, 100 Bd du Général Leclerc, 92110 Clichy, France
| | - Jacques Belghiti
- Department of HPB Surgery & Liver Transplantation, Beaujon Hospital (Assistance Publique Hôpitaux de Paris), University Denis Diderot Paris 7, 100 Bd du Général Leclerc, 92110 Clichy, France.,Department of HPB Surgery & Liver Transplantation, Beaujon Hospital (Assistance Publique Hôpitaux de Paris), University Denis Diderot Paris 7, 100 Bd du Général Leclerc, 92110 Clichy, France
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43
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Wurst C, Jandt K, Schuele S, Rauchfuß F, Settmacher U. Liver transplantation for neuroendocrine tumors: review of the literature and future perspectives. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2014. [DOI: 10.2217/ije.14.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Liver transplantation for metastases of neuroendocrine tumors is still a subject of controversial discussion. Over the years, more and more data have been collected to demonstrate that transplantation is feasible and contributes to long-term overall survival. Most data are of retrospective nature and, thus, it is difficult to draw definitive conclusions. Over the years, indications, surgical technique and perioperative care have improved. The most recent data have been collected prospectively and show a very favorable outcome in selected patients. Liver transplantation should be considered in patients with neuroendocrine liver metastases, but the decision needs to be made on an individual basis with particular emphasis on the tumor biology. In the future, we may need to work more with living organ donation and perhaps, especially in Europe, think about challenging the scoring system model of end-stage liver disease for this indication.
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Affiliation(s)
- Christine Wurst
- University of Jena, Department of General Visceral & Vessel Surgery, Erlangerallee 101, 07740 Jena, Germany
| | - Karin Jandt
- University of Jena, Department of General Visceral & Vessel Surgery, Erlangerallee 101, 07740 Jena, Germany
| | - Silke Schuele
- University of Jena, Department of General Visceral & Vessel Surgery, Erlangerallee 101, 07740 Jena, Germany
| | - Falk Rauchfuß
- University of Jena, Department of General Visceral & Vessel Surgery, Erlangerallee 101, 07740 Jena, Germany
| | - Utz Settmacher
- University of Jena, Department of General Visceral & Vessel Surgery, Erlangerallee 101, 07740 Jena, Germany
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Norlén O, Daskalakis K, Öberg K, Åkerström G, Stålberg P, Hellman P. Indication for liver transplantation in young patients with small intestinal NETs is rare? World J Surg 2014; 38:742-7. [PMID: 24233660 DOI: 10.1007/s00268-013-2331-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND A majority of patients with small intestinal neuroendocrine tumors (SI-NETs) present with or develop liver metastases (LM). A number of treatments for LM are used clinically, including liver transplantation (LTx). Indications for LTx are under debate; young age(<65 years), absence of extrahepatic disease, resected primary tumor and limited extent of LM have been suggested as inclusion criteria for LTx with the aim to optimize outcome. MATERIALS AND METHODS From our series of 672 patients with SI-NET treated at the University Hospital in Uppsala between 1985 and 2012, we identified 78 patients according to the following criteria: <65 years of age, locoregional surgery (LRS) of the primary tumor and mesenteric metastases successfully performed, LM present but no extrahepatic disease. Baseline was chosen as the first date the following points were met: First visit to our center,LRS performed, LM present. The patients underwent treatment according to the standard clinical protocols at our center, and during this time period we did not perform or refer any SI-NET patients for LTx. Kaplan-Meier survival analyses were performed in three different groups based on hypothetical criteria for LTx. RESULTS Five-year overall survival rates for patients <65 years (n = 78) and <55 years (n = 36) of age were 84 ± 8 and 92 ± 9 %, respectively. For patients fulfilling the Milan criteria (n = 33) the 5-year survival was 97 ± 6 %. CONCLUSIONS Most young patients (<65 years) with SINET and LM have a favorable survival with standardized multimodality treatment. Indeed, most survival figures reported after LTx of NET do not surpass these figures.
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45
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Alagusundaramoorthy SS, Gedaly R. Role of surgery and transplantation in the treatment of hepatic metastases from neuroendocrine tumor. World J Gastroenterol 2014; 20:14348-14358. [PMID: 25339822 PMCID: PMC4202364 DOI: 10.3748/wjg.v20.i39.14348] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 04/24/2014] [Accepted: 06/13/2014] [Indexed: 02/06/2023] Open
Abstract
Neuroendocrine tumors (NET) are a heterogeneous group of cancers, with indolent behavior. The most common primary origin is the gastro-intestinal tract but can also appear in the lungs, kidneys, adrenals, ovaries and other organs. In general, NET is usually discovered in the metastatic phase (40%-80%). The liver is the most common organ involved when metastases occur (40%-93%), followed by bone (12%-20%) and lung (8%-10%).A number of different therapeutic options are available for the treatment of hepatic metastases including surgical resection, transplantation, ablation, trans-arterial chemoembolization, chemotherapy and somatostatin analogues. Recently, molecular targeted therapies have been used, usually in combination with other treatment options, to improve outcomes in patients with metastases. This article emphasizes on the role of surgery in the treatment of liver metastases from NET.
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46
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Grąt M, Remiszewski P, Smoter P, Wronka K, Grąt K, Lewandowski Z, Koperski Ł, Górnicka B, Pacho R, Zborowska H, Patkowski W, Krawczyk M. Outcomes Following Liver Transplantation for Metastatic Neuroendocrine Tumors. Transplant Proc 2014; 46:2766-9. [PMID: 25380913 DOI: 10.1016/j.transproceed.2014.09.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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47
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Frilling A, Clift AK. Therapeutic strategies for neuroendocrine liver metastases. Cancer 2014; 121:1172-86. [PMID: 25274401 DOI: 10.1002/cncr.28760] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 04/09/2014] [Accepted: 04/10/2014] [Indexed: 12/16/2022]
Abstract
Patients who have neuroendocrine tumors frequently present with liver metastases. A wide panel of treatment options exists for these patients. Liver resection with curative intent achieves the best long-term results. Highly selected patients may be considered for liver transplantation. Substantial recurrence rates reported after surgical approaches call for neoadjuvant and adjuvant concepts. Liver-directed, locally ablative procedures are recommended for patients with limited, nonresectable tumor burden. Angiographic liver-directed techniques, such as transarterial embolization, transarterial chemoembolization, and selective internal radiotherapy, offer excellent palliation for patients with liver-predominant disease. Peptide receptor radionuclide therapy is a promising palliative procedure for patients with hepatic and/or extrahepatic metastases. The efficacy of these treatment options needs to be evaluated in randomized trials. Somatostatin analogues have demonstrated effectiveness not only for symptomatic relief in patients with secreting tumors but also for the control of proliferation in small intestinal neuroendocrine tumors and most recently also in those originating from the pancreas. Chemotherapy is an option mainly for those with pancreatic neuroendocrine tumors and high-grade tumors irrespective of the origin. Novel drugs targeting specific pathways within the tumor cell have produced improved progression-free survival compared with placebo in patients with pancreatic neuroendocrine tumors. Despite such a diverse armamentarium, there is uncertainty with regard to the optimal treatment regimens. Newly introduced molecular-based markers, along with the conduction of clinical trials comparing the efficacy of treatment modalities, offer a chance to move the treatment of neuroendocrine tumor disease toward personalized patient care. In this report, the authors review the approaches for treatment of neuroendocrine liver metastases, identify shortcomings, and anticipate future perspectives. Furthermore, clinical practice recommendations are provided for currently available treatment options. Although multiple modalities are available for the treatment of neuroendocrine liver metastases, optimal management is unclear. The current knowledge pertaining to these treatment options is analyzed.
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Affiliation(s)
- Andrea Frilling
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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48
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Abstract
Neuroendocrine tumors have a disposition toward metastasis to the liver. A range of treatment modalities for neuroendocrine liver metastases is available in the clinical arena, the indications for which depend on tumor characteristics such as patterns of metastasis, tumor grade, and anatomical origin. The complete surgical resection of liver deposits represents the only option with the intent to cure and is the gold standard approach, whereas cytoreductive resection (debulking) presents another surgical option aiming to ameliorate the symptoms and prolong survival. Liver transplantation is generally an accepted option for highly selected patients. For patients ineligible for radical surgery, liver-directed therapies-transarterial embolization/chemoembolization, selective internal radiotherapy, and local tumor ablation-present alternative strategies. Systemic therapies include peptide receptor radiotherapy, somatostatin analogues, cytotoxic chemotherapeutics, and novel molecularly targeted drugs. However, despite the variety of treatments available, there exists little evidence to guide optimal clinical practice with currently available data predominantly retrospective in nature. In this review, we discuss the diagnostic procedures that influence the trajectory of treatment of patients with neuroendocrine liver metastases before critically appraising the evidence pertaining to these therapeutic strategies.
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Affiliation(s)
| | - Andrea Frilling
- Prof. Andrea Frilling, Department of Surgery and Cancer, Imperial College London, Hammersmith Campus, DuCane Road, London W12 0NN, United Kingdom, T: 00442083833210, F: 00442083833963,
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49
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Hackl C, Schlitt HJ, Kirchner GI, Knoppke B, Loss M. Liver transplantation for malignancy: Current treatment strategies and future perspectives. World J Gastroenterol 2014; 20:5331-5344. [PMID: 24833863 PMCID: PMC4017048 DOI: 10.3748/wjg.v20.i18.5331] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 12/31/2013] [Accepted: 02/27/2014] [Indexed: 02/06/2023] Open
Abstract
In 1967, Starzl et al performed the first successful liver transplantation for a patient diagnosed with hepatoblastoma. In the following, liver transplantation was considered ideal for complete tumor resection and potential cure from primary hepatic malignancies. Several reports of liver transplantation for primary and metastatic liver cancer however showed disappointing results and the strategy was soon dismissed. In 1996, Mazzaferro et al introduced the Milan criteria, offering liver transplantation to patients diagnosed with limited hepatocellular carcinoma. Since then, liver transplantation for malignant disease is an ongoing subject of preclinical and clinical research. In this context, several aspects must be considered: (1) Given the shortage of deceased-donor organs, long-term overall and disease free survival should be comparable with results obtained in patients transplanted for non-malignant disease; (2) In this regard, living-donor liver transplantation may in selected patients help to solve the ethical dilemma of optimal individual patient treatment vs organ allocation justice; and (3) Ongoing research focusing on perioperative therapy and anti-proliferative immunosuppressive regimens may further reduce tumor recurrence in patients transplanted for malignant disease and thus improve overall survival. The present review gives an overview of current indications and future perspectives of liver transplantation for malignant disease.
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50
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Rossi RE, Burroughs AK, Caplin ME. Liver transplantation for unresectable neuroendocrine tumor liver metastases. Ann Surg Oncol 2014; 21:2398-405. [PMID: 24562931 DOI: 10.1245/s10434-014-3523-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Liver transplantation (LT) is performed in selected patients with neuroendocrine hepatic metastases. Survival benefit and the risk of tumor recurrence after LT, also exacerbated by immunosuppressive therapy, remain important clinical issues. Whether patients with particular types of neuroendocrine tumors (NET) benefit more than others is unclear. METHODS Bibliographical searches were performed in PubMed for the terms "liver transplantation and neuroendocrine tumors," "liver transplant and neuroendocrine tumors," "liver transplantation and immunosuppressive therapy," "tumor recurrence." RESULTS Promising results have been reported for LT for NET metastases with 5-year survival of up to 90 % in patients with well-differentiated gastroenteropancreatic NETs, but only few patients are free of tumor 5 years after LT. Better outcomes have been reported for gastrointestinal tumors than for pancreatic NETs for both survival and risk or recurrence after LT. Selection criteria for LT are limited and include the 2007 Milan Criteria and the 2012 European Neuroendocrine Tumor Society guidelines, including: well-differentiated NET (Ki-67 <10 %), age <55 years, absence of extrahepatic disease, primary tumor removed before transplantation, stable disease for at least 6 months before LT, and <50 % liver involvement. CONCLUSIONS LT might be considered in carefully selected patients. The risk of tumor recurrence remains a significant clinical problem after LT, but data focused on immunosuppression issue are lacking, and there are no currently approved strategies for prevention of recurrence or follow-up protocols. Further studies are needed to define universally accepted inclusion criteria, reliable predictors of better outcome, and optimal timing for LT.
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Affiliation(s)
- Roberta Elisa Rossi
- Neuroendocrine Tumour Unit, Centre of Gastroenterology, Royal Free Hospital, London, UK
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