Palliative operations for patients with unresectable endocrine neoplasia

Malignant nonfunctioning endocrine tumors of the pancreas: predictive factors for survival after surgical treatment

BACKGROUND

There are scant studies that have analyzed the prognostic factors for malignant nonfunctioning endocrine tumors of the pancreas. We identified the predictive factors associated with long-term survival after surgical resection for malignant nonfunctioning endocrine tumors.

METHODS

Among the 25 patients seen at our hospital with a diagnosis of malignant nonfunctioning endocrine tumor, a review was performed on 22 of these patients who were surgically treated at our institution over the last 10 years. The following factors were evaluated for disease-specific mortality: age, gender, tumor location, tumor size, histological differentiation, status of the resection margin, and status of lymph node involvement.

RESULTS

Tumor recurrence was noted in 9 cases (40.9%) among the 22 operated patients. Of the 9 recurrent cases, 7 patients (77.8%) had liver metastases. The median follow-up period was 24.8 (range: 3.7-121.4) months. The overall actuarial 1-, 2- and 5-year survival rates were 84.1%, 72.5%, and 52.8%, respectively. The factor shown to have a favorable independent prognostic significance was a negative resection margin (odds ratio = 19.44, 95% confidence interval = 1.22-310.54, P = 0.036).

CONCLUSIONS

Definitive surgical resection of the primary tumor was a predictor of long-term survival after surgical resection for malignant nonfunctioning endocrine tumor.

Malignant metastatic insulinoma-postoperative treatment and follow-up

The rarity of malignant insulinoma limits reports on therapeutic strategies and outcome. The treatment and follow-up of 10 patients, all presenting an insulinoma with metastatic disease of the liver and newly diagnosed between 1992 and 2002, is reported. Pancreatic surgery with successful removal of the primary tumor preferentially located in the tail was performed in 7 women and 3 men, median age 55 years (range 36-82 years). If appropriate, 5 patients underwent additional hepatic surgery and lymph node resections. Liver metastases as the major cause of postoperatively persistent hypoglycemia were subsequently treated by repeated transarterial hepatic chemoembolization and chemoperfusion protocols using high-dose transhepatic streptozocin perfusions (3-4 g per session). The current median survival time for all 10 patients is 2.6 years (range: 1.6-9.7 years). Six patients are currently alive with a median survival of 3.7 years (1.7-9.7 years), five of them with stable disease and free of hypoglycemia. Four patients died after a median survival of 1.8 years (range: 1.6-7.5 years) from complications of unmanageable hypoglycemia. It is concluded that the necessity to treat debiliating and life-threatening hypoglycemia in metastatic malignant insulinoma warrants the option of radical endocrine surgery in combination with extended and repeated postoperative chemoembolization of liver metastases.

Nonfunctioning islet cell carcinoma of the pancreas: survival results in a contemporary series of 163 patients

BACKGROUND

The natural history of nonfunctioning islet cell carcinoma of the pancreas is poorly defined. We therefore reviewed our institutional experience during a period of 12 years to define more clearly the natural history of this disease as a basis for individual therapeutic recommendations.

METHODS

The records of all patients who had histologically or cytologically confirmed nonfunctioning islet cell carcinoma of the pancreas were retrospectively reviewed. Patients were grouped by extent of disease at diagnosis and by initial treatment. Survival distributions were estimated by Kaplan-Meier analysis.

RESULTS

One hundred sixty-three patients with nonfunctioning islet cell carcinoma of the pancreas were identified. The overall median survival duration was 3.2 years. The median survival was 7.1 years in patients with localized disease who underwent a potentially curative resection and 5.2 years in those with locally advanced, unresectable, nonmetastatic disease (P = .04). Patients with metastatic disease that could not be resected had a median survival of 2.1 years.

CONCLUSIONS

Patients with completely resected localized disease had a long median survival. Patients with nonmetastatic but unresectable locally advanced disease also had a surprisingly long median survival; major treatment-related morbidity may be hard to justify in this subgroup. The short median survival in patients with metastatic disease suggests that the frequent practice of observation in this patient subgroup needs to be reexamined and that continued investigation of regional and systemic therapies with novel agents is warranted.

Surgical management of gastrointestinal endocrine tumours

The surgical management of gastrointestinal endocrine tumours must involve a multidisciplinary approach. The importance of accurate diagnosis, rendering the patient safe, and, in our opinion, localizing the tumour(s) before embarking on surgery cannot be overemphasized. Surgery is the only available treatment for cure. Occult primary tumours are now rarely a problem with novel imaging techniques, which can also improve detection and hence clearance of local spread. Surgical management in extensive metastatic or multicentric disease is less rigidly defined, and is dependent on the endocrine syndrome. A better understanding of tumour pathology, for example in MEN 1, has not always simplified matters. An appreciation of the benefit of chemotherapy, use of somatostatin analogues and hepatic artery embolization are vital to target appropriate palliative surgery. Hepatic transplantation may have an increasing role in the future. Surgical strategies must adapt to new medical treatments. If therapeutically relevant, advances in tumour biology (for example somatostatin receptor subtypes and growth factors) will influence surgical strategies in the future.