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Neuroendocrine tumours
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Evidence supporting the management of NETs

CANADIAN GUIDELINES

“Optimal management of GI-NETs is in a multidisciplinary environment and is multimodal, requiring collaboration between medical, surgical, imaging and pathology specialties.”

- Cancer Treatment Reviews (June 2016)

“Diagnosis and management should occur through a collaborative team of health care practitioners well-experienced in managing pNETs.”

“Patients with NF-pNETs 2 cm in size or smaller demonstrated to have low Ki67 and no evidence of invasion or metastatic disease can be considered for surveillance.”

- Annals of Surgical Oncology (August 2015)

SYSTEMIC THERAPY

Long-acting somatostatine analogs

“Lanreotide was associated with significantly prolonged progression-free survival among patients with metastatic enteropancreatic neuroendocrine tumors of grade 1 or 2 (Ki-67<10%).”

- New England Journal of Medicine (July 2014)

“Octreotide LAR significantly lengthens time to tumor progression compared with placebo in patients with functionally active and inactive metastatic midgut NETs.”

- Journal of Clinical Oncology (October 2009)

Biotherapy

“Everolimus, as compared with placebo, significantly prolonged progression-free survival among patients with progressive advanced pancreatic neuroendocrine tumors and was associated with a low rate of severe adverse events.”

- New England Journal of Medicine (February 2011)

“Continuous daily administration of sunitinib at a dose of 37.5 mg improved progression-free survival, overall survival, and the objective response rate as compared with placebo among patients with advanced pancreatic neuroendocrine tumors.”

- New England Journal of Medicine (February 2011)

“Treatment with everolimus was associated with significant improvement in progression-free survival in patients with progressive lung or gastrointestinal neuroendocrine tumours.”

- The Lancet (December 2015)

SURGERY

Debulking surgery for NETs metastases

“As well as consideration of purely morphological characteristics, attention should be paid to the localization and biological features of LM from NET in order to better assess prognosis and implement patient-tailored management.”

- British Journal of Surgery (January 2009)

“The benefits of the operation clearly outweigh this relatively low morbidity rate, which is no higher than that for hepatic resection for other conditions.”

“We consider hepatic resection for neuroendocrine metastases to the liver to be a safe procedure that provides control of symptoms, reduces the need for pharmacologic therapy, and improves survival.”

- Journal of the American College of Surgeons (July 2003)

“While it is necessary to obtain negative margins in curative resections of other liver metastases, such as colorectal carcinomas, the impact of margin status in NET-LM is unclear. The heterogeneous behaviour of NET in some patients may allow for potential symptomatic benefit from liver resections, even with positive margins, for diffuse multifocal liver metastases as long as sufficient liver parenchyma is preserved.”

- Canadian Journal of Surgery (April 2014)

“Hepatectomy for liver metastases from well-differentiated endocrine neoplasms is indicated when all visible intra- and extra hepatic lesions can be resected safely. The number, size, and localization of the tumor sites are less important than performing a complete (or near-complete) resection.”

- Surgery (April 2003)

“The results of the present study suggest that, in both symptomatic and asymptomatic patients with low disease burden, HR should be considered as first-line therapy.”

- Surgery (August 2015)

Surgery for intestinal NET

“Patients in whom the lymph node metastases were removed within 3 years after the primary operation (either in conjunction with the primary surgery or at a reoperative procedure) had a longer survival and better symptom relief than patients in whom the lymph nodes metastases were not removed.”

“Especially in these patients [with liver metastases] it seems beneficial to resect the primary tumor as well as the mesenteric lymph node metastases, supporting the notion that aggressive surgery (sometimes denoted debulking surgery) is advantageous also in the case of spread disease.”

- World Journal of Surgery (August 2002)

Surgery for pancreatic NET

“Patients with NF-pNETs [non-functional pancreatic NET] 2 cm in size or smaller demonstrated to have low Ki67 and no evidence of invasion or metastatic disease can be considered for surveillance”

“Aggressive resections (e.g., multivisceral) of locally advanced G1/G2 pNETs can be technically feasible and have been reported to result in promising disease-free and overall survival rates for appropriately selected candidates.”

- Annals of Surgical Oncology (August 2015)

LIVER DIRECTED THERAPY

“Hepatic arterial (chemo)embolization is a safe and very effective treatment for patients with progressive liver metastases and/ or major liver involvement from midgut endocrine tumors. […] the addition of intra-arterial chemotherapy to embolization does not prolong PFS [Progression Free Survival].”

- Neuroendocrinology (December 2012)

Videos of minimally invasive surgeries

Note: the educational videos below may be too graphic for some viewers.

  • Laparoscopic intra-gastric resection:
    • This video details the steps to intra-gastric laparoscopic resection. This technique is ideally suited for sub-mucosal gastric tumours in challenging location for traditional partial gastrectomy.
  • Laparoscopic cystogastrostomy:
    • This videos shows the steps to a laparoscopic cystogastrostomy, guided by intra-operative ultrasound to ensure complete drainage of the cyst.