Small Intestine Neuroendocrine Tumours (SI NETs): To cut or not to cut?

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Small Intestine Neuroendocrine Tumours (SI NET) are one of the most common types of Neuroendocrine Cancer, and also one of the most challenging to diagnose and then treat. Patients can have a very good outlook even when presenting with metastatic disease.  However, it’s true to say that some NET centres of excellence (CoE) or multi-disciplinary team (MDT) see a lot of SI NET patients have built up considerable experience in treating them, including the use of surgery.  The surgical challenges are such that a surgeon not experienced in treating these cases may shy away or think they are inoperable, whereas MDTs or CoEs potentially have the experience available to operate or to make sound judgements based on their own experience.  At the very least, they can offer a second opinion. 

I wrote about my own experiences in “Small Intestine, Large Surgery” where I quoted one NET specialist who said “this is not normal bowel surgery”. I had a surgeon who believed in aggressive approaches in the first 12 months after diagnosis but would emphasise that not everyone can go down this route, patients much be carefully selected, there are many factors involved.  There are some data available to show the benefits of upfront surgical resection for SI NETs and they can be found in the link above.  

This is a huge subject within my group, bringing up many posts and comments from across the world.  Some of the questions patients have span the spectrum of clinical situations in which questions frequently arise in the management of patients with SI NETs, where the answers are not clear from the literature. Many doctors and surgeons specialising in the care of NET patients generally agree on some of the approaches outlined below. I was delighted to see this document attached where a group of specialists reviewed the relevant data addressing many questions and have put forth consensus recommendations. Here’s a quote from the document to set the scene: “The objective of this conference was to improve the care of NET patients by increasing awareness of treatment options and providing expert recommendations based on clinical experience and careful review of the literature. Although the lack of randomized trials makes it difficult to prove the validity of these clinical recommendations, consensus or near consensus of our expert panel was reached for all of these questions. Our hope is that this article will offer guidance for physicians struggling to decide on how to deliver optimal care to their patients with SBNETs” (note:  NANETS use SBNETs (Small Bowel NETs) rather than the use of “SI NETs” in ENETS guidelines). 

The document cited below, lists a number of expert recommendations that commonly come up in discussions in my group.  I wanted to provide you with expert consensus to help guide conversations with your own doctors and surgeons (some of whom may even be listed in the authors). 

1. The use of Octreotide in SI NET surgery.

2. Types of surgery for small intestine resections (open or laparoscopy).

3. Lymph node management in SI NETs.

4. Misc SI NET scenarios: Surgery in high grade tumours, peritoneal metastases, Hyperthermic Intraperitoneal Chemotherapy (HIPEC), unknown primary in the presence of liver metastases, asymptomatic patients with inoperable liver metastases.

5. Liver surgery in SI NETs.

6. Gallbladder and somatostatin analogues.

7. Optimum imaging for SI NETs.

8. Camera Pill use in SI NETs.

“The Surgical Management of Small Bowel Neuroendocrine Tumors: Consensus Guidelines of the North American Neuroendocrine Tumor Society (NANETS)” Click link in blue below:

The Surgical Management of Small Bowel Neuroendocrine Tumors

Howe JR, Cardona K, Fraker DL, Kebebew E, Untch BR, Wang YZ, Law CH, Liu EH, Kim MK, Menda Y, Morse BG, Bergsland EK, Strosberg JR, Nakakura EK, Pommier RF. The Surgical Management of Small Bowel Neuroendocrine Tumors: Consensus Guidelines of the North American Neuroendocrine Tumor Society. Pancreas. 2017 Jul;46(6):715-731. doi: 10.1097/MPA.0000000000000846. PMID: 28609357; PMCID: PMC5502737.

ENETS surgical guidelines emphasise the importance of “running the bowel” in their statement:

“What Is the Best Procedure for Detecting Multifocal siNETs?” (1).   Multifocal siNETs occur in around 20–30% of patients and their correlation with a poorer prognosis is controversial.  CT and MR have demonstrated a very low accuracy in detecting multifocal siNETs. An accurate and systematic intraoperative bidigital palpation of the entire small intestine from the ligament of Treitz to the caecal valve bowel has been demonstrated to be more effective in detecting multifocal siNETs compared with all preoperative imaging modalities.”.   

(1) – ENETS Consensus Guidelines for the Standards of Care in Neuroendocrine Tumours: Surgery for Small Intestinal and Pancreatic Neuroendocrine Tumours.  N25 Feb 2017, 105(3):255-265

This recent Swedish study confirms the importance of ‘running the bowel’ due to the potential for each small bowel primary NET to generate its own metastases. Read more by clicking here or on the graphic. 

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