At the end of 2014, I was feeling pretty good celebrating 4 years since my first ‘big’ surgery in 2010. It prompted me to write an article Surgery – the gift that keeps on giving. In that particlar article, I really just wanted to say I was grateful for the early surgical treatment and as I was just about to spend another Christmas with my family, I was reminiscing what a wonderful gift it was at the time. Other than some detail of the surgery, I didn’t get too technical, I just wanted to generate a thankful and festive mood. However, a recent private message from a subscriber prompted me to study the current benefits of surgery for Neuroendocrine Tumours (NETs) in more detail just to ensure my understanding was still in line with best practice.  Some of the surgeries involved with NETs are not normal for the area of the anatomy involved.  Take my own primary as an example where I wrote this explanation of something described as “not normal bowel surgery” – Small Intestine, Large Surgery

It’s very well known that NETs can present a major challenge to physicians in their recognition and treatment requirements.  For example, NETs can cause various syndromes, not only for requiring treatment for primary and loco-regional tumours to minimise the risk of abdominal complications and future growth; but also for removal of tumour including liver and other metastases to palliate hormonal symptoms. Some tumours can be quite large and require extensive surgery to remove.

I searched reputable websites and European and North American NET treatment guidelines to find that surgical treatment of these tumours still appears to remain an important intervention, not just for curative treatment (where this is possible) but also for symptom palliation and survival. Although more treatment modalities are available than ever before (e.g. radiotherapy including PRRT, liver embolisation, liver ablation, somatostatin analogues, targeted therapies such as Afinitor and Sunitinib, some chemo combinations), surgery still appears to be the mainstay treatment to be offered when it is appropriate in well differentiated NETs.  For some it isn’t appropriate or will be held in reserve for watch and wait scenarios or as ‘adjuvant’ treatment downstream. On paper, it appears to be the only current option for a curative scenario if the cancer is caught early enough and has not grown too distant from the primary site.

I had an amazing surgeon with an impressive CV in Neuroendocrine disease.  Mr Neil Pearce of Southampton UK believes in early and aggressive surgery (within normal guidelines) and always in conjunction with other treatment modalities and only when required.  I found a video of one of his lectures which you may find useful.  Another surgeon who talks with knowledge and passion is Rodney F. Pommier, MD of Portland, Oregon and one of his videos can be viewed here. I’m sure there are many others.  They are different characters but they both seem to believe in getting as much tumour out as early as possible and also emphasise that sometimes it can be too risky so the focus moves to other treatment.  Both presentations provide statistical evidence that debulking/cytoreductive surgery can often offer a better outlook even for those with advanced neuroendocrine disease.

I think I have a soft spot for surgeons – they also seem to love their job despite it being particularly ‘gory’. On the subject of ‘gory’, I recently came across another surgical video which I found totally fascinating – Nicholas Nissen, MD from Cedars Sinai, LA, California.  This one contains amazing footage of real surgery and if you are like me, you will find this very educational. It’s an old video (2015) so perhaps he now offers more up to date techniques. It’s also a very well-structured presentation. Some of you may have seen it before and some of you could even have even been at the presentation! If you don’t have time, skip forward to approximately ’19 minutes’ and watch them take out large and small tumours of the liver using a technique called enucleation!   (Click here to watch).  There’s another one here from the same surgeon in 2016 covering a wider abdominal area – (Click here to watch).

Here’s another well-constructed video by Dr James Howe at a NET Research Foundation conference – click here

Hope you enjoyed this session as much as I enjoyed writing it?