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Management of Obstruction-Related Symptoms for NETs

Insights From:Jennifer Eads, MD, Case Western Reserve University; Matthew H. Kulke, MD, Harvard Medical School; Diane Reidy Lagunes, MD, Memorial Sloan-Kettering Cancer Center; Eric H. Liu, MD, FACS, Rocky Mountain Cancer Center; James C. Yao, MD, The University of Texas MD Anderson Cancer Center
Published: Thursday, Apr 14, 2016


Transcript:

Matthew H. Kulke, MD:
I want to raise another issue. We have such great evidence now that somatostatin analogs (SSAs) improve PFS, that everolimus helps improve PFS. A lot of times, these patients are symptomatic. They have intermittent bowel discomfort, especially small bowel carcinoid patients. And the question that comes up is, should I start them on one of these treatments? On a SSA or on everolimus? Is that going to help these obstructive symptoms? Eric, what are your thoughts on that?

Eric H. Liu, MD, FACS: That is a very important point, Matt, because the problem—especially with small bowel obstruction—is you can’t see it on the CT scan. We’ve seen several patients who said they have an NET of unknown primary. And then when I explore them and I show them the primary, well, here it is. And just because we don’t see it, there are frequently hints to it. There may be some mesenteric lymph nodes, so we should always go after it. But the thing we should never forget: just because the patient is metastatic doesn’t mean they’re not a surgical candidate. Because with surgery, if they’re going to live still another 4 or 5 years with all your advancements, why not just get rid of that chronic small bowel obstruction? Why not improve that nutritional status?

Sometimes people develop, even in the pancreas, splenic vein thromboses. So, there are a lot of complications that we’d like to avoid, and you always want to do surgery when the patient is well and healthy. Think back to when you were in medical school, when you saw someone with a small bowel obstruction; they were sick. And for me to operate on that is always much more complicated with increased risks. Definitely have a good relationship with your surgeon and make sure you always tap into it. It always gets back to the multidisciplinary aspect of neuroendocrine tumors. I happen to have clinic with my medical oncologist colleague and my interventional radiologist. So, having multiple views is really very helpful, especially when you’re looking at this complicated patient.

Matthew H. Kulke, MD: Let me ask you a potentially controversial question. Do you ever do a palliative resection in a pancreatic neuroendocrine tumor patient?

Eric H. Liu, MD, FACS: Yes, that’s actually a very controversial issue. You can hear me talking pretty freely about small bowel because the risk of a small bowel operation is very low. Frequently, I can do it laparoscopically. But the pancreas is a little bit unclear because there are some retrospective studies that have said maybe you can improve survival. The question is, am I doing surgery on patients who would have had very good survival anyway, much like Dr. Yao’s patient who’s been well for 12 years? I’m not exactly sure. So, a lot of it depends. Location, location, that’s very important in the pancreas. Sure, if you do a distal pancreatectomy, the operation is much safer. However, if you have a lesion in the head of the pancreas—which is going to be obstructive and cause pancreatitis and cause cholangitis—then that’s something you have to consider. We certainly have endoscopic techniques in which we can relieve those things, but surgery is still, by far, the most durable. So, when it comes to the pancreas, I think much harder and much more carefully about it.

Transcript Edited for Clarity
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Transcript:

Matthew H. Kulke, MD:
I want to raise another issue. We have such great evidence now that somatostatin analogs (SSAs) improve PFS, that everolimus helps improve PFS. A lot of times, these patients are symptomatic. They have intermittent bowel discomfort, especially small bowel carcinoid patients. And the question that comes up is, should I start them on one of these treatments? On a SSA or on everolimus? Is that going to help these obstructive symptoms? Eric, what are your thoughts on that?

Eric H. Liu, MD, FACS: That is a very important point, Matt, because the problem—especially with small bowel obstruction—is you can’t see it on the CT scan. We’ve seen several patients who said they have an NET of unknown primary. And then when I explore them and I show them the primary, well, here it is. And just because we don’t see it, there are frequently hints to it. There may be some mesenteric lymph nodes, so we should always go after it. But the thing we should never forget: just because the patient is metastatic doesn’t mean they’re not a surgical candidate. Because with surgery, if they’re going to live still another 4 or 5 years with all your advancements, why not just get rid of that chronic small bowel obstruction? Why not improve that nutritional status?

Sometimes people develop, even in the pancreas, splenic vein thromboses. So, there are a lot of complications that we’d like to avoid, and you always want to do surgery when the patient is well and healthy. Think back to when you were in medical school, when you saw someone with a small bowel obstruction; they were sick. And for me to operate on that is always much more complicated with increased risks. Definitely have a good relationship with your surgeon and make sure you always tap into it. It always gets back to the multidisciplinary aspect of neuroendocrine tumors. I happen to have clinic with my medical oncologist colleague and my interventional radiologist. So, having multiple views is really very helpful, especially when you’re looking at this complicated patient.

Matthew H. Kulke, MD: Let me ask you a potentially controversial question. Do you ever do a palliative resection in a pancreatic neuroendocrine tumor patient?

Eric H. Liu, MD, FACS: Yes, that’s actually a very controversial issue. You can hear me talking pretty freely about small bowel because the risk of a small bowel operation is very low. Frequently, I can do it laparoscopically. But the pancreas is a little bit unclear because there are some retrospective studies that have said maybe you can improve survival. The question is, am I doing surgery on patients who would have had very good survival anyway, much like Dr. Yao’s patient who’s been well for 12 years? I’m not exactly sure. So, a lot of it depends. Location, location, that’s very important in the pancreas. Sure, if you do a distal pancreatectomy, the operation is much safer. However, if you have a lesion in the head of the pancreas—which is going to be obstructive and cause pancreatitis and cause cholangitis—then that’s something you have to consider. We certainly have endoscopic techniques in which we can relieve those things, but surgery is still, by far, the most durable. So, when it comes to the pancreas, I think much harder and much more carefully about it.

Transcript Edited for Clarity
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