If the tumors are technically resectable, then the question is, “Should we do it?” That involves consideration of the biology of the tumor, the behavior, and what other factors are there that would suggest not as good of outcomes as someone else. If their disease has spread to the liver, or there are a large number of lymph nodes in the primary tumor—things of that nature—then we consider their fitness for an operation. Are they healthy enough to go through an operation of this magnitude? Do they have comorbid disease? Liver disease? Those are important factors to know about ahead of time and can, in many cases, prevent an operation from happening.
Looking at the future of surgery, while taking SIRT into consideration, what lies ahead?
Right now, the use of SIRT is limited to patients who have nonresectable disease and who have failed at least 1 line of chemotherapy. The likelihood of success with almost any regimen is going to be limited, possibly except for liver-directed pump chemotherapy, or something like that.
SIRT has also been looked at as upfront treatment combined with chemotherapy and it hasn’t really shown a benefit there. It is hard to know exactly where it will fit in. Using it earlier in the course of someone's disease, before they have exhausted all of their chemotherapy options, may be the right thing to do. Combining SIRT and resection—I know people do that and have done it in selected situations—is not going to be a common event, where we are going to use SIRT to shrink tumors and then go to the operating room. I don’t think SIRT, right now, has the capability of bringing about those kinds of responses that we can get with chemotherapy.