Laparoscopic Resection of Hepatic Neuroendocrine Metastases

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Shawn Tsuda
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The natural history of liver metastases of digestive endocrine tumors (LMDET) is unclear, not least because few patients are left untreated. The main factors of poor prognosis are the modifications of LMDET (increase of at least 25% of 2 CTscan at six months apart), tumor differentiation (poor prognosis for LMDET poorly differentiated) and absence of resection of the primary tumor.

Chemoembolization is the best palliative treatment of LMDET and as such should be proposed early in the disease progression. This technique allows response, both morphological and symptomatic in more than 90% of patients. Retrospective studies seem to show that its use prolongs survival.

The RFA is still under evaluation. This technique seems to demonstrate local efficiency superior than the chemo, but its indications are limited to few small tumors. Its target population is close to the surgical one, surgery which remains today the best proven treatment. However, when wide resections are necessary for removal of small metastases in recurrent disease, we can probably consider these two techniques in a multidisciplinary committee.

The place of liver transplantation for metastases of endocrine tumors remains a controversial topic because of the high risk of hepatic and extrahepatic recurrence and long survivals obtained with palliative medical treatment.

The hepatectomies are contraindicated for endocrine tumors poorly differentiated whose prognosis is short term. For well differentiated endocrine tumors (WDET), the 5‐year survival of metastatic patients is generally only 22%. In 2004, only surgery can cure a WDET. When a hepatectomy is possible (selected patients), the 5‐year survival is between 70% and 75%, much higher than that obtained by medical treatment or IA chemo‐embolization. However, 70% of patients recur in the liver during the 10 years that followed, and no plateau appears in their survival curve, meaning we can not cure these patients with very long term.

Hepatectomy is indicated when: 1) the WDET is slowly progressive, 2) it is capable of handling all locations within and outside the liver, 3) when the operative risk is not excessive. Indeed, a) LMDET are usually multiple and bilateral, and all pre‐operative imaging greatly underestimate the true extent of lesions (2/3 are major hepatectomies), b) the extrahepatic lesions (primary tumor, lymph nodes, peritoneal carcinomatosis) exist in 2/3 of cases. It is therefore most often intra and extrahepatic major surgery, which requires the use of complementary techniques of hepatectomy: radiofrequency ablation (RFA), selective preoperative portal embolization, specific treatment of a carcinomatosis associated. This explains operative mortality (4%) and morbidity (40%) higher than usual. For MEN1, the indications and results of hepatectomies are similar to those of sporadic forms. Ici se pose surtout le problème de la prévention de l’apparition des MH en réséquant les tumeurs primitives avant qu’elles ne dépassent 25 mm de diamètre. » Here arises mainly the problem of preventing the onset of LMDET in resecting primary tumors before they exceed 25 mm in diameter (Communication Elias D, JHFOD Paris 2004).

Laparoscopy for these liver metastases has exactly the same advantages and limits than for colorectal ones.