Houston 2011 - Robotic liver resection for neuroendocrine metastatic tumors
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Robotic liver resection is an effective surgical intervention for neuroendocrine liver metastases (NLMs), which are common in patients with neuroendocrine tumors and significantly impact prognosis. Surgical options, including transplant and various liver-directed therapies, have shown superior outcomes compared to non-operative treatments, with minimally invasive techniques offering additional benefits. Recent experiences suggest that robotic surgery enhances the feasibility and safety of liver resections, supporting its expanding role in treating NLMs.
Houston 2011 - Robotic liver resection for neuroendocrine metastatic tumors
- 1. PC GIULIANOTTI, MD, FACS
- 4. PC GIULIANOTTI, MD, FACS ROBOTIC LIVER RESECTION FOR NEUROENDOCRINE HEPATIC METASTASIS
- 5. Neuroendocrine liver metastases (NLMs) 46%–93% of patients with Neuroendocrine Tumors shows NLMs at the time of diagnosis Liver involvement is related to significantly worse prognosis Surgical interventions forNLMs have consistently been shown to have superior outcomes to nonoperative therapies HARRING T ET AL INT J HEPATOL. EPUB OCT 13 2011 MAYO SC ET AL. ANN SURG ONCOL. EPUB JUN 17 2011 FRILLING A ET AL. HPB, 12(6); 2010
- 6. NLMs PROGNOSTIC FACTORS: Tumor grade Tumor size Number Location In 2008, the ENETS (European Neuroendocrine Tumor Society) proposed guideline for surgical resection based on the 3 distinct patterns of liver involvement: 1.SIMPLE pattern of metastasis located in one or two contiguous lobes (20–25%) 2.COMPLEX pattern where there is one major focus and other lesions are contained in the contralateral lobe (10–15%) 3.DIFFUSE disease in both lobes (60–70%) SAXENA A ET AL. J SURG ONCOL. EPUB OCT 17 2011 YANG Z ET AL. AM J SURG PATH 35(6); 2011 FRILLING A ET AL. BR J SURG 96(2); 2009 STEINMULLER T ET AL. NEUROENDOCRINOLOGY 87(1); 2007
- 7. NLMs Resection alone is supported by favorable long-term outcomes in large retrospective trials Complete surgical R0 treatment is an option for only 10 % of these patients Surgery remains the only potential for cure in patients with NLMs Even in the setting of incurable disease, surgery offers the best chance for prolonged survival OPTIONS: 1. Surgery 2. Other Liver directed therapies 3. Non-Liver-Directed Therapies HARRING T ET AL INT J HEPATOL. EPUB OCT 13 2011 MAYO SC ET AL. ANN SURG ONCOL. EPUB JUN 17 2011
- 8. 1. Surgery FIVE-YEAR SURVIVAL: greater than 60%, 80% in some selected series Minimal mortality (<5%) and morbidity (<30%) reported Cytoreductive surgery can be usually recommended only in cases where >90% of the tumor volume can be excised Recent review of 74 cases demonstrated a greater than 60% 5-year survival in all patients underwent resection FRILLING A ET AL. BR J SURG 96(2); 2009 GLAZER ES ET AL. HPB 12(6); 2010 FRILLING A ET AL. HPB, 12(6); 2010 SAXENA A ET AL. J SURG ONCOL. EPUB OCT 17 2011
- 9. 1. OLTx Liver transplantation for neuroendocrine tumors is one of the only accepted indications for metastatic disease 185 liver transplants performed for metastatic neuroendocrine tumors in the United States at March 2011 The overall 5-year survival: 57.8% - worse than the 74% 5-year survival for all other patients - good for this group of patients OLTx criteria: (1) not a resection candidate (2) identification and complete resection of primary malignancy at least one year prior to evaluation (3) no evidence of extrahepatic disease demonstrated on cross-sectional imaging or nuclear medicine scan (4) evidence of stability of disease for at least one year (5) failure of nonoperative treatments TREUT YP ET AL. AM J TRANSPL 8(6); 2008 MATHE Z ET AL. TRANSPLANTATION 91(5); 2011 HARRING T ET AL INT J HEPATOL. EPUB OCT 13 2011
- 10. 2. Other Liver directed therapies NETs are predisposed to form highly vascular metastatic lesions in the liver and derive more than 90% of their oxygenation and nutrition from the hepatic artery 1. Radiofrequency Ablation 2. Hepatic Artery Embolization 3. Hepatic Artery Radioembolization 4. Selective Radiation Therapy HARRING T ET AL INT J HEPATOL. EPUB OCT 13 2011
- 11. 3. Non-Liver-Directed Therapies Lack of consensus on a nonsurgical treatment algorithm No comparative studies OPTIONS: 1. Chemotherapy 2. Peptide Receptor Radionuclide Therapy 3. Somatostatin Analogs 4. Interferon-α 5. Targeting mTOR Pathway 6. Targeting Vascular Endothelial Growth Factors
- 12. NLMs Algorithm Modified from: HARRING T ET AL INT J HEPATOL. EPUB OCT 13 2011
- 13. Minimally invasive approach STATEMENTS Recent studies have shown similar perioperative and long-term outcomes of anatomic and non-anatomic liver resection Multiple simultaneous parenchyma-sparing resections should be preferred over single major resection in case of multiple lesions LAPAROSCOPIC TECHNIQUE Facilitate concomitant multiple resections as well as repeated resections due to minimal adhesion formation BUT The parenchyma-sparing liver resection is challenging in laparoscopy, principally for posterosuperior segments KING J ET AL. CANCER 113(5); 2008 STROSBERG JR ET AL. CANCER CONTROL 18(2); 2011 KHASRAW MJ ET AL. CLIN GASTROENT 43(9); 2009
- 14. Minimally invasive approach From: EDWIN B. SC J SURG; 2011
- 15. Robotic Liver Resection No metanalysis, no randomized controlled comparisons 2010
- 17. Our Experience 113 Robotic Liver resections 55 males and 58 females Mean age 55.3 yrs (range 20 – 84) Major Hepatectomies: 48 Right hepatectomy 32 pts Left hepatectomy 5 pts Extended right hepatectomy 4 pts Extended left hepatectomy 3 pts Trisegmentectomy or multiple (>3 segments) resections 4 pts Minor Resections: 65 Segmentectomy 21 pts Bisegmentectomy 19 pts Left lateral sectionectomy 11 pts Wedge resections 14 pts
- 18. Case report 70- year old lady bowel obstruction from an intussusception at the ileum in March 2008 associated with liver mass (CT scan) Emergency laparotomy, ileocolic resection and liver biopsy Pathology report: metastatic carcinoid tumor of the distal ileum PLAN: - Robotic segmentectomy of segments 5 versus right hepatectomy - CT Liver volumetry
- 19. Case report VOLUME: 865 cc total liver 595 cc right liver 1.9 x 1.7 cm low attenuating lesion within the inferior right hepatic lobe
- 20. Case report Wedge resection V segment Total Operative Time: 180 minutes Estimated Blood Loss: 350 cc Hospital stay: 4 days Follow up: Alternating CT scan and PET scan Alive without evidence of recurrence at 40 months
- 23. Conclusions Minimally invasive liver resections for neuroendocrine mets have a role in the treatment of this disease. Minimally invasive surgery presents a lot of advantages for this application and also have some limitations. Robotic surgery seems to overcome the limitations of laparoscopy and expands the role of minimally invasive approachs