ASO Author Reflections: Refining the Surgical Management of Pancreatic Neuroendocrine Tumors
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: Refining the Surgical Management of Pancreatic Neuroendocrine Tumors Jordan M. Cloyd, MD1,2
, and George A. Poultsides, MD, MS3
1
Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH; 2James Comprehensive Cancer Center, Columbus, OH; 3Department of Surgery, Stanford University, Stanford, CA
PAST
PRESENT
Well-differentiated pancreatic neuroendocrine tumors (PNETs) are a heterogeneous neoplasm whose clinical presentation can range from small incidental tumors to advanced metastatic disease. PNETs also vary depending on their biological aggressiveness, typically measured by the Ki67 proliferative index, and whether they produce symptoms characteristic of classic clinical syndromes. Due to more widespread use of cross-sectional imaging and advanced endoscopic procedures, the incidence of PNETs, particularly early-stage disease, is increasing. Traditionally, formal pancreatectomy and regional lymphadenectomy has been the standard approach for patients with localized disease; however, increasing evidence suggests that active surveillance is a safe strategy for small asymptomatic tumors and that pancreas/spleen-preserving approaches are reasonable for those at low-risk for lymph node metastases. On the other hand, recent developments in systemic therapies have enabled the selection of patients for whom aggressive surgical approaches may benefit. In the accompanying Landmark Series review, we highlight the critical studies that define the contemporary surgical management of PNETs.1
Accumulating data suggest that small, asymptomatic, low-grade PNETs without high-risk radiographic features may be safely observed.2 Most retrospective studies report a low conversion to surgery rate during surveillance, with minimal risks of distant disease progression. Based on these limited data, many consensus guidelines now recommend observation for nonfunctional PNETs \ 1 cm in size and that active surveillance can be considered for select patients with tumors 1–2 cm in size. Similarly, the role of lymphadenectomy continues to be debated.3 Although lymph node status is one of the strongest prognostic factors for overall survival, the rate of lymph node metastasis correlates with tumor size. Therefore, enucleation, central pancreatectomy, and spleen-preserving distal pancreatectomy, techniques that typically harvest fewer lymph nodes than formal pancreatectomy, may be indicated for patients with small tumors and other low-risk criteria. Selective sampling of lymph nodes should still be considered when employing these techniques. Finally, minimally invasive approaches, including laparoscopic and robotic surgery, are associated with excellent short- and long-term outcomes and should be considered for patients with PNETs, especially for routine distal pancreatectomy and pancreatic enucleation.4
ASO Author Reflections is a brief invited commentary on the article ‘‘The Landmark Series: Pancreatic Neuroendocrine Tumors’’, Ann Sur
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