Prognosis of Resected Neuroendocrine Metastases: A Complex Puzzle Can Only be Solved One Small Piece at a Time
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EDITORIAL – HEPATOBILIARY TUMORS
Prognosis of Resected Neuroendocrine Metastases: A Complex Puzzle Can Only be Solved One Small Piece at a Time Lana Bijelic, MD Hospital Moise`s Broggi Sant Joan Despı´, Consorci Sanitari Integral, Barcelona, Spain
Many aspects of care for patients with gastrointestinal neuroendocrine tumors present challenges and uncertainties for clinicians. This is true for the entire spectrum of possible presentations spanning a wide range—from management of small, incidentally discovered duodenal or pancreatic tumors, to that of liver metastases. In this issue of Annals of Surgical Oncology, Xiang and colleagues attempt to deepen our understanding of prognosis (expressed using disease-free survival [DFS]) after curative liver resection of neuroendocrine liver metastasis by developing a novel nomogram, a first for this subgroup of patients.1 Considering the relative rarity of the disease, those researchers have assembled a robust collaborative group: six institutions provided data for the development set, consisting of 279 patients, and two institutions formed the validation set of 98 patients. The multi-institutional nature of the study and the ability to analyze prognostic factors in a large cohort is clearly one of the strengths of this study. It allowed the authors to perform a multivariable analysis and identify several prognostic variables associated with DFS. Despite surgery being the standard of care for patients with resectable neuroendocrine liver metastases, recommended by both the National Comprehensive Cancer Network (NCCN) guidelines and the European Society for Neuroendocrine Tumors (ENETS), the identification of well-established prognostic variables associated with better outcomes after surgery has been relatively slow.2 Unlike for liver metastases from colon cancer, we lack prognostic
Ó Society of Surgical Oncology 2020 First Received: 11 May 2020 L. Bijelic, MD e-mail: [email protected]
scores specific for patients treated with liver resection to help inform decisions and formulate follow-up plans. In a 2019 study, Lv et al. studied prognostic factors in 108 patients with neuroendocrine liver metastases treated with various modalities, including liver-directed therapy, surgery, and systemic therapy (or combinations) and found that hepatic tumor number, treatment modality, and elevated Ki-67 index between the metastatic and primary lesions were associated with overall survival (OS). The resulting nomogram had a C index of 0.63, significantly lower than the value proposed in the study published in this current issue, which had a C index of 0.754 in the training cohort and 0.748 in the validation cohort.3 Furthermore, unlike the present study, Lv et al. used OS as an endpoint, which has significant drawbacks in a disease with a relatively indolent course, even in the metastatic setting. In fact, a consensus report of the National Cancer Institute Neuroendocrine Tumor Clinical Trials Planning Meeting indicated PFS as the recommended primary endpoint for clinical trials of ad
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