Is Surgery Indicated for Patients with Symptomatic Nonfunctioning Pancreatic Neuroendocrine Tumor and Unresectable Hepatic Metastases?

Patients with advanced pancreatic neuroendocrine tumor, even in the presence of unresectable hepatic metastases, have survival usually measured in years than in months. Theoretically, we would have reason to resect symptomatic primary pancreatic neuroendocrine tumors from these patients palliatively. However, the effect and feasibility of removing symptomatic primary pancreatic neuroendocrine tumor in patients with unresectable hepatic metastases has never been addressed.

In 2000, we instituted a prospective study to resect symptomatic primary tumors and treat unresectable hepatic metastases by lanreotide and hepatic artery embolization in patients with definite tissue proof of pancreatic neuroendocrine tumor.

Thirteen patients were included in this study; seven patients underwent pancreaticoduodenectomy, and six underwent distal pancreatectomy and splenectomy. There were no operative deaths. Eight of thirteen patients had no radiologic evidence of disease progression. The other five patients had disease progression by their 6-month follow-up; they underwent hepatic artery chemoembolization or chemotherapy. One patient died of multiple lung and bone metastases 80 months after operation, and one patient died of continuous progression of liver metastases 18 months after operation. Telephone interviews of 11 patients who survived revealed that 10 reported improved quality of life after resection of symptomatic primary pancreatic neuroendocrine tumor and one patient reported no change.

We suggest that symptomatic primary pancreatic neuroendocrine tumors should be resected even when unresectable hepatic metastases are found at diagnosis because of the relatively low risk of pancreatic surgery, effective elimination of symptoms caused by primary tumors, and slow progression of hepatic metastases under lanreotide and hepatic artery embolization.