Determining Surgical Candidacy in NETs

Transcript:Matthew H. Kulke, MD: We’re talking a lot about hormones and drugs. I want to turn to Eric, because one other aspect of neuroendocrine tumors that is really important is whether patients are candidates for surgery. And last time I checked, surgery was the only way to cure these patients. One question for you is, how do surgeons work as part of the team, and how important is it for patients to see a surgeon, an endocrinologist, a medical oncologist? It’s something that can be really confusing sometimes.

Eric H. Liu, MD, FACS: That’s exactly right, Matt. Actually, surgery is one tool of many when it comes to taking care of these patients. And it highlights the importance of having a multidisciplinary team, as you just mentioned. These patients can suffer from lots of different symptoms, from lots of different causes. We always say cut is the cure, but, unfortunately, neuroendocrine tumors have a very high metastatic and recurrence rate. So, we do what we can. But having the surgeon on board with the radiologist, with the medical oncologist, with the endocrinologist, and the whole team, is absolutely vitally important.

And the other thing to keep in mind is that you always want to have the surgeon involved because there may be some point when another lesion comes up, like Dr. Yao described previously, that can still be treated. And we have more and more tools for surgery, and we’re doing it much more safely now. You may have disease in the neck which requires some surgery, or in the liver, or maybe in the bone. And so, having another pair of eyes that can perform a procedure for you, or having an interventionalist with you, is a very important tool to have when it comes to caring for these patients.

Matthew H. Kulke, MD: Another issue that comes up a lot is that surgeons are used to seeing pancreatic adenocarcinoma or metastatic colon cancer. Neuroendocrine tumors are very different; they’re more indolent. How does the surgical thinking differ or shift compared to some of these other malignancies? Are their criteria different?

Eric H. Liu, MD, FACS: Absolutely correct. It really is a difference in philosophy because it’s a difference of biology. We are aggressive about adenocarcinomas to try to remove them. We shy away when there’s metastatic disease, which is actually very different from neuroendocrine. Frequently, we’ll have very small tumors that turn into very bulky disease. But these patients, even in the setting of stage IV disease in the bone, in the liver, and elsewhere, can still live a very long time.

The question is, how do we treat them and make their quality of life good? How do we extend their survival? And we can do that not only with your medications, with your hormones, but with my surgical techniques also. So, if a patient, for example, has a blocked intestine, you can’t live with that. So, you have to have it surgically removed. If you have someone, for example, with lots of liver lesions, and maybe it’s not so simple to treat them with your medications, perhaps I can remove most of them and then you can help treat the smaller ones later on.

We have many symptoms in which patients have hormone secretion, and we do something called debulking surgery, which is very valuable. And the great thing about surgery and anesthesia is it’s become so safe nowadays, that we can use it over and over and over again. One thing we do encourage frequently is that the patients and the physicians think about the hormonal aspects of these tumors. Because during surgery, if a patient, for example, has a high tumor load and secretes a lot of hormone, they can have anesthesia and surgical complications, which we frequently call carcinoid crisis. It’s something to be aware of, and it’s certainly nice to have people with experience and expertise doing those procedures.

Matthew H. Kulke, MD: There are some situations where a general surgeon might be perfectly appropriate for some of these patients, but they are different in many ways. And I think what you’re saying is that, in many cases, patients may benefit from getting referred in to someone who sees a lot of these patients, whether it’s a specialist at an academic center or otherwise.

Eric H. Liu, MD, FACS: Absolutely.

Transcript Edited for Clarity