Treatment of Oligometatic PNET Mets to Liver Following Resection Michael Nichols, MD Andrew J. Lipnik, MD Bryan Hartley, MD Daniel B. Brown, MD, FSIR Vanderbilt University Interventional Oncology

History 2013: 53 y/o F with pancreatic head mass detected on workup for refractory hyperglycemia 2.7 x 2.1 cm pancreatic head mass with periportal and retroperitoneal adenopathy, and several suspected liver metastases 2014: Patient underwent laparoscopic pancreaticoduodenectomy, portal lymphadenectomy, and resection of lesions in liver segments 1, 5, and 7. Low grade tumor by path Ki-67: 1%

Additional History CT obtained 4 months post-op demonstrated new 2.1 cm lesion in hepatic segment 5, suspicious for PNET metastasis. The patient had a prolonged recovery from surgery and was referred to Interventional Oncology Clinic

Post-operative Imaging

Biopsy performed Confirmed diagnosis of metastatic PNET Ki-67: 15% Discussed risks (abscess) and options including Observation Ablation Patient elected to wait Still recovering from surgery

3 Months Later No change in size Patient now amenable Moxifloxacin prep started

MWA of Lesion in Segment 5 Two 19-gauge PR antennae 5 minute ablation at 65 watts 3 additional minutes at 60 watts after retracting antennae 1 cm each After 5 min

MWA Final imaging demonstrates a margin of least 1.2 cm on all sides Patient recovered without infectious complications

Questions In this patient, should immediate intervention been performed without symptoms? If not, what would trigger you to treat? What treatment options should be considered in this case? Surgical, medical, interventional, other? Does the relatively short disease-free interval following surgery change your approach to treatment of a new liver metastasis? The primary tumor had a lower grade and Ki-67% than the metastasis. How do you incorporate these values into your approach?