1. Surgery for NE Tumors The University of Texas M. D
Surgery for NE Tumors The University of Texas M. D. Anderson Cancer Center Houston, Texas Jason B. Fleming Carcinoid / Islet Cell

2. GI Neuroendocrine Tumors
Midgut Carcinoid Tumors
Pancreatic Neuroendocrine Tumors
Important Variables (assuming patient is suitable candidate)
Biology of Tumor
Detailed Knowledge of Pertinent Anatomy
Goals of the Operation

3. Midgut Carcinoid
A 63-year-old man has an ulcerated mass at the ileocecal valve identified during routine colonoscopy. Biopsy identifies a well-differentiated neuroendocrine tumor. He is taken to the operating room for planned laparoscopic right hemicolectomy.

5. Biology of Tumor
Detailed Knowledge of Pertinent Anatomy
Goals of the Operation

6. Variability in Neuroendocrine Tumors
Low Grade NET
Islet Cell Carcinoma (pancreas)
Carcinoid
Forgut (Lung (typical, atypical), Thymic)
Midgut (SB)
Hindgut (CR)

7. Genetic Differences of Carcinoid
ILEAL
NON-ILEAL GI
Kim do, et al. Genes Chromosomes Cancer. 2008

8. Survival of NET by Site and Stage
Localized
Regional
Survival probability
Months
Distant
Median survival, months
Survival probability
Yao, et al. JCO, 2008.

9. Survival by NET Histology
Carcinoid/islet cell: well-differentiated
Carcinoid/islet cell: unspecified grade
Carcinoid/islet cell: moderately differentiated
Neuroendocrine: poorly differentiated
Neuroendocrine: undifferentiated
Neuroendocrine: unspecified grade
Yao, et al. JCO, 2008.

10. Midgut Carcinoid Biology of Tumor
Prognosis is favorable
Regional lymph node metastasis likely
Detailed Knowledge of Pertinent Anatomy
Goals of the Operation

11. Anticipated Lymphatic Drainage
3rd
2nd
1st
Wang, et al Surgery Dec;146(6):993-7

12. Mesentery Arterial Anatomy
SMV, ileal br
Pancreas D
Ohrvall UWorld J Surg 2000; 24: 1402–1408.

13. Midgut Carcinoid Biology of Tumor Prognosis is favorable
Regional lymph node metastasis likely
Detailed Knowledge of Pertinent Anatomy
Predictable Lymphatic Chain at Risk
Dual Venous Drainage of Mesentery
Redundant Arterial Supply
Goals of the Operation

14. Palliative Benefits of R0 Resection
82% of the patients (n=125) demonstrated complete or partial symptom
alleviation
Makridis, World J Surg. 1996

15. Affect of Surgery on Survival
Retrospective review of 314 patients
Hellman P, World J Surg. 2002

16. Midgut Carcinoid Biology of Tumor Prognosis is favorable
Regional lymph node metastasis likely
Detailed Knowledge of Pertinent Anatomy
Predictable Lymphatic Chain at Risk
Dual Venous Drainage of Mesentery
Redundant Arterial Supply
Goals of the Operation
Palliative at least
Potentially Curative at best
R0 resection with bowel preservation