They couldn't get it all ... so what?

 Even Partial Tumor Removal Can Improve Your Life

Dr. Liu reaches conclusion: surgical intervention, even if incomplete, improves QOL and OS

Dr. Eric Liu, M.D.

"We removed the SBO (small bowel obstruction) but then we discovered a metastatic condition so we didn't do anything more," said one surgeon to another at a conference. I was in the elevator and could not keep from hearing the exchange. "Why," the other surgeon asked, "did you not attempt to remove any of the other tumors?"

 "That's not what we do," the first surgeon answered. "If there's any spread, we just close them up."

Unfortunately, this is the protocol for many hospitals, practices, individual surgeons and surgical 'teams. They don't know or don't believe that reducing a neuroendocrine cancer patient's tumor burden - even if they can't "get it all" - is the correct path. 

At the recent NETs symposium in October, Dr. Eric Liu, head of the Vanderbilt University's NETs clinic, outlined the reasons why partial removal (also called de-bulking) is appropriate in most NETs cases.

Dr. Liu presented data compiled by the well-known Kenner team, composed of Drs. Woltering, Boudreaux and Wang, near New Orleans. The group aggressively treats metastatic carcinoid cancer by removing tumors whenever possible.

Liu's points were: 

• Debulking surgery, even if not complete, improves Quallity of Life (QOL.)
• Disease recurs regardless of therapy: 84% of patients show recurrence after five years; 94% show recurrence by 10 years.
• Despite recurrence and incomplete resection, Overall Survival (OS) improved with surgery.

*About 20% of NETs patients overall survive five years; 15%  go on for 10 years without intervention.

Look what happens with intervention

After liver resection 61% showed OS of five years; 35% OS for 10 years.

After partial resection 74% had OS of five years.

Parts of this message may be sobering. It would be great if the disease could be cut out and never show up again but that's not realistic. Not yet. Even without surgery, twenty-percent of us will still be alive in five years. And 15% will last another five - to hit the 10-year mark. 

But here's the good news: having the liver resected ups your chances of living five years - you're four times more likely to celebrate five years and more than twice as likely to hit the 10th year alive after liver resection. 

First-line treatment

A lot of discussion in medical circles turns around which interventions should be tried first. Do you give drugs first to stop the progression, then operate? Or do you use a liver-directed therapy like embolization to get the mass smaller, then attempt surgery?

While every case of NETs is different, Liu says for most patients"

Surgery first - take out all you can.

Embolization next, if needed

Palliative care - such as octreotide therapy or some other drug.

Conflicting opinions happen

These remarks are still regarded as preliminary and they are bound to draw detractors. For example, there is a group of NETs specialists who believe embolization could be a first-line treatment. There's something to be said for that because it gets symptoms under control so surgery to reduce the tumor burden will not be so precarious.

There is no one-size-fits-all solution

NETs is one of the most variable and individual diseases we know. People with mid-gut primary usually have liver involvement sooner or later and the well-recognized "carcinoid syndrome" meaning flushing and diarrhea.

Patients with rectal primary often have no further symptoms and no metastasis for many years - perhaps never. They almost never have flushing.

Those with lung primary may have tumors in the mediastinum or spine before they have liver mets. Or these growths may all pop up at one time. Drugs that work to stabilize tumors in one patient do nothing for another with the same set of symptoms and the same type of primary tumor. In fact, one tumor may be different in cell structure and secretions from another tumor in the same location - in the same patient.

That insight was presented by Dr. Thomas O'orisio (U of Iowa) and Dr. Eugene Woltering (LSU) at a NETs patients' conference in Dallas in October. I could hear minds blowing in the quiet conference room.

Things can change

As research continues, some reports from the NETs symposium will be refuted; some will be upheld. These presentations for the most part, are pre-publication. They are reports from the front line. In time, there will be published reports; theories may change, depending on the amount of scientifically proven information the studies contain.

No More Wait and See

At least data refutes some old ideas about NETs. There are still a depressing number of doctors who believe NETs should not be treated at all ... that the best way to manage a NETs case is to wait until the patient is in life-threatening condition before attempting surgery. Others believe it is not worthwhile to remove tumors that will recur, especially when the disease is eventually terminal. Time to refute those concepts. Humane medicine upholds quality of life and sustains it as long as possible.

*From the SEER database- Surveillance, Epidemiology and Eventual Results, which tracks all reported cases of cancer from initial diagnosis to death.

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