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Role of Preoperative Staging in Patients With Small Intestinal Neuroendocrine Tumors
Andrea Frilling*1, Ashley K. Clift1, Omar Faiz2, Adil AL-Nahhas1, Harpreet Wasan1
1Department of Surgery and Cancer, Imperial College London, London, United Kingdom; 2Department of Surgery, St Mark's Hospital, London, United Kingdom
Background: Neuroendocrine neoplasms (NEN) are a heterogeneous collective of tumors most commonly originating in the gastroenteropancreatic (GEP) system (70-80% of cases), with 30% of all NEN derived from the small bowel. Tumor grade and the presence of hepatic metastasis represent the most important clinical prognosticators and trigger decisions for treatment.
Aims: To assess the stage of disease in patients initially presenting with small bowel NEN.
Patients and Methods: Review of clinical imaging and histopathological data from patients presenting to two institutions - Imperial College Healthcare NHS Trust, London, UK and University Hospital, Essen, Germany. Patients presented between April 1998 and October 2014.
Results: Seventy-nine patients were included (37 females, 42 males). All patients underwent standard radiological investigation including computed tomography (CT), and also 68-Gallium (68Ga) DOTATATE/DOTATOC positron emission tomography (PET)/CT. The later modality has the highest accuracy in detection of metastatic disease. All patients underwent surgery. Histology confirmed Grade 1 or 2 tumors (Ki67 index of ≤2% and 3-20%, respectively) in all cases. Of these 79 patients, only 9 (11.4%) had no dissemination of the primary tumor, with 70 (88.6%) demonstrating mesenterial lymph node involvement at initial presentation, and 52 (65.8%) demonstrating distant metastasis. Forty-seven patients (59.5%) harboured liver metastases, including 2 patients with metastatic disease to both the liver and bone. Solely pulmonary, peritoneal and bone metastases were observed in 1 (1.27%), 2 (2.53%) and 2 (2.53%) patients, respectively. The majority of patients underwent multimodal treatment including surgery, peptide receptor radionuclide therapy, selective internal radiotherapy and therapy with somatostatin analogues.
Conclusions: Despite all patients presenting with G1/G2 NEN, a striking proportion of our cohort had lymph node and distant metastasis at initial diagnosis. Somatostatin-receptor targeted nuclear medicine imaging with 68Ga-DOTA peptides represents the most sensitive radiological modality for the detection and accurate staging of neuroendocrine tumor disease, which influences treatment trajectories. Due to advanced tumor stages at initial diagnosis, a large proportion of patients with small bowel NEN require multimodal treatment.
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