Neuroendocrine Tumor Surgery

What is needed before surgery

• a histopathology report with the Ki-67 index and grade — without it the approach cannot be defined;
• somatostatin receptor PET-CT (for example, with 68Ga-DOTATATE) — to find the primary tumor and metastases of well-differentiated tumors;
• contrast-enhanced CT of the abdomen and pelvis and liver MRI — mesentery, lymph nodes, metastases;
• 24-hour urine 5-HIAA — for small bowel tumors and symptoms of carcinoid syndrome;
• echocardiography — with carcinoid syndrome or high 5-HIAA levels;
• for rectal tumors — endoscopic ultrasound or pelvic MRI.

The disease itself, grades G1–G3 and symptoms are described on the page “Intestinal Neuroendocrine Tumors”.

When surgery is needed

Risk factors for appendiceal tumors of 1–2 cm are invasion into the mesoappendix of more than 3 mm, lymphovascular invasion, grade 2, location at the base of the appendix and a positive margin. If the tumor was found after an appendectomy, these details in the histopathology report determine whether another operation is needed.

If surgery is not possible right now

For slow-growing well-differentiated tumors with somatostatin receptors, somatostatin analogs are often used — injections every few weeks that slow tumor growth and relieve the symptoms of carcinoid syndrome. If the tumor progresses, radionuclide therapy and targeted drugs are used, and for neuroendocrine carcinomas — chemotherapy.

Because these tumors often grow slowly, in selected patients the tumor board may reassess the possibility of surgery after a response to treatment.

How the operation is performed

For a small bowel tumor, the segment of bowel is removed together with the mesentery and lymph nodes, preserving the vessels that supply the rest of the bowel. For appendiceal tumors, when indicated, and tumors of the right colon, a right hemicolectomy is performed; for large or invasive rectal tumors — resection with the mesorectum, as for cancer.

Patients with carcinoid syndrome are given a somatostatin analog before surgery to reduce the risk of carcinoid crisis — sharp blood pressure swings, bronchospasm and arrhythmias during the procedure. When the tumor location and extent of resection allow it, the operation is performed laparoscopically — through a few small incisions.

Hospital stay, recovery and follow-up

Recovery follows the enhanced recovery (ERAS) protocol: early mobilization, early eating, controlled pain relief. After resection of a segment of small bowel or a right hemicolectomy, digestion usually recovers, although changes in bowel habits are possible; after removal of the last part of the ileum, vitamin B12 levels are monitored.

Adjuvant chemotherapy after radical removal of a G1–G2 tumor is usually not needed. In patients receiving somatostatin analogs long term, the gallbladder is monitored because these drugs promote gallstone formation.

Follow-up is usually long-term, because recurrences can appear late. The exception is completely removed G1 tumors of the appendix or rectum under 1 cm without adverse features. CT or MRI is used, and when indicated somatostatin receptor PET-CT and 5-HIAA; the intervals are set by the doctor.

Risks and complications

Risks are what patients ask about least often, although they are the most important thing to discuss before surgery. The main ones are:

• carcinoid crisis — in patients with carcinoid syndrome; this is why a somatostatin analog is given before surgery;
• anastomotic leak — when the join in the bowel does not heal;
• bleeding during or after surgery;
• infection and general surgical complications, including thrombosis.

The likelihood of each depends on the organ, the extent of surgery and general condition. I will explain the risks in your particular case at the consultation.

What the cost depends on

The cost depends on the organ and extent of surgery, the approach, whether liver metastases are removed, the number of days in the hospital and the tests. The exact amount is named once the treatment plan has been defined. The payment can be split into parts — installments are available. The in-person consultation is free. More details are on the page “Cost of Surgery: What It Depends On”.

What documents are needed and how to book

• the histopathology and immunohistochemistry report with the Ki-67 index and grade, tissue blocks and slides;
• CT, MRI and PET-CT discs with the reports;
• the operative or endoscopic removal report, if the tumor has already been removed;
• 5-HIAA and chromogranin A results and echocardiography results, if performed;
• a list of the medications you take, including somatostatin analogs.

Book a consultation by phone or through the form. If you are from another city, send the documents in advance — how to do this is described on the page “Online Oncologist Consultation”.