Surgery after neoadjuvant chemotherapy in metastatic poorly differentiated neuroendocrine carcinoma
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Slide 1 :
Case-report.Curative surgery after neoadjuvant chemotherapy in metastatic poorly differentiated endocrine carcinoma. Halfdan SørbyeHaukeland University HospitalBergen, Norway
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Most patients with poorly differentiated (PI> 15%) neuroendocrine carcinoma have metastatic disease at the time of diagnosis. Median survival of 6 months without treatment Surgery has then not been recommended, leaving palliative chemotherapy as the only option.
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Case 52y male patient with multiple liver metastasis and enlarged regional lymph nodes from a poorly differentiated endocrine carcinoma Abdominal and thorax CT scans showed up to 20 cm large liver metastasis and regional lymph nodes up to 10 cm in size, but no signs of a primary tumour. Endoscopic ultrasound showed a 14-mm lesion in the pancreatic head.
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Plasma chromogranin A (CgA) level was elevated, 590 ng/ml (UNL<30). Somatostatin receptor scintigraphy was negative. Liver biopsy with immunohistochemistry (IH) showed CgA, synaptophysin and p53 staining, Ki-67 estimate was 50%.
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Immunohistochemistry of liver biopsy CgA Ki-67 p53 p53 does often occur in poorly differentiated endocrine tumours, but not in low-grade
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Treatment Neoadjuvant chemotherapy was given with etoposide 130 mg/m2 day 1-3 and cisplatin 45 mg/m2 day 2-3 every 4th week. A partial response was found at CT scan evaluation after 2 and 4 months of treatment.
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After 4 months of chemotherapy the patient was operated with: resection of segment 4B, segment 5 and nonanatomic resection of segment 8 regional lymph node dissection (gastric, duodenal, ductus choledochus and pancreas) Bilroth I gastric resection local resection of the pancreas
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Histology : metastasis from a poorly differentiated endocrine carcinoma to the liver and regional lymph nodes with large areas of necrosis. No tumor in pancreas. The patient received 4 months postoperative chemotherapy with the same regimen. No signs of recurrence during 5 years of follow-up with normal CgA levels and CT scans.
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Should surgery have been performed first, and then rather give postoperative adjuvant chemotherapy? We favour a neoadjuvant approach as this allows: eradication of micrometastases at an earlier stage optimal blood supply to deliver chemotherapy treatment of a fit patient patients with PD avoid unnecessary surgery a neoadjuvant approach has recently shown to be efficient in resectable gastric cancer (MAGIC study)
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Conclusions The possibility for secondary surgery after a good response on chemotherapy should always be kept in mind (Oncosurgery). In metastatic poorly differentiated endocrine patients surgery after neoadjuvant chemotherapy can be of long term benefit in selected cases.
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PowerPoint Presentation on Surgery after neoadjuvant chemotherapy in metastatic poorly differentiated neuroendocrine carcinoma or PowerPoint Presentation on Case rapport on Curative surgery after neoadjuvant chemotherapy in metastatic poorly differentiated neuroendocrine carcinoma. Published as lesson of the month in: Eur J Surg Oncol 33: 1209-10, 2007.
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