Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Aug 7, 2018; 24(29): 3201-3203
Published online Aug 7, 2018. doi: 10.3748/wjg.v24.i29.3201
Upfront surgery of small intestinal neuroendocrine tumors. Time to reconsider?
Kosmas Daskalakis, Apostolos V Tsolakis
Kosmas Daskalakis, Department of Surgical Sciences, Uppsala University, Uppsala 75185, Sweden
Apostolos V Tsolakis, Department of Oncology and Pathology, Karolinska Institute, Stockholm SE-171 76, Sweden
Apostolos V Tsolakis, Cancer Center Karolinska, Karolinska University Hospital Solna R8:04, Stockholm SE-171 76, Sweden
Apostolos V Tsolakis, Department of Gastrointestinal Endoscopy, Karolinska University Hospital Huddinge, Stockholm SE-141 86, Sweden
Author contributions: Daskalakis K and Tsolakis AV both designed and wrote the editorial.
Conflict-of-interest statement: The authors state that they do not have any conflict of interest to declare.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Apostolos V Tsolakis, MD, PhD, Doctor, Staff Physician, Department of Gastrointestinal Endoscopy, Karolinska University Hospital Huddinge, Stockholm SE-141 86, Sweden. apostolos.tsolakis@ki.se
Telephone: +46-8-58580000
Received: June 1, 2018
Peer-review started: June 1, 2018
First decision: July 4, 2018
Revised: July 9, 2018
Accepted: July 16, 2018
Article in press: July 16, 2018
Published online: August 7, 2018

Small intestinal neuroendocrine tumors (SI-NETs) may demonstrate a widely variable clinical behavior but usually it is indolent. In cases with localized disease, locoregional resective surgery (LRS) is generally indicated with a curative intent. LRS of SI-NETs is also the recommended treatment when symptoms are present, regardless of the disease stage. Concerning asymptomatic patients with distant metastases, prophylactic LRS has been traditionally suggested to avoid possible future complications. Even the current European Neuroendocrine Tumor Society guidelines emphasize a possible effect of LRS in Stage IV SI-NETs with unresectable liver metastases. On the contrary, the 2017 National Comprehensive Cancer Network Guidelines on carcinoid tumors do not support the resection of a small, asymptomatic, relatively stable primary tumor in the presence of unresectable metastatic disease. Furthermore, a recent study revealed no survival advantage for asymptomatic patients with distant-stage disease who underwent upfront LRS. At the aforementioned paper, it was suggested that delayed surgery as needed was comparable with the upfront surgical approach in terms of postoperative morbidity and mortality, the length of the hospital stay and the rate of incisional hernia repairs but was associated with fewer reoperations for bowel obstruction. On the other hand, it is also important to note that some patients might benefit from a prophylactic surgical approach and our attention should focus on identifying this patient population.

Keywords: Small intestinal neuroendocrine tumors, Locoregional resective surgery

Core tip: Upfront locoregional resective surgery of small intestinal neuroendocrine tumors is the mainstay treatment when radical resection is feasible or when symptoms are present, regardless of the disease stage. However, in the light of contemporary evidence, the traditional upfront surgical approach is challenged regarding patients with distant metastases without local tumor-related symptoms.