Gastrointestinal Carcinoid Tumours Surgical management

1
Gastrointestinal Carcinoid TumoursSurgical
management

• Bruce D George
• John Radcliffe Hospital

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GI Carcinoids

• Appendix
• Ileum/jejunum
• Rectum

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Appendiceal tumours

• Carcinoid
• Usually lt1cm
• Near tip
• incidental
• Adenocarcinoid (Goblet cell carcinoid)
• Colonic type neoplasms
• Miscellaneous
• Lymphoma, soft tissue etc

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Appendiceal carcinoids

• 30-60 of appendiceal tumours
• Size matters
• lt2cm 0 of 127 metastases
• 2-3cm 3 of 14
• gt4cm 4 of 9
• Moertel 1968

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Predictors of metastatic potential

• Size
• Over 2cm (1.5cm fixed)
• Mesoappendiceal extension
• Incomplete excision
• More likely at base

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Current protocols

• lt1cm, R0, no mesorectal involvement
• No further assessment
• gt2cm, R1 or mesoappendiceal involvement
• Staging followed by radical right hemicolectomy
• 1cm-2cm
• ?

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Associated malignancy

• Moertel 1968
• 19 of 144 patients
• Conner et al 1998
• 33 synchronous/metachronous, mainly colorectal
  cancer
• Modlin et al 2003
• 18 co-existing neoplasm

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Rectal carcinoids

• Usually small, incidental findings
• lt1cm local excision
• 1-2cm ? Local excision ?Anterior
  resection
• gt2cm anterior resection

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Jejunal/ileal carcinoids

• Most commonly mid/distal ileum
• 30 multiple
• Small primary, large nodes
• Florid desmoplastic reaction
• Kinking/obstruction
• Ischaemic necrosis
• Occlusive sclerosis of mesenteric vessels

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Jejunal/ileal carcinoids

• Size still matters
• lt2cm 20 liver metastases
• gt2cm 53 liver metastases
• Strodel et al 1983

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5 year survival

• Localised primary 92
• Nodal involvement 86
• Distant metastases 40
• US SEER data (Cancer 1995 75 154)

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Modes of presentation

• Small incidental tumour
• Localising symptoms
• Metastatic disease
• Carcinoid syndrome

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Surgical management of small bowel disease

• Localised disease
• Limited resection with adjacent nodes
• Obstructive symptoms
• Resection with nodes if possible
• Diagnosis often made post-operatively
• Metastatic disease/carcinoid syndrome
• Changing opinions

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Hellman, Oberg et alWorld J Surgery 2002 26
991-7

• 314 patients with midgut carcinoids mesenteric
  node / liver metastases (249 with liver
  metastases)
• 46 of operated patients presented with
  pain/obstruction and operated on before diagnosis
• Survival improved in patients who had resection
  of primary
• Resection of primary tumour and mesenteric nodes
  associated with reduced tumour related symptoms

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Summary

• Appendiceal carcinoids
• uncontroversial
• Rectal carcinoids
• uncontroversial
• Small bowel carcinoids
• Trend towards more aggressive surgical management
  of primary tumour/nodes