SURGERY

Surgery is a powerful diagnostic and therapeutic modality in NETs; however, its application is different in NETs than in adenocarcinoma. For NETs, relatively early surgical intervention is encouraged to prevent future complications. Primary tumors (especially of the small intestine) are associated with morbidity, such as obstruction and bleeding. Surgical debulking is particularly helpful as it can help prevent mechanical issues and decrease the hormone-producing tumor load that may be associated with carcinoid or other hormonal syndromes. Mesenteric metastases from the small intestines can cause a desmoplastic reaction and chronic or acute small bowel obstruction if not resected early. Pancreatic lesions can cause venous thrombosis, left-sided varices, and biliary duct obstruction. Lung lesions may obstruct the airway and cause bleeding, pneumonia, and persistent symptoms. Absolute eradication of disease is not necessary to obtain benefits of NET surgery. Because NETs tends to be a systemic disease, surgery should be considered a method of wide local-regional control that provides safe and significant long-term benefit to the patient by improving symptoms and delaying the requirement for more toxic systemic treatments.

Special precautions must be taken during surgical procedures for NET patients. Massive hormone release can cause hemodynamic instability and major morbidity (also known as carcinoid crisis). In addition to standard anesthetic care, intravenous octreotide should be considered to help suppress hormone production. For very low blood pressure, intravenous Solucortef can be considered to inhibit tumor release of bradykinin, a potent vasodilator. Intraoperative carcinoid crisis is currently under investigation because no well-established protocol exists.