Minimally invasive techniques in management of hepatic neuroendocrine metastatic disease

The development of new technologies and therapies provides an exciting new chapter in the management of neuroendocrine disease. Fundamentally (albeit through an extensive array of retrospectively based studies), the use of cytoreductive therapies (whether it be through open surgery, laparoscopic approaches, percutaneous, or endovascular) have clearly demonstrated the ability to control symptoms, decrease tumor burden, and in selected series, translate into survival benefit. However, this situation is not without challenge, as overall strategy and consensus has not been reached as to the optimal therapy. In general, local regional therapy for hepatic metastatic disease should begin with the decision of the intent to treat. Transplant (which, at present has a very limited role), surgical resection, and ablative therapies, such as RF, cryoablation, and microwave provide (in these circumstances) the only options for 100% destruction of macroscopic disease (ie, that disease burden that is visualized by current imaging technology), assuming that the primary tumor has been removed or resected. Endovascular methods may have the ability to treat microscopic disease, however, is considered palliative, as the entire disease burden may not be fully addressed. One potential advantage of endovascular therapy (and in particular Y-90 radioembolization) is to provide the possibility to downstage (shrink) disease to resection or ablation, while providing cytoreduction. Although not discussed in this forum, systemic therapeutic options also offer much promise, and readers are encouraged to examine the current literature in this regard. A summary of recent published literature concerning response and applications of systemic chemotherapy (Table 1) and systemic radiotherapy is provided for review (Table 4). With the advancement of local regional disease management through medical, surgical, and radiologic methods, a multidisciplinary approach must be implemented to prospectively develop treatment algorithms and draw from the expertise and experience of each discipline. The current challenges facing the medical and patient community are deciding what the best-suited therapy is for an individual, given the state of the art. No therapy is without inherent risk, and thus the second consideration, the risk to benefit ratio must also be discussed. Simply put, it must be ensured that the benefit derived from the procedure or intervention must outweigh the risk, effect on quality of life, and the potential of effecting other therapeutic options.