Multimodal and Mini-Invasive Treatment of a Multifocal Metastatic Mid-Gut Neuroendocrine Tumor: A Surgical Case Report

Guido Poggi,Benedetta Montagna,Annamaria Ruggieri,Fabrizio Gambarini,Carlo D’Angelo,Mario Martinotti

doi:10.31487/j.scr.2020.08.21

Abstract

Neuroendocrine tumors represent the most common small bowel malignancy. At the time of presentation, they often debut as metastatic disease. Consensus guidelines recommend a multimodal and multidisciplinary approach that includes punctual investigations, aggressive surgical resection of the primary tumor and the assessment of possible synchronous metastasis through surgical procedures or ablative techniques. This report details the case of a 77-year-old male with a multifocal mid-gut neuroendocrine tumor with nodal dissemination and synchronous hepatic metastasis. He underwent a laparoscopic procedure that included an ileal resection with intracorporeal side-to-side ileo-ileal anastomosis, a large mesenteric nodal dissection extended up to superior mesenteric vein, a laparoscopic dissection of hepatic metastasis and an ultra-soundguided thermal ablation of two hepatic metastasis. This case highlights the efficacy of laparoscopy, providing a mini-invasive radical treatment and the importance of an aggressive multimodal approach in facing a metastatic multifocal mid-gut neuroendocrine tumor.

Highlights

Neuroendocrine tumors (NETs) are a rare heterogeneous type of tumor that arises from specialized cells of the neuroendocrine system, dispersed throughout the body
The authors illustrate a clinical example of midgut multifocal neuroendocrine tumor with loco-regional nodal metastasis and hepatic metastasis, radically treated with a multimodal approach
As a result of a biopsy of the bigger hepatic lesion, further investigations (CT, positron emission tomography (PET) and intestinal magnetic resonance imaging (MRI)) were undertaken. These examinations demonstrated the origin from a multifocal neuroendocrine tumor located along the middle ileum, with loco-regional nodal dissemination

Summary

Introduction

Neuroendocrine tumors (NETs) are a rare heterogeneous type of tumor that arises from specialized cells of the neuroendocrine system, dispersed throughout the body. Some authors doubted the use of laparoscopy for midgut NETs because of the need for the manual palpation for correct identification of the smaller primary lesions, the extensive nodal dissection, and the assessment of possible synchronous lesions It is widely known how in selected patient laparoscopic surgery allows to get oncological efficacy with a mini-invasive approach for these tumors too [12,13,14]. During re-staging, CEUS and MRI confirmed a multifocal ileal neuroendocrine tumor with lymph-nodal dissemination in the mesentery (Figure 1) and a metastasis in the VI-VII segment of the liver (Figure 2). These examinations showed two new lesions in the V segment of the liver (Figure 3), suspected to be metastasis. A laparoscopic side-to-side ileo-ileal intracorporeal anastomosis was performed using a 60 mm blue load Echelon Stapler (Figure 12) and 3-0 V-Loc suture for the mesenteric structures (Figure 13)

B Figure 10

Findings

Discussion