Parenchyma-sparing Resection Research Articles

Implementation of Current ENETS Guidelines for Surgery of Small (≤2cm) Pancreatic Neuroendocrine Neoplasms in the German Surgical Community: An Analysis of the Prospective DGAV StuDoQ|Pancreas Registry.

ENETS guidelines recommend parenchyma-sparing procedures without formal lymphadenectomy, ideally with a minimally invasive laparoscopic approach for sporadic small pNENs (≤2cm). Non-functioning (NF) small pNENs can also be observed. The aim of the study was to evaluate how these recommendations are implemented in the German surgical community. Data from the prospective StuDoQ|Pancreas registry of the German Society of General and Visceral Surgery were analyzed regarding patient's demographics, tumor characteristics, surgical procedures, histology and perioperative outcomes. Eighty-four (29.2%) of 287 patients had sporadic pNENs ≤2cm. Forty-three (51.2%) patients were male, and the mean age at diagnosis was 58.8 ± 15.6years. Twenty-five (29.8%) pNENs were located in the pancreatic head. The diagnosis pNEN was preoperatively established in 53 (65%) of 84 patients. Sixty-two (73.8%) patients had formal pancreatic resections, including partial pancreaticoduodenectomy or total pancreatectomy (21.4%). Only 22 (26.2%) patients underwent parenchyma-sparing resections and 23 (27.4%) patients had minimally invasive procedures. A lymphadenectomy was performed in 63 (75.4%) patients, and lymph node metastases were diagnosed in 6 (7.2%) patients. Eighty-two (97.7%) patients had an R0 resection. Sixty (72%) tumors were classified G1, 24 (28%) tumors G2. Twenty-seven (32.2%) of 84 patients had postoperative relevant Clavien-Dindo grade ≥3 complications. Thirty- and 90-day mortalities were 2.4% and 3.6%. ENETS guidelines for surgery of small pNENs are yet not well accepted in the German surgical community, since the rate of formal resections with standard lymphadenectomy is high and the minimally invasive approach is underused. The attitude to operate small NF tumors seems to be rather aggressive.

Long-term oncologic results of anatomic vs. parenchyma-sparing resection for hepatocellular carcinoma. A propensity score-matching analysis

PurposeThe extent of liver resection for the optimal treatment of hepatocellular carcinoma (HCC) is debated. The purpose of this study was to compare the impact of anatomic resection (AR) vs. parenchyma-sparing resection (PSR) on disease recurrence and patient survival. MethodsWe retrospectively analyzed patients with HCC who underwent liver resection from January 2001 to August 2015. Patients receiving AR or PSR were compared by a propensity score analysis (PSA) (caliper = 0.1). The primary outcomes were disease-free survival (DFS) and overall survival (OS) rates, and assessed by the Kaplan-Meier method. Results455 consecutive patients were evaluated. After PSA 354 patient were studied (177 pairs for each group). The median follow-up time was 28.2 months. The median OS was 47.5 months (95% CI: 30.0–65.9) for AR and 56.5 months (95% CI 33.2–79.6) for PSR (p = 0.169). The median DFS was 29.2 months (95% CI 17.6–40.8) for AR and 24.8 months (95% CI: 15.2–34.2) for PSR (p = 0.337). The multivariate regression model showed that cirrhosis (HR 2.85, 95% CI: 1.53–5.32; p = 0.001), BCLC grade B (HR 4.15, 95% CI: 1.33–12.95; p = 0.014), microvascular invasion (HR 1.55, 95% CI: 1.03–2.31; p = 0.033), presence of satellitosis (HR 1.94, 95% CI: 1.25–3.01; p = 0.003), severe complications (HR 6.09, 95% CI: 2.26–16.40; p > 0.001) were independently associated with poor long-term oncologic outcomes. ConclusionsThe extent of resection did not significantly affect overall and disease-free survival while tumor characteristics and underlying liver function appeared significant determinants.

Pattern of hepatocarcinoma recurrence in cirrhosis: The role of anatomic and parenchyma-sparing resection. A propensity score analysis

Background: Disease recurrence mechanisms after surgical resection for hepatocarcinoma are still poorly understood. Further investigations on this matter may offer additional elements for more personalized therapeutic strategies. The aim of the study was to investigate the role of anatomic resection (AR) and parenchyma-sparing resection (PSR) on the patterns of disease recurrence.

Pure Laparoscopic Transhepatic Enucleation of a Mucinous Cystic Neoplasm Abutting the Major Hepatic Veins at the Hepatocaval Confluence (with Video)

BackgroundA mucinous cystic neoplasm (MCN) of the liver is a rare disease entity, occurring predominantly in the left hemiliver as reported by Simo et al.1 Thomas et al.2 and Vogt et al.3 Surgical resection of tumors at the hepatocaval confluence is a technically demanding procedure. Enucleation procedures have been performed for the management of benign or premalignant lesions such as cystic tumors as previously described by Thomas et al.2 and Vogt et al.3. We present a patient who underwent pure laparoscopic transhepatic enucleation to treat a MCN abutting the major hepatic veins at the hepatocaval confluence. MethodsWe treated a 77-year-old man who presented with a 5-cm-sized cystic mass at the hepatocaval confluence. Using the Pringle maneuver, we performed liver parenchymal transection along the junction between the origin of the middle hepatic vein (MHV) and the inferior vena cava (IVC) as reported by Kim4. The MHV formed the left-sided boundary of the cystic mass. After dissection of the left boundary of the cystic wall, the dorsal side of the cystic mass was carefully dissected. Liver parenchymal transection was continued up to the right hepatic vein (RHV). Laparoscopic enucleation was performed to expose the RHV and MHV, as well as the IVC. ResultsThe operation time was 270 min, the estimated blood loss was 80 mL, and no transfusion was necessary in this patient. The final histopathological diagnosis of the mass was MCN. Postoperatively, the patient recovered uneventfully, and he was discharged on postoperative day 5. ConclusionsLaparoscopic transhepatic enucleation for MCNs at the hepatocaval confluence is technically feasible and offers the benefits of a parenchyma-sparing resection. However, this procedure requires a high level of technical skills and shows a steep learning curve.

A case of carcinoid tumour of the right main bronchus treated with parenchymal sparing resection and bronchoplasty

A case of carcinoid tumour of the right main bronchus treated with parenchymal sparing resection and bronchoplasty

Liver Resection and Surgical Strategies for Management of Primary Liver Cancer

Primary liver cancer—including hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC)—incidence is increasing and is an important source of cancer-related mortality worldwide. Management of these cancers, even when localized, is challenging due to the association with underlying liver disease and the complex anatomy of the liver. Although for ICC, surgical resection provides the only potential cure, for HCC, the risks and benefits of the multiple curative intent options must be considered to individualize treatment based upon tumor factors, baseline liver function, and the functional status of the patient. The principles of surgical resection for both HCC and ICC include margin-negative resections with preservation of adequate function of the residual liver. As the safety of surgical resection has improved in recent years, the role of liver resection for HCC has expanded to include selected patients with preserved liver function and small tumors (ablation as an alternative), tumors within Milan criteria (transplant as an alternative), and patients with large (>5 cm) and giant (>10 cm) HCC or with poor prognostic features (for whom surgery is infrequently offered) due to a survival benefit with resection for selected patients. An important surgical consideration specifically for ICC includes the high risk of nodal metastasis, for which portal lymphadenectomy is recommended at the time of hepatectomy for staging. For both diseases, onco-surgical strategies including portal vein embolization and parenchymal-sparing resections have increased the number of patients eligible for curative liver resection by improving patient outcomes. Multidisciplinary evaluation is critical in the management of patients with primary liver cancer to provide and coordinate the best treatments possible for these patients.

Perioperative and Long-Term Outcome for Intrahepatic Cholangiocarcinoma: Impact of Major Versus Minor Hepatectomy

BackgroundThe objective of the current study was to investigate both short- and long-term outcomes of patients undergoing curative-intent resection for intrahepatic cholangiocarcinoma (ICC) stratified by extent of hepatic resection relative to overall final pathological margin status. MethodsOne thousand twenty-three patients with ICC who underwent curative-intent resection were identified from a multi-institutional database. Demographic, clinicopathological, and operative data, as well as overall (OS) and recurrence-free survival (RFS) were compared among patients undergoing major and minor resection before and after propensity score matching. ResultsOverall, 608 (59.4%) patients underwent major hepatectomy, while 415 (40.6%) had a minor resection. Major hepatectomy was more frequently performed among patients who had large, multiple, and bilobar tumors. Roughly half of patients (n = 294, 48.4%) developed a postoperative complication following major hepatectomy versus only one fourth of patients (n = 113, 27.2%) after minor resection (p < 0.001). In the propensity model, patients who underwent major hepatectomy had an equivalent OS and RFS versus patients who had a minor hepatectomy (median OS, 38 vs. 37 months, p = 0.556; and median RFS, 20 vs. 18 months, p = 0.635). Patients undergoing major resection had comparable OS and RFS with wide surgical margin (≥10 and 5–9 mm), but improved RFS when surgical margin was narrow (1–4 mm) versus minor resection in the propensity model. In the Cox regression model, tumor characteristics and surgical margin were independently associated with long-term outcome. ConclusionsMajor hepatectomy for ICC was not associated with an overall survival benefit, yet was associated with increased perioperative morbidity. Margin width, rather than the extent of resection, affected long-term outcomes. Radical parenchymal-sparing resection should be advocated if a margin clearance of ≥5 mm can be achieved.

Short and long-term outcomes of laparoscopic compared to open liver resection for colorectal liver metastases.

Minimally invasive surgery (MIS) is now established as standard of care for a variety of gastrointestinal procedures for benign and malignant indications. However, due to concerns regarding superiority to open liver resection (OLR), the uptake of laparoscopic liver resection (LLR) has been slow. Data on long-term outcomes of LLR for colorectal liver metastases (CRLM) remain limited. We conducted a systematic review and meta-analysis of short and long-term outcomes of LLR compared to OLR for CRLM. Five electronic databases were systematically searched for studies comparing LLR and OLR for CRLM and reporting on survival outcomes. Two reviewers independently selected studies and extracted data. Primary outcomes were overall survival (OS) and recurrence free survival (RFS). Secondary outcomes were operative time, estimated blood loss, post-operative major morbidity, mortality, length of stay (LOS), and resection margins. Eight non-randomized studies (NRS) were included (n=2,017 total patients). Six were matched cohort studies. LLR reduced estimated blood loss [mean difference: -108.9; 95% confidence interval (CI), -214.0 to -3.7) and major morbidity [relative risk (RR): 0.68; 95% CI, 0.56-0.83], but not mortality. No difference was observed in operative time, LOS, resection margins, R0 resections, and recurrence. Survival data could not be pooled. No studies reported inferior survival with LLR. OS varied from 36% to 60% for LLR and 37% to 65% for OLR. RFS ranged from 14% to 30% for LLR and 22% to 38% for OLR. According to the grade classification, the strength of evidence was low to very low for all outcomes. The use of parenchymal sparing resections with LLR and OLR could not be assessed. Based on limited retrospective evidence, LLR offers reduced morbidity and blood loss compared to OLR for CRLM. Comparable oncologic outcomes can be achieved. Although LLR cannot be considered as standard of care for CRLM, it is beneficial for well-selected patients and lesions. Therefore, LLR should be part of the liver surgeon's armamentarium.

Pulmonary Metastases of Colorectal Carcinoma

Treatment strategies for patients with pulmonary metastases of colorectal carcinoma are continuously evolving. This applies mostly to new systemic therapeutic approaches. For carefully selected patients surgical removal of pulmonary metastases remains an important interdisciplinary therapeutic option and is recommended as first treatment option by the guidelines. Five-year survival rates of up to 60 % are reported following pulmonary metastasectomy. Parenchyma sparing resection has been well established in this setting with low morbidity and mortality. Prognostic factors are, among others, complete resection, thoracic lymph node involvement, the number of metastases and the disease free interval. Although data result mostly from retrospective studies, these factors currently help in patient selection.

Laparoscopic parenchymal-sparing resections for centrally located liver lesions over the postero-superior segments: technical aspects, clinical outcomes and oncological efficiency of the “diamond technique”

Laparoscopic parenchymal-sparing resections for centrally located liver lesions over the postero-superior segments: technical aspects, clinical outcomes and oncological efficiency of the “diamond technique”

Laparoscopic parenchymal-sparing resections for centrally located non-peripheral liver lesions, the diamond technique: technical aspects, clinical outcomes and oncological efficiency

Laparoscopic parenchymal-sparing resections for centrally located non-peripheral liver lesions, the diamond technique: technical aspects, clinical outcomes and oncological efficiency

The Impact of Segmental Anatomy on Hepatic Oncologic Resections

A precise knowledge of the surgical anatomy of the liver is essential for the performance of safe oncological liver resections. The role of the Couinaud’s segmental anatomy of the liver has changed the surgical management of primary and metastatic liver disease. Advances in liver resection techniques, with improved methods of vascular control and segmental-based surgical resections over the last two decades have reduced operative mortality from 17 to 2–4 % in most large series. Intraoperative ultrasound has improved the surgical oncological outcome by identifying adequacy of resection margins and facilitating parenchymal-sparing resection with less morbidity as well as assisting in identifying the segmental anatomy real time in the resection. Liver surgery has evolved from a dangerous procedure to a safe one and now offers the chance of long-term survival and cure for liver malignancy.

Ex situ reimplantation technique, in central lung tumors.

The parenchyma-sparing resection is most often performed in patients with impaired preoperative lung or cardiovascular function who would not be able to tolerate a pneumonectomy. Our experience on the ex situ reimplantation procedure and the outcome of patients with lung malignancies, who underwent upper or upper-middle lobectomy, with reimplantation of the lower lobe was reported. We present 9 patients mean age 62.6+16.2 years (7 males/2 females) underwent ex situ reimplantation due to extensive lung tumor of upper lobes. The surgical technique precludes IV heparinization and then radical pneumonectomy. The entire lung was immersed in Ringer's solution (temperature 4 degrees centigrade) and bench surgery was performed. The involved upper (or upper-middle) lobes with involved lymph nodes were resected, thus leaving the healthy lower lobe of the lung. Pneumoplegia solution, named "Papworth pneumoplegia", was administered (1,473 mL) through catheterization of the pulmonary artery and vein stumps (ante grade and retrograde) along with 250 mL of prostaglandin E1. Re-implantation of the lower lobe was performed (I) on the right side, implantation involved the anastomosis of lower pulmonary vein in the site of the cuff of left atrium, followed by suturing the stump of the intermedius pulmonary artery to the right main pulmonary artery and finally the bronchial stumps-intermedius bronchus to the right main bronchus; (II) on the left side the pulmonary vein was anastomosed first, followed by the bronchial stumps and finally by the pulmonary artery. The graft ischemia time was 70.2+8.4 minutes ranged between 55 and 80 minutes. Re-implantation or auto-transplantation should be considered as a safe option for the appropriate patient with lung cancer. The ex situ separation of the cancerous lobes is technically feasible and allows extensive pulmonary resection while minimizing the loss of pulmonary reserve. Based on our work, the major factors that play a role for the survival of initially resected and then re-implanted lung graft, are: (I) the ischemia time of the re-implanted lobe; (II) the proper use of pneumoplegia solutions, along with prostaglandin E1 and heparin; (III) the occurrence of pulmonary vein thrombosis; and (IV) the bronchial anastomosis.

Segmentectomy: is minimally invasive surgery going to change a liver dogma?

Nowadays, the respective approach to hepatic resections (for malignant or benign liver lesions) is oriented toward minimal parenchymal resection. This surgical behavior is sustained by several observations that surgical margin width is not correlated with recurrence of malignancies. Parenchymal-sparing resection reduces morbidity without changing long-term results and allows the possibility of re-do liver resection in case of recurrence. Minimally invasive liver surgery (MILS) is performed worldwide and is considered a standard of care for many surgical procedures. MILS is associated with less blood loss, less analgesic requirements, and shorter length of hospital with a better quality of life. One of the more frequent criticisms to MILS is that it represents a more challenging approach for anatomical segmentectomies and that in most cases a non-anatomical resection could be performed with thinner resection margins compared with open surgery. But even in the presence of reduced surgical margins, oncological results in the short- and long-term follow-up seem to be the same such as open surgery. The purpose of this review is to try to understand whether chasing at any cost laparoscopic anatomical segmentectomies is still necessary whereas non-anatomical resections, with a parenchymal-sparing behavior, are feasible and overall recommended also in a laparoscopic approach. The message coming from this review is that MILS is opening more and more new frontiers that are still need to be supported by further experience.

Laparoscopic liver resection: Toward a truly minimally invasive approach.

In the surgical treatment of hepatocellular carcinoma and colorectal liver metastasis, it is important to preserve sufficient liver volume after resection in order to avoid post-hepatectomy liver sufficiency and to increase the feasibility of repeated hepatectomy in case of intrahepatic recurrence. Parenchyma-sparing approach, which minimizes the extent of resection while obtaining sufficient surgical margins, has been developed in open hepatectomy. Although this approach can possibly have positive impacts on morbidity and mortality, it is not popular in laparoscopic approach because parenchyma-sparing resection is technically demanding especially by laparoscopy due to its intricate curved transection planes. "Small incision, big resection" is the words to caution laparoscopic surgeons against an easygoing trend to seek for a superficial minimal-invasiveness rather than substantial patient-benefits. Minimal parenchyma excision is often more important than minimal incision. Recently, several reports have shown that technical evolution and accumulation of experience allow surgeons to overcome the hurdle in laparoscopic parenchyma-sparing resection of difficult-to-access liver lesions in posterosuperior segments, paracaval portion, and central liver. Laparoscopic surgeons should now seek for the possibility of laparoscopic parenchyma-sparing hepatectomy as open approach can, which we believe is beneficial for patients rather than just a small incision and lead laparoscopic hepatectomy toward a truly minimally-invasive approach.

Pulmonary Artery Reconstruction With Pulmonary Vein Conduit for Lung Cancer: Medium-Term Results

The use of an autologous pulmonary vein (PV) conduit for reconstruction of the pulmonary artery (PA) in lung-sparing resections was first described in 2009, but to date only two case reports appeared and no medium-term and long-term results have been reported, to our knowledge. We present the first case series with medium-term follow-up. Between December 2009 and December 2012, 9 patients undergoing PA sleeve resection for centrally located lung cancer received reconstruction by this technique. Three of these patients underwent induction chemotherapy. The venous graft was obtained from the proximal extraparenchymal portion of the superior PV and was sutured to the proximal and distal PA stumps with the standard anastomotic technique. All 9 patients underwent left upper lobectomy with sleeve resection of the PA without associated bronchoplasty. The postoperative morbidity rate was 33% (1 chylothorax, 1 atrial fibrillation, and 1 parenchymal atelectasis). No adverse events related to the reconstructive procedure occurred. There was no postoperative mortality. Complete patency of the reconstructed PA was shown in all patients by postoperative contrast computed tomography every 6 months. All patients are alive at a mean follow-up time of 32 ± 12.4 months (range, 6 to 42 months). Tumor recurrence has been observed in 2 patients (1 local, 1 systemic). The median survival time is 38 months. The median disease-free survival time is 33 months. Reconstruction of the PA by a PV graft is a feasible and effective option for parenchymal-sparing resections. The PV conduit shows tissue characteristics similar to those of the arterial wall. This technique is safe and is supported by good medium-term results.

Re-classification of mixed-type IPMNs allows for better definition of epidemiology, biology and outcomes after surgical resection

s / Pancreatolog S4 Aims: To evaluate the long-term outcome after surgical resection of sporadic, asymptomatic NF-pNET < 2 cm, stratifying the results by resection type and histopathologic features. Patients & methods: Patients resected between June 1997 and November 2008 at our institution (minimum follow-up of 60months) were retrieved from a prospectively maintained electronic database and analyzed retrospectively. Results: Study population consisted of 49 patients (27 females and 22 males), with amedian age of 59 years (range 38-61). 31 patients underwent parenchyma-sparing resections (15 enucleations, 15 middle pancreatectomies, 1 spleen-preserving distal pancreatectomies), while 18 patients underwent formal resections (8 pancreaticoduodenectomies, 10 distal pancreactomies with splenectomy). Mean lymph node yielding was 1.35 (0-9) in atypical resections and 19 (7-32) in formal resections (p1⁄40.0001). Lymph node metastases were found in only one patient undergoing pancreaticoduodenectomy. The median tumor size was 16 mm. 48 tumors were G1, one was G2, none was G3 (2010 WHO classification). The final pathologic report showed microscopic local invasion (perineural invasion, lymph vascular invasion or fat invasion) in 8 patients. At a median followup of 80 months (60-193), 4 patients died of other causes, 4 were lost to follow-up the remaining 37 patients did not develop recurrence and are alive and disease-free. Conclusion: Long-term outcome of surgically resected asymptomatic sporadic NF-pNET < 2 cm is excellent. Atypical resections with limited lymph node dissection may be oncologically adequate. Microscopic local invasion did not impact on the natural history of the disease.

Pancreatic serous cystadenoma related mortality is almost nil

s / Pancreatolog S4 Aims: To evaluate the long-term outcome after surgical resection of sporadic, asymptomatic NF-pNET < 2 cm, stratifying the results by resection type and histopathologic features. Patients & methods: Patients resected between June 1997 and November 2008 at our institution (minimum follow-up of 60months) were retrieved from a prospectively maintained electronic database and analyzed retrospectively. Results: Study population consisted of 49 patients (27 females and 22 males), with amedian age of 59 years (range 38-61). 31 patients underwent parenchyma-sparing resections (15 enucleations, 15 middle pancreatectomies, 1 spleen-preserving distal pancreatectomies), while 18 patients underwent formal resections (8 pancreaticoduodenectomies, 10 distal pancreactomies with splenectomy). Mean lymph node yielding was 1.35 (0-9) in atypical resections and 19 (7-32) in formal resections (p1⁄40.0001). Lymph node metastases were found in only one patient undergoing pancreaticoduodenectomy. The median tumor size was 16 mm. 48 tumors were G1, one was G2, none was G3 (2010 WHO classification). The final pathologic report showed microscopic local invasion (perineural invasion, lymph vascular invasion or fat invasion) in 8 patients. At a median followup of 80 months (60-193), 4 patients died of other causes, 4 were lost to follow-up the remaining 37 patients did not develop recurrence and are alive and disease-free. Conclusion: Long-term outcome of surgically resected asymptomatic sporadic NF-pNET < 2 cm is excellent. Atypical resections with limited lymph node dissection may be oncologically adequate. Microscopic local invasion did not impact on the natural history of the disease.

Nonintubated thoracoscopic segmentectomy-left upper lobe trisegmentectomy.

Enhanced computed tomography screening protocols have recently identified increasing numbers of small lung tumors in patients with high surgical risks (1). Consequently there has been increasing interest in minimally invasive surgical approaches, including thoracoscopic approaches, parenchyma-sparing resection, and less invasive anesthesia for management of lung tumors (2). The role of thoracoscopic segmentectomy is therefore increasingly reevaluated, not only as a traditional parenchyma-sparing procedure in high-risk patients with compromised medical conditions but also in patients with non-small cell lung cancer less than 2.0 cm (1). From 2009, we started a nonintubated thoracoscopic surgery program for patients who were reluctant or unsuitable to have a conventional intubated single lung ventilation during thoracic surgery (3). With a combination of target-controlled sedation and regional anesthesia—either by thoracic epidural anesthesia or intercostal nerve blocks with intrathoracic vagal blockade—the results of nonintubated thoracoscopic surgery are encouraging (2-5). In the current video, we demonstrate how a nonintubated technique was applied in thoracoscopic segmentectomy and mediastinal lymphadenectomy to treat a patient with early stage lung cancer (Video 1). Video 1 Nonintubated thoracoscopic segmentectomy—left upper lobe trisegmentectomy. Clinical vignette A 74-year-old man, who had undergone a total gastrectomy for gastric cancer in a different institution in 2003, was transferred to our hospital for management of an incidentally discovered left upper lobe lung nodule. Computed tomography-guided biopsy of the tumor revealed a primary pulmonary adenocarcinoma. Preoperative pulmonary function tests showed that he had a mild obstructive defect with forced expiratory volume in one second being 84.9% of predicted. Considering his age and reduced lung function, lingual-preserving left upper lobectomy (left upper lobe tri-segmentectomy) was planned instead of left upper lobectomy to preserve more lung parenchyma after surgery.

Nonfunctional Pancreatic Neuroendocrine Tumors

BackgroundThe optimal surgical management of small nonfunctional pancreatic neuroendocrine tumors (NF-PNETs) remains controversial. We sought to identify (1) clinicopathologic factors associated with survival in NF-PNETs and (2) preoperative tumor characteristics that can be used to determine which lesions require resection and lymph node (LN) harvest. MethodsThe records of all 116 patients who underwent resection for NF-PNETs between 1989 and 2012 were reviewed retrospectively. Preoperative factors, operative data, pathology, surgical morbidity, and survival were analyzed. ResultsThe overall 5- and 10-year survival rates were 83.9 and 72.8 %, respectively. Negative LNs (p = 0.005), G1 or G2 histology (p = 0.033), and age <60 years (p = 0.002) correlated with better survival on multivariate analysis. The 10-year survival rate was 86.6 % for LN-negative patients (n = 73) and 34.1 % for LN-positive patients (n = 32). Tumor size ≥2 cm on preoperative imaging predicted nodal positivity with a sensitivity of 93.8 %. Positive LNs were found in 38.5 % of tumors ≥2 cm compared to only 7.4 % of tumors <2 cm. ConclusionsLN status, a marker of systemic disease, was a highly significant predictor of survival in this series. Tumor size on preoperative imaging was predictive of nodal disease. Thus, it is reasonable to consider parenchyma-sparing resection or even close observation for NF-PNETs <2 cm.