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Gastrointestinal Carcinoid Tumours Surgical management

Gastrointestinal Carcinoid Tumours Surgical management. Bruce D George John Radcliffe Hospital. Appendix Ileum/jejunum Rectum. GI Carcinoids. Carcinoid Usually <1cm Near tip incidental Adenocarcinoid (Goblet cell carcinoid) Colonic type neoplasms Miscellaneous

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Gastrointestinal Carcinoid Tumours Surgical management

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  1. Gastrointestinal Carcinoid TumoursSurgical management Bruce D George John Radcliffe Hospital

  2. Appendix Ileum/jejunum Rectum GI Carcinoids

  3. Carcinoid Usually <1cm Near tip incidental Adenocarcinoid (Goblet cell carcinoid) Colonic type neoplasms Miscellaneous Lymphoma, soft tissue etc Appendiceal tumours

  4. 30-60% of appendiceal tumours Size matters: <2cm 0 of 127 metastases 2-3cm 3 of 14 >4cm 4 of 9 Moertel 1968 Appendiceal carcinoids

  5. Size Over 2cm (1.5cm fixed) Mesoappendiceal extension Incomplete excision More likely at base Predictors of metastatic potential

  6. <1cm, R0, no mesorectal involvement No further assessment >2cm, R1 or mesoappendiceal involvement Staging followed by radical right hemicolectomy 1cm-2cm ? Current protocols

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

  8. Rectal carcinoids • Usually small, incidental findings • <1cm: local excision • 1-2cm: ? Local excision ?Anterior resection • >2cm anterior resection

  9. 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

  10. Size still matters: <2cm 20% liver metastases >2cm 53% liver metastases Strodel et al 1983 Jejunal/ileal carcinoids

  11. Localised primary 92% Nodal involvement 86% Distant metastases 40% US SEER data (Cancer 1995; 75: 154) 5 year survival

  12. Small incidental tumour Localising symptoms Metastatic disease Carcinoid syndrome Modes of presentation

  13. 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 Surgical management of small bowel disease

  14. 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 Hellman, Oberg et alWorld J Surgery 2002; 26: 991-7

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

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