Surgery plays a crucial role in the treatment of neuroendocrine cancer (NETs). For many people, it remains the most effective way to control or even cure the disease, particularly when the tumour is detected early.
However, the decision to operate is not always straightforward. NETs vary widely in growth rate, hormone production, and metastatic potential, which means surgical planning must be tailored to each patient’s individual situation.
NeuroEndocrine Cancer Australia (NECA), is dedicated to assisting individuals diagnosed with NETs, and their families. NECA offers a wealth of resources, educational programs, and advocacy efforts aimed at deepening the understanding of NETs, improving patient care, and encouraging research advancements. People diagnosed with neuroendocrine cancer can engage with NECA’s comprehensive support and information by calling the NET nurse line.
As Australia’s only not-for-profit medical charity focused on neuroendocrine cancer, we want to provide a comprehensive overview of:
The first step in deciding whether surgery is appropriate is a careful assessment by a multidisciplinary team (MDT) that typically includes surgical oncologists, medical oncologists, endocrinologists, radiologists, and pathologists.
Surgical intervention is generally recommended when:
A person with metastatic disease, may be considered for surgery f, to manage cancer related complications, to control symptoms or as part of a staged approach to treatment that combines surgery with systemic therapy or PRRT.
Curative surgery aims to completely remove all visible disease and achieve a long-term remission or cure. This is most achievable in localised disease, such as a small bowel NET confined to the ileum or a localised pancreatic NET. Curative procedures often include removal of regional lymph nodes to ensure complete clearance.
Palliative surgery, by contrast, is not aimed at cure but at improving quality of life or preventing or managing serious complications from cancer. This might involve management of a bowel obstruction, controlling bleeding, or reducing tumour bulk to manage hormone-related symptoms and pain..
Evidence consistently shows that surgery offers the best chance for long-term survival in patients with localised NETs. Five-year survival rates for patients undergoing resection of localised small bowel NETs exceed 70–80 per cent, and for pancreatic NETs, rates of 50–60 per cent are reported for those who have surgery compared to much lower survival for those who do not.
In liver metastases, surgical resection or debulking of metastases has been associated with five-year survival rates approaching 60–70 per cent in highly selected patients, which is substantially better than systemic therapy alone.
For patients with localised NETs, surgery can be curative, particularly if the tumour is well-differentiated and has a low Ki-67 index. However, for those with metastatic disease, surgery often serves a debulking purpose, reducing tumour burden and symptoms but not necessarily curing the disease.
Patients with metastatic disease who undergo debulking surgery have improved symptom control and, in some series, prolonged progression-free survival compared with those managed without surgery. The extent of debulking matters: greater than 70 per cent removal of tumour volume is associated with better outcomes.
Despite successful surgery, recurrence is common, particularly in intermediate- and high-grade NETs. Recurrence rates can range from 20 to 50 per cent within five years, depending on tumour biology and stage at diagnosis.
Because recurrence can occur many years after surgery, long-term surveillance is recommended. This often involves regular imaging (CT, MRI, or Ga-68 DOTATATE PET/CT) and monitoring of biochemical markers such as Chromogranin A or 5-HIAA.
Progression-free survival after surgery is influenced by:
How does surgery for NETs affect quality of life? While certain procedures may seem invasive, many patients can have improved long-term outcomes.
NET surgery frequently improves quality of life by reducing symptoms caused by hormone secretion or tumour mass effect. For example, resection of a serotonin-secreting tumour can significantly reduce diarrhoea and flushing, while removing a mesenteric mass can relieve abdominal pain and prevent bowel obstruction.
Post-operative quality of life generally improves over time, though recovery can take weeks to months depending on the extent of surgery.
Patients who undergo surgery often report better long-term physical function and emotional wellbeing compared to those managed medically alone. Minimally invasive techniques, such as laparoscopic or robotic surgery, are increasingly used and associated with faster recovery, shorter hospital stays, and reduced post-operative pain.
Many factors influence surgical outcomes, and these outcomes will vary from patient to patient.
The complexity of surgery is closely tied to where the tumour is located. Small bowel NETs often require segmental bowel resection with lymphadenectomy, while pancreatic NETs may need more extensive operations like a Whipple procedure. Larger tumours or those invading adjacent organs may require more extensive surgery.
High-grade NETs and Neuroendocrine Carcinomas (NECs) although sometimes resectable, tend to recur quickly and are often managed with systemic therapy first to assess response before surgery is considered.
The decision to operate is also shaped by the patient’s overall health. Older age is not an absolute contraindication, but comorbidities such as heart disease, liver dysfunction, or carcinoid heart disease must be optimised before surgery.
Prehabilitation (improving fitness, nutrition, and mental preparedness before surgery) is gaining traction as a way to improve outcomes.
Surgery remains the only modality that can potentially cure NETs. Systemic therapies such as SSAs, PRRT, targeted agents (e.g., everolimus, sunitinib), and chemotherapy are highly effective at controlling disease.
Many patients benefit from a combined approach, where surgery is integrated with other therapies. Examples include resecting the primary tumour in combination with PRRT for metastatic disease, or using pre-operative systemic therapy to shrink tumours before attempting resection. Staged liver resections and parenchymal-sparing liver surgery are increasingly common in centres of excellence.
New surgical techniques are expanding the number of patients who can benefit from resection. These include advanced laparoscopic and robotic approaches, portal vein embolisation to increase the volume of future liver remnant before surgery, and staged hepatectomy procedures.
Enhanced recovery after surgery (ERAS) protocols have become standard in many hospitals, reducing complications, shortening hospital stays, and improving patient experience.
Clinical trials are underway to refine patient selection criteria for surgery and to explore the role of neoadjuvant therapy in borderline resectable disease. Research is also examining molecular and genetic biomarkers that could predict which patients will benefit most from aggressive surgical intervention.
There is growing interest in combining surgery with immunotherapy and targeted therapies to reduce recurrence risk and improve survival in high-risk patients.
Surgery remains the cornerstone of treatment for many patients with neuroendocrine tumours. It can provide the possibility of cure in localised disease and meaningful symptom relief in advanced disease. However, it requires careful planning and expert execution, ideally in high-volume centres with multidisciplinary teams experienced in NET care.
As surgical techniques continue to evolve and research sheds light on which patients stand to gain the most from resection, the future for people living with NETs looks increasingly hopeful. A personalised, integrated approach that balances surgery with systemic and targeted therapies offers the best chance for prolonged survival and improved quality of life.
Further information and support for people diagnosed with NETs is available by calling the NECA NET nurse line.
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