title: Surgery versus intra-arterial therapy for neuroendocrine liver metastasis: a multicenter international analysis.
abstract: BACKGROUND
  Management of patients with neuroendocrine liver metastasis (NELM) remains controversial. We sought to examine the relative efficacy of surgical management versus intra-arterial therapy (IAT) for NELM and determine factors predictive of survival.
  
  
  METHODS
  A total of 753 patients who had surgery (n = 339) or IAT (n = 414) for NELM from 1985 to 2010 were identified from nine hepatobiliary centers. Clinicopathologic data were assessed with regression modeling and propensity score matching.
  
  
  RESULTS
  Most patients had a pancreatic (32%) or a small bowel (27%) primary tumor; 47% had a hormonally active tumor. There were statistically significant differences in characteristics between surgery versus IAT groups (hormonally active tumors: 28 vs. 48%; hepatic tumor burden >25%: 52% vs. 76%) (all P < 0.001). Among surgical patients, most underwent hepatic resection alone without ablation (78%). The median number of IAT treatments was 1 (range, 1-4). Median and 5-year survival of patients treated with surgery was 123 months and 74% vs. 34 months and 30% for IAT (P < 0.001). In the propensity-adjusted multivariate Cox model, asymptomatic disease (hazard ratio 2.6) was strongly associated with worse outcome (P = 0.001). Although surgical management provided a survival benefit over IAT among symptomatic patients with >25% hepatic tumor involvement, there was no difference in long-term outcome after surgery versus IAT among asymptomatic patients (P = 0.78).
  
  
  CONCLUSIONS
  Asymptomatic patients with a large (>25%) burden of liver disease benefited least from surgical management and IAT may be a more appropriate treatment strategy. Surgical management of NELM should be reserved for patients with low-volume disease or for those patients with symptomatic high-volume disease.
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Skye C
authors.initials: SC
authors.lastname: Mayo
authors.forename: Mechteld C
authors.initials: MC
authors.lastname: de Jong
authors.forename: Mark
authors.initials: M
authors.lastname: Bloomston
authors.forename: Carlo
authors.initials: C
authors.lastname: Pulitano
authors.forename: Bryan M
authors.initials: BM
authors.lastname: Clary
authors.forename: Srinevas K
authors.initials: SK
authors.lastname: Reddy
authors.forename: T
authors.initials: T
authors.lastname: Clark Gamblin
authors.forename: Scott A
authors.initials: SA
authors.lastname: Celinski
authors.forename: David A
authors.initials: DA
authors.lastname: Kooby
authors.forename: Charles A
authors.initials: CA
authors.lastname: Staley
authors.forename: Jayme B
authors.initials: JB
authors.lastname: Stokes
authors.forename: Carrie K
authors.initials: CK
authors.lastname: Chu
authors.forename: David
authors.initials: D
authors.lastname: Arrese
authors.forename: Alessandro
authors.initials: A
authors.lastname: Ferrero
authors.forename: Richard D
authors.initials: RD
authors.lastname: Schulick
authors.forename: Michael A
authors.initials: MA
authors.lastname: Choti
authors.forename: Jean-Francois H
authors.initials: JF
authors.lastname: Geschwind
authors.forename: Jennifer
authors.initials: J
authors.lastname: Strub
authors.forename: Todd W
authors.initials: TW
authors.lastname: Bauer
authors.forename: Reid B
authors.initials: RB
authors.lastname: Adams
authors.forename: Luca
authors.initials: L
authors.lastname: Aldrighetti
authors.forename: Gilles
authors.initials: G
authors.lastname: Mentha
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Capussotti
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
mesh_terms: D000971:Antineoplastic Combined Chemotherapy Protocols / Q000008:administration & dosage*; D005260:Female; D005500:Follow-Up Studies; D006498:Hepatectomy; D006801:Humans; D007269:Injections, Intra-Arterial; D007390:International Agencies; D008113:Liver Neoplasms / Q000188:drug therapy* / Q000556:secondary / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D009364:Neoplasm Recurrence, Local / Q000188:drug therapy / Q000473:pathology / Q000601:surgery; D018358:Neuroendocrine Tumors / Q000188:drug therapy* / Q000473:pathology / Q000601:surgery*; D011379:Prognosis