Surgery for Gastrointestinal Carcinoid Tumors

Many gastrointestinal (GI) carcinoid) tumors can be cured by surgery alone. The type of operation will depend on a number of factors, including the size and location of the tumor, whether the person has any other serious diseases, and whether the tumor is causing the carcinoid syndrome.

Surgeons often try to cure localized carcinoid tumors by removing them completely, which is usually successful.

The options for GI carcinoid tumors that have spread to nearby tissues or to distant parts of the body are more complex. Because most carcinoid tumors grow slowly and some do not cause any symptoms, completely removing all metastatic carcinoid tumors may not always be needed. But in some patients, surgery to remove all visible cancer is the best option. This is particularly true if removing most of the cancer will reduce the level of hormone-like substances causing symptoms.

Several types of operations can be used to treat GI carcinoid tumors. Some of these remove the primary tumor (where the cancer started), while others remove or destroy cancer that has spread (metastasized) to other organs.

Endoscopic mucosal resection

In this procedure, the cancer is removed through an endoscope. This is most often used to treat small carcinoid tumors of the stomach and duodenum (the first part of the small intestine) and it also can be used to remove small carcinoid tumors of the rectum.

Local excision

This operation removes the primary tumor and some normal tissue around it. The edges of the defect are then sewn together. This usually doesn’t cause any prolonged problems with eating or bowel movements. This operation may be done for small carcinoid tumors (no larger than 2 cm, or a little less than an inch).

Carcinoid tumors are sometimes removed during an operation being done for some other reason. This often happens with carcinoid tumors of the appendix. When the appendix is removed (for some other reason), it is examined after surgery, and sometimes a carcinoid tumor is found. Most doctors believe that if the tumor is small — 2 cm or less — removing the appendix (appendectomy) is curative and no other surgery is needed. If the tumor is larger than 2 cm, more surgery may be needed.

Rectal carcinoid tumors may be taken out through the anus, without cutting the skin. Other GI carcinoid tumors can sometimes be locally excised through an endoscope but usually it is done through an incision (cut) in the skin.

More extensive surgeries

A larger incision (cut) is needed to remove a larger tumor along with nearby tissues. This also gives the surgeon the chance to see if the tumor has grown into other tissues in the abdomen (belly). If it has, the surgeon may be able to remove the areas of cancer spread.

Partial gastrectomy: In this operation, part of the stomach is removed. If the upper part is removed, sometimes part of the esophagus is removed as well. If the lower part of the stomach is removed, sometimes the first part of the small intestine (the duodenum) is also taken. Nearby lymph nodes are also removed. This operation is also known as a subtotal gastrectomy.

Small bowel (intestine) resection: This is an operation to remove a piece of the small intestine (also called the small bowel). When it is used to treat a small bowel carcinoid, this surgery includes removing the tumor and some of the small bowel around it (called a wide margin resection). It will also remove nearby (regional) lymph nodes and the supporting connective tissue (called the mesentery) that contains lymph nodes and vessels that carry blood to and from the intestine. Tumors in the terminal ileum (the last part of the small bowel) may require removing the right side of the colon (hemicolectomy).

Pancreaticoduodenectomy (Whipple procedure): This operation is most often used to treat pancreatic cancer, but it is also used to treat cancers of the duodenum (the first part of the small intestine). It removes the duodenum, part of the pancreas, nearby lymph nodes and part of the stomach. The gallbladder and part of the common bile duct are removed and the remaining bile duct is attached to the small intestine so that bile from the liver can continue to enter the small intestine. This is a complex operation that requires a lot of skill and experience. It carries a relatively high risk of complications that could even be fatal.

Segmental colon resection or hemicolectomy: This operation removes between one-third and one-half of the colon, as well as the nearby layers of tissue that hold and connect the intestines ( the mesentery), which includes blood vessels and lymph nodes.

Low anterior resection: This operation can be used for some tumors in the upper part of the rectum. It removes some of the rectum and the remaining ends are sewn together. This does not have much effect on digestive function.

Abdominoperineal (AP) resection: This surgery is done for large or very invasive cancers in the lower part of the rectum. It removes the anus, rectum, and lower part of the colon. After this operation, the end of the colon is connected to an opening on the skin on the abdomen (called a colostomy). A bag attached over this opening collects stool (feces) as it leaves the body. (For more information, see Colostomy Guide).

Surgery and other procedures for carcinoid tumors that have spread to the liver

If the cancer spreads to the liver, treating the tumors in the liver may help with symptoms. When there are only 1 or 2 tumors in the liver, they may be removed with surgery. If there are more than just a few liver tumors (or if a person is too sick for surgery), other techniques may be used.

Liver resection

In this operation, one or more pieces of the liver that contain areas of cancer are removed. If it isn’t possible to remove all areas of cancer, surgery may still be done to remove as much tumor as possible to help reduce symptoms of carcinoid syndrome. This is sometimes called cytoreductive surgery. Removing liver metastases may help some people with carcinoid tumors live longer, but most people who have this surgery will eventually develop new liver metastases.

Ablation

Ablation techniques destroy tumors without removing them. They are generally best for tumors no more than about 2 cm (a little less than an inch) across.

Radiofrequency ablation (RFA) uses high-energy radio waves for treatment. A thin, needle-like probe is placed through the skin and into the tumor. Placement of the probe is guided by ultrasound or CT scans. The tip of the probe releases a high-frequency current that heats the tumor and destroys the cancer cells.

Ethanol (alcohol) ablation (also known as percutaneous ethanol injection) kills the cancer cells by injecting concentrated alcohol directly into the tumor. This is usually done through the skin using a needle guided by ultrasound or CT scans.

Microwave thermotherapy

Uses microwaves to heat and destroy the cancer cells.

Cryosurgery (cryotherapy)

Cryotherapy destroys a tumor by freezing it with a metal probe. The probe is guided through the skin and into the tumor using ultrasound. Then very cold gasses are passed through the probe to freeze the tumor, killing the cancer cells. This method may be used to treat larger tumors compared to the other ablation techniques, but it sometimes requires general anesthesia (where you are asleep).

Embolization

Intra-arterial therapy and chemoembolization (also known as transarterial embolization or TAE): This is another option for tumors that can’t be removed completely. It can be used for larger tumors (up to about 5 cm or 2 inches across). This technique reduces the blood flow to the cancer cells by blocking the branch of the hepatic artery feeding the area of the liver containing the tumor. Blood flow is blocked (or reduced) by injecting materials that plug up the artery. Most of the healthy liver cells will not be affected because they get their blood supply from a different blood vessel, the portal vein.

In this procedure a thin, flexible catheter is put into an artery in the inner thigh and threaded up into the liver. A dye is then injected into the bloodstream to allow the doctor to monitor the path of the catheter via angiography, a special type of x-ray. Once the catheter is in place, small particles are injected into the artery to plug it up.

Chemoembolization (also known as trans-arterial chemoembolization or TACE): This procedure combines embolization with chemotherapy. Most often, this is done by using tiny beads that release a chemotherapy drug during the embolization. TACE can also be done by giving chemotherapy through a thin catheter directly into the artery, then plugging up the artery.

Radioembolization: In the United States, this is done by injecting small radioactive beads into the hepatic artery. The beads travel to the tumor and give off small amounts of radiation only at the tumor sites.