Re-evaluating resection of primary pancreatic neuroendocrine tumors

A trend has been emerging in the surgical treatment of cancer during the past several decades: Less surgery is often better than radical surgery, or at least just as good. This trend has also been the case in the surgical treatment of breast cancer after the National Surgical Adjuvant Breast and Bowel Project B-06 trial, lead by Bernard Fisher, demonstrated that lumpectomy and radiation, and even lumpectomy with no radiation, had survival rates equivalent to mastectomy. This was true even though the less radical operations had greater local recurrence rates, which were as great as 43% at 5 years in the group treated with lumpectomy alone. Another great example was the landmark trial spearheaded by Steven Rosenberg, Sir Murray Brennan, Paul Sugarbaker, and others comparing limb-sparing resection plus radiation to radical amputation for soft-tissue sarcomas of the extremities. Similar to the B-06 trial results, the less radical operations were associated with greater local recurrence rates than amputations, but the survival rates were again equivalent. In both examples, these seemingly paradoxial results are attributable to the fact that the survival is ultimately determined—not by the local control of the primary tumor—but rather by the distant metastases, which are likely already preordained by the time the primary tumor is discovered.