Metastatic endocrine tumors: medical treatment, surgical resection, or liver transplantation

Role of radiolabeled octreotide therapy in patients with metastatic neuroendocrine neoplasms

Peptide receptor radionuclide therapy is a new therapeutic modality for patients with nonresectable neuroendocrine tumors. The technique is based on the unique ability of these tumors to express cell membrane-specific peptide receptors that can be targeted with radiolabeled somatostatin analogues. A high level of uptake on somatostatin receptor scintigraphy is a prerequisite for effective treatment. The efficacy of this method has been proven in several clinical trials. In a substantial number of patients, an improvement of life quality has been achieved in addition to a marked morphologic and biochemical tumor response. Serious side effects are rarely observed. Attention must be paid to kidney protection during the treatment. The present review summarizes the clinical experience with the treatment of advanced neuroendocrine tumors with radiolabeled somatostatin analogues and focuses on patient selection and the appropriate timing of the therapy. Finally, it emphasizes treatment-related issues that deserve attention in the future.

New developments in the treatment of gastrointestinal neuroendocrine tumors

Patients with metastatic gastrointestinal neuroendocrine tumors have traditionally been faced with few effective treatment options. Somatostatin analogs often successfully control symptoms of hormonal hypersecretion but seldom result in tumor regression. Some patients with hepatic metastases are also candidates for ablative therapies such as surgical debulking or embolization. The role of systemic agents such as interferon alfa or cytotoxic chemotherapy remains ill defined. The more prevalent use of these modalities has been restricted by low tumor response rates and the potential for toxicity. Novel agents, including radiolabeled somatostatin analogs, inhibitors of the vascular endothelial growth factor pathway, and inhibitors of mammalian target of rapamycin, have shown promising activity in recent clinical studies. Continued investigation of these agents should render a better understanding of their efficacy in patients with advanced neuroendocrine tumors.

An aggressive surgical approach leads to long-term survival in patients with pancreatic endocrine tumors

OBJECTIVE

To evaluate the outcome of reoperations in patients with duodenopancreatic neuroendocrine tumors (PETs) in a tertiary referral center.

SUMMARY BACKGROUND DATA

The management of reoperations in PETs is still controversial.

METHODS

A total of 125 patients with PETs that underwent surgery between 1987 and 2004 at our institution were retrospectively evaluated. The diagnosis of PETs was based on clinical symptoms, biochemical tests, and histopathology. Patients with at least one reoperation were analyzed regarding clinical characteristics, pathology, operations, and long-term follow-up.

RESULTS

A total of 33 patients with a median age of 42 years were identified for this study: 13 patients had gastrinomas, 12 patients had nonfunctional islet cell tumors, 6 patients had insulinomas, and 2 patients had vipomas; 24 patients had sporadic NETs, 9 patients had a MEN-1-syndrome; 27 patients had histologically verified malignant tumors; 33 initial operations and 50 reoperations were performed. The initial procedures comprised 27 resections of the primary tumor and 6 explorative laparotomies; 28 of all reoperations were resections of distant metastases, including 15 liver resections; 19 resections of the pancreas or duodenum were performed during reoperations. The overall morbidity and mortality was 45% and 4.8%, respectively. After a median follow-up of 124 months (range, 16-384 months), 27 of 33 patients are still alive, 12 without evidence of disease. All 6 patients with benign tumors are still alive. The 5-, 10-, and actuarial 25-year survival rate for patients with malignant tumors were 81%, 72%, and 36%, respectively. The survival rate was significantly related to the patients age at time of initial operation and better in patients younger than 50 years compared with patients older than 50 years (P = 0.0007), and the presence or development of metastases (none or lymph node metastases versus distant metastases: P = 0.01).

CONCLUSION

We show that an aggressive surgical approach leads to long-term survival in patients with malignant PETs. Although long-term cure can only be achieved in a proportion of patients with malignant PETs, significant long-term palliation can be achieved.

Surgery for hepatic neuroendocrine tumors: a single institutional experience in Japan

BACKGROUND

Surgical resection has been advocated as an effective treatment for hepatic neuroendocrine tumors (HNETs) in Western countries, but few data are available to define its indications. We evaluated the results of Japanese patients to determine the prognostic factors and the feasibility of our aggressive surgical approach.

METHODS

The records of all consecutive patients who underwent surgical resection for HNETs at our institution were retrospectively reviewed. Patients were selected for surgery if all tumors were deemed resectable, regardless of their extent.

RESULTS

A total of 21 patients were identified. Bilobar disease was present in 13 patients (62%). Eleven patients (52%) underwent major hepatectomy, which included right trisectionectomy, extended right or left hepatectomy and right hepatectomy. No in-hospital death occurred. The overall 1-, 3- and 5-year survival rates were 95, 68 and 41%, respectively, with a median follow-up of 34 months. Metastatic HNETs from bronchopulmonary primaries exhibited significantly poor outcome compared with other primary sites (P = 0.04). Patients who underwent curative resection had an improved overall 5-year survival rate of 73% compared with palliative resection (0%, P = 0.01). The longest survival in the latter group was 57 months. Complete symptom resolution rate was 92%.

CONCLUSIONS

This is the first study from Asia demonstrating the safety of aggressive hepatic resection for HNETs. Significant symptom relief and long-term survival were achieved irrespective of the extent of disease or the magnitude of operation. Metastatic HNETs from bronchopulmonary primaries may represent a more lethal subset of tumors.

Hepatic resection for metastatic gastrointestinal and pancreatic neuroendocrine tumours: outcome and prognostic predictors

BACKGROUND

Treatment modalities for hepatic metastases from neuroendocrine tumours (NETs) include surgery, somatostatin analogues and arterial embolization. The aims of this study were to evaluate the outcome of patients following surgery and to identify prognostic predictors of recurrent disease.

PATIENTS AND METHODS

This was a retrospective clinico-pathological analysis of patients managed with hepatic NET metastases over a 13-year period (January 1994 to December 2006).

RESULTS

Eighteen patients with hepatic metastases from NET were identified with a median age of 53 years (range 31-75). The localization of the primary tumour was the terminal ileum (n=8), pancreas (n=7), appendix (n=2) or duodenum (n=1). Twelve patients had synchronous disease and six patients developed metachronous hepatic tumours over a median period of 20 months (range 6-144). Presenting symptoms included abdominal pain (n =13), recurrent diarrhoea (n=7) and flushing (n=7). Fifteen patients underwent surgery with complete cytoreduction and three patients had partial cytoreduction. The overall 2- and 5-year actuarial survival rates were 94% and 86%, respectively. The 2- and 5-year disease-free rates following hepatic resection with complete cytoreduction were both 66%. Partial or complete control of endocrine-related symptoms was achieved in all patients with functioning tumours following surgery. Recurrent disease occurred in four patients following complete cytoreductive surgery. Resection margin involvement was associated with developing recurrent disease (p=0.041).

CONCLUSION

Surgical resection for hepatic NET metastases results in good long-term survival in selected patients and resection margin involvement was associated with recurrent disease.

Selective hepatic artery embolization for treatment of patients with metastatic carcinoid and pancreatic endocrine tumors

BACKGROUND

Prognosis in patients with carcinoid and pancreatic endocrine tumors with diffuse, unresectable liver metastases is poor. Palliation is often difficult despite the use of somatostatin analogs, interferon alpha, or systemic chemotherapy. Several reviews have suggested that hepatic artery embolization, with or without intraarterial chemotherapy, can be used for control of symptoms and for cytoreduction in patients with liver dominant metastases.

METHODS

Between 2000 and 2002, 161 embolizations using polyvinyl alcohol or microspheres were performed on 84 patients with carcinoid or pancreatic endocrine tumors metastatic to the liver. A retrospective review was performed to evaluate symptomatic response, biochemical response, adverse effects, and duration of survival. Baseline and follow-up computed tomography scans were also assessed to determine radiographic response rates. Further analysis of survival was performed to assess the possible impact of various postembolization therapies.

RESULTS

Eighty-four patients underwent bland hepatic artery embolizations during the study period. Among 55 symptomatic patients, 44 patients had fewer symptoms, and among 35 patients whose tumor markers were followed, 28 had a major biochemical response. Objective radiographic responses were observed in 11 of 23 patients. No deaths occurred during therapy, and major toxicities were rare. Median overall survival was 36 months from time of initial embolization.

CONCLUSIONS

Hepatic artery embolization frequently results in clinical and radiographic responses in patients with unresectable liver metastases from carcinoid or pancreatic endocrine tumors. Morbidity is low when appropriate supportive care is provided. Hepatic artery embolization often results in regressions in patients with unresectable liver metastases from carcinoid or pancreatic endocrine tumors.

Liver transplantation for patients with metastatic endocrine tumors: single-center experience with 15 patients

In contrast to other secondary liver malignancy, orthotopic liver transplantation (OLT) is considered as a treatment modality for nonresectable endocrine liver metastases in selected patients. However, only few series have assessed patient selection criteria and long-term results, and no reports have focused on the impact of new technologies in this regard. Between 1992 and 2004, 28 patients with malignant endocrine tumors underwent evaluation for OLT according to our protocol. Data were entered into a prospective database. During pretransplant evaluation, somatostatin receptor scintigraphy detected extrahepatic metastases not diagnosed in standard imaging in 10 patients. Of them, 3 showed aberrant Ki67 labeling results. One patient was excluded from further evaluation due to severe carcinoid heart. Thus far, 15 patients, 10 men and 5 women, aged 37 to 67 years, were subjected to the transplant procedure (11 deceased donor OLT, 3 living donor liver transplantations, and 1 cluster transplantation). Four patients died during the hospital treatment. The median follow-up of the discharged patients was 60.8 months. The actuarial patient survival was 78.3% at 1 year and 67.2% at 5 years. The actuarial 1-, 2-, and 5-year tumor-free survival amounted to 69.4%, 48.3%, and 48.3%, respectively. Two patients underwent surgery for isolated tumor recurrence. In 2 patients, peptide receptor radiotherapy was carried out because of multilocular recurrent disease. In conclusion, liver transplantation is a realistic therapeutic option for highly selected patients with hepatic metastases of endocrine tumors. Our strategy, which implements strict pretransplant selection and aggressive surgical approach, in case of disease recurrence, in addition to systemic radiopeptide treatment, led to an excellent long-term survival cure, however, is unlikely to be achieved.

Endocrine tumors of the pancreas

PURPOSE OF REVIEW

Neoplasms of the endocrine pancreas, commonly referenced as pancreatic islet cell tumors, are rare, often well differentiated endocrine neoplasms, whose biology remains poorly characterized. This article reviews the current clinical management of pancreatic islet cell tumors and describes the molecular events that have been studied to guide future therapies of these peculiar neoplasms.

RECENT FINDINGS

While some islet cell tumors arise in association with the MEN-1 syndrome, the majority of these neoplasms are sporadic lesions whose underlying genetic and molecular events remain largely unknown. Recent work has identified changes in gene expression occurring in metastatic and non-metastatic islet cell tumors, which appear to correlate with the occurrence of lymph node and liver metastases. Epigenetic alterations of select tumor suppressor genes may influence patient survival, and the presence of gene promoter methylation may be used as a prognostic marker system. In addition, multiple molecular alterations, including changes in expression of cellular proteins with migratory, cell cycle or angiogenic functions, have been demonstrated to influence islet cell tumor growth, invasion and metastatic spread.

SUMMARY

Understanding the molecular events underlying the biology of pancreatic islet cell tumors will aid the development of accurate prognostic markers and will guide improved therapeutic modalities in the future.

Therapeutic options for gastrointestinal carcinoids

Although wide surgical resection is the optimal curative therapy for carcinoid tumors, in most patients the presence of metastatic disease at diagnosis usually renders excision a palliative procedure. This nevertheless decreases tumor burden, facilitates symptom control, and prevents complications caused by bleeding, perforation, or bowel obstruction resulting from fibrosis. In the stomach (types I and II) and rectum endoscopic excision may be adequate provided the lesion(s) are local. Long-term therapy is focused on symptom alleviation and improvement of quality of life using somatostatin analogues, particularly in a subcutaneous depot formulation. In some instances interferons may have a role but their usage often is associated with substantial adverse events. Conventional chemotherapy and external radiotherapy either alone or in a variety of permutations are of minimal efficacy and should be balanced against the decrease in quality of life often engendered by such agents. Hepatic metastases may be amenable to surgery, radiofrequency ablation, or embolization either alone or in combination with chemotherapeutic agents or isotopically loaded microspheres. Rarely hepatic transplantation may be of benefit although controversy exists as to its actual use. Peptide-receptor-targeted radiotherapy for advanced disease using radiolabeled octapeptide analogs (111In/90Yt/177Lu-octreotide) appear promising but data are limited and its status remains investigational. A variety of antiangiogenesis and growth factor-targeted agents have been evaluated, but as yet have shown little promise. The keystone of current therapy remains the long-acting somatostatin analogues that alleviate symptomatology and substantially improve quality of life with minimal adverse effects.

Liver transplantation for metastatic neuroendocrine tumor: a case report and review of the literature

Neuroendocrine tumors are divided into gastrointestinal carcinoids and pancreatic neuroendocrine tumors. The WHO has updated the classification of these lesions and has abandoned the term "carcinoid". Both types of tumors are divided into functional and non-functional tumors. They are characterized by slow growth and frequent metastasis to the liver and may be limited to the liver for long periods. The therapeutic approach to hepatic metastases should consider the number and distribution of the liver metastases as well as the severity of symptoms related to hormone production and tumor bulk. Surgery is generally considered as the first line therapy. In patients with unresectable liver metastases, alternative treatments are dependent on the type and the growth rate. Initial treatments consist of long acting somatostatin analogs and/or interferon. Streptozocin-based chemotherapy is usually reserved for symptomatic patients with rapidly advancing disease, but generally the therapy is poorly tolerated and its effects are short-lived. Locoregional therapy directed such as hepatic-artery embolization and chemoembolization, radiofrequency thermal ablation and cryosurgery, is often used instead of systemic therapy, if the disease is limited to the liver. However, liver transplantation should be considered in patients with neuroendocrine metastases to the liver that are not accessible to curative or cytoreductive surgery and if medical or locoregional treatment has failed and if there are life threatening hormonal symptoms. We report a case of liver transplantation for metastatic neuroendocrine tumor of unknown primary source and provide a detailed review of the world literature on this controversial topic.

Living-related liver transplantation for multiple liver metastases from rectal carcinoid tumor: a case report

A 42-year-old woman was admitted to our hospital because of multiple liver tumors detected by ultrasonography. Colonoscopy revealed submucosal tumor in the rectum, which was considered the primary lesion. Endoscopic mucosal resection followed by histopathological examination revealed that the tumor was carcinoid. The resected margin of the tumor was positive for malignant cells. Two courses to transcatheter arterial chemotherapy for liver metastasis were ineffective. Accordingly, the rectal tumor and metastatic lymph nodes were surgically resected. One month after the operation, she received liver transplantation (left lateral segment and caudate lobe) from her son. No recurrent lesion has been observed at two years after the liver transplantation. Liver transplantation should be considered as a treatment option even in advanced case of carcinoid metastasis to the liver. We also discuss the literature on liver transplantation for metastatic carcinoid tumor.

[Surgical treatment of gastric, enteric pancreatic endocrine tumors. Part 2. treatment of hepatic metastases]

The development of hepatic metastases (HM) marks a turning point in the evolutionand prognosis of well-differentiated endocrine tumors (ET). Management is usually multicisciplinary (chemotherapy, arterial chemo-embolization, percutaneous ablation, somatostatin analogs, biotherapy, and surgery). A thorough pre-operative work-up is neecessary to exclude extrahepatic disease and to detect tiny HM's. Complete resection (RO) is the only curative treatment for well-differentiated ET with HM. The type of resection is specific to each case and may range from wedge resection of a metastasis to complex hepatectomy with simultaneous resection of the primary ET. Cytoreductive surgery may be indicated for palliation when medical therapy fails to control endocrine symptoms. Operative mortality is low (0-6%) and global survival is 60-70% afterafter R) resection of HM of well-differentiated ET's. After resection of HM involving only one hepatic lobe, 5 year survival is better than 90%. When HM are multiple, bilobar and synchronous, the prognosis is very poor--only 10% of such patients can have a complete resection and this often requires a long prologue of ancillary procedures (chemotherapy, chemoembolization, portal vein ligation, percutaneous ablation). Hepatic transplantation (HT) has only a limited rôle in the treatment of HM for ET; mortality is high when HT is associated with large and complex resections, i.e. pancreaticoduodenectomy. Although there is no consensus in the literature, HT should be limited to the most optimal cases (young, good general health, well-differentiated tumor, slow evolution, complete resection of the primary rumor, and unresectable liver metastases). Global survival for HT in patients with ET is 60% at 2 years, 47% at 5 years; tumor-free survival at 5 years is 24%. HT for HM has better survival results for ET's of intestinal origin (carcinoids) than for duodenopancreatic ET's.

Treatment of neuroendocrine cancer metastatic to the liver: the role of ablative techniques

Carcinoid tumors and islet cell neoplasms are neuroendocrine neoplasms with indolent patterns of growth and association with bizarre hormone syndromes. These tumors behave in a relatively protracted and predictable manner, which allows for multiple therapeutic options. Even in the presence of hepatic metastases, the standard of treatment for neuroendocrine malignancy is surgery, either with curative intent or for tumor cytoreduction, i.e., resection of 90% or more of the tumor volume. Image-guided ablation, as either an adjunct to surgery or a primary treatment modality, can be used to treat neuroendocrine cancer metastatic to the liver. Image-guided ablative techniques, including radiofrequency ablation, alcohol injection, and cryoablation, can be used in selected patients to debulk hepatic tumors and improve patient symptoms. Although long-term follow-up data are not available, the surgical literature indicates that significant ablative debulking may improve patient survival. In this review, we discuss metastatic neuroendocrine disease and its treatment options, especially image-guided ablative techniques.

[Liver transplantation in the management of unresectable bilateral neuroendocrine metastases]

INTRODUCTION

Neuroendocrine tumors are rare neoplasms that present bilateral liver metastases at diagnosis. Because of the good initial results obtained, liver transplantation is considered as a potentially curative treatment.

OBJECTIVE

Present our experience of the use of liver transplantation in the management of unresectable bilateral neuroendocrine metastases.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of eight patients (four men and four women), with a mean age of 45 years, who underwent liver transplantation due to bilateral neuroendocrine liver metastases between January 1996 and January 2005. The most frequent location of the primary tumor was the pancreas in five patients (one carcinoid, one gastrinoma and three non-functioning tumors). The remaining three tumors were located in the small bowel (two) and in the lung.

RESULTS

Only one patient died due to technical complications related to the transplant, representing a mortality rate for the entire group of 14%. After a median follow-up of 3 years (range: 1 month-6 years), two patients died due to tumoral recurrence at 15 and 17 months, representing a tumoral recurrence rate of 33%. The survival rate at 1 and 3 years was 86% and 57%, respectively.

CONCLUSIONS

Despite the initial promising results obtained with liver transplantation in the management of unresectable neuroendocrine liver metastases, our results indicate that careful patient selection is required. The key to obtaining good results is individualization of the indication for this procedure.

Endocrine tumours of the gastrointestinal tract. Transplantation in the management of metastatic endocrine tumours

Patients with neuroendocrine tumours often present with synchronous liver metastases or develop hepatic metastases in the course of their disease. A complete removal of liver metastases with an intention to cure may be accomplished by liver resection or, if hepatic disease is disseminated or hormonal symptoms and pain cannot be controlled medically, by total hepatectomy and transplantation. The indications for orthotopic liver transplantation for metastatic neuroendocrine tumour disease should be anchored in a multimodal and multidisciplinary therapeutic approach. Approximately, 120-130 cases of orthotopic liver transplantation for neuroendocrine tumours have been published so far, but follow-up after transplantation has been limited, and most reports comprise a small number of patients. After considering published studies and data, some recommendations may be given, although these are based on a low level of evidence. After excluding extrahepatic tumour manifestations by imaging procedures and diagnostic laparoscopy, the indication should be chosen restrictively. Few prognostic markers, for example age below 50 years and absence of concurrent extensive surgery, were identified by multivariate analysis in a large retrospective analysis. The prognostic impact of primary tumour localisation is still controversial. However, further indicators of favourable long-term prognosis are needed. Tumour biology characterised by Ki67 and E-cadherin expression may help to identify patients with a favourable outcome so that patient selection can be improved, but this needs further evaluation in larger patient cohorts. Orthotopic liver transplantation for patients with remission of disease or stable disease under medical treatment, and orthotopic liver transplantation for palliative reasons, should be restricted to selected individual cases.

Endocrine tumours of the gastrointestinal tract. Management of metastatic endocrine tumours

Gastroenteropancreatic tumours are rare. They compromise a heterogenous class of neoplasm. If there is no hypersecretion syndrome, symptoms may be uncharacteristic and thus diagnosis occurs rather late after the first manifestations of the disease. The most important prognostic parameters are histological classification, the localisation of the primary, the tumour size and stage at diagnosis, and the presence or absence of metachronous or synchronous neoplasia. The article will focus on the importance of each of these parameters for the various treatment options in patients with metastatic disease.

Surgical treatment of advanced-stage carcinoid tumors: lessons learned

OBJECTIVE

To evaluate clinical outcomes in a large group of advanced-stage carcinoid patients (stage IV) following multimodal surgical therapy.

SUMMARY BACKGROUND DATA

Patients with advanced-stage carcinoid have traditionally experienced poor 5-year survival (18%-30%). Few recent series have evaluated a large number of patients treated with aggressive surgical rescue therapy.

METHODS

This single-center retrospective review analyzes the records of 82 consecutive carcinoid patients treated by the same 2 surgeons, from August 1998 through August 2004 with a 3- to 72-month follow-up.

RESULTS

Surprisingly, one third of 26 (32%) patients were found to have intestinal obstructions; 10 being moribund at presentation. Mesenteric encasement with intestinal ischemia was successfully relieved in 10 of 12 cases. Five of eighty-two "terminal" patients were rendered free of macroscopic disease. Karnofsky performance scores improved from 65 to 85 (P < 0.0001). Two- and four-year survival for patients with no or unilateral liver metastases (n = 23) was 89%, while 2- and 4-year survival for patients with bilateral liver disease (n = 59) was 68% and 52% (P = 0.072), respectively.

CONCLUSION

We think that all patients with advanced-stage carcinoid should be evaluated for possible multimodal surgical therapy. Primary tumors should be resected, even in the presence of distant metastases to prevent future intestinal obstruction. The "wait and see" method of management of this slow-growing cancer no longer has merit. We offer an algorithm for the surgical evaluation and management of these patients.

Palliative management strategies of advanced gastrointestinal carcinoid neoplasms

BACKGROUND/AIMS

Optimal management of gastrointestinal carcinoid neoplasms that metastasize to the liver is controversial. Although operative resection seems to be the most effective approach to metastatic disease, hepatic metastases are usually multicentric and often non-resectable. We investigated the effectiveness of several forms of palliative tumor cytoreduction followed by administration of somatostatin analogues in advanced carcinoid neoplasms.

METHODS

We reviewed our experience with 34 patients with gastrointestinal carcinoid neoplasms. Eighteen patients had metastases and 14 had hormonal symptoms. Twenty-two patients underwent radical surgery, ten with multiple liver metastases were treated with a combination of debulking (resection, radiofrequency ablation, chemoembolization), followed by medical treatment with long-acting octreotide and eventually by radiolabelled somatostatin analogues, and two patients with intractable disease received only biotherapies.

RESULTS

The six patients with metastatic disease who underwent radical curative liver resection had a median survival of 52 months, compared with a median survival of 48 months in the ten patients who underwent palliative debulking. Symptomatic improvement was observed in all the patients after debulking procedures. The two patients who underwent only medical treatment died after 9 and 18 months.

CONCLUSIONS

Aggressive tumor debulking should be performed in patients with liver metastases already at diagnosis even when complete resection is not feasible because the combination of cytoreductive procedures followed by biotherapies may provide good long-term survival and achieves symptom control in most patients with advanced disease.

Neuroendocrine hepatic metastases: does aggressive management improve survival?

OBJECTIVE

The aim of this study was to determine whether aggressive management of neuroendocrine hepatic metastases improves survival.

SUMMARY BACKGROUND DATA

Survival in patients with carcinoid and pancreatic neuroendocrine tumors is significantly better than adenocarcinomas arising from the same organs. However, survival and quality of life are diminished in patients with neuroendocrine hepatic metastases. In recent years, aggressive treatment of hepatic neuroendocrine tumors has been shown to relieve symptoms. Minimal data are available, however, to document improved survival with this approach.

METHODS

The records of patients with carcinoid (n = 84) and pancreatic neuroendocrine tumors (n = 69) managed at our institution from January 1990 through July 2004 were reviewed. Eighty-four patients had malignant tumors, and hepatic metastases were present in 60 of these patients. Of these 60 patients, 23 received no aggressive treatment of their liver metastases, 19 were treated with hepatic resection and/or ablation, and 18 were managed with transarterial chemoembolization (TACE) frequently (n = 11) in addition to resection and/or ablation. These groups did not differ with respect to age, gender, tumor type, or extent of liver involvement.

RESULTS

Median and 5-year survival were 20 months and 25% for the Nonaggressive group, >96 months and 72% for the Resection/Ablation group, and 50 months and 50% for the TACE group. The survival for the Resection/Ablation and the TACE groups was significantly better (P < 0.05) when compared with the Nonaggressive group. Patients with more than 50% liver involvement had a poor outcome (P < 0.001).

CONCLUSIONS

These data suggest that aggressive management of neuroendocrine hepatic metastases does improve survival, that chemoembolization increases the patient population eligible for this strategy, and that patients with more than 50% liver involvement may not benefit from an aggressive approach.

Current status of gastrointestinal carcinoids

Gastrointestinal (GI) carcinoids are ill-understood, enigmatic malignancies, which, although slow growing compared with adenocarcinomas, can behave aggressively. Carcinoids are classified based on organ site and cell of origin and occur most frequently in the GI (67%) where they are most common in small intestine (25%), appendix (12%), and rectum (14%). Local manifestations--mass, bleeding, obstruction, or perforation--reflect invasion or tumor-induced fibrosis and often result in incidental detection at emergency surgery. Symptoms are protean (flushing, sweating, diarrhea, bronchospasm), usually misdiagnosed, and reflect secretion of diverse amines and peptides. Biochemical diagnosis is established by elevation of plasma chromogranin A (CgA), serotonin, or urinary 5-hydroxyindoleacetic acid (5-HIAA), while topographic localization is by Octreoscan, computerized axial tomography (CAT) scan, or endoscopy/ultrasound. Histological identification is confirmed by CgA and synaptophysin immunohistochemistry. Primary therapy is surgical excision to avert local manifestations and decrease hormone secretion. Hepatic metastases may be amenable to cytoreduction, radiofrequency ablation, embolization alone, or with cytotoxics. Hepatic transplantation may rarely be beneficial. Chemotherapy and radiotherapy have minimal efficacy and substantially decrease quality of life. Intravenously administered receptor-targeted radiolabeled somatostatin analogs are of use in disseminated disease. Local endoscopic excision for gastric (type I and II) and rectal carcinoids may be adequate. Somatostatin analogues provide the most effective symptomatic therapy, although interferon has some utility. Overall 5-year survival for carcinoids of the appendix is 98%, gastric (types I/II) is 81%, rectum is 87%, small intestinal is 60%, colonic carcinoids is 62%, and gastric type III/IV is 33%.

Clinical endocrinology and metabolism. Gut endocrine tumours

Endocrine tumours of the gastrointestinal tract and pancreas may present at different disease stages with either hormonal or hormone-related symptoms/syndromes, or without hormonal symptoms. They may occur either sporadically or as part of hereditary syndromes. In the therapeutic approach to a patient with these tumours, excessive hormonal secretion and/or its effects should always be controlled first. A team approach is needed to achieve a balanced opinion on the use of the different therapeutic options in patients with these tumours.

Current concepts in functioning endocrine tumors of the pancreas

Duodenal and pancreatic endocrine tumors are uncommon and their surgical treatment is often difficult. The management of these tumors has changed with recent advancements in tumor localization, intraoperative hormone measurements, standardized surgical techniques, and a better understanding of the genetic basis of multiple endocrine neoplasia syndrome. We present our experience with 191 endocrine tumors and elaborate the contemporary management of functioning duodenopancreatic endocrine tumors.

Laparoscopic resection of a pancreatic polypeptidoma with a solitary liver metastasis

Pancreatic neuroendocrine tumor is an uncommon disease, and surgery is the only potentially curative treatment even when there is hepatic metastasis. A patient undergoing concomitant laparoscopic distal pancreatectomy and hepatectomy for pancreatic polypeptidoma with a solitary liver metastasis is reported.

Major hepatectomy with simultaneous pancreatectomy for advanced hepatobiliary cancer1 1No competing interests declared

BACKGROUND

Combined major hepatectomy with pancreatectomy (MHP) is a rarely used operation for the treatment of hepatobiliary cancer. Few reports have discussed the utility of this procedure and its indications are poorly defined. The aim of this study was to review our experience with MHP.

STUDY DESIGN

A review of our prospective hepatobiliary surgical database between January 1994 and July 2000 identified 17 patients who had undergone MHP. Preoperative radiographic and laboratory data, intraoperative findings, hospital outcomes, and longterm followup were obtained.

RESULTS

A total of 3,579 patients with hepatobiliary malignancy were seen at our institution, of which 1,280 underwent resection and 17 (1.3%) had an MHP. The median age was 58 years (range 24 to 76). Histology was as follows: eight neuroendocrine carcinoma, three sarcoma, two cholangiocarcinoma, one ampullary carcinoma, one gallbladder carcinoma, one gastric carcinoma recurrence, and one benign fibrosis. All 17 patients underwent resection of two or more hepatic segments. Nine patients underwent a distal pancreatectomy and eight underwent a pancreaticoduodenectomy. Median operative time was 6 hours (range 4 to 8) and the median blood loss was 900 mL (range 150 to 2,500). Postoperative complications occurred in eight patients (47%), and there were three perioperative deaths (18%). All three deaths occurred in patients who underwent a pancreaticoduodenectomy combined with a hemi-hepactomy or greater. Eight patients are free of disease with a median followup of 54 months. Six patients have recurred, two of whom have died of disease with a median disease-free interval of 8 months.

CONCLUSIONS

MHP is associated with a high morbidity and mortality and should only be considered in highly selected patients when a significant potential oncologic benefit is possible.

The doxorubicin-streptozotocin combination for the treatment of advanced well-differentiated pancreatic endocrine carcinoma; a judicious option?

Due to their rarity, only few trials have studied the role of the doxorubicin-streptozotocin (DS) combination in advanced well-differentiated pancreatic endocrine carcinomas (AWDPEC). However, the published results are inconsistent. We reviewed all AWDPEC (5-year period, 45 patients) treated in our institution with the DS combination for: objective response rate (ORR), progression-free survival, overall survival (OS) and toxicity. An ORR of 36% (95% Confidence Interval (CI) 22-49) was obtained, with 16 partial responses (PR). The mean duration of PR was of 19.7 months. Two and 3-year OS rates were 50.2 and 24.4%, respectively. Toxicities were mainly digestive (grade > or =3 vomiting, 13%) and haematological (grade > or =3 neutropenia, 24%). Previous systemic chemotherapy and malignant hepatomegaly were associated with a poorer ORR (P=0.033, P=0.016) and OS (P=0.008, P=0.045). Multivariate analysis demonstrated previous chemotherapy as the only independent predictive-factor for survival (P=0.013). In conclusion, our data confirm the sensitivity of AWDPEC to the DS combination, with an ORR of 36% and a remarkable median response duration of 19.7 months, and suggests that it could be considered as a valid option in first-line therapy.

Liver transplantation for neuroendocrine tumors

Liver transplantation for the treatment of metastatic neuroendocrine tumors (NETs) is radical. Although cure is not impossible, it is improbable. The reported experience with transplantation for NETs is limited to less than 150 cases with widely varying results and few 5-year disease-free survivors. We reviewed our experience with transplantation for patients with NETs. Fourteen symptomatic patients with unresectable NET liver metastases who had failed medical management were listed for transplantation. Two patients listed for transplantation underwent prior right lobectomies. Three patients were listed but did not undergo transplantation: one was lost to follow-up, one died 14 months after listing, and one remains waiting over 4 years. Eleven patients underwent liver transplantation, three with living donor grafts. There were four men (36.4%) and seven women (63.6%) who had a mean age of 51.2+/-6.3 years. Three patients had distal pancreatectomies and one patient had a Whipple procedure at the time of transplantation. There were six nonfunctioning tumors (54.6%), three carcinoid tumors (27.3%), and two (18.2%) Vipomas. In one patient, with fulminant hepatic failure, the NET was an incidental finding in the explant. The 1- and 5-year survival among transplanted patients is 73% and 36%, respectively, with a mean follow-up of 34+/-40 months (range 0 to 119 months). Of the three patients surviving more than 5 years, only one was disease free. In carefully selected patients with metastatic NETs, liver transplantation may be an appropriate option.

Insulinoma

More than 90% of insulinomas are benign tumors. Insulinomas cause hypoglycemia and thereby symptoms of neuroglycopenia and catecholamine response. During symptoms, blood glucose levels should be less than 40 mg/dl (less than 2.2 mmol/l), concomitant insulin levels should be > or =6 IU/ml (> or =43 pmol/l) and concomitant C-peptide levels > or =0.2 pmol/l. Most insulinomas can be identified intraoperatively by experienced surgeons. Initial therapy consists of administration of frequent meals and/or by glucose infusion. In patients with solitary insulinomas, complete surgical removal of the tumor should be the primary goal. In patients with metastatic insulinomas, symptoms of insulin hypersecretion will only completely disappear after complete resection of all metastases.

Role of liver transplantation in the management of metastatic neuroendocrine tumors

INTRODUCTION

In the majority of patients transplanted for unresectable liver metastases, long-term results are disappointing because of early tumor recurrence. Due to its biologically less aggressive nature, neuroendocrine metastases (NM) may represent a good indication for liver transplantation (LT).

PATIENTS AND METHODS

Between January 1996 and May 2000, five patients with NM were transplanted. The primary tumors were located in the pancreas (n=4) and the small bowel (n=1). In three cases there were symptoms related to hormone production: two carcinoids, and one gastrinoma. The management of primary tumors was sequential in three patients with the tumor being resected before LT (one Whipple procedure and two left pancreatectomies). In two patients the resections of the primary tumors and the LT were simultaneous namely one bowel resection and one left pancreatectomy. All patients were treated with chemotherapy.

RESULTS

Two patients developed recurrent disease succumbing at 15 months (nonfunctioning NE pancreatic head tumor) and 17 months (carcinoid of the pancreatic tail) post-LT. Another patient died at 3 months post-LT due to technical complications. The other two patients are alive and free of recurrence.

CONCLUSION

Despite the promising results obtained with LT for NM, our experience indicates that patients must be carefully selected. Perhaps the use of more aggressive chemotherapeutic protocols combined with an individualized approach will improve the results.

Surgical treatment of neuroendocrine metastases to the liver: a plea for resection to increase survival

BACKGROUND

Hepatic metastases from neuroendocrine tumors have a protracted natural history and are associated with endocrinopathies. Resection is indicated for symptom control. Previous reports have suggested improvement in survival for patients undergoing debulking procedures.

STUDY DESIGN

The records of all consecutive patients undergoing resection of hepatic metastases from neuroendocrine tumors between 1977 and 1998 were reviewed. Tumors were classified according to histology, endocrine activity, and primary location. Patients lost to followup before 1 year were excluded. Followups were based on outpatient evaluations and were updated by correspondence. The Kaplan-Meier method was used to generate survival and recurrence curves, and the log-rank test was used for comparison.

RESULTS

A total of 170 patients fulfilled the inclusion criteria, of whom 73 were men. Mean age (+/-SD) was 57 (+/-11.5) years. Carcinoid (n = 120) and nonfunctioning islet cell tumors (n = 18) predominated; the ileum (n = 85) and the pancreas (n = 52) were the most common primary sites. Major hepatectomy (one or more lobes) was performed in 91 patients (54%). The postoperative complication rate was 14%, and two patients died (1.2%). Operation controlled symptoms in 104 of 108 patients, but the recurrence rate at 5 years was 59%. Operation decreased 5-hydroxyindoleacetic acid levels considerably, and no patient experienced carcinoid heart disease postoperatively. Recurrence rate was 84% at 5 years. Overall survival was 61% and 35% at 5 and 10 years, respectively, with no difference between carcinoid and islet cell tumors.

CONCLUSIONS

Hepatic resection for metastatic neuroendocrine tumors is safe and achieves symptom control in most patients. Debulking extends survival, although recurrence is expected. Hepatic resection is justified by its effects on survival and quality of life.

Liver resection (and associated extrahepatic resections) for metastatic well-differentiated endocrine tumors: a 15-year single center prospective study

BACKGROUND

The timing and benefits of hepatectomy remain controversial for metastatic well-differentiated endocrine neoplasms, which are generally considered slow growth tumors. However, surveillance alone yields only a 22% 5-year survival when metastases occur. The aim of this study was to determine the results of hepatic and extra hepatic resections and to clarify the indications of surgery.

METHODS

To define the role of hepatic resection, a database regrouping all patients (n = 47) who underwent hepatectomy with curative intent (R0 status) for well-differentiated endocrine neoplasms in the Gustave-Roussy Institute was constructed in 1984. New prognostic factors such as tumor growth and liver tumor mitotic index were studied. Median follow-up was 62 months.

RESULTS

Hepatectomy was associated with extrahepatic tumor resection in 77% of the patients (primary tumor in 51%, lymph nodes in 21%, peritoneal carcinomatosis in 25%, and other in 6%). Resection was curative (R0) only in 53% of the patients, despite removing at least 97% of the tumor in each patient. Mortality was 5%, and morbidity was 45%. Median survival was 91 months, 5-year and 10-year overall survival rates were 71% and 35%, respectively. Liver recurrence rate was 75% at 10 years. No prognostic factor was correlated with overall survival in this population in which at least 97% of the tumor load was resected. The completeness of surgery, the presence of bilateral liver metastases, the number of liver metastases (>10) and a primary tumor from pancreatic origin were all significantly correlated with the disease-free survival. Preoperative tumor growth rate, mitotic index, and Ki67 expression were not predictive of prognosis. No significant prognostic factors could be found by the comparison of the patients who did and did not recur during the 3 years after hepatectomy.

CONCLUSION

Hepatectomy for liver metastases from well-differentiated endocrine neoplasms is indicated when all visible intra- and extra hepatic lesions can be resected safely. The number, size, and localization of the tumor sites are less important than performing a complete (or near-complete) resection.

Hepatic surgery for metastases from neuroendocrine tumors

Cytoreductive therapy is effective in the management of metastatic neuroendocrine tumors to the liver, independent of their functioning status. In functioning tumors, clinical endocrinopathies are relieved in most patients and this response usually lasts for several months. Major morbidity and mortality are not greater than the average complication rate for resection for nonneuroendocrine metastatic tumors at major centers; therefore, surgical outcomes appear to justify operative intervention. Patients whose primary tumor can be controlled, whose metastases outside the liver are limited, and who have a reasonable performance status are candidates for resection. The authors' data support the previous statements. The current mortality rate of 1.2% and major morbidity rate of 15% clearly represent the success of the operative approach in such complex cases (54% of patients received a resection of at least one lobe) [9]. A symptomatic response in the 95% range with a median response of 45 months adds many months of symptom-free survival to the lives of most patients [9]. In the literature reviewed for this article, more than half of the patients also underwent a major hepatic resection and 40% of them had concurrent resection of the primary tumor. These data confirm that resection in selected patients is not more complicated or risky than resection for other metastatic tumors. Endocrinopathies have not increased anesthetic or operative risk in this population; however, these results are the product of managing these patients over time, becoming familiar with their clinical syndromes, and being active in the prevention of life-threatening endocrine complications (i.e., carcinoid crisis). The authors have learned over time that patients with valvular disease are not good candidates for surgery. These patients develop right-sided heart failure with an increase in the central venous pressure. This condition can result in massive hemorrhage during the liver resection because of the difficulty in controlling backbleeding from the hepatic veins [26]. Correction of valvular disease is warranted for safe liver resection. The authors' current policy is to rule out valvular disease in every patient with carcinoid tumors and repair the valves prior to hepatic resection when indicated [27]. This policy clearly has decreased the complication rate. Even though liver transplantation seems to be very attractive as a means of eradicating the disease, this has not been common in clinical practice because of the shortage of allografts, and the overall costs and complications of the procedure override its benefits, especially when compared with partial hepatectomy. Current methods to detect the spread of disease that were not readily available in the past, such as MRI and indium-111 pentetreotide (Octreoscan), may expand the applications of transplantation and allow for better selection of candidates. The option of transplantation is still open for improvement and is dependent on organ availability and better staging of the disease. Metastases from neuroendocrine tumors are hypervascular, favoring the application of MRI as the single imaging method; MRI not only evaluates the location and characteristics of the lesions but also determines the relationship with major vessels and bile ducts. Spiral CT scan has been used extensively in the past with acceptable results. Indium-111 pentetreotide functions on the base of somatostatin receptors present in these tumors, but its use has not been established definitely in the work-up of these patients. Perhaps the best use of indium-111 pentetreotide is in the evaluation of disease beyond the primary and liver locations, including bone metastases; its use therefore will likely affect the preoperative work-up of candidates for transplantation [28]. Once the patient has been deemed to have resectable disease by the preoperative work-up, several steps need to be completed prior to surgery to decrease the effect of specific endocrinopathies. For patients with symptoms related to carcinoid tumors, preoperative preparation with 150 to 500 micrograms of somatostatin decreases the chances of carcinoid crisis, which is manifested by hemodynamic instability [29]. The use of this medication intraoperatively should be kept in mind because a carcinoid crisis can occur despite anesthetic premedication. For islet cell tumors, treatment of underlying endocrinopathy has been initiated before referral for surgical treatment in most patients. Surgery is appropriate for patients with metastatic neuroendocrine tumors for the following two reasons: (1) many of them still have the primary tumor in place and resection should be undertaken to avoid acute complications and (2) the addition of adjunctive ablative therapies to surgical resection accomplishes the control of greater than or equal to 90% of the bulk of the tumor. If preoperative evaluation indicates that less than 90% of the tumor is treatable, surgical therapy is contraindicated. Last, even when complete resections are performed, the recurrence rate for these tumors is extremely high. In practical terms, patients with metastatic neuroendocrine tumors are seldom cured. The best hope physicians can offer these patients is an extended survival period with minimal endocrine symptoms and decreased requirements of somatostatin analogs.

[The surgical treatment of liver metastasis of carcinoid tumors]

Liver metastasis of carcinoid tumors from the digestive tract are rare entities, with characteristic symptoms and slow evolution. Symptomatic metastases may justify surgical resection. Herein, we report a series of nine patients, who underwent 14 hepatic resections (6 major and 8 minor), which was radically operated in 71%. The postoperative mortality was zero and the morbidity was 7%. Mean follow-up was 82 month (median 75 months) and global survival rate was 89%. Two patients are in complete remission. Our experience suggest that surgical hepatic resection, when feasible, is efficient and associated with prolonged survival despite a high recurrence rate.

Periampullary pancreatic somatostatinoma

BACKGROUND

Somatostatinomas involving the gastrointestinal tract are extremely rare neoplasms that typically present with indolent, nonspecific symptoms in the absence of systemic neuroendocrine manifestations that characterize the somatostatinoma syndrome. Because of a relatively large size at the time of presentation (average diameter of 5 cm) and common location within the head of the pancreas, the Whipple procedure (pancreaticoduodenectomy) serves as the predominant modality for curative and palliative surgical approaches.

METHODS

Two cases of somatostatinoma involving the minor duodenal papilla with concomitant pancreatic divisum were reviewed, with a general overview of this unique islet cell tumor.

RESULTS

Unlike typical somatostatinomas, these two tumors were subcentimeter in size but were associated with synchronous regional metastasis.

CONCLUSIONS

Somatostatinomas are often associated with regional and/or portal metastases at the time of diagnosis, and only 60% to 70% of surgical cases result in complete tumor resection. Predictors of an unfavorable prognosis include size >3 cm, poor cytological differentiation, regional and/or portal metastasis, and incomplete surgical resection. Even in the presence of synchronous metastases, the 5-year overall survival for patients with somatostatinoma is approximately 40%. Currently, there are no clinical trials demonstrating significant improvement in survival with the use of adjuvant therapy.

Hepatic artery embolization for control of symptoms, octreotide requirements, and tumor progression in metastatic carcinoid tumors

Hepatic artery embolization (HAE) has been utilized for treatment of advanced hepatic carcinoid metastases, with promising symptom palliation and tumor control. Our institution employs transcatheter HAE using Lipiodol/Gelfoam for treatment of carcinoid hepatic metastases, and this report presents our experience with twenty-four patients, examining symptom control, quality-of-life, octreotide dependence, and tumor progression. Twenty-four (11 male, 13 female, mean age = 59.4 +/- 2.5 yr) patients with carcinoid and unresectable hepatic metastases, confirmed by urinary 5-hydroxyindole acetic acid (5-HIAA) measurement and biopsy, were treated with Lipiodol/Gelfoam HAE from 1993-2001. Median follow-up was 35.0 months. Before HAE, 14 patients (58.3%) had malignant carcinoid syndrome, with symptoms quantified using our previously reported Carcinoid Symptom Severity Score, and 13 patients (54.2%) required octreotide for symptom palliation. Following treatment, symptom severity, octreotide dose, and tumor response were measured. Asymptomatic patients did not develop symptoms or require following treatment. Hepatic metastases remained stable (n = 4) or decreased (n = 19) in 23 patients (95.8%). Mean pretreatment Symptom Severity Scores (3.8 +/- 0.2), decreased to 1.4 +/- 0.1 post-treatment (P < 0.00001), with 64.3% of patients becoming asymptomatic. Mean pretreatment octreotide dosages (679.6 +/- 73.0 microg/d), decreased to 262.9 +/- 92.7 microg/d (P = 0.0024) post-treatment, with 46.2% of patients discontinuing octreotide. There were no treatment-related serious complications or deaths. This study demonstrates that Lipiodol/Gelfoam HAE produces excellent control of malignant carcinoid syndrome, allowing patients to decrease or eliminate use of octreotide, while controlling hepatic tumor burden.

Hepatic cytoreduction followed by a novel long-acting somatostatin analog: a paradigm for intractable neuroendocrine tumors metastatic to the liver

BACKGROUND

Optimal management of symptomatic neuroendocrine tumors that metastasize to the liver is controversial. We investigated aggressive hepatic cytoreduction and postoperative administration of octreotide long-acting release (LAR), a long-acting somatostatin analog.

METHODS

Between December 1992 and August 2000, 31 patients underwent hepatic surgical cytoreduction (20 carcinoid, 10 islet cell, and 1 medullary). All patients had progressive symptoms refractory to conventional therapy.

RESULTS

Hepatic cytoreduction (resection, cryosurgery, and/or radiofrequency ablation) eliminated symptoms in 27 patients (87%) and decreased secretion of hormones by an overall mean of 59%. When minor symptoms returned and/or hormonal levels increased during follow-up, adjuvant therapy was started. Ten patients received adjuvant octreotide LAR once a month, and 21 received other adjuvants. At a median postoperative follow-up of 26 months, 16 patients had progressive/recurrent disease, 13 had died of their disease, and 2 remained free of disease. Median symptom-free interval was 60 months (95% confidence interval, 48-72) with octreotide LAR and 16 months (95% confidence interval, 10-29) with other adjuvants (P = .0007). Two-year symptom-free survival rate was 100% with octreotide LAR and 33% with other adjuvants.

CONCLUSIONS

Hepatic surgical cytoreduction can palliate progressive symptoms associated with liver metastases from intractable neuroendocrine tumors. Postoperative adjuvant therapy with octreotide LAR can prolong symptom-free survival.

Metastasectomy for liver metastases of non-colorectal primaries

BACKGROUND

Resection of liver metastases of non-colorectal primary malignancies has been reported to prolong survival. We studied the results in our hospital and compared the survival data with that described in the literature.

PATIENTS AND METHODS

Since 1991, a prospective database has been kept at The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital of patients undergoing hepatic surgery (n=180). Between 1991 and 1999, 32 patients underwent laparotomy for hepatic metastases of non-colorectal primaries. This study evaluates the operative technical aspects and determines morbidity, mortality, disease-free and overall survival.

RESULTS

There were 11 males and 21 females with a median age of 52 (25-69) years. Histology of the primary tumour were various carcinomas (n=22), melanomas (n=4) and sarcomas (n=6). Resection was performed in 28 patients; four patients appeared to be irresectable. There was no perioperative mortality. Morbidity was 23%. One re-operation was necessary because of haemorrhage. The median disease-free survival for the 28 patients was 12 months with an actuarial 5-year disease-free survival of 20% (Kaplan-Meier). The 5-year overall survival was 35% with a median survival of 21 months.

CONCLUSION

Liver metastasectomy for selected types of non-colorectal primary tumours is relatively safe and shows in selected patients long-term survival comparable to that of metastasectomies for colorectal origin.

The surgical management of pancreatic neuroendocrine tumors

NETs of pancreas are rare and may or may not be associated with symptoms of hormone overproduction. Treatment is required for control of tumor growth and for relief of symptoms associated with excess hormone. With advances in the nonsurgical management of many hormone-related symptoms (e.g., proton pump inhibitors or somatostatin analogues), care for many of these patients has shifted toward the control of tumor progression. Complete surgical resection is the only curative treatment for these tumors. With improvements in the preoperative imaging and intraoperative localization techniques, it is hoped that these tumors will be identified and resected for cure with increased frequency. For patients with hepatic metastasis, initial expectant observation and medical management of symptoms is appropriate in view of the long and indolent course of the disease. Hepatic arterial embolization is the preferred mode of palliation for pain and hormonal symptoms. A curative hepatic resection may be possible in selected patients.

Islet cell tumors of the pancreas: the medical oncologist's perspective

Islet cell tumors of the pancreas are rare, indolent, neuroendocrine tumors. Approximately 50% of the patients diagnosed with these tumors present with symptoms related to various biologically active hormones that are secreted by these neoplasms. Currently, the only curative treatment for islet cell tumors is complete surgical resection. Management of metastatic disease is conservative. Initial treatment of these tumors includes expectant observation and medical management of symptoms with clinical monitoring and serial CT scans to assess tumor growth. Patients with rapidly progressive disease, with local symptoms caused by tumor bulk, or with uncontrolled symptoms related to hormone secretion require more aggressive medical or surgical intervention. The somatostatin analogue octreotide may help control hormone secretion and stabilize tumor growth. Patients refractory to octreotide with tumor predominantly in the liver are potential candidates for mechanical ablative techniques, such as hepatic arterial embolization. Radiofrequency ablation and cryosurgical techniques may also be useful, although specific data are limited. Surgical resection of metastatic disease may offer palliative relief of symptoms related to hormone secretion in carefully selected patients. Chemotherapy may be used for palliation when ablative techniques have failed or when significant extrahepatic disease is present. Streptozicin-based combinations remain the first line standard, but major objective responses are less common than had been previously thought. Because of the overall modest success of current chemotherapeutic regimens, patients with advanced disease in need of treatment should be encouraged to enroll in clinical trials testing newer antineoplastic agents or newer treatment strategies.

Surgery as primary treatment in patients with liver metastases from carcinoid tumors: a retrospective, unicentric study over 13 years

BACKGROUND

The heterogeneous nature of carcinoid tumors makes it difficult to develop a standardized treatment strategy for the primary tumor itself and for probable liver metastases. However, prolongation of the 5-year survival rate (5-ysr) and amelioration of the incapacitating symptoms after resection of the primary tumor and its metastases demonstrate that surgical intervention must be the treatment of choice in these tumors.

METHODS

The data of 31 patients (17 patients with midgut carcinoids, 10 patients with an endocrine carcinoma (carcinoid) of the pancreas, and 4 patients with carcinoids of the lung) who underwent liver operation for metastatic carcinoid tumors between 1983 and 1996 were analyzed, with special regard to factors influencing postoperative survival.

RESULTS

Ten patients underwent curative resection (5-ysr, 86%), and palliative operations were performed in 21 patients (5-ysr, 26%). The overall 5-ysr was 47%, with a mean postoperative follow-up of 3.5 years (range, 4 months to 10.8 years). Postoperative morbidity rate was 13%. Size of liver metastases, radicality of the operation and localization of the primary tumor were factors influencing postoperative survival.

CONCLUSIONS

Surgery for metastatic carcinoid tumors may be curative or palliative, with a potential for cure in some cases and prolongation of survival and amelioration of symptoms in the majority of patients.

Radiofrequency ablation treatment of refractory carcinoid hepatic metastases

BACKGROUND

Our institution has experienced excellent success using hepatic artery embolization for treating symptoms and slowing tumor progression for patients with unresectable hepatic metastases for carcinoid tumors. Our previous treatment strategies used hepatic artery embolization alone, examining control of symptoms and dependence on octreotide therapy. However, some patients exhibit hepatic metastases that are unresponsive to embolization. This report describes the use of radiofrequency ablation (RFA) as salvage treatment for these refractory metastases.

METHODS

Thirteen patients with unresectable bilobar hepatic metastases from biochemically confirmed carcinoid tumors were treated with selective hepatic artery embolization using Lipiodol/Gelfoam between 1994 and 2000. Three patients developed symptoms resistant to embolization treatment resulting from progression of existing metastases or development of new metastases. These patients underwent surgical exploration and intraoperative ultrasound of their refractory lesions, followed by treatment with RFA. Tumor size, symptoms of carcinoid syndrome, and octreotide requirements were monitored postoperatively.

RESULTS

Median follow-up for the three patients treated with RFA was 6 months. During the first 3-month interval following RFA, all three patients demonstrated decrease in the size of treated lesions. Using our previously developed symptom scoring system, all three patients demonstrated decreased symptoms following treatment. One patient was able to discontinue octreotide treatment, and the other two patients required decrease octreotide dosages.

CONCLUSIONS

This study demonstrates that utilization of RFA treatment for carcinoid metastases refractory to hepatic artery embolization may represent a useful adjunct for symptomatic control, decreased octreotide dependence, and slowing of disease progression.

Interventional treatment of gastrointestinal neuroendocrine tumours

Neuroendocrine (NE) tumours of the gastrointestinal tract (carcinoids and endocrine pancreatic tumours) are rare diseases. In the presence of liver metastases these patients may suffer from disabling symptoms due to hormone overproduction. Patients with localized disease can be resected for cure and also patients with liver metastases can undergo potentially curative tumour resection. However, long-term follow-up of the latter cases indicates frequent recurrence of tumour. Using close biochemical monitoring of tumour markers combined with newer techniques for tumour visualization, these recurrences can often be diagnosed at an early stage so that repeat surgical procedures can be performed. During the last years very active surgery has been recommended for NE tumours, many of which have a relatively slow growth. Even in patients not amenable to curative liver surgery, debulking can be considered if the main tumour burden can be safely excised. The primary aim of this type of treatment is palliation of hormonal symptoms. An important question is whether the aggressive treatment actually prolongs survival. No prospective studies have been performed. Such studies are hampered by the lack of strict surgical programs running over long periods and the relative rarity of NE tumours. Liver transplantation may be another treatment modality in selected cases.

Hepatic neuroendocrine metastases: does intervention alter outcomes?

BACKGROUND

In most instances, advanced neuroendocrine tumors follow an indolent course. Hepatic metastases are common, and although they can cause significant pain, incapacitating endocrinopathy, and even death, they are usually asymptomatic. The appropriate timing and efficacy of interventions, such as hepatic artery embolization (HAE) and operation, remain controversial.

STUDY DESIGN

The records of 85 selected patients referred for treatment of hepatic neuroendocrine tumor metastases between 1992 and 1998 were reviewed from a prospective database. A multidisciplinary group of surgeons, radiologists, and oncologists managed all patients. Overall survival among this cohort is reported and prognostic variables, which may be predictive of survival, are analyzed.

RESULTS

There were 37 men and 48 women, with a median age of 52 years. There were 41 carcinoid tumors, 26 nonfunctional islet cell tumors, and 18 functional islet cell tumors. Thirty-eight patients had extrahepatic metastases, and in 84% of patients, the liver metastases were bilobar. Eighteen patients were treated with medical therapy or best supportive care, 33 patients underwent HAE, and 34 patients underwent hepatic resection. Both the HAE-related mortality and the 30-day operative mortality rates were 6%. By univariate analysis, earlier resection of the primary tumor, curative intent of treatment, and initial surgical treatment were associated with prolonged survival (p < 0.05). On multivariate analysis, only curative intent to treat remained significant (p < 0.04). Patients with bilobar or more than 75% liver involvement by tumor were least likely to benefit from surgical resection. One-, 3-, and 5-year survival rates for the entire group were 83%, 61%, and 53%, respectively. The 1-, 3-, and 5-year survivals for patients treated with medical therapy, HAE, and operation were 76%, 39%, and not available; 94%, 83%, and 50%; and 94%, 83%, and 76%, respectively.

CONCLUSIONS

Hepatic metastases from neuroendocrine tumors are best managed with a multidisciplinary approach. Both HAE and surgical resection provide excellent palliation of hormonal and pain symptoms. In select patients, surgical resection of hepatic metastases may prolong survival, but is rarely curative.