Long-term outcome after chemoembolization and embolization of hepatic metastatic lesions from neuroendocrine tumors

[A case of epidural abscess occurred after liver abscess complicated by transarterial chemoembolization in a patient with metastatic cancer to liver]

Transarterial chemoembolization (TACE) is one of the most effective therapies for unresectable hepatocelluar carcinoma or metastatic hypervascular tumors. Abscess occurring in the other organs beside the liver after TACE is a complication that often occurs, sometimes potentially fatal. We report a case of spinal epidural abscess occurred after liver abscess complicated by TACE in a patient with metastatic neuroendocrine tumors to the liver. A 67-year-old female underwent TACE first for the metastatic lesions to liver, with a history of pancreatoduodenectomy for the primary pancreatic neuroendocrine tumor. Four days after TACE, sudden high fever occurred, and liver abscess was found on abdominal CT. Two days later, back pain and radiating pain to the right leg occurred, and lumbar spine MRI showed spinal epidural abscess. After intravenous antibiotics for 8 weeks and partial laminectomy, the patient recovered and was discharged without complications.

Production and quality control of [(90)Y]DOTATOC for treatment of metastatic neuroendocrine tumors: results of 85 syntheses

The aim of this paper was to describe the optimized labeling protocol and quality control measures used in the production of [(90)Y]DOTATOC, starting from three different radioactivity levels to treat one, two, or three patients per therapeutic session. We investigated three different starting radioactivity levels. For the low radioactivity preparation we used 5138±280 MBq of [Y] isotope, for the medium radioactivity preparation we used 8893±900 MBq, and for the high radioactivity preparation we used 11250±715 MBq. The radiochemical purity levels for the low radioactivity preparation, medium radioactivity preparation, and high radioactivity preparation were 99.95±0.09, 99.84±0.34, and 99.84±0.53%, respectively, and the radiochemical yields of the labeling procedures were 77.52±1.28, 75.53±3.72, and 78.00±3.20%, respectively. Media fill validation of the process was performed, and the parameters of pH, bacterial endotoxins, sterility, and osmolality were tested at process control. All radiopharmaceutical preparations satisfied the predetermined specifications fixed in our protocol regardless of the starting radioactivity level. The validation of the method guaranteed the safety and quality of the final products, contributing to providing the basis for constructing an informative and successful clinical trial.

Intervention in gastro-enteropancreatic neuroendocrine tumours

Neuroendocrine tumours require dedicated interventions to control their capacity to secrete hormones but also, antitumour growth strategies. Recommendations for early interventions in NET include the management of hormone-related symptoms and poorly differentiated neuroendocrine carcinomas. In contrast, prognostic heterogeneity is a key feature of well differentiated NET that complexified the antitumour strategy whatever the stage in this subgroup of tumour. In this review, timely therapeutic interventions to control hormone-related symptoms and tumour growth in GEP NET patients are discussed. The necessity of controlling hormone-related symptoms as the first step of any strategy affects also the tumour growth control strategy. In the absence of cure at the metastatic stage, progresses are expected in the recognition of well differentiated NET subgroups that display either excellent or poor prognosis.

Repetitive transarterial chemoembolization (TACE) of liver metastases from gastric cancer: local control and survival results

OBJECTIVE

To evaluate the local tumor control and survival data after transarterial chemoembolization with different drug combinations in the palliative treatment of patients with liver metastases of gastric cancer.

MATERIALS AND METHODS

The study was retrospectively performed. 56 patients (mean age, 52.4) with unresectable liver metastases of gastric cancer who did not respond to systemic chemotherapy were repeatedly treated with TACE in 4-week intervals. In total, 310 chemoembolization procedures were performed (mean, 5.5 sessions per patient). The local chemotherapy protocol consisted of mitomycin alone (30.4%), mitomycin and gemcitabine (33.9%), or mitomycin, gemcitabine and cisplatin (35.7%). Embolization was performed with lipiodol and starch microspheres. Local tumor response was evaluated by MRI according to RECIST. Survival data from first chemoembolization were calculated according to the Kaplan-Meier method.

RESULTS

The local tumor control was: complete response in 1.8% (n=1), partial response in 1.8% (n=1), stable disease in 51.8% (n=29) and progressive disease in 44.6% (n=25) of patients. The 1-, 2-, and 3-year survival rate from the start of chemoembolization were 58%, 38%, and 23% respectively. The median and mean survival times were 13 and 27.1 months. A Statistically significant difference between patients treated with different chemotherapy protocols was noted (ρ=0.045) with the best survival time in the mitomycin, gemcitabine and cisplatin group.

CONCLUSION

Transarterial chemoembolization is a minimally invasive therapy option for palliative treatment of liver metastases in patients with gastric cancer.

Radioembolization and chemoembolization for unresectable neuroendocrine liver metastases - a systematic review

This review examines the clinical efficacy and safety of the use of hepatic arterial chemoembolization, bland embolization and radioembolization in the treatment of unresectable neuroendocrine tumor liver metastases (NETLM). Response to treatment, survival outcome and toxicity were examined in this review of 37 studies comprising 1575 patients. These therapies are safe and effective in the treatment of NETLM. Prospective clinical trials to compare the relative efficacy and toxicity are warranted.

Liver-directed therapies in liver metastases from neuroendocrine tumors of the gastrointestinal tract

Presence of liver metastases in neuroendocrine tumors is a major factor altering both quality of life and prognosis. Surgery is recognized as the sole curative treatment. When it is not possible, radiological directed therapies are crucial, particularly in liver metastases from the small bowel. Thermal ablative therapies as radiofrequency ablation and microwave are alternative treatments alone or in combination with surgery. Hepatic artery embolization or chemoembolization, as radioembolization, has been shown to have good clinical, biochemical, and morphological responses when liver burden does not permit ablative therapies. However, technical issues are multiple and there is no randomized study to compare their efficacy. The choice of management depends on liver burden and metastases pattern, but also on origin of the primary tumor, tumor differentiation, and tumor proliferative activity. These patients should benefit of a multidisciplinary management to limit morbidity and mortality.

Hepatic artery embolization for neuroendocrine tumors: postprocedural management and complications

BACKGROUND

There is scant evidence to guide the management of patients after hepatic artery embolization (HAE). We examined length of stay (LOS), laboratory patterns, medication usage, morbidity, and mortality of patients hospitalized after HAE for metastatic neuroendocrine tumors.

METHODS

Data were abstracted retrospectively from electronic medical records on LOS, liver function tests (LFTs), i.v. antibiotics, analgesia, peak temperature, bacteremia, hepatic abscess formation, carcinoid crisis, and metastatic burden on cross-sectional imaging.

RESULTS

In 2005-2009, 72 patients underwent 174 HAEs for carcinoid and islet cell tumors. The median LOS was 4 days (range, 1-8 days). There was no correlation between peak LFTs and tumor burden. Declines in LFTs were not uniform before hospital discharge; 25%, 37%, 30%, 53%, and 67% of patients were discharged before their respective aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and total and direct bilirubin levels began to decline, with no readmissions for acute hepatic failure. The median i.v. analgesia dose was 60 mg oral morphine equivalents (range, 3-1,961 mg). Pre-HAE i.v. antibiotics were administered in 99% of cases; post-HAE fever occurred in 37% of patients, with no documented bacteremia. One patient developed a hepatic abscess after HAE. There were two carcinoid crises. The single in-hospital death was associated with air in the portal veins.

CONCLUSIONS

The duration and intensity of in-hospital care following HAE should be managed on an individual basis. A downward trend in LFTs is not required before discharge. Modest use of i.v. analgesia suggests that many patients could exclusively receive oral analgesics. Given the rarity of serious complications, hospital stays could be shortened, thereby reducing costs and nosocomial risks.

Treatment of liver metastases in patients with neuroendocrine tumors of gastroesophageal and pancreatic origin

Well-to-moderately differentiated neuroendocrine tumors of gastroesophageal and pancreatic origin (GEP-NETs) with liver metastasis are a heterogeneous group of malignancies for which a range of therapeutic options have been employed. Surgical resection of hepatic metastases or hepatic artery embolization may be beneficial in patients with hepatic-predominant metastatic disease. Patients with "carcinoid" syndrome and syndromes associated with functional pancreatic NET (PNET) can be effectively treated with somatostatin analogs. On the other hand, the efficacy of systemic chemotherapy for these patients is limited. A placebo-controlled, double-blind, prospective, and randomized study showed that octreotide LAR improves progression-free survival in patients with advanced midgut functional "carcinoids." In patients with advanced pancreatic NET, randomized, placebo-controlled studies have recently demonstrated that treatment with the tyrosine kinase inhibitor sunitinib or with mTOR inhibitor everolimus is associated with improved progression-free survival. Based on these studies, octreotide LAR, sunitinib, or everolimus are now considered as first-line therapeutic options in patients with advanced NET. Future studies will likely further define the role of these agents in patients with carcinoid liver metastasis and pancreatic NET liver metastasis.

New treatment strategies in advanced neuroendocrine tumours

Malignant well-differentiated neuroendocrine tumours of the pancreas and the gastrointestinal tract are rare and clinically challenging heterogeneous neoplasms. This review focuses on neuroendocrine tumours grade 1 and grade 2 (new WHO classification 2010), in comparison to the neuroendocrine tumours grade 3 group, corresponding to poorly differentiated neuroendocrine carcinomas. Surgical resection of the primary and metastases remains the only curative treatment, however many patients with neuroendocrine tumours are diagnosed once unresectable metastases have occurred; management of functioning syndromes with somatostatin analogues remains the priority. Pasireotide, a new somatostatin analogue, is currently undergoing evaluation for carcinoid syndrome. Treatment options for advanced neuroendocrine tumours differ from pancreatic gastrointestinal tract neuroendocrine tumours: (a) in pancreatic neuroendocrine tumours, streptozotocin-based chemotherapies are challenged by other cytotoxic agents (dacarbazine, temozolomide and oxaliplatin); two randomized, placebo-controlled phase III studies have demonstrated that everolimus and sunitinib significantly improved progression-free-survival; (b) in midgut neuroendocrine tumours, octreotide improved time-to-progression in patients with a low proliferation index and low liver burden; preliminary data suggesting efficacy of bevacizumab are still to be confirmed; the effect of everolimus associated with octreotide was almost significant on progression-free-survival in a phase III trial. Liver-directed therapies are effective in both tumour types. New techniques of embolization need further evaluation and must be formally compared to other therapies. Finally, peptide receptor radionuclide therapy has shown promising activity in non-comparative studies in advanced neuroendocrine tumours.

Surgical treatment of liver metastases in neuroendocrine neoplasms

Neuroendocrine neoplasms (NENs) are a distinctive entity, and nearly 10% of patients already have liver metastases at presentation. The management of neuroendocrine liver metastases (NEN-LM) is complex with differing patterns of metastatic presentation. An aggressive approach should be used to resect the primary tumor, to remove regional lymph nodes, and to resect or treat appropriate distant metastases (including liver tumors). Despite having an indolent course, NENs have a significantly reduced survival when liver metastases are untreated. Though a wide range of therapies are now available with a multimodal approach to the treatment, surgical treatment offers the only chance for a significant survival prolongation and/or improvement of symptoms and quality of life. A review of the existing surgical modalities for NEN-LM is discussed in this paper.

A multimodal approach to the management of neuroendocrine tumour liver metastases

Neuroendocrine tumours (NETs) are often indolent malignancies that commonly present with metastatic disease in the liver. Surgical, locoregional, and systemic treatment modalities are reviewed. A multidisciplinary approach to patient care is suggested to ensure all therapeutic options explored.

Hepatic arterial embolization versus chemoembolization in the treatment of liver metastases from well-differentiated midgut endocrine tumors: a prospective randomized study

BACKGROUND

Liver surgery is the best treatment for endocrine liver metastases, but it is often impossible due to diffuse disease. Systemic chemotherapy is poorly effective. Hepatic arterial embolization (HAE) and chemoembolization (HACE) have shown efficacy but have never been compared.

PATIENTS AND METHODS

Patients with progressive unresectable liver metastases from midgut endocrine tumors were randomly assigned to receive HAE or HACE (two procedures at 3-month interval). The primary end point was the 2-year progression-free survival (PFS) rate. Secondary end points were response rates, overall survival, and safety.

RESULTS

Twelve patients were assigned to receive HACE and 14 to receive HAE. The patient characteristics were well matched across the treatment arms. The 2-year PFS rates were 38 and 44% in the HACE and HAE arms, respectively (p = 0.90). Age, gender, previous resection of the primary tumor or liver metastases, extent of liver involvement, and concomitant treatment with somatostatin analogues were not associated with changes in PFS, whereas elevated baseline urinary 5-HIAA and serum chromogranin A levels were associated with shorter PFS. The 2-year overall survival rates were 80 and 100% in the HACE and HAE arms, respectively (p = 0.16). The disease control rate on CT scan was 95%. Grade 3 toxicity occurred in 19% of patients, with no treatment-related deaths and no differences in the treatment arms.

CONCLUSION

HACE and HAE are safe and permit tumor control in 95% of patients with progressive liver metastases from midgut endocrine tumors. The 2-year PFS was not higher among patients receiving HACE, not favoring the hypothesis of an additive efficacy of arterial chemotherapy or embolization alone.

Treatment of neuroendocrine tumor liver metastases

In the care of patients with hepatic neuroendocrine metastases, medical oncologists should work in multidisciplinary fashion with surgeons, interventional radiologists, and radiation oncologists to assess the potential utility of liver-directed and systemic therapies. This paper addresses the various roles and evidence basis for cytoreductive surgery, thermal ablation (radiofrequency, microwave, and cryoablation), and embolization (bland embolization (HAE), chemoembolization (HACE), and radioembolization) as liver-directed therapies. Somatostatin analogues, cytotoxic chemotherapy, and the newer agents everolimus and suntinib are discussed as a means for controlling intra- and extrahepatic disease, along with peptide receptor radiotherapy (PRRT). Finally, the experience with orthotopic liver transplant for neuroendocrine tumors is described.

Hepatic arterial embolization for the treatment of metastatic neuroendocrine tumors

Neuroendocrine tumors (NETs) have a high predilection for metastasizing to the liver and can cause severe debilitating symptoms adversely affecting quality of life. Although surgery remains the treatment of choice, many liver metastases are inoperable at presentation. Hepatic arterial embolization procedures take advantage of the arterial supply of NET metastases. The goals of these therapies are twofold: to increase overall survival by stabilizing tumor growth, and to reduce the morbidity in symptomatic patients. Patients treated with hepatic arterial embolization demonstrate longer progression-free survival and have 5-year survival rates of nearly 30%. The safety of repeat embolizations has also been proven in the setting of recurrent symptoms or progression of the disease. Despite not being curative, hepatic arterial embolization should be used in the management of NETs with liver metastases. Long-term survival is not uncommon, making aggressive palliation of symptoms an important component of treatment.

Initial experience with repetitive transarterial chemoembolization (TACE) as a third line treatment of ovarian cancer metastasis to the liver: indications, outcomes and role in patient's management

OBJECTIVE

To evaluate local tumor control and survival data after transarterial chemoembolization (TACE) with different drug combinations in the palliative third-line treatment of patients with ovarian cancer liver metastases.

METHODS

Sixty-five patients (mean age: 51.5 year) with unresectable hematogenous hepatic metastases of ovarian cancer who did not respond to systemic chemotherapy were repeatedly treated with TACE in 4-week intervals. The local chemotherapy protocol consisted of Mitomycin (group 1) (n=14; 21.5%), Mitomycin with Gemcitabine (group 2) (n=26; 40%), or Mitomycin with Gemcitabine and Cisplatin (group 3) (n=25; 38.5%). Embolization was performed with Lipiodol and starch microspheres. Local tumor response was evaluated by MRI according to RECIST criteria. Survival data were calculated according to the Kaplan-Meier method.

RESULTS

The local tumor control was: partial response (PR) in 16.9% (n=11), stable disease (SD) in 58.5% (n=38) and progressive disease (PD) in 24.6% (n=16) of patients. In group 1, we observed SD in 78.6% (11/14), and PD in 21.4% (3/14) of patients. In group 2, PR in 7.7% (2/26), SD in 57.7% (15/26), and PD in 34.6% (9/26) of patients. In group 3, PR in 36% (9/25), SD in 48% (12/25), and PD in 16% (4/25) of patients. Survival rate from the start of TACE was 58% after 1-year, 19% after 2-years, and 13% after 3-years. The median and mean survival times were 14 and 18.5 months without statistically significant difference for the 3 groups of patients (p=0.502).

CONCLUSION

Transarterial chemoembolization is effective palliative treatment in achieving local control in selected patients with liver metastases from ovarian cancer.

Multimodality treatment of neuroendocrine liver metastases

BACKGROUND

Neuroendocrine liver metastases have a distinct tumor biology and symptomatology that render their management challenging. This difficulty is reflected in the literature, which lacks consensus on a treatment algorithm. The aim of this study is to propose a treatment algorithm based on patient morbidity and the efficacy of different treatment options.

METHODS

The medical records of 127 patients with neuroendocrine liver metastases were reviewed. As first-line treatment, 69 of these patients underwent radiofrequency ablation (RFA), 29 patients were treated by liver resection, and 29 underwent embolization. Clinical characteristics and surgical parameters were analyzed with the chi-square test, and cumulative survival was analyzed with the Kaplan-Meier method. All data are expressed as mean ± standard error of the mean.

RESULTS

Of the 3 treatment modalities, RFA was the most commonly used initial treatment for patients with up to approximately 16 discrete lesions. Resection was used to debulk large tumors of limited number. Embolization was the first-line treatment for more extensive disease not amenable to RFA or resection. RFA provided effective cytoreduction while affording patients a shorter duration of stay and lower complication rates. On univariate analysis, the size of dominant metastases, extrahepatic disease, resection of primary tumor, and treatment modality affected survival. On multivariate analysis, sex, the size of dominant metastases, and extrahepatic disease were independent predictors of survival.

CONCLUSION

To our knowledge, this study is the largest report on a multimodality approach to the treatment of neuroendocrine liver metastases yet published in the literature. Because of the patient selection criteria used in our study, a direct comparison of the treatment arms is not strictly possible. We used an initial treatment algorithm based on the presentation of the patient. Because this disease has a multifocal nature and accompanying elevated recurrence rate, careful follow-up of patients and subsequent treatments are often needed to minimize disease burden.

Surgery versus intra-arterial therapy for neuroendocrine liver metastasis: a multicenter international analysis

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.

Current surgical management of pancreatic endocrine tumor liver metastases

BACKGROUND

The management of metastatic disease in pancreatic endocrine tumors (PETs) demands a multidisciplinary approach and the cooperation of several medical specialties. The role of surgery is critical, even when a radical excision cannot always be achieved.

DATA SOURCES

A PubMed search of relevant articles published up to February 2011 was performed to identify current information about PET liver metastases regarding diagnosis and management, with an emphasis on surgery.

RESULTS

The early diagnosis of metastases and their accurate localization, most commonly in the liver, is very important. Surgical options include radical excision, and palliative excision to relieve symptoms in case of failure of medical treatment. The goal of the radical excision is to remove the primary tumor bulk and all liver metastases at the same time, but unfortunately it is not feasible in most cases. Palliative excisions include aggressive tumor debulking surgeries in well-differentiated carcinomas, trying to remove at least 90% of the tumor mass, combined with other additional destructive techniques such as hepatic artery embolization or chemoembolization to treat metastases or chemoembolization to relieve symptoms in cases of rapidly growing tumors. The combination of chemoembolization and systemic chemotherapy results in better response and survival rates. Other local destructive techniques include ethanol injection, cryotherapy and radiofrequency ablation.

CONCLUSION

It seems that the current management of PETs can achieve important improvements, even in advanced cases.

Hepatic arterial chemoembolization using drug-eluting beads in gastrointestinal neuroendocrine tumor metastatic to the liver

PURPOSE

This study was designed to evaluate short (<3 months) and intermediate-term (>3 months) follow-up in patients with metastatic neuroendocrine tumor to the liver who underwent hepatic arterial chemoembolization with drug-eluting beads at a single institution.

METHODS

Institutional review board approval was obtained for this retrospective review. All patients who were treated with 100-300 or 300-500 μm drug-eluting LC Beads (Biocompatibles, UK) preloaded with doxorubicin (range, 50-100 mg) for GI neuroendocrine tumor metastatic to the liver from June 2004 to June 2009 were included. CT and MRI were evaluated for progression using Response Evaluation Criteria In Solid Tumors (RECIST) or European Association for the Study of the Liver (EASL) criteria. Short-term (<3 months) and intermediate-term (>3 months) imaging response was determined and Kaplan-Meier survival curves were plotted.

RESULTS

Thirty-eight drug-eluting bead chemoembolization procedures were performed on 32 hepatic lobes, comprising 21 treatment cycles in 18 patients. All procedures were technically successful with two major complications (biliary injuries). At short-term follow-up (<3 months), 22 of 38 (58%) procedures and 10 of 21 (48%) treatment cycles produced an objective response (OR) with the remainder having stable disease (SD). At intermediate-term follow-up (mean, 445 days; range, 163-1247), 17 of 26 (65%) procedures and 8 of 14 (57%) treatment cycles produced an OR. Probability of progressing was approximately 52% at 1 year with a median time to progression of 419 days.

CONCLUSIONS

Drug-eluting bead chemoembolization is a reasonable alternative to hepatic arterial embolization and chemoembolization for the treatment of metastatic neuroendocrine tumor to the liver.

Recent progress in the understanding, diagnosis, and treatment of gastroenteropancreatic neuroendocrine tumors

Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are relatively rare tumors that arise from the diffuse neuroendocrine system. This heterogeneous group of tumors was often considered a single entity. This belied their biological diversity, and the biggest advance in understanding these tumors over the past decades has been in understanding this diversity. Diagnosis of these tumors has been aided by advances in pathological diagnosis and classification and tumor imaging with endoscopic ultrasound and somatostatin receptor fusion imaging. Genetic and molecular advances have identified molecular targets in the treatment of these tumors. Surgery remains the mainstay of treatment, amply supported by interventional radiological techniques, including embolization. Treatment of metastatic disease has improved significantly with the addition of several new agents, including tyrosine kinase inhibitors, mammalian target of rapamycin inhibitors, and yttrium-90-DOTA (1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid) and lutetium-177-DOTA octreotate. Despite significant advances in the understanding and management of GEP-NETs, the survival of patients remains largely unchanged and there remains a need for the development of national and international research collaborations to spearhead future efforts.

Treatment of liver metastases in patients with neuroendocrine tumors: a comprehensive review

Patients diagnosed with Neuroendocrine Tumors (NET) often are also diagnosed with Neuroendocrine Liver Metastases (NLM) during the course of their disease. NLM can cause significant morbidity and mortality, oftentimes much more than compared to patients with NET. Treatment options have been limited in the past, focusing on surgical resections, for which only a minority of patients are candidates. However, developments of new treatment modalities have progressed rapidly and patients with NLM now have significantly more options, including surgical-directed therapies; liver-directed therapies; and nonsurgical, non-liver-directed therapies. This review provides information about the roles of hepatic resection, orthotopic liver resection, radiofrequency ablation, hepatic artery embolization and hepatic artery chemoembolization, hepatic artery radioembolization and selective internal radiation therapy, peptide receptor radionuclide therapy, systemic chemotherapy, biotherapies including somatostatin analogs and interferon-α, vascular endothelial growth factor and mTOR targets, and microRNA-regulated pathways. Given these new options, the clinician can tailor therapy specific to the patient diagnosed with NLM, thereby giving the patient the best possible chance of prolonged survival.

Semiautomated segmentation for volumetric analysis of intratumoral ethiodol uptake and subsequent tumor necrosis after chemoembolization

OBJECTIVE

Linear measurements, such as those described by the Response Evaluation Criteria in Solid Tumors (RECIST) criteria, may be limited for assessment of response after transarterial chemoembolization (TACE). The purpose of this pilot study was to show intra- and interobserver reproducibility of volumetric measurements of Ethiodol (ethiodized oil) seen within tumor 24 hours after TACE and of necrotic and viable tumor 1 month after treatment. Volumetric measurements are compared with linear measurements and survival outcomes.

MATERIALS AND METHODS

Between 2006 and 2009, 37 consecutive TACE procedures were performed in 27 patients with hepatic malignancies. CT images obtained 24 hours and 1 month after TACE were retrospectively analyzed. Three observers measured volumes twice. Intraoperator reproducibility was determined using Wilcoxon's signed rank test to assess whether the difference in each volumetric measurement approaches zero. The intraclass correlation coefficient (ICC) and Bland-Altman plots were used to determine interoperator reproducibility. Survival data were retrospectively obtained from the electronic medical record.

RESULTS

Good intraobserver reproducibility and interobserver reproducibility (p > 0.05, ICC > 0.9, respectively) were shown for Ethiodol, whole tumor, and necrotic tumor volumes. The volume of Ethiodol correlated with subsequent necrotic tumor volume (p = 0.009), reduction in whole tumor volume (p = 0.004), and patient survival (p = 0.029). Kaplan-Meier curves suggest that Ethiodol accumulation in more than 50% of the tumor and a 10% or greater increase in the volume of necrotic tumor correlated with survival (p = 0.028 and 0.047, respectively).

CONCLUSION

Semiautomated volumetric analysis can be performed with good intra- and interobserver reproducibility. The volume of Ethiodol accumulated in the tumor after TACE correlates with subsequent necrosis. These early measurements may predict survival outcomes.

Multimodal management of neuroendocrine liver metastases

BACKGROUND

The incidence of neuroendocrine tumours (NET) has increased over the past three decades. Hepatic metastases which occur in up to 75% of NET patients significantly worsen their prognosis. New imaging techniques with increasing sensitivity enabling tumour detection at an early stage have been developed. The treatment encompasses a panel of surgical and non-surgical modalities.

METHODS

This article reviews the published literature related to management of hepatic neuroendocrine metastases.

RESULTS

Abdominal computer tomography, magnetic resonance tomography and somatostatin receptor scintigraphy are widely accepted imaging modalities. Hepatic resection is the only potentially curative treatment. Liver transplantation is justified in highly selected patients. Liver-directed interventional techniques and locally ablative measures offer effective palliation. Promising novel therapeutic options offering targeted approaches are under evaluation.

CONCLUSIONS

The treatment of neuroendocrine liver metastases still needs to be standardized. Management in centres of expertise should be strongly encouraged in order to enable a multidisciplinary approach and personalized treatment. Development of molecular prognostic factors to select treatment according to patient risk should be attempted.

Transarterial liver-directed therapies of neuroendocrine hepatic metastases

Neuroendocrine tumors (NETs) comprise a diverse group of slowly growing tumors with an indolent course, characterized by the capacity to synthesize and secrete polypeptide products that are hormonally active. Presence of liver metastases results in significant debilitating hormonal symptoms, and is associated with poor prognosis. Systemic chemotherapy has limited success in the management of patients with NET hepatic metastases. Although somatostatin analogs are effective in controlling symptoms in many of these patients, the disease can become refractory to treatment. For these reasons, interventional radiologic techniques for liver-directed therapy have become an important treatment option in patients with metastatic NETs. Transcatheter arterial procedures such as transarterial embolization (TAE), transarterial chemoembolization (TACE), and selective internal radiation therapy (SIRT) have been shown to reduce hormone levels, palliate symptoms, and reduce the tumor burden in many patients with unresectable and symptomatic NET hepatic metastases. This article summarizes the most recent information on arterial-based liver-directed therapies in the treatment of metastatic NETs.

Neuroendocrine liver metastases

This review summarizes regional strategies for management of neuroendocrine liver metastases (NLM), including hepatic resection, ablation, liver transplantation, and hepatic arterial embolization/chemoembolization. Despite early disease recurrence and/or progression, resection of NLM with or without combined ablation provides long-term survival and symptom improvement. When complete resection of gross liver disease is not feasible, resection as a tumor debulking strategy should be considered in patients with extreme hormonal symptoms refractory to other treatments or with tumors in locations that would affect short-term quality of life. Hepatic arterial embolization with or without local instillation of chemotherapy may induce disease response, symptomatic improvement, and prolonged survival in patients with unresectable NLM. Early disease recurrence, high postoperative mortality, the absence of extensive experience, and lack of universal indications for organ allocation preclude orthotopic liver transplantation as an option for most patients with unresectable NLM.

Factors predicting response and survival after yttrium-90 radioembolization of unresectable neuroendocrine tumor liver metastases: a critical appraisal of 48 cases

BACKGROUND

Yttrium-90 (90Y) radioembolization is a promising treatment option for unresectable neuroendocrine tumor liver metastases (NETLM). This study is the first to evaluate the prognostic variables that influenced radiologic response and survival in patients with unresectable NETLM who were treated with 90Y radioembolization. As a secondary outcome, the impact of this treatment on serologic toxicity was assessed.

METHODS

Forty-eight patients underwent resin-based 90Y radioembolization for unresectable NETLM at a single institution between December 2003 and May 2009. Patients were assessed radiologically and serologically at 1 month and then at 3 month intervals after treatment. Prognostic variables that affected response and survival were determined. The impact of this treatment on serologic toxicity over a 6-month period was assessed.

DISCUSSION

No patient was lost to follow-up. The median follow-up for the patients who were alive was 41 months. The median survival was 35 months (range: 5-63). On imaging follow-up, 7 patients (15%) had a complete response and 19 patients (40%) had a partial response to treatment. Eleven patients (23%) had stable disease and 11 patients (23%) had progressive disease. Five prognostic factors were associated with an improved survival: complete/partial response (P=0.003), low hepatic tumor burden (P=0.022), female gender (P=0.022), well-differentiated tumor (P=0.001), and absence of extra-hepatic metastasis (P<0.001). Three factors were associated with a complete/partial response: female gender (P=0.040), well-differentiated tumor (P<0.001) and low hepatic tumor burden (P=0.041). There was a significant increase in the level of alkaline phosphatase over the 6-month period (P<0.001).

CONCLUSIONS

90Y radioembolization is a promising treatment option for unresectable NETLM. Patients with low hepatic tumor burden, well-differentiated tumor, female gender, and no extrahepatic disease benefit most from treatment.

Nonresectable combined hepatocellular carcinoma and cholangiocarcinoma: analysis of the response and prognostic factors after transcatheter arterial chemoembolization

PURPOSE

To evaluate the clinical effectiveness of transcatheter arterial chemoembolization (TACE) performed in patients with nonresectable combined hepatocellular carcinoma (HCC) and cholangiocarcinoma and analyze the prognostic factors of patient survival after TACE.

MATERIALS AND METHODS

Each patient provided informed consent for TACE. The institutional review board approved the current study and waived the requirement for patient consent for this retrospective review. From 1997 to 2009, 50 patients underwent TACE for nonresectable combined HCC-cholangiocarcinoma. Tumor response was evaluated on the basis of findings on computed tomographic (CT) scans obtained a mean of 30.7 days after TACE. The survival rate and the prognostic factors of patient survival were evaluated.

RESULTS

After TACE, 35 (70%) of the 50 patients were classified as responders--having either a partial response or stable disease with successful (>50%) tumor necrosis--and 15 (30%) were classified as nonresponders. Tumor response was significantly related to tumor vascularity: One (10%) of the 10 patients with hypovascular tumors and 34 (85%) of the 40 patients with hypervascular tumors were responders (P < .001). The median patient survival period was 12.3 months. Results of multivariable Cox regression analyses confirmed that tumor size (hazard ratio [HR], 2.49; P = .028), tumor vascularity (HR, 4.19; P = .001), Child-Pugh class (HR, 4.3; P = .001), and portal vein invasion (HR, 6.45; P < .001) were the independent factors associated with patient survival duration after TACE.

CONCLUSION

TACE is safe and may be effective for prolonging the survival of patients with nonresectable combined HCC-cholangiocarcinoma, as compared with the historically reported survivals of these patients. Tumor vascularity is highly associated with tumor response. The patient survival period after TACE for combined HCC-cholangiocarcinoma is significantly dependent on tumor size, tumor vascularity, Child-Pugh class, and presence or absence of portal vein invasion.

Transarterial chemoembolization (TACE) with mitomycin C and gemcitabine for liver metastases in breast cancer

The purpose of this study was to evaluate the efficacy of transarterial chemoembolization (TACE) using different drug combinations in the treatment of breast cancer liver metastases in terms of local tumor control and survival rate. A total of 208 patients (mean age 56.4 years, range 29-81) with unresectable hepatic metastases of breast cancer were repeatedly treated with TACE at 4-week intervals. In total, 1,068 chemoembolizations were performed (mean 5.1 sessions/patient, range 3-25). The chemotherapy protocol consisted of mitomycin-C only (8 mg/m(2); n = 76), mitomycin-C with gemcitabine (n = 111), and gemcitabine only (1,000 mg/m(2); n = 21). Embolization was performed with lipiodol and starch microspheres. Tumor response was evaluated by MRI according to RECIST criteria. Survival rates were calculated using Kaplan-Meier method. For all protocols, local tumor control was partial response 13% (27/208), stable disease 50.5% (105/208), and progressive disease 36.5% (76/208). The 1-, 2-, and 3-year survival rates after TACE were 69, 40, and 33%. Median and mean survival times from the start of TACE were 18.5 and 30.7 months. Treatment with mitomycin-C only showed median and mean survival times of 13.3 and 24 months, with gemcitabine only they were 11 and 22.3 months, and with a combination of mitomycin-C and gemcitabine 24.8 and 35.5 months. TACE is an optional therapy for treatment of liver metastases in breast cancer patients with better results from the combined chemotherapy protocol.

[Arterial embolization of hepatic metastases from neuroendocrine tumors]

Neuroendocrine tumors are slowly growing neoplasms and 75% of patients already present with hepatic metastases at the time of diagnosis. Size and growth of liver metastases is of prognostic value. Due to arterial vascularization of metastases, transarterial embolization (TAE) is a suitable procedure, which can also be combined with chemotherapeutic agents. Indications for embolization or chemoembolization (TACE) are growth of liver metastases or inadequate symptom control. The majority of patients show clinical improvement and partial remission can be achieved in 50% of cases with 5-year survival rates of 50-60%. Response rates, survival or complications are not dependent on the embolization technique (TAE or TACE). Embolization is usually performed in several sessions depending on individual tumor stage and disease progression. Embolization is a cost-effective procedure and is included in the treatment algorithm of international guidelines. Therefore, evaluation of new embolization therapies must be evaluated in randomized controlled studies.

Primary hepatic angiosarcoma: imaging findings and palliative treatment with transcatheter arterial chemoembolization or embolization

AIM

To describe the image findings and results of transcatheter arterial chemoembolization (TACE) or transcatheter arterial embolization (TAE) for treating primary hepatic angiosarcoma.

MATERIALS AND METHODS

A retrospective review of the electronic medical database from 2002 to 2007, revealed six patients with primary hepatic angiosarcoma confirmed by percutaneous liver biopsy. The computed tomography (CT) and angiography imaging findings, the TACE or TAE results, and the post-procedure course were evaluated in all patients.

RESULTS

On CT and angiography, each tumour appeared as a solitary mass or as multiple nodules or masses with heterogeneously early and progressive enhancement. One of the two patients with tumour response to TACE died 8 months after initial presentation, and the remaining patient was still alive at the last follow-up 12 months after initial presentation. However, two patients with no response to TACE and two patients who underwent emergent TAE for tumour rupture died 1 week to 5 months (mean 2.1 months) after initial presentation.

CONCLUSIONS

Primary hepatic angiosarcoma appears as a solitary or multiple, hypervascular lesions with heterogeneously early and progressive enhancement on CT and angiography. Although TAE may be the primary procedure for achieving emergent bleeding control caused by the rupture of hepatic angiosarcomas, TACE may be effective for treating patients with a dominant hepatic angiosarcoma with or without intrahepatic metastases.

Nonfunctioning neuroendocrine pancreatic tumors: our experience and management

BACKGROUND AND PURPOSE

We present our experience in the treatment of nonfunctioning neuroendocrine pancreatic tumors (NFNPTs) to define the clinical and pathological characteristics and to suggest proper management.

METHODS

The records of 17 patients with NFNPTs operated on between 1998 and 2008 were retrospectively reviewed, and all tumors were classified clinicopathologically as benign, uncertain, and malignant, based on the World Health Organization (WHO) classification of neuroendocrine tumors.

RESULTS

There were four benign, six uncertain, and seven malignant NFNPTs. The most frequent symptoms were abdominal pain (five patients) and obstructive jaundice (one patient). Most of these symptomatic patients had malignant tumors. Mean tumor size of benign, uncertain, and malignant tumors were 1.0 +/- 0.3, 3.2 +/- 1.6, and 5.3 +/- 2.4 cm, respectively. Metastatic lesions of malignant tumors were lymph node (six patients), liver (four patients), and adrenal gland (one patient). Six of seven patients with malignant tumors underwent curative rejection. There were recurrences in four of six patients with curatively rejected malignant tumors. Two patients underwent more rejection, three patients received systemic chemotherapy, and two patients underwent radiofrequency ablation and transcatheter arterial chemoembolization for liver metastases. Survival of patients with malignant tumors was significantly shorter than that of patients with benign and uncertain tumors. However, three patients with malignant tumors had long survival of more than 3 years, even with metastases or recurrences.

CONCLUSIONS

Aggressive surgical resection should be performed in patients with resectable NFNPTs, even with metastases. Even when a tumor was unresectable or there were recurrences, long-time palliation could be achieved by a multidisciplinary approach.

Treatment of liver metastases from neuroendocrine tumours in relation to the extent of hepatic disease

BACKGROUND

Hepatic surgery is presumed to improve survival of patients with liver metastases (LM) from neuroendocrine tumours (NET). This study identified LM-specific variables that could be used as additional selection criteria for aggressive treatment.

METHODS

A novel classification of LM from NET was established based on their localization and presentation.

RESULTS

From 1992 to 2006, 119 patients underwent staging and treatment of LM. Three growth types of LM were identified radiologically: single metastasis (type I), isolated metastatic bulk accompanied by smaller deposits (type II) and disseminated metastatic spread (type III). The three groups differed significantly in terms of chronological presentation of LM, hormonal symptoms, Ki-67 index, 5-hydroxyindoleacetic acid and chromogranin A levels, lymph node involvement, presence of bone metastases and treatment options. The 3-, 5- and 10-year disease-specific survival rates for the entire cohort were 76.4, 63.9 and 46.5 per cent respectively. There were significant differences in survival between the three groups: 5- and 10-year rates were both 100 per cent for type I, 84 and 75 per cent respectively for type II, and 51 and 29 per cent for type III.

CONCLUSION

The localization and biological features of LM from NET defines therapeutic management and is predictive of outcome.

Proceedings of the IASLC International Workshop on Advances in Pulmonary Neuroendocrine Tumors 2007

The International Association for the Study of Lung Cancer, (IASLC) International Congress on Advances in Pulmonary Neuroendocrine Tumors was a two-day meeting held at the Royal Brompton Hospital in London, United Kingdom on the thirteenth and forteenth of December 2007. The meeting was led by 14 member international faculty-in the disciplines of pathology, surgery, medicine, oncology, endocrinology, nuclear medicine, diagnostic imaging, and biostatistics. The aims were twofold, as an educational meeting, and to develop the IASLC International Pulmonary Neuroendocrine Tumors Registry. The meeting highlighted the difference in presentation of the tumors, management options for early and advanced stage disease including the use of novel agents and approaches. The need, process, and approach to an International Registry of Pulmonary Neuroendocrine Tumors were emphasized. International collaboration to develop a retrospective registry, prospective data collection, virtual tissue bank, and collaborative clinical trials were universally agreed as the best way to advance our understanding and treatment of these rare tumors.

Hepatic neuroendocrine metastases: chemo- or bland embolization?

INTRODUCTION

Aggressive management of hepatic neuroendocrine (NE) metastases improves symptoms and prolongs survival. Because of the rarity of these tumors, however, the best method for hepatic artery embolization has not been established. We hypothesized that in patients with hepatic NE metastases, hepatic artery chemoembolization (HACE) would result in better symptom improvement and survival compared to bland embolization (HAE).

METHODS

Retrospective review identified all patients with NE hepatic metastases managed by HACE or HAE at three institutions from January 1996 through December 2007.

RESULTS

We identified 100 patients managed by HACE (n = 49) or HAE (n = 51) that were similar with respect to age, gender, and primary tumor type. The percentage of patients experiencing morbidity, 30-day mortality, and symptom improvement were similar between the two groups (HACE vs. HAE: 2.4% vs. 6.6%; 0.8% vs. 1.8%; and 88% vs. 83%, respectively.) No differences in the median overall survival were observed between HACE and HAE from the time of the first embolization procedure (25.5 vs. 25.7 months, p = 0.79). Multivariate analysis revealed that resection of the primary tumor predicted survival (73.8 vs. 19.4 months, p < 0.04).

CONCLUSIONS

These data suggest that morbidity, mortality, symptom improvement, and overall survival are similar in patients with hepatic neuroendocrine metastases managed by chemo- or bland hepatic artery embolization.

Gastrointestinal neuroendocrine tumors: pancreatic endocrine tumors

Pancreatic endocrine tumors (PETs) have long fascinated clinicians and investigators despite their relative rarity. Their clinical presentation varies depending on whether the tumor is functional or not, and also according to the specific hormonal syndrome produced. Tumors may be sporadic or inherited, but little is known about their molecular pathology, especially the sporadic forms. Chromogranin A appears to be the most useful serum marker for diagnosis, staging, and monitoring. Initially, therapy should be directed at the hormonal syndrome because this has the major initial impact on the patient's health. Most PETs are relatively indolent but ultimately malignant, except for insulinomas, which predominantly are benign. Surgery is the only modality that offers the possibility of cure, although it generally is noncurative in patients with Zollinger-Ellison syndrome or nonfunctional PETs with multiple endocrine neoplasia-type 1. Preoperative staging of disease extent is necessary to determine the likelihood of complete resection although debulking surgery often is believed to be useful in patients with unresectable tumors. Once metastatic, biotherapy is usually the first modality used because it generally is well tolerated. Systemic or regional therapies generally are reserved until symptoms occur or tumor growth is rapid. Recently, a number of newer agents, as well as receptor-directed radiotherapy, are being evaluated for patients with advanced disease. This review addresses a number of recent advances regarding the molecular pathology, diagnosis, localization, and management of PETs including discussion of peptide-receptor radionuclide therapy and other novel antitumor approaches. We conclude with a discussion of future directions and unsettled problems in the field.

Neuroendocrine tumors: role of interventional radiology in therapy

The management of neuroendocrine tumors (NETs) is complex. Although NETs can affect a variety of organ systems, hepatic metastatic disease in particular lends itself to a wide range of interventional treatment options. Prior detailed radiologic assessment and careful patient selection are required. Curative surgery should always be considered but is rarely possible. Embolization, radionuclide therapy, or ablative techniques may then be undertaken. Transcatheter arterial embolization (TAE) may be used alone or in combination with transcatheter arterial chemoembolization (TACE). NET type and extent of hepatic involvement are factors that can help predict the success of either TAE or TACE. Embolization techniques can also be useful in patients with nonhepatic NETs. Radionuclide therapy is emerging as a valuable adjunct and is dependent on positive somatostatin receptor status. Therapeutic radiopeptides may be delivered arterially. Ablative techniques have been shown to play a role in the palliation of symptoms and principally involve radiofrequency ablation. Hepatic cryotherapy and percutaneous ethanol injection have also been used. A multidisciplinary approach to treatment and follow-up is important. Imaging should involve dual-phase multidetector computed tomography and contrast material-enhanced magnetic resonance imaging. The role of the interventional radiologist will continue to expand as imaging techniques become more refined.

Liver metastases of neuroendocrine carcinomas: interventional treatment via transarterial embolization, chemoembolization and thermal ablation

The aim of this review article is to provide a practical clinical guideline for indication, technical aspects, protocol guideline and strategies for the interventional treatment of liver metastases from neuroendocrine tumors and focusing on the results of various protocols of management. The response to therapy, in the published articles, is calculated on the basis of the following clinical parameters; including symptomatic response (SR), biologic response (BR), morphological response (MR), progress free survival (PFS), and survival periods (SP). Transarterial chemoembolization (TACE) has been associated with SR rates of 60-95%, BR of 50-90%, MR of 33-80%, SR of 20-80 months, and a 5-year survival of between 50% and 65%. PFS was also between 18 and 24 months. In the transarterial embolization (TAE) group, SR was similar to the TACE group, MR was 32% and 82%, survival was between 18 and 88 months with a survival rate of 40-67%, and BR was between 50% and 69%. Radiofrequency ablation (RFA), either percutaneous or during surgery, has been associated with SR of 71-95% for a mean duration of 8-10 months, BR of 65%, and mean SP of 1.6 years after ablation. The mean survival following surgical resection for operable cases is 4.26 years+/-S.D.: 1.1.

CONCLUSION

The interventional protocols for the management of liver metastases from neuroendocrine tumors: for oligonodular liver metastatic deposits, local resection or RFA and/or LITT is recommended, while in multinodular diseases with higher tumor load, TACE or TAE is recommended.

Transcatheter arterial chemoembolization or chemoinfusion for unresectable intrahepatic cholangiocarcinoma: clinical efficacy and factors influencing outcomes

BACKGROUND

The role of transcatheter arterial chemoembolization (TACE) or transcatheter arterial chemoinfusion (TACI) for unresectable intrahepatic cholangiocarcinoma (ICC) has recently been questioned. The aim of the study was to evaluate the clinical efficacy of TACE or TACI in patients with unresectable ICC and to identify prognostic factors associated with clinical success.

METHODS

From 1997 to 2007, 49 patients with unresectable ICC were treated with TACE (n = 124) or transcatheter arterial chemoinfusion (TACI) (n = 96). Tumor response was evaluated based on computed tomography scans obtained 1 month to 3 months after TACE or TACI. Factors associated with clinical success were evaluated using multivariate logistic regression analysis. Factors associated with the survival period were evaluated using multivariate Cox regression analysis.

RESULTS

After treatment, 27 (55%) of the patients showed radiographic response. Multivariate analysis confirmed that tumor vascularity (odds ratio [OR], 31.2; P = .002) was the only independent factor associated with radiographic response. The median and mean survival periods in our study patients were 12 and 24 months. Multivariate Cox regression analyses showed that tumor size (OR, 2.64; P = .048), tumor vascularity (OR, 13.5; P < .001), and the Child-Pugh class (OR, 3.65; P = .014) were the independent factors associated with the length of the survival period.

CONCLUSIONS

Hepatic intra-arterial chemotherapy is well tolerated and may be effective to prolong survival of patients with unresectable ICC. Tumor vascularity is significantly associated with radiographic response. Large tumor size, tumor hypovascularity, and Child-Pugh class B were poor prognostic factors for determining the patient survival period.

Radioembolization with selective internal radiation microspheres for neuroendocrine liver metastases

BACKGROUND

There are limited effective treatment options available and a poor 5-year survival for patients with inoperable neuroendocrine liver metastases (NETLMs). In this study, the authors prospectively assessed the safety and efficacy of treatment with yttrium 90 ((90)Y) radioactive microspheres for patients with unresectable NETLMs.

METHODS

Radioactive (90)Y resin microspheres (selective internal radiation [SIR-Spheres]) were administered through a temporarily placed percutaneous hepatic artery catheter concomitantly with a 7-day systemic infusion of 5-fluorouracil to patients with progressive, unresectable NETLMs. Patients were monitored prospectively, and the response to treatment was measured by using cancer markers and tumor size on computed tomography imaging studies.

RESULTS

Thirty-four patients (22 men) with a mean age 61 years (range, 32-79 years) who had unresectable NETLMs were treated between December 2003 and December 2005. The mean (+/-standard error) follow-up was 35.2 +/- 3.2 months. The site of the primary neuroendocrine tumor was the bronchus in 1 patient, the medullary thyroid in 2 patients, gastrointestinal in 15 patients, the pancreas in 8 patients, and of unknown origin in 8 patients. The tumors were classified as vipoma (1 tumor), somatostatinoma (1 tumor), glucagonoma (2 tumors), large cell (3 tumors), carcinoid (25 tumors), and of unknown origin (2 tumors). Complications after (90)Y radioembolization included abdominal pain, which was mild to severe; nausea and fever; and lethargy that lasted from 1 week to 1 month. Two patients developed biopsy-proven radiation gastritis, 1 patient developed a duodenal ulcer, and there was 1 early death from liver dysfunction and pneumonia. Subjective changes from recorded baseline hormone symptoms were reported every 3 months. Symptomatic responses were observed in 18 of 33 patients (55%) at 3 months and in 16 of 32 patients (50%) at 6 months. Radiologic liver responses were observed in 50% of patients and included 6 (18%) complete responses and 11 (32%) partial responses, and the mean overall survival was 29.4 +/- 3.4 months). In patients who had evaluable chromogranin A (CgA) marker levels, there was a fall in CgA marker levels after (90)Y radioembolization in 19 patients (26%) at 1 month, in 19 patients (41%) at 3 months, in 15 patients (43%) at 6 months, in 11 patients (42%) at 12 months, in 8 patients (38%) at 24 months, and in 3 patients (46%) at 30 months.

CONCLUSIONS

In this open study of 34 patients, the results demonstrated that radioembolization with (90)Y resin microspheres can achieve relatively long-term responses in some patients with nonresectable NETLMs.