Carcinoid disease: review of the literature

Chromogranin a Measurement in Neuroendocrine Tumors

Neuroendocrine tumors (NETs) are rare neoplasms characterized by a low proliferative index and, in some cases, a favorable prognosis. These tumors often overproduce and release biologically active substances that are responsible for severe syndromes. Tumor marker measurement provides the clinician with useful information for the management of NET patients. The substances released by overproducing tumors are currently used as biomarkers, but there is a need for sensitive markers also for the “biochemically silent” NETs. The most effective and reliable blood marker available today is chromogranin A (CgA). Because of its high sensitivity and specificity, this glycoprotein can be used for the diagnosis, prognosis and follow-up of NETs. Furthermore, CgA measurement can be used for monitoring those tumors not overproducing or releasing any hormones or biological amines. This paper is a synthetic review on the value of CgA in NET management and reports our experiences with CgA measurement in NET patients.

Primary Ovarian Carcinoid: Extensive Clinical Experience With an Underrecognized Uncommon Entity

Purpose

Primary ovarian neuroendocrine tumors (NETs) develop in pure form or in association with other tumors, mainly teratomas. The available data regarding this rare condition are limited. Much of the literature focuses on single case reports, previously dismissed as a totally benign disorder, and thus long-term considerations and evidence-based management guidelines are lacking. The objective of the current study was to describe the clinical and pathologic characteristics and the effect of various therapeutic modalities on patient morbidity and mortality from 2 major centers. A secondary objective was to highlight that carcinoid syndrome may be manifest in the absence of metastatic disease.

Methods

The authors retrospectively studied a cohort of 34 consecutive patients with primary ovarian NETs who attended either the Oxford University Hospitals or Beatson Oncology Centre, Glasgow, between 1984 and 2014, and had their ovarian carcinoid data (eg, tumor growth, chemotherapy regimen) and mortality outcomes assessed.

Results

All patients were women, with an average age of 53 years (range, 23–87 years) at diagnosis. Of the 34 patients, 8 patients (23.5%) presented with carcinoid symptoms. Carcinoid heart disease was evident in 2 of the 34 patients (6%). All patients had a primary ovarian carcinoid tumor on histopathology, and 2 patients had bilateral ovarian carcinoids. Teratoma associations could be assessed in 29 tumors, with 20 (69%) of 29 showing a pathological association. The mean tumor size was 48 mm (range, 4–120 mm; SD, 40 mm). The mean follow-up was 4.5 years, ranging up to 17 years. The disease has been quiescent with no evidence of relapse in 22 of 34 patients; in 12 of 34 patients, it was metastatic. There were 5 patients who received treatment with somatostatin analogs or chemotherapy, whereas 8 patients (23.5%) died of disease. Metastatic disease was found up to 11 years from initial diagnosis.

Conclusions

Primary ovarian NET is rare and likely underrepresented in the literature. It can no longer be simply dismissed as a generally benign entity and may present with both the carcinoid syndrome and carcinoid heart disease. It requires careful evaluation and long-term review.

Diagnostic value of circulating chromogranin a for neuroendocrine tumors: a systematic review and meta-analysis

Background

In previous decades, chromogranin A (CgA) has been demonstrated to be the most promising biomarker for the diagnosis of neuroendocrine tumors (NETs), but its diagnostic value is still controversial. This meta-analysis aimed to estimate the potential diagnostic value of circulating CgA for NETs.

Methods

We collected relevant studies from several electronic databases as well as from reference lists. Diagnostic indices of CgA were pooled with random effects models. Pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR) and summary receiver operating characteristic (SROC) curves for the diagnosis of NETs were used to estimate the overall diagnostic efficiency.

Results

Through a search strategy, 13 studies met the inclusion criteria and were included. These studies contained 1260 patients with NETs and 967 healthy controls in the total sample. As a result, the overall sensitivity, specificity and diagnostic odds ratio (DOR) were 0.73 (95% CI: 0.71 to 0.76), 0.95 (95% CI: 0.93 to 0.96) and 56.29 (95% CI: 25.27 to 125.38), respectively, while the summary positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 14.56 (95% CI: 6.62 to 32.02) and 0.26 (95% CI: 0.18 to 0.38), respectively. In addition, the area under the curve (AUC) of the circulating CgA in the diagnosis of NETs was 0.8962.

Conclusions

These data demonstrate that circulating CgA is an efficient biomarker for the diagnosis of NETs with high sensitivity and specificity, which indicates that it may be helpful for the clinical management of NETs. However, further studies are needed to clarify this issue.

Surgical resection of hepatic and cardiac neuroendocrine metastases from a caecal primary tumour

A 66-year-old patient had an incidentally detected caecal neuroendocrine tumour that had metastasised to the liver and left atrium. He was asymptomatic with regard to this tumour and did not have carcinoid syndrome. Resection of the primary tumour and the metastatic deposits (with the ablation of one lesion) is thought to be curative.

Intra-arterial liver-directed therapies for neuroendocrine hepatic metastases

Hepatic metastases, which are frequently seen in patients with neuroendocrine tumors (NETs), have a major adverse impact on the patient's quality of life and survival. Surgery is the treatment of choice for hepatic metastases but is possible in only a small percentage of patients. Systemic chemotherapy yields disappointing results. Somatostatin analogs are effective in controlling symptoms in many of these patients; however, the disease can become refractory to treatment. Transcatheter intra-arterial liver-directed therapies, such as hepatic artery embolization, chemoembolization, and radioembolization are frequently used in patients with NETs metastatic to the liver, especially in patients with refractory, unresectable, or recurrent disease. These treatments are effective in palliating the hormonal symptoms as well as achieving objective tumor responses. This review focuses on the technique, safety, and clinical efficacy of hepatic artery embolization, chemoembolization, and radioembolization in patients with metastatic NETs.

Intestinal ischaemia associated with carcinoid tumor: a case report with review of the pathogenesis

Carcinoid tumors are rare, slow-growing neuroendocrine neoplasms that are often indolent and may not become clinically apparent until there is a metastatic spread or evidence of carcinoid syndrome. A 44-year-old man presented to our clinic department with a history of previous left colon cancer operation, chronic crampy left lower quadrant pain, mass and severe anemia. A MR scan was obtained which demonstrated a calcified mesenteric mass 12×8×10 cm diameter with surrounding left colon mesenteric infiltration. The liver was normal. A case of ischaemic ileal necrosis is reported. It was associated with elastic vascular sclerosis produced by mesenteric metastases of an ileal carcinoid tumor. It is postulated that intestinal ischaemia may be of more importance in the production of abdominal pain by carcinoid tumors than has been generally accepted, and that it is the result of functional and structural changes in and around the mesenteric blood vessels, caused by substances secreted by the carcinoid tumor.

Clinical and biochemical aspects of the carcinoid syndrome in neuroendocrine tumors of the abdominal and retroperitoneal organs and its impact for the disease prognosis

Overall and relapse-free survival of 238 patients with neuroendocrine tumors of the abdominal and retroperitoneal organs was evaluated with consideration for the presence of the carcinoid syndrome. The incidence of the carcinoid syndrome was 15.6%. The presence of the carcinoid syndrome was inessential for survival and relapse prognosis in patients with neuroendocrine tumors of the abdominal and retroperitoneal organs. A trend to the development of earlier relapses was noted in patients with this syndrome. Diarrhea was found to be a prognostically unfavorable factor. The time of the carcinoid syndrome development was prognostically significant in patients with malignant neuroendocrine tumors. The mean secretion of epinephrine, norepinephrine, and dopamine with daily urine was significantly higher in patients with the carcinoid syndrome. A significant positive correlation between urinary excretion of catecholamines was detected (r=0.53; p<0.05).

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.

Liver metastases of neuroendocrine tumors: treatment with hepatic transarterial chemotherapy using two therapeutic protocols

OBJECTIVE

The objective of our study was to retrospectively determine the effectiveness of hepatic transarterial chemotherapy using two therapeutic protocols-mitomycin C alone and combined mitomycin C and gemcitabine-on local tumor control and survival rate in patients with liver metastases from neuroendocrine tumors.

MATERIALS AND METHODS

This article describes a retrospective study of 48 patients (age range, 37-77 years; mean age, 61.1 years; SD, 10.3) with liver metastases from neuroendocrine tumors who underwent repetitive selective hepatic artery chemotherapy using mitomycin C alone (group 1, n = 18 patients who underwent 182 therapeutic sessions; mean, 10.11 sessions per patient) and combined mitomycin C and gemcitabine chemotherapy agents (group 2, n = 30 patients who underwent 312 therapeutic sessions; mean, 10.4 sessions per patient) with 4-week intervals between treatment sessions.

RESULTS

Both treatment protocols were well tolerated by all patients. Only minor side effects occurred in both groups, and no major complications developed. Local tumor control evaluation according to the Response Evaluation Criteria in Solid Tumors (RECIST) revealed the following for group 1: partial response, 11.1%; stable disease, 50%; and progressive disease, 38.9%. RECIST criteria for group 2 indicated partial response in 23.33%, stable disease in 53.34%, and progressive disease in 23.33%. The survival rate from the initial diagnosis to the fifth year for group 1 was 11.11% and for group 2, 46.67%. The median survival time from the initial diagnosis of group 1 was 38.67 months, whereas in group 2 it was 57.1 months.

CONCLUSION

Transarterial hepatic chemotherapy using mitomycin C and gemcitabine can be an effective therapeutic protocol for controlling local metastases and improving survival time in patients with hepatic metastases from neuroendocrine tumors.

[Gastrointestinal carcinoid tumors: cellular biology, molecular expression and physiopathological consequences of an enigmatic neoplasia]

Gastrointestinal carcinoid tumors arise from cells of the diffuse neuroendocrine system localized in the digestive trace and represent more than 70% of all carcinoid tumors in humans. The present article reviews the following topics: 1) The biological profile of these tumors (histopathology, cytokine markers, metabolic alterations, storage of neuroamines and hormonal proteins, cytodynamic behavior, and biological behavior according to embryological origin). 2) The etiological circumstances (exceptional hereditary factors, association of gastric carcinoid tumors with autoimmune gastritis, little-known exogenous factors). 3) Pathogenic aspects (persistent mitogenesis of endocrine cells associated with hypergastrinemia, inactivation of some putative tumor suppressor genes, the doubtful participation of oncogenes, autocrine action of some cellular growth-stimulating proteins). 4) The repercussions of certain physiopathological events (peritumoral desmoplastic reaction causing the "mass effect" on the digestive tube, the "kidnapping" of dietary tryptophan by tumoral cells toward an abnormal metabolic pathway; the easy metastatic dissemination coexisting with low tumoral aggressivity, and the release into the bloodstream of stored secretory products leading to "carcinoid syndrome" and some endocrine hyperfunction syndromes. Finally, it should be remembered that gastrointestinal carcinoid tumors represent only a proportion of the neoplasms classified as neuroendocrine tumors.

Neuroendocrine tumors. Molecular targeted therapy for carcinoid and islet-cell carcinoma

Carcinoid and islet-cell carcinoma are often also known as low-grade neuroendocrine carcinomas. They are often slow-growing but can be resistant to standard therapy. While somatostatin analogues are often used to control hormonal syndromes, there is currently no therapy approved in the US for control of carcinoid tumor growth. For islet-cell carcinoma, streptozocin-based chemotherapy may induce tumor shrinkage, but second-line option are limited. This chapter reviews the molecular biology of neuroendocrine tumors, including the roles of MENIN, TSC2, NF-1, vHL, p53, bcl-2, bax, VEGF, IGF, PDGF, EGFR, and mTOR. Recently, there has been interest in developing molecularly targeted therapy for this group of diseases. Phase-II studies with imatinib, bevacizumab, sunitinib, gefitnib, temsirolimus, and everolimus (RAD001) have completed accrual. Encouraging results have been observed in studies with VEGF and mTOR inhibitors. Phase-III study of bevacizumab is planned in the US. Large-scale multinational phase-II and -III studies of everolimus are under way.

The chromogranin-A (CgA) in prostate cancer

Prostate cancer is one of the most frequent tumors in men. The neuroendocrine differentiation in prostate cancer has become more widely recognized and has attracted considerable attention as a potentially new finding with major diagnostic, prognostic and therapeutic implications. We investigated the role of the serum concentrations of CgA in a group of 57 patients with prostate cancer and in 61 elderly subjects with benign prostate hyperplasia (BPH). Neuron-specific enolase (NSE) is the most frequently employed marker to detect neuroendocrine features. Serum prostate-specific antigen (PSA), CgA and NSE levels were determined. Comparing prostate cancer group versus BPH group, the CgA level difference was 63.00 ng/ml (p<0.0001) and the PSA level difference was 50.86 mcg/ml (p<0.0001). Between prostate cancer group and control group the CgA level difference was 94.3 ng/ml (p<0.0001), the PSA level difference was 52.91 mcg/ml (p<0.0001), and the NSE level difference was 1.34 microg/l (p<0.0001). Patients with higher CgA levels had poorer prognosis and survival, compared to those with lower CgA levels. These results support the concept that serum CgA level determination before treatment is a potential prognostic factor for prostate cancer.

Primary insular carcinoid of the ovary

BACKGROUND

Primary insular carcinoid tumor of the ovary is a rare tumor and accounts for fewer than 1% of all cases of carcinoid in the body. With the exception of a single reported case, all previously described functioning ovarian carcinoid tumors have measured at least 10 cm in diameter. Thus, there appears to be a good correlation between the size of the tumor and the presence of the carcinoid syndrome.

CASE REPORT

We describe a case of a functioning primary insular carcinoid tumor of the ovary measuring just 6 cm in maximal diameter.

CONCLUSION

Although primary ovarian carcinoid tumor is very rare, a high clinical index of suspicion must be maintained, especially in a patient presenting with carcinoid syndrome and a small adnexal mass.

Abdominal angina in patients with a midgut carcinoid, a sign of severe pathology

In 36 consecutive patients with a foregut carcinoid with extensive local tumor growth and liver metastases with a carcinoid syndrome, six patients had complaints of postprandial abdominal pain and attacks of subileus based on segmental intestinal ischemia. A diagnosis of abdominal angina was supported by a positive response to nitroglycerin in two and ischemia of the ileum demonstrated by angiography in two other patients. Complaints were reduced in all patients after surgery. Histopathology of the resected small bowel specimens showed elastic vascular sclerosis in three patients and ischemic changes in three other patients, confirming the clinical diagnosis. Resection of ischemic bowel can provide relief in patients with segmental intestinal ischemia caused by carcinoid-induced vascular sclerosis.

Management of Less Common Tumors of the Colon, Rectum, and Anus

The majority of colorectal and anal malignancies are adenocarcinomas and squamous cell cancers, respectively. Despite the predominance of these neoplasms in these locations, rare histiotypes of the colon, rectum, and anus do occur. These histotypes include but are not limited to lymphoma, melanoma, diffuse cavernous hemangioma, and sarcomas, such as leiomyosarcoma or Kaposi's sarcoma. These tumors often present challenges to clinicians with respect to diagnosis, staging, management, and pathology because of their unfamiliarity. A Medline search using "colon," "rectum,""anus," "lymphoma," "melanoma," "diffuse cavernous hemangioma," "squamous cell carcinoma," "carcinoid," "sarcoma," "leiomyosarcoma," "Kaposi's sarcoma," "Paget's disease," "Bowen's disease," and "basal cell carcinoma" as key words was performed as well as a cross-referencing of the bibliography cited in each work. Rare tumors of the colon, rectum, and anus present diagnostic and management dilemmas for clinicians. Because of their infrequency and poor prognosis, the optimal management of these tumors is controversial. For some histotypes, such as squamous cell carcinoma and carcinoids of the rectum, treatment depends on location and size of the tumor. For uncommon anal lesions, such as Bowen's disease, Paget's disease, and basal cell carcinoma, wide local excision (WLE) with negative margins is the standard of care. For other lesions such as anorectal melanoma or leiomyosarcoma, abdominal perineal resection versus WLE is still being debated. Because the optimal treatment of these tumors is still unclear, we recommend a multidisciplinary approach including a surgeon, primary care physician, medical oncologist, radiation oncologist, and pathologist to offer the patient the best outcome.

Serum peptide profiles in patients with carcinoid tumors

BACKGROUND

Patterns of elevated serum peptides may reveal additional markers and permit better classification of tumors based on (secondary) peptide secretion.

METHODS

Fasting peptide profiles were obtained from 31 carcinoid patients. vasoactive intestinal peptide (VIP), pancreatic polypeptide (PP), neurotensin, substance P, gastrin-releasing polypeptide (GRP), calcitonin, gastrin, and pancreastatin were measured. Peptide elevation patterns were correlated with disease sites, syndrome, and survival.

RESULTS

Elevations in patients were as follows: VIP 0%, PP 13%, neurotensin 10%, substance P 20%, GRP 3%, calcitonin 10%, and gastrin 3%. There were no consistent patterns of elevated peptides with regard to site or syndrome. Pancreastatin was elevated in 81% of profiles and was the only abnormal peptide in 57% of patients.

CONCLUSION

Peptide profile results do not permit improved classification, predict syndrome development, or correlate with survival. In contrast, pancreastatin is elevated in most cases and may be utilized to monitor disease progression and evaluate response to therapy.

Permanent transarterial embolization of neuroendocrine metastases of the liver using cyanoacrylate and lipiodol: assessment of mid- and long-term results

OBJECTIVE

The purpose of our study was to assess the results of hepatic artery embolization using N-butyl-2-cyanoacrylate and ethiodized oil for the treatment of small-bowel neuroendocrine metastases to the liver as part of a multimodality protocol for the treatment of liver metastases from neuroendocrine small-bowel tumors.

MATERIALS AND METHODS

Twenty-three patients underwent permanent embolization of the hepatic artery using cyanoacrylate and Lipiodol for treatment of liver metastases after radical resection of small-bowel neuroendocrine tumors. All patients received additional treatment including somatostatin, and most patients received interferon as well. Cumulative survival rates were estimated using the Kaplan-Meier method.

RESULTS

Overall, 75 embolizations (range, 1-10; mean, 3.3) were performed. Median survival time was 69 months, and the estimated cumulative survival rates reached 95.7% and 65.4% for 1 and 5 years, respectively. Two deaths (8.7%) occurred within 1 month of treatment, and one patient experienced a vascular complication at the time of embolization.

CONCLUSION

Permanent embolization of hepatic arteries as part of a multimodality treatment protocol is beneficial in long-term follow-up for patients with metastasized small-bowel neuroendocrine tumors. The use of cyanoacrylate as an embolic agent is safe and effective.

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.

7-Hydroxytryptophan, a novel, specific, cytotoxic agent for carcinoids and other serotonin-producing tumors

BACKGROUND

Carcinoids and small cell lung carcinomas stimulate their growth in an autocrine manner by releasing serotonin, an effect that is blocked by selective serotonergic receptor antagonists that, unfortunately, exert undesirable side effects on serotonergic central nervous function. Moreover, conventional chemotherapeutic agents, such as streptozocin, fluorouracil, cyclophosphamide, and doxorubicin, which target tumor cells directly, have produced disappointing results in the treatment of patients with these tumors in the advanced stage. Therefore, there is still a need for more specific and potent chemotherapeutic agents in the fight against serotonin-producing tumors.

METHODS

The authors synthesized 7-hydroxytryptophan to test its chemotherapeutic value in cell culture, using a system consisting of serotonin-producing and nonproducing cell lines.

RESULTS

The authors chose tryptophan hydroxylase, the rate-limiting enzyme of serotonin biosynthesis, which is expressed highly in small cell lung carcinomas and carcinoids, as a target for the induction of cellular suicide by chemotherapy. They found that this otherwise substrate specific enzyme was capable of metabolizing in situ a harmless tryptophan analogue, 7-hydroxytryptophan, to a potent toxin, 5,7-dihydroxytryptamine, a conversion blocked by the specific tryptophan hydroxylase inhibitor parachlorophenylalanine.

CONCLUSIONS

These data suggest that 7-hydroxytryptophan may be a highly specific chemotherapeutic compound against serotonin-producing tumors that also interferes with the autocrine capabilities of serotonin synthesis.

Efficacy of a chemotherapy combination for the treatment of metastatic neuroendocrine tumours

OBJECTIVES

Neuroendocrine tumours (NETs) are heterogeneous neoplasms for which there is no standard treatment. We have previously proposed an effective polychemotherapy (5-fluorouracil, dacarbazine and epirubicin), which only produced objective responses of brief duration. The present study aimed to assess in a multidisciplinary manner the efficacy of the same regimen at intensified doses in patients with advanced NETs.

PATIENTS AND METHODS

Eighty-two consecutive patients entered the study, of whom 21 had inoperable, locally advanced disease and 61 had metastatic disease. Seventy-two patients were evaluated for objective, biochemical and subjective responses. Response rate, time to progression (TTP) and overall survival (OS) were evaluated based on histotype.

RESULTS

An objective response was observed in 20 patients (intention-to-treat and standard analysis 24.4% and 27.8%, respectively). Complete biochemical and subjective responses were obtained in 25.1% and 38.9% of the cases. The median duration of treatment was 4 months and the objective responses had a median duration of 38 months. After a 60-month follow-up the median TTP and OS were 21 and 38 months, respectively.

CONCLUSIONS

Our polychemotherapy regimen is effective, with long duration, and is well tolerated both for gastroenteropancreatic and lung NETs, as well as for tumours with a more aggressive clinical behaviour. The new WHO endocrine tumour histotyping, examining also the tumour biology, may give additional information for selecting patients to chemotherapy.

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.

Complete histological regression of metastatic carcinoid tumour after treatment with octreotide

A 69-year-old woman was admitted with facial flushing, weight loss and intermittent diarrhoea. Urinary 5-hydroxyindole-acetic acid (5-HIAA) level was elevated at 200 micromol/24 h (normal: < 50). Computerized tomography (CT) demonstrated multiple enhancing liver metastases with biopsy proven carcinoid metastases with no evidence of primary tumour at this stage. Octreotide was initiated, resulting in marked improvement in carcinoid symptoms. Nine years later, she presented with abdominal pain and slightly deranged liver function tests. Repeat colonoscopy at this stage, showed an ileal tumour causing impending obstruction, necessitating urgent right hemicolectomy. Histology demonstrated primary carcinoid tumour. She continued on octreotide. Three years later at the age of 81 years, she suffered a fatal haemorrhagic stroke. Autopsy revealed complete regression of hepatic carcinoid metastases.

Molecular identification of metastatic cancer to the skin using laser capture microdissection: a case report

BACKGROUND

In the current study the authors report a 57-year-old woman with a scalp tumor and cervical lymphadenopathy who had a previously resected duodenal carcinoid. Histologic and immunophenotypic characteristics of the duodenal carcinoid differed from those of the scalp and cervical lymph node tumors, prompting the use of molecular methodologies to make the diagnosis.

METHODS

Paraffin embedded tissues from the duodenal carcinoid, scalp, and lymph node tumors were dissected using microscopic visualization and laser capture microdissection. DNA was extracted and polymerase chain reaction (PCR) was performed to evaluate loss of heterozygosity and microsatellite alterations using primers flanking 22 polymorphic microsatellite markers from 9 chromosomal regions, including genes associated with MEN-1 (11q), CDKN2 (9p), p53 (17p), and bronchial carcinoid (3p). Microdissected lymphocytes from the three tissues were used as source of constitutional DNA (controls).

RESULTS

Fourteen of the 22 markers were informative (heterozygous in control lymphocytes). A marker on 3p12 showed loss of the same parental allele in the three tumors. A different marker on 3p14.2 showed an identical shifted band in the three tumors indicative of a common microsatellite alteration.

CONCLUSIONS

The shared molecular abnormalities among the three tumors indicated a common clonal origin, leading to a diagnosis of primary duodenal carcinoid with clear cell metastases to the scalp and cervical lymph nodes. These findings led to radiation therapy and immunotherapy rather than chemotherapy. This case illustrates the novel application of laser capture microdissection combined with PCR-based analyses of genomic markers for the identification of the origin of metastatic disease.

Carcinoid tumor of the cystic duct

A 69-year-old male was admitted to an outside institution for severe right abdominal pain radiating to the flank. An extensive work-up, including lower GI series, IVP, and ultrasound of the kidneys were normal. Ultrasound of the liver demonstrated a thickened gallbladder as well as cholelithiasis. Despite some improvement, his symptoms returned intermittently and cholecystectomy was performed. Pathologic examination of the gallbladder showed a carcinoid tumor, 5.4 mm in maximum diameter, in the cystic duct. A small metastatic focus was also found in the cystic duct lymph node. In this paper we compare the clinical presentation, pathological findings and outcome of this case to the previously reported six cases of cystic duct carcinoid. A comparison is also made between the general features of carcinoid at this rare location and the more common gastrointestinal carcinoid.

Chromogranin A, neuron specific enolase, carcinoembryonic antigen, and hydroxyindole acetic acid evaluation in patients with neuroendocrine tumors

BACKGROUND

Chromogranin A (CgA), neuron specific enolase (NSE), carcinoembryonic antigen (CEA), and urinary 5-hydroxyindole-3-acetic acid (5-HIAA) are the markers currently used in the diagnosis, prognosis, and follow-up of patients with neuroendocrine tumors (NETs). The authors examined the role of such biomarkers in a large series of patients with NETs.

METHODS

One hundred and twenty-seven patients entered the study. Multiple blood and 24-hour urine specimens were assayed for biomarker quantitation.

RESULTS

The accuracy of each marker was assessed in patients with (n = 106) and without (n = 21) disease. CgA proved to be the best marker (specificity of 85.7% and sensitivity of 67.9%). Patients with disease had significantly higher CgA and NSE levels compared with disease free patients (P = 0.00003 and P = 0.00240, respectively). NSE and 5-HIAA determination showed a very high specificity (100%) but a rather low sensitivity (32.9% and 35.1%, respectively). CEA was found to have little diagnostic value (sensitivity of 15.4%). CgA was the most sensitive marker for detecting patients with disseminated disease and 5-HIAA displayed the highest sensitivity in identifying syndromic patients. Tumor marker modifications were studied during follow-up. In particular, rises in CgA were associated with progressive disease in 83.3% of cases and stable CgA was associated with stable disease in 53.8% of cases. The relation between CgA modifications and liver lesions during follow-up also was studied; increases in CgA levels were associated with local progression in 100% of cases and stable marker levels were found in 68.7% of the patients with unchanged lesions.

CONCLUSIONS

The results of the current study demonstrate that CgA has the highest accuracy and is the most reliable biomarker reflecting the clinical evolution of NETs.

Recent advances in systemic therapy for gastrointestinal neuroendocrine tumors

Neuroendocrine tumors of the gastrointestinal tract are rare tumors which can be classified as amine precursor uptake and decarboxylation tumors (APU-Domas). Although the majority of clinically apparent tumors are malignant, they are frequently slow growing. Despite this characteristic, they may generate disabling hormonal syndromes requiring aggressive treatment to achieve palliation. Recent advances in understanding the pathophysiology of these tumors has led to better medical therapy with chemotherapeutic agents, somatostatin analogues, and biologic therapies. This review will update the recent efforts in systemic therapies of the gastrointestinal neuroendocrine tumors.

A novel cytotoxic agent for human carcinoid tumors

BACKGROUND

Conventional adjuvant therapy for advanced carcinoid tumors remains disappointing; novel therapeutic agents are needed. We have shown previously that inhibiting polyamine biosynthesis with alpha-difluoromethylornithine (DFMO) slows the growth of carcinoid tumors. However, the clinical utility of DFMO has been limited by its cytostatic property. Synthetic polyamine analogs such as 1,19-bis(ethylamino)-5,10,15-triazanonadecane (BE-4-4-4-4) appear to be cytotoxic against several human tumors. The purpose of our study was to determine whether BE-4-4-4-4 is a more effective antiproliferative and cytotoxic agent than DFMO on human carcinoid (BON) cells in vitro.

METHODS

BON cells were treated with either 5 mmol/L DFMO, 0.5 to 10 mumol/L BE-4-4-4-4, or vehicle (control). Ornithine decarboxylase activity was determined by the rate of 14CO2 production, and intracellular polyamine levels were determined by chromatography. Cell number and viability were determined by Coulter counter and trypan blue exclusion, respectively.

RESULTS

BE-4-4-4-4 inhibited ornithine decarboxylase activity and depleted all 3 polyamines. BE-4-4-4-4 decreased cell numbers by 81% compared with control and 27% compared with DFMO. BE-4-4-4-4 also induced a 2-fold increase in cell death compared with control or DFMO.

CONCLUSIONS

BE-4-4-4-4 is cytotoxic and more effective than DFMO in inhibiting growth of BON cells. Polyamine analogs such as BE-4-4-4-4 may be effective adjuvant therapeutic agents for advanced carcinoid tumors.

Tonsillar metastasis from malignant pulmonary carcinoid tumour

Tumour metastases to the tonsil are rare and are usually due to spread from malignant melanoma and carcinomas of the breast, lung, kidney or stomach. We describe the clinical and histological findings of a tonsillar metastasis from a malignant pulmonary carcinoid tumour, an occurrence not previously reported.