Improved Outcome With Cytoreduction Versus Embolization for Symptomatic Hepatic Metastases of Carcinoid and Neuroendocrine Tumors

Background Few data exist regarding outcomes after resection versus embolic treatment of symptomatic metastatic carcinoid and neuroendocrine tumors. The purpose of this study was to determine whether cytoreduction provides any benefit over embolic management of diffuse neuroendocrine tumors. Methods A prospective database of 734 patients treated at our institution was retrospectively queried for symptomatic metastatic tumors treated with embolization or cytoreduction. Patients were compared with regard to pretreatment performance status, relief of symptoms, and survival. Results A total of 120 patients were identified: 59 undergoing embolization and 61 undergoing cytoreduction. Twenty-three patients had palliative cytoreduction (gross residual disease). Pretreatment performance status (Eastern Cooperative Oncology Group) was similar for both groups: .7 ± .70 (embolization) versus .8 ± .72 (cytoreduction; P = .27). Complete symptomatic relief was observed in 59% and partial relief in 32% of patients who underwent embolization, with a mean symptom-free interval of 22 ± 13.6 months. A total of 69% of patients who underwent cytoreduction had complete symptomatic relief, and 23% had partial relief (P = .08 vs. embolization). The mean duration of relief was 35 ± 22.0 months (P < .001 vs. embolization). The mean survival for the patients who underwent embolization was 24 ± 15.8 months versus 43 ± 26.1 months for those who underwent cytoreduction (P < .001). Survival in patients who underwent palliative cytoreduction was 32 ± 18.9 months (P < .001 vs. embolization), whereas it was 50 ± 27.6 months in patients who underwent curative resection (P < .001 vs. embolization; P < .001 vs. palliative). Conclusions Cytoreduction for metastatic neuroendocrine tumors resulted in improved symptomatic relief and survival when compared with embolic therapy in this nonrandomized study. Cytoreduction should be pursued whenever possible even if complete resection may not be achievable. An erratum to this article is available at .     

Palliative management strategies of advanced gastrointestinal carcinoid neoplasms

Background/aims Optimal management of gastrointestinal carcinoid neoplasms that metastasize to the liver is controversial. Although operative resection seems to be the most effective approach to metastatic disease, hepatic metastases are usually multicentric and often non-resectable. We investigated the effectiveness of several forms of palliative tumor cytoreduction followed by administration of somatostatin analogues in advanced carcinoid neoplasms.Methods We reviewed our experience with 34 patients with gastrointestinal carcinoid neoplasms. Eighteen patients had metastases and 14 had hormonal symptoms. Twenty-two patients underwent radical surgery, ten with multiple liver metastases were treated with a combination of debulking (resection, radiofrequency ablation, chemoembolization), followed by medical treatment with long-acting octreotide and eventually by radiolabelled somatostatin analogues, and two patients with intractable disease received only biotherapies.Results The six patients with metastatic disease who underwent radical curative liver resection had a median survival of 52 months, compared with a median survival of 48 months in the ten patients who underwent palliative debulking. Symptomatic improvement was observed in all the patients after debulking procedures. The two patients who underwent only medical treatment died after 9 and 18 months.Conclusions Aggressive tumor debulking should be performed in patients with liver metastases already at diagnosis even when complete resection is not feasible because the combination of cytoreductive procedures followed by biotherapies may provide good long-term survival and achieves symptom control in most patients with advanced disease.Paper presented at the First Constituent Congress of the European Society of Endocrine Surgeons (ESES), Pisa, Italy, 14–15 May 2004     

Biomarkers Predict Outcomes Following Cytoreductive Surgery for Hepatic Metastases from Functional Carcinoid Tumors

BACKGROUND: Cytoreductive therapy for metastatic carcinoid provides symptomatic relief and improvement in overall survival. We evaluated whether CgA and 5HIAA could predict symptomatic relief and control of disease progression after cytoreductive surgery. METHODS: We retrospectively reviewed 70 patients who underwent cytoreductive surgery for neuroendocrine hepatic metastases between 1996 and 2005. Twenty-two patients had pre and post-operative CgA and/or 5HIAA levels measured. Reduction of biomarkers following cytoreduction was correlated with patient symptoms and progression of disease following surgery. RESULTS: Our study consisted of 14 males and 8 females with a mean age of 55 (+/-12 years). Median follow-up was 18 months (range 5-64 months). Six patients (26.1%) had complete (R0) cytoreduction, while 4 (17.4%) and 13 (56.5%) had microscopic (R1) and gross (R2) disease remaining. All patients reported improvements in their symptoms, with 12 (54.5%) reporting complete resolution (CR) and 10 (45.5%) reporting partial resolution (PR). Reduction of CgA of >or= 80% was highly predictive of complete resolution of symptoms (P = 0.007) and stabilization of disease (P = 0.034). Reduction of 5HIAA levels of >or= 80% (or normalization) was predictive of symptomatic relief, but not progression of disease (P = 0.026 and P = 0.725). Five of six patients who had R0 resections had CR and were free of disease at last follow-up (median 24.5 months, range: 11-48, P = 0.002). CONCLUSIONS: We conclude that >or= 80% reduction in CgA level following cytoreductive surgery for carcinoid tumors is predictive of subsequent symptom relief and disease control. Substantial reduction in CgA is associated with improved patient outcomes, even after incomplete cytoreduction.     

Survival and functional quality of life after resection for hepatic carcinoid metastasis

Retrospective studies suggest that resection improves 5-year survival for patients with hepatic carcinoid metastasis (HCM). The purpose of our study was to describe clinical outcomes following resection for HCM, including survival and longitudinal functional quality of life (QOL). We reviewed the records of patients undergoing resection for HCM from 1980 to 2001 at our institution. Outcome measures included tumor symptoms, biochemical tumor markers, functional QOL through Karnofsky functional scores, and survival. Thirteen patients underwent a total of 17 resections. Overall 5-year survival was 85%. Eleven patients were symptomatic, including eight with classic carcinoid syndrome. Nine experienced complete relief of symptoms and two had incomplete relief for 30 ± 12 months. Eight patients had elevated tumor markers, and 50% of these had postoperative normalization of all tumor markers that persisted to the close of the study. For the 10 patients with longitudinal follow-up available to 54 months, significant improvement in functional QOL was observed at all follow-up time points compared to preresection functional QOL (P< 0.05). Resection of &#x2265;90% tumor volume was significantly associated with more favorable survival and tumor marker normalization compared to resection of <90% tumor volume P< 0.01 and P< 0.05, respectively), but trajectory of functional QOL improvement did not differ between these two groups (P= 0.24). We conclude that resection for HCM is associated with significantly improved and sustained functional QOL and prolonged survival. Resection of ≥90% tumor volume is significantly associated with extended survival and normalization of tumor markers, but is not required for symptomatic or functional QOL improvement. Presented at the 2003 meeting of the American Hepato-Pancreato-Biliary Association, Miami Beach, Florida, February 27–March 2, 2003.     

胃癌肝转移患者的手术治疗及预后分析

目的探讨胃癌肝转移患者手术治疗的指征和效果。方法回顾性分析我院1995年9月至2002年5月间经手术治疗的43例胃癌肝转移患者的临床资料。结果全组肝转移程度与患者性别、年龄、肿瘤侵犯深度、分化程度及有无淋巴结转移无相关关系(P>0.05)。异时性肝转移行肝切除4例,中位生存时间为35.0个月,预后明显优于同时性肝转移肝切除患者(中位生存时间10.0个月)(P=0.0233)。同时性肝转移组中,单纯胃切除32例,中位生存时间6.0个月;胃加肝切除7例,中位生存时间10.0个月,两组差异无统计学意义(P=0.2799)。不同肝转移程度姑息性胃切除术后生存时间比较,H1、H2和H33组分别为7.5、6.0和4.0个月,差异具有统计学意义(P=0.0007)。结论异时性胃癌肝转移患者肝切除术后预后良好,应争取积极手术切除;胃癌肝转移患者同期行胃加肝切除生存率未见明显改善;H3肝转移患者姑息性胃切除预后不佳。     

Surgical experience with functioning pancreatic neuroendocrine tumors

Pancreatic islet-cell tumors (ICTs) are rare malignancies usually recognized by specific clinical endocrinopathies. The purpose of this study is to evaluate our surgical experience with functioning pancreatic ICT in an academic referral center. Twenty patients (male:female 12:8) with a mean age of 53 years (range 26-82) underwent surgery for a functioning pancreatic ICT [gastrinoma (eight), multiple endocrine neoplasia (three), insulinoma (seven), glucagonoma (four), and VI-Poma (vasoactive intestinal peptide; one)] between June 1975 and March 2001. Signs and symptoms of hormonal excess were present in 95 per cent (19 of 20). One patient (glucagonoma) presented with obstructive jaundice and mild glucose intolerance. Elevated peptide levels were detected preoperatively in 65 per cent, including all patients with an insulinoma. Curative resections were attempted in 80 per cent including three procedures for insulinoma. Palliative procedures were performed in 20 per cent--all gastrinomas. One patient with an insulinoma had diffuse nesidioblastosis. Three patients (with gastrinoma, insulinoma, and glucagonoma) had lymph node-positive disease and three patients with gastrinoma had liver metastasis. The overall 30-day morbidity rate was 30 per cent and mortality rate 0 per cent. Symptomatic improvement was achieved in 90 per cent at a mean follow-up of 44 months. Two patients developed diabetes after a subtotal and a total pancreatectomy, respectively. Sixty-three per cent of patients who underwent an attempted curative resection are alive at a mean follow-up of 47 months (range 3-231) and all patients who underwent a palliative procedure are alive at a mean follow-up of 31 months (range 27-36). Functioning pancreatic ICTs are fascinating tumors that produce distinct clinical syndromes. Symptomatic improvement is accomplished in the majority of patients after surgery and short-term palliation is achieved in patients with nonresectable disease.     

Chromogranin A,a Marker of the Therapeutic Success of Resection of Neuroendocrine Liver Metastases: Preliminary Report

Recent publications indicate that life may be prolonged by surgical debulking of neuroendocrine tumors. A minimum 90% reduction of liver metastases has been suggested to alleviate symptoms of the carcinoid. We have used the tumor marker chromogranin A (CgA) to assess hepatic resection in patients with neuroendocrine metastatic tumor disease. Since 1998, seven patients (3 men) of median age 73 years (range 64–84 years) with carcinoid primary tumors in the ileum who had solitary (n = 2) or multiple (n = 5) liver metastases underwent hepatic resections. Two patients had synchronous small intestinal and liver resections; the rest had deferred hepatic resections after intestinal resection. Hormonal manifestations in the form of loose stools or diarrhea or flushing were observed in five patients, and five had abdominal symptoms from partial obstruction of the small bowel. The resection was deemed radical in five patients. Two patients with non-radical resection needed postoperative octreotide treatment, and symptoms were alleviated or improved in the others. All seven patients are alive with an observation period from 6 to 64 months (median 36 months). Median CgA (normal < 30 ng/ml) was 292 ng/ml (range 79-14,000 ng/ml) before liver surgery. Postoperatively, CgA became normal in three of the radically resected patients, whereas in two others, it decreased to a lowest median level of 79 ng/ml (range 52–105 ng/ml). In two palliatively resected patients, one had a near normalization to 65 ng/ml, and the last patient had a reduction from 14,000 to 2400 ng/ml following debulking surgery. A similar postoperative reduction was noted for 24 hr urinary 5-HIAA excretion. Postoperative octreotide scintigraphy suggested residual hepatic or extrahepatic tumors in three of the patients thought radically resected, whereas two had no clear sign of disease corresponding to a normal CgA value. The CgA values, however, reflected the extent of positive scintigraphy findings. Serum CgA levels monitored the extent and short-term course of the disease and corresponded well with scintigraphy findings and 5-HIAA excretion, but prolonged follow-up in more patients may be necessary before decisive conclusions are allowed to be drawn.     

The role of abdominal resectional surgery in metastatic melanoma

BACKGROUND: We reviewed our experience to determine the role of resectional surgery in metastatic melanoma to the abdomen. METHOD: An observational study of 25 patients at the Austin Hospital, Melbourne from 1997 to 2005. RESULTS: The median survival after abdominal resectional surgery was 8.3 (range 0.4-41.1) months. Fourteen patients who underwent resection with curative intent (extra-abdominal disease controlled and complete macroscopic clearance of abdominal disease) had improved survival compared with 11 patients who underwent palliative resection (12 month survival, 89 vs 10%, respectively, P < 0.0001). Survival was also superior in patients with up to two metastases compared with more than two (P = 0.0001) and in patients with serum albumin of at least 35 g/L (P = 0.0031). Intent of surgery (curative vs palliative) was the only factor significant on multivariate analysis (P = 0.001). Of patients with preoperative symptoms, 87% had resolution of these symptoms. Operative morbidity was 12%, and 30-day mortality was 4%. CONCLUSIONS: In a highly selected group of patients with intra-abdominal melanoma metastases, resection of intra-abdominal metastases with curative intent resulted in prolonged survival compared with patients who underwent palliative resection. Those who underwent palliative resection had good relief of symptoms with minimal morbidity.     

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.     

Effective long-term palliation of symptomatic, incurable metastatic medullary thyroid cancer by operative resection.

OBJECTIVE: To evaluate the short- and long-term consequences of palliative reresection of specific symptomatic lesions in patients with widely disseminated (incurable) medullary thyroid cancer (MTC). SUMMARY BACKGROUND DATA: Although reoperative neck microdissections can normalize calcitonin levels in patients with metastatic MTC confined to regional lymph nodes, there is no curative therapy for widely metastatic disease. However, these patients frequently have prolonged survival, but often with debilitating symptoms. METHODS: Between October 1981 and January 1997, 16 patients (mean age, 46 +/- 3 years; 10/16 female) underwent 21 palliative reoperations for unresectable MTC at the Johns Hopkins Hospital. All patients had significant symptom(s) or impending compromise of vital structures by a discrete lesion and had unequivocal preoperative evidence of a total disease burden that was unresectable. RESULTS: The mean interval from initial thyroidectomy to palliative surgery was 5.8 +/- 1.5 years. All patients had significant tumor burdens as evidenced by preoperative calcitonin values ranging from 900 to 222,500 pg/mL (nL < or = 17 pg/mL). The palliative operations consisted of reoperative neck dissection/mass excision (11), mediastinal mass resection (4), esophagectomy (1), liver trisegmentectomy (1), sigmoidectomy (1), bilateral simple mastectomies (1), pituitary resection (1), and subcutaneous mass excisions (1). All but two of the operative specimens contained MTC. There was no perioperative mortality. The long-term morbidity rate was limited to one recurrent laryngeal nerve injury. All patients had initial relief of the index symptom(s) after the palliative surgery, followed by a median actuarial symptom-free survival rate of 8.2 years. CONCLUSIONS: Patients with widely metastatic MTC often live for years, but many develop symptoms secondary to tumor persistence or progression. Judicious palliative, reoperative resection of discrete, symptomatic lesions can provide significant long-term relief of symptoms with minimal operative mortality and morbidity. In selected patients with metastatic MTC lesions causing significant symptoms or physical compromise, palliative reoperative resection should be considered despite the presence of widespread incurable metastatic disease.     

Primary cancers of the small bowel: analysis of prognostic factors and results of surgical management

HYPOTHESIS: This study was done to review the clinical presentation, surgical management, pathologic features, and prognostic factors for primary small-bowel cancers. DESIGN: Retrospective case series. SETTING: Tertiary care, university hospital. PATIENTS: One hundred twenty-nine patients were surgically treated between January 1, 1977, and December 31, 2000. There were 73 men and 56 women, with a median age of 55 years (age range, 19-82 years). Median follow-up was 36 months. MAIN OUTCOME MEASURES: Presenting symptoms and signs, operations performed, and surgical pathologic features were analyzed and survival curves were generated. RESULTS: Clinical findings included abdominal pain (63%), vomiting (48%), weight loss (44%), and gastrointestinal tract bleeding (23%). The distribution of tumors by histological features was as follows: adenocarcinoma (33%), carcinoid tumor (29%), lymphoma (19%), and sarcoma (19%). Cumulative 5-year survival rate was 37% in the adenocarcinoma group, 64% in the carcinoid tumor group, 29% in the lymphoma group, and 22% in the sarcoma group. Significant prognostic predictors of overall survival for the entire cohort and for each tumor subtype included complete resection and American Joint Committee on Cancer tumor stage (P<.05). Patient age, tumor location, histological grade, and use of chemotherapy and radiation therapy did not significantly influence survival. Curative resections were accomplished in 83 patients (64%) with a median survival of 37 months compared with 46 patients undergoing incomplete or palliative resections with a median survival of 10 months (P<.05). Adjacent organ resection was required in 18 (22%) of the 83 patients undergoing potentially curative resections. The median time to recurrence was 16 months. Twenty-one patients (16%) developed associated primary cancers. CONCLUSIONS: Aggressive surgical resection in an attempt to achieve complete tumor removal seems warranted. Despite complete resections, patients with high-stage tumors remain at risk for recurrence.     

The role of surgery in the treatment of colorectal metastases from primary skin melanoma

Aim The study assessed the role of colorectal surgery in the treatment of metastatic melanoma and identified patients who can most benefit from surgical resection. Method A retrospective analysis was made of 34 consecutive patients with skin melanoma who underwent surgical resection of large bowel metastasis. Results The median disease‐free interval between diagnosis of the primary and metastatic melanoma was 24 (7–98) months. Nine (27%) patients underwent emergency surgery for obstruction and 25 (73%) had an elective procedure. Resection with curative intent was performed in 14 (41%) and palliative resection in 20 (59%) patients. There was no postoperative mortality and morbidity occurred in 9%. The median survival following surgery was 11.5 (4–68) months. The 1‐, 2‐ and 5‐year survival rates were 50%, 32% and 17% respectively. Median survival was significantly increased in patients without extra‐abdominal metastases, with no evidence of non‐large‐bowel metastases, if the disease‐free interval was longer than 24 months and when curative resection was performed. In multivariate analysis, an apparently complete or palliative resection and the absence or presence of extra‐abdominal metastases were the most important prognostic factors. Conclusion An aggressive surgical approach to large bowel metastatic melanoma results in good palliation and effective relief of symptoms with acceptable morbidity and mortality.     

Is Surgery Indicated for Patients with Symptomatic Nonfunctioning Pancreatic Neuroendocrine Tumor and Unresectable Hepatic Metastases?

Background Patients with advanced pancreatic neuroendocrine tumor, even in the presence of unresectable hepatic metastases, have survival usually measured in years than in months. Theoretically, we would have reason to resect symptomatic primary pancreatic neuroendocrine tumors from these patients palliatively. However, the effect and feasibility of removing symptomatic primary pancreatic neuroendocrine tumor in patients with unresectable hepatic metastases has never been addressed. Methods In 2000, we instituted a prospective study to resect symptomatic primary tumors and treat unresectable hepatic metastases by lanreotide and hepatic artery embolization in patients with definite tissue proof of pancreatic neuroendocrine tumor. Results Thirteen patients were included in this study; seven patients underwent pancreaticoduodenectomy, and six underwent distal pancreatectomy and splenectomy. There were no operative deaths. Eight of thirteen patients had no radiologic evidence of disease progression. The other five patients had disease progression by their 6-month follow-up; they underwent hepatic artery chemoembolization or chemotherapy. One patient died of multiple lung and bone metastases 80 months after operation, and one patient died of continuous progression of liver metastases 18 months after operation. Telephone interviews of 11 patients who survived revealed that 10 reported improved quality of life after resection of symptomatic primary pancreatic neuroendocrine tumor and one patient reported no change. Conclusions We suggest that symptomatic primary pancreatic neuroendocrine tumors should be resected even when unresectable hepatic metastases are found at diagnosis because of the relatively low risk of pancreatic surgery, effective elimination of symptoms caused by primary tumors, and slow progression of hepatic metastases under lanreotide and hepatic artery embolization.     

Obstruction of the extrahepatic bile ducts by tumor debris and/or clots in primary cancer of the liver. Diagnostic and therapeutic problems. Apropos of 9 personal cases and review of the literature

The onset of jaundice in patients with primary liver cancer is sometimes caused by intra ductal biliary system tumor casts, free floating debris or hemobilia. The diagnosis of this complication is now possible by E.R.C.P. or P.T.C. We report 9 cases of unrecognized primary liver tumor revealed by intra biliary system migration of tumor casts or free floating debris. In three patients the diagnosis was operative, but for the last six cases the E.R.C.P. data in addition with U.S., C.A.T. Scan and/or hepatic angiography were helpful in determining the nature of the hepatic and biliary changes, the operability (size, location, extent). A curative surgery was not indicated in our 8 operated patients: liver resection and biliary decompression. With the palliative procedures, bilio enteric by pass (2 cases) T tube (1 case) trans hepatic uni or bilateral tubes. The survey was not longer than 11 months. Three patients died in post operative course. Only 56 patients among 117 observations of the literature have been operated: 10 liver resections including the main hepatic junction in two cases were performed with one hospital death, two patients were alive over 2 years with recurrence and three patients were disease free with a follow up less than one year. The operative mortality with palliative procedures was 34.4%; the one-two years survival was 23%; the two longest survivors lived 41 and 61 months.     

Surgical treatment of recurrent colorectal cancer. Five-year follow-up

Analysis of 81 consecutive patients with recurrent colorectal cancer was undertaken to evaluate the rationale and efficacy of surgical re-treatment. The disease-free interval after primary surgery and the diagnostic delay did not clearly differ between the modes of recurrences. Symptoms preceded the diagnosis of recurrence in 73% (59) of the cases, with pain being the most frequent symptom (n = 22). Of the patients, 58% (47) underwent reoperations, 38% (31) underwent reresections, and 10% (8) underwent radical resections. The overall postoperative mortality was 13%, and the postoperative morbidity was 45%. The postoperative relief of cancer symptoms after resective surgery was 8 months and, after nonresective surgery, 2 months. The median survival was 24 months for patients who underwent resections, 8 months for patients who were treated by nonresective surgery, and 15 months for patients who were treated conservatively. Radical resection clearly prolonged survival when compared with palliative resections and nonresective procedures. On the basis of these results, it was concluded that resective surgery, when possible, can improve survival and patient comfort after recurrence of colorectal cancer.     

Pancreatic VIPomas: Subject Review and One Institutional Experience

VIPomas are rare pancreatic endocrine tumors associated with a well-defined clinical syndrome characterized by watery diarrhea, hypokalemia, and metabolic acidosis. The objective of this study was to review a single institution’s experience with VIPomas, as well as to review the English literature. A retrospective review of the Johns Hopkins pancreatic database revealed four cases of VIPoma, with three patients being male. All patients presented with watery diarrhea, hypokalemia, hypercalcemia, and acidosis. All patients had no family history of multiple endocrine neoplasia. Computed tomography revealed the primary pancreatic tumor in all patients, with three tumors located in the tail of the pancreas. One tumor involved the entire pancreas. Computed tomography and/or octreotide radionuclide scans identified hepatic metastasis in three patients. Mean serum vasoactive intestinal polypeptide levels were 683 pg/ml (range 293 to 1,500 pg/ml). All patients underwent resection of the pancreatic primary tumor. Two patients also had simultaneous liver resections. All patients had evidence of malignancy as defined by the presence of metastatic lymph nodes and/or hepatic metastases. Two patients had complete resolution of symptoms after surgical resection. One patient required radioablation of liver metastases and adjuvant octreotide therapy for control of symptoms. One patient died of progressive metastatic disease 96 months after surgery, whereas the other three remain alive. Extended, meaningful survival can be achieved for VIPoma patients, combining an aggressive surgical approach with additional strategies for treatment of unresected disease.     

Effective palliative treatment of metastatic carcinoid tumors with intra-arterial chemotherapy/chemoembolization combined with octreotide acetate.

Survival in patients with metastatic carcinoid tumors is dependent on control of tumor growth and adequate palliation of vasoactive amine-induced symptoms of flushing, diarrhea, wheezing, and valvular heart disease. Eight patients with carcinoid tumors metastatic to the liver were treated with long-term octreotide acetate therapy (100 to 500 micrograms three times a day), intra-arterial 5-fluorouracil infusion (2 g/day x 5 days), and hepatic tumor chemoembolization. All eight patients became asymptomatic and have remained so with a mean follow-up duration of 22 months from the time of first infusion. Following institution of subcutaneous octreotide acetate, intra-arterial infusion, and tumor chemoembolization, all patients are alive with a mean survival of 40 months from the time of diagnosis of carcinoid syndrome (range: 2 to 108 months). Four patients had greater than a 50% decrease in tumor size after therapy (mean follow-up duration: 10.6 months), and the other four patients have had stable disease after institution of therapy. It appears that combinations of long-term subcutaneous administration of octreotide acetate, intra-arterial 5-fluorouracil, and tumor chemoembolization effectively control progressive liver metastasis and provide excellent symptomatic palliation in patients with hepatic metastasis from functional carcinoid tumors.     

Surgical treatment of small bowel cancer: A 20-year single institution experience

Small bowel malignancies are rare. The aims of this study were to evaluate the outcomes associated with surgical therapy for small bowel cancers and to define prognostic factors. The medical records of 96 consecutive patients with primary small bowel cancer (excluding lymphoma) treated at our institution over a 20 year period were reviewed. Survival was analyzed using the Kaplan-Meier method (mean follow-up period 57 months). Mean patient age was 56 years, and 58% of patients were male. Sixty percent of patients had an adenocarcinoma, 21% had a sarcoma, and 19% had a carcinoid tumor. The percentages of patients who underwent complete (curative) resection were 51%, 90%, and 50% for those with adenocarcinoma, sarcoma, and carcinoid tumor, respectively. For patients with adenocarcinoma who underwent curative resection, tumor (T) and node (N) stages were significant prognostic factors predicting overall survival. For patients with sarcomas who underwent curative resection, tumor grade was a significant prognostic factor predicting overall survival. The prognosis for patients with small intestinal carcinoid tumors is uniformly favorable. The prognosis for patients with sarcomas and adenocarcinomas is generally poor, although long-term survival is achieved by patients with favorable prognostic factors. Presented at the Society of Surgical Oncology Fifty-Sixth Annual Cancer Symposium, Los Angels, California, March 5–9, 2003.     

Efficacy of Trans-septal Trans-sphenoidal Surgery in Correcting Visual Symptoms Caused by Hematogenous Metastases to the Sella and Pituitary Gland

The rate of symptomatic improvement of visual symptoms associated with hematogenous metastases to the sella and pituitary was evaluated retrospectively in seven patients (five men, two women; mean age, 52.3 years) with primarily visual symptoms (diplopia alone in three, diplopia with blurred vision in one, blurred vision alone in one, loss of peripheral vision in one, and unilateral complete blindness in one). Symptom duration ranged from 0.5 to 2 months. The primary diseases were non-small cell lung cancer in two patients, renal cell carcinoma in two patients, prostate cancer in two patients, and medullary thyroid carcinoma in one patient. All patients had widespread metastatic disease. Three patients had a suprasellar tumoral component. One patient had a clival extension, and one patient had extension into the cavernous sinus. All underwent trans-sphenoidal surgery to correct visual symptoms. Gross total resection was achieved in three patients. Subtotal resections and a partial resection were performed in three patients and one patient, respectively. Surgical blood loss averaged 282 mL. One patient died from sepsis. Five patients developed complications (cerebrospinal fluid leakage in three, diabetes insipidus in two, anterior pituitary dysfunction in two, and colitis in one). At a mean follow-up of 15 months, three patients were alive. Visual symptoms improved in five patients and were unchanged in two. Trans-sphenoidal surgery helped improve visual symptoms in most patients. The morbidity rate was high and likely related to the locally destructive and extensive nature of the lesions in overall morbid patients with widespread metastatic disease. Unless nonoperative measures can provide equal results, however, this approach provides reasonable palliation.     

Cancer of the gallbladder

Of 21 patients with primary carcinoma of gallbladder the diagnosis has been considered before operation in three. Nine patients underwent laparotomy only, six a palliative resection, and six a curative resection. In these three groups, 17 patients died. The mean survival time was respectively 1.5.4.3, an 8.6 months. Four patients are alive. Three of them had a resection for a carcinoma limited to the wall of gallbladder. Two patients had radiation therapy, one after palliative resection (died 11th month), the other one after biliary and digestive by-pass (alive with a follow-up of 15 months). Three patients had dosages of carcino-embryonic antigen. Our experience suggested that: diagnosis may be suggested by echography, The usefulness of carcino-embryonic-antigen levels, radiotherapy may increase the effectiveness and length of palliation.