Malignant rectal carcinoid: a sequential multidisciplinary approach for successful treatment of hepatic metastases.

A malignant rectal carcinoid metastatic to the liver presents a formidable challenge. The uniformly fatal course in patients with liver metastases (average survival of 2 years) justifies an aggressive approach. Although in an occasional patient the tumor is resectable, most are managed by chemotherapy, which generally is of limited effectiveness. Although certain drug combinations such as 5-fluorouracil and streptozotocin have achieved higher response rates, these responses are often brief (3 to 4 months) and poorly documented. Surgical hepatic dearterialization and, more recently, hepatic intraarterial embolization are quite effective in inducing regression in a variety of hepatic neoplasms, including metastatic carcinoids, but these are usually temporary. We have been timely instructed on the value of combined therapy by a patient who is a long-term survivor of a metastatic carcinoid to the liver. She is the only survivor among a group of 14 patients who had an average survival of 17 months. This patient emphasizes the benefit of combined hepatic dearterialization and chemotherapy in patients with metastatic carcinoid to the liver. She initially had intrahepatic infusion of 5-fluorouracil and streptozotocin through the surgically placed hepatic artery and portal vein catheters, but this was curtailed after 2 months because of catheter sepsis. She then had four sequential selective hepatic intraarterial embolizations with Gelfoam over a 16 month period. She also received systemic therapy with 5-fluorouracil and streptozotocin during a major portion of this period (10 months). Significant tumor regression was documented radiologically. Although she had another trial with intrahepatic chemotherapy infusion using surgically placed catheters, this was again discontinued because of catheter sepsis, and systemic chemotherapy was resumed. Currently, the patient is asymptomatic, has excellent performance status, and continues to show objective tumor regression on a program of systemic therapy with fluorodeoxyuridine and doxorubicin. She has survived more than 7 years with liver metastases from a rectal carcinoid.

Silver stains and immunocytochemical analysis with monoclonal serotonin antibodies for liver metastases of endocrine tumors. A study on percutaneous biopsy specimens.

With the aid of ultrasonography, representative percutaneous biopsy specimens were obtained from 20 of 21 patients (95 percent) with liver metastases of carcinoids and endocrine pancreatic tumors. The specimens were examined with silver stains and immunocytochemically after the application of monoclonal serotonin antibodies. The Grimelius argyrophil silver nitrate stain was positive in all tumor metastases, demonstrating that they were of neurohormonal endocrine type. The argentaffin reaction stained 14 of 15 metastases of small intestinal carcinoids, whereas tumors with other primary sites were unreactive. Immunocytochemical analysis with monoclonal serotonin antibodies stained all metastases of small intestinal carcinoids, and the other endocrine tumor metastases were unreactive. With immunocytochemical analysis, optimal results were obtained in Bouin-fixed tumor specimens, whereas for the argentaffin reaction, formalin was preferable. The results show that silver stains and immunocytochemical analysis with monoclonal serotonin antibodies on small percutaneous biopsy specimens of liver metastases of endocrine tumors and carcinoids are valid for the prediction of the location of the primary tumors.

Anaesthesia for an unusual carcinoid metastasis.

The intra-operative course of a patient found to have a metastatic serotonin-secreting carcinoid tumour in the orbit is reported. No prophylactic or intra-operative therapy was necessary during the administration of enflurane anesthesia. This case demonstrates again the wide spectrum of clinical responses observed among patients with this disease.

Anaesthesia for removal of carcinoid metastases. A case of serotonin-secreting secondary tumour in the lumbar spine.

A case of general anaesthesia for removal of carcinoid metastases is presented. Evidence of serotonin hypersecretion was shown by raised levels of 5-hydroxyindoleacetic acid, hypertension and tachycardia. The rarity of osteoblastic carcinoid metastases is discussed.