Abstract
For patients with localized carcinoid tumors, surgical resection alone is often curative. Patients with metastatic disease, on the other hand, often present a therapeutic challenge. While somatostatin analogs are highly effective in controlling symptoms of hormonal secretion, they are only rarely associated with tumor regression. Selected patients with hepatic metastases may benefit from surgical debulking, embolization, or other ablative therapies. The clinical benefit associated with the administration of systemic agents such as alpha interferon or cytotoxic chemotherapy is less clear, and the widespread use of such regimens has been limited by their relatively modest anti-tumor activity as well as concerns regarding their potential toxicity. New treatment approaches for patients with metastatic carcinoid tumors are being actively explored.
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References
Harpole D, Feldman J, Buchanan S, et al. Bronchial carcinoid tumors: a retrospective analysis of 126 patients. Ann Thorac Surg. 1992;54:50–5.
Vadasz P, Palffy G, Egervary M, et al. Diagnosis and treatment of bronchial carcinoid tumors: clinical and pathological review of 120 operated patients. Eur J Cardiothorac Surg. 1993;7:8–11.
Okike N, Bernatz P, Woolner L. Carcinoid tumors of the lung. Ann Thorac Surg. 1976;22:270–7.
Fink G, Krelbaum T, Yellin A, et al. Pulmonary carcinoid: presentation, diagnosis, and outcome in 142 cases in Israel and review of 640 cases from literature. Chest. 2001;119:1647–51.
Oberg K, Alm G, Magnusson A, et al. Treatment of malignant carcinoid tumors with recombinant interferon alfa-2b: development of neutralizing interferon antibodies and possible loss of antitumor activity. J Natl Cancer Inst. 1989;81:531–5.
McCaughan B, Martini N, Bains M. Bronchial carcinoids: review of 124 cases. J Thorac Cardiovasc Surg. 1985;89:8–17.
Chughtai T, Morin J, Sheiner N, et al. Bronchial carcinoid-twenty years’ experience defines a selective surgical approach. Surgery. 1997;122:801–8.
Skuladottir H, Hirsch F, Hansen H, et al. Pulmonary neuroendocrine tumors: incidence and prognosis of histological subtypes. A population-based study in Denmark. Lung Cancer. 2002;37:127–35.
Torre M, Barberis M, Barbieri B, et al. Typical and atypical bronchial carcinoids. Respir Med. 1989;83:305–8.
Rindi G, Luinetti O, Cornaggia M, et al. Three subtypes of gastric argyrophil carcinoid and the gastric neuroendocrine carcinoma: a clinicopathologic study. Gastroenterology. 1993;104:994–1006.
Rindi G, Bordi C, Rappel S, et al. Gastric carcinoids and neuroendocrine carcinomas: pathogenesis, pathology, and behavior. World J Surg. 1996;20:168–72.
Barclay T, Schapira D. Malignant tumors of the small intestine. Cancer. 1983;51:878–81.
Moertel C, Sauer W, Dockerty M, et al. Life history of the carcinoid tumor of the small intestine. Cancer. 1961;14:901–12.
Burke AP, Thomas RM, Elsayed AM, et al. Carcinoids of the jejunum and ileum: an immunohistochemical and clinicopathologic study of 167 cases. Cancer. 1997;79:1086–93.
Makridis C, Oberg K, Juhlin C, et al. Surgical treatment of mid-gut carcinoid tumors. World J Surg. 1990;14:377–85.
Eckhauser FE, Argenta LC, Strodel WE, et al. Mesenteric angiopathy, intestinal gangrene, and midgut carcinoids. Surgery. 1981;90:720–8.
Hellman P, Lundstrom T, Ohrvall U, et al. Effect of surgery on the outcome of midgut carcinoid disease with lymph node and liver metastases. World J Surg. 2002;26:991–7.
Moertel C, Dockerty M, Judd E. Carcinoid tumors of the vermiform appendix. Cancer. 1968;21:270–8.
Modlin IM, Lye KD, Kidd M. A 5-decade analysis of 13,715 carcinoid tumors. Cancer. 2003;97:934–59.
Moertel CG, Weiland LH, Nagorney DM, et al. Carcinoid tumor of the appendix: treatment and prognosis. N Engl J Med. 1987;317:1699–701.
Anderson J, Wilson B. Carcinoid tumors of the appendix. Br J Surg. 1985;72:545–6.
Syracuse D, Perzin K, Weidel P, et al. Carcinoid tumors of the appendix: mesoappendiceal extension and nodal metastases. Ann Surg. 1979;190:58–63.
Bowman G, Rosenthal D. Carcinoid tumors of the appendix. Am J Surg. 1983;146:700–3.
Thirlby R, Kasper C, Jones R. Metastatic carcinoid tumor of the appendix: report of a case and review of the literature. Dis Colon Rectum. 1984;27:42–6.
MacGillivray D, Heaton R, Rushin J, et al. Distant metastases from a carcinoid tumor of the appendix less than one centimeter in size. Surgery. 1992;111:466–71.
Pearlman D, Srinivasan K. Malignant carcinoid of the appendix: metastases from a small primary tumor which appeared as appendiceal intussusception. N Y State J Med. 1971;71:1529–31.
Jetmore A, Ray J, Gathright J, et al. Rectal carcinoids: the most frequent carcinoid tumor. Dis Colon Rectum. 1992;35:717–25.
Soga J. Carcinoids of the rectum: tumors of the carcinoid family-urgut endocrinomas. Acta Med Biol. 1982;29:157–201.
Naunheim K, Zeitels J, Kaplan E, et al. Rectal carcinoid tumors – treatment and prognosis. Surgery. 1983;94:670–6.
Woodard P, Feldman J, Paine S, et al. Midgut carcinoid tumors: CT findings and biochemical profiles. J Comput Assist Tomogr. 1995;19:400–5.
Sugimoto E, Lorelius L, Eriksson B, et al. Midgut carcinoid tumors: CT appearance. Radiologica. 1995;36:367–71.
Lamberts S, Bakker W, Reubi J, et al. Somatostatin receptor imaging in the localization of endocrine tumors. N Engl J Med. 1990;323:1246–9.
Kvols LK, Brown ML, O’Connor MK, et al. Evaluation of a radiolabeled somatostatin analog (I-123 octreotide) in the detection and localization of carcinoid and islet cell tumors. Radiology. 1993;187:129–33.
Kaltsas G, Korbonits M, Heintz E, et al. Comparison of somatostatin analog and meta-iodobenzylguanidine radionuclites in the diagnosis and localization of advanced neuroendocrine tumors. J Clin Endocrinol Metab. 2001;86:895–902.
Krenning E, Kwekkeboom D, Bakker W, et al. Somatostatin receptor scintigraphy with [111In-DTPA-D-Phe1] - and [123-Tyr3]-octreotide: the Rotterdam experience with more than 1000 patients. Eur J Nucl Med. 1993;20:716–31.
Schillaci O, Scopinaro F, Danieli R, et al. Single photon emission computerized tomography increases the sensitivity of indium-111-pentetreotide scintigraphy in detecting abdominal carcinoids. Anticancer Res. 1997;17:1753–6.
Schillaci O, Corleto V, Annibale B, et al. Single photon emission computed tomography procedure improves accuracy of somatostatin receptor scintigraphy in gastro-entero pancreatic tumours. Ital J Gastroenterol Hepatol. 1999;31 Suppl 2:S186–9.
Gibril F, Reynolds J, Doppman J, et al. Somatostatin receptor scintigraphy: its sensitivity compared to that of other imaging methods in detection of primary and metastatic gastrinomas. A prospective study. Ann Intern Med. 1996;125:26–34.
Feldman JM, O’Dorisio TM. Role of neuropeptides and serotonin in the diagnosis of carcinoid tumors. Am J Med. 1986;81:41–8.
Meko JB, Norton JA. Management of patients with Zollinger-Ellison syndrome. Annu Rev Med. 1995;46:395–411.
Eriksson B, Oberg K, Stridsberg M. Tumor markers in neuroendocrine tumors. Digestion. 2000;62 Suppl 1:33–8.
Janson E, Holmberg L, Stridsberg M, et al. Carcinoid tumors: analysis of prognostic factors and survival in 301 patients from a referral center. Ann Oncol. 1997;8:685–90.
Lundin L, Norheim I, Landelius J, et al. Carcinoid heart disease: relationship of circulating vasoactive substances to ultrasound-detectable cardiac abnormalities. Circulation. 1988;77:264–9.
Simula D, Edwards W, Tazelaar H, et al. Surgical pathology of carcinoid heart disease: a study of 139 valves from 75 patients spanning 20 years. Mayo Clin Proc. 2002;77:139–47.
Robiolio P, Rigolin V, Wilson J, et al. Carcinoid heart disease: correlation of high serotonin levels with valvular abnormalities detected by cardiac catherterization and echocardiography. Circulation. 1995;77:264–9.
Pellikka P, Tajik A, Khandheria B, et al. Carcinoid heart disease: clinical and echocardiographic spectrum in 74 patients. Circulation. 1993;87:1188–96.
Moller J, Connolly H, Rubin J, et al. Factors associated with progression of carcinoid heart disease. N Engl J Med. 2003;348:1005–15.
Zuetenhorst J, Bonfrer J, Korse C, et al. Carcinoid heart disease: the role of urinary 5-hydroxyindoleacetic acid excretion and plasma levels of atrial antriuretic peptide, transforming growth factor beta and fibroblast growth factor. Cancer. 2003;97:1609–15.
Connolly H, Nishimura R, Smith H, et al. Outcome of cardiac surgery for carcinoid heart disease. J Am Coll Cardiol. 1995;25:410–6.
Voigt P, Braun J, Teng O, et al. Double bioprosthetic valve replacement in right sided carcinoid heart disease. Ann Thorac Surg. 2005;79:2147–9.
Que F, Nagorney D, Batts K, et al. Hepatic resection for metastatic neuroendocrine carcinomas. Am J Surg. 1995;169:36–43.
McEntee G, Nagorney D, Kvols L, et al. Cytoreductive hepatic surgery for neuroendocrine tumors. Surgery. 1990;108:1091–6.
Norton J, Warren R, Kelly M, et al. Aggressive surgery for metastatic liver neuroendocrine tumors. Surgery. 2003;134:1057–65.
Alsina A, Bartus S, Hull D, et al. Liver transplant for metastatic neuroendocrine tumor. J Clin Gastroenterol. 1990;12:533–7.
LeTreut Y, Delpero J, Dousset B. Results of liver transplantation in the treatment of metastatic neuroendocrine tumors: a 31 case French multicentric report. Ann Surg. 1997;225:355–64.
Lang H, Oldhafer K, Weimann A, et al. Liver transplantation for metastatic neuroendocrine tumors. Ann Surg. 1997;225:347–54.
Ajani J, Carrasco C, Charnsangavej C, et al. Islet cell tumors metastatic to the liver: effective palliation by sequential hepatic artery embolization. Ann Intern Med. 1988;108:340–4.
Moertel CG, Johnson CM, McKusick MA, et al. The management of patients with advanced carcinoid tumors and islet cell carcinomas. Ann Intern Med. 1994;120:302–9.
Ruszniewski P, Rougier P, Roche A, et al. Hepatic arterial chemoembolization in patients with liver metastases of endocrine tumors. A prospective phase II study in 24 patients. Cancer. 1993;71:2624–30.
Eriksson B, Larsson E, Skogseid B, et al. Liver embolizations of patients with malignant neuroendocrine gastrointestinal tumors. Cancer. 1998;83:2293–301.
Gupta S, Yao JC, Ahrar K, et al. Hepatic artery embolization and chemoembolization for treatment of patients with metastatic carcinoid tumors: the M.D. Anderson experience. Cancer J. 2003;9:261–7.
Dominguez S, Denys A, Madeira I, et al. Hepatic arterial chemoembolization with streptozotocin in patients with metastatic digestive endocrine tumours. Eur J Gastroenterol Hepatol. 2000;12:151–7.
Drougas JG, Anthony LB, Blair TK, et al. Hepatic artery chemoembolization for management of patients with advanced metastatic carcinoid tumors. Am J Surg. 1998;175:408–12.
Diamandidou E, Ajani JA, Yang DJ, et al. Two-phase study of hepatic artery vascular occlusion with microencapsulated cisplatin in patients with liver metastases from neuroendocrine tumors. AJR Am J Roentgenol. 1998;170:339–44.
Loewe C, Schindl M, Cejna M, et al. Permanent transarterial embolization of neuroendocrine metastases of the liver using cyanoacrylate and lipiodol: assessment of mid- and long-term results. AJR Am J Roentgenol. 2003;180:1379–84.
Brown KT, Koh BY, Brody LA, et al. Particle embolization of hepatic neuroendocrine metastases for control of pain and hormonal symptoms. J Vasc Interv Radiol. 1999;10:397–403.
Kennedy AS, Dezarn WA, McNeillie P, et al. Radioembolization for unresectable neuroendocrine hepatic metastases using resin 90Y-microspheres: early results in 148 patients. Am J Clin Oncol. 2008;31:271–9.
King J, Quinn R, Glenn DM, et al. Radioembolization with selective internal radiation microspheres for neuroendocrine liver metastases. Cancer. 2008;113:921–9.
Hellman P, Ladjevardi S, Skogseid B, et al. Radiofrequency tissue ablation using cooled tip for liver metastases of endocrine tumors. World J Surg. 2002;26:1052–6.
Chung MH, Pisegna J, Spirt M, et al. Hepatic cytoreduction followed by a novel long-acting somatostatin analog: a paradigm for intractable neuroendocrine tumors metastatic to the liver. Surgery. 2001;130:954–62.
Reubi J, Kvols L, Waser B, et al. Detection of somatostatin receptors in surgical and percutaneous needle biopsy samples of carcinoids and islet cell carcinomas. Cancer Res. 1990;50:5969–77.
Kvols L, Moertel C, O’Connell M, et al. Treatment of the malignant carcinoid syndrome: evaluation of a long-acting somatostatin analog. N Engl J Med. 1986;315:663–6.
Rubin J, Ajani J, Schirmer W, et al. Octreotide acetate long-acting formulation versus open-label subcutaneous octreotide acetate in malignant carcinoid syndrome. J Clin Oncol. 1999;17:600–6.
Faiss S, Rath U, Mansmann U, et al. Ultra-high-dose lanreotide treatment in patients with metastatic neuroendocrine gastroenteropancreatic tumors. Digestion. 1999;60:469–76.
Wymenga A, Eriksson B, Salmela P, et al. Efficacy and safety of prolonged-release lanreotide in patients with gastrointestinal neuroendocrine tumors and hormone-related symptoms. J Clin Oncol. 1999;17:1111.
O’Toole D, Ducreux M, Bommelaer G, et al. Treatment of carcinoid syndrome: a prospective crossover evaluation of lanreotide versus octreotide in terms of efficacy, patient acceptability, and tolerance. Cancer. 2000;88:770–6.
Ducreux M, Ruszniewski P, Chayvialle J, et al. The antitumoral effect of the long-acting somatostatin analog lanreotide, interferon alpha, and their combination for therapy of metastatic neuroendocrine gastroenteropancreatic tumors – the International Laureodtide and Interferon Alfa Study Group. Am J Gastroenterol. 2000;95:3276–81.
Faiss S, Pape UF, Bohmig M, et al. Prospective, randomized, multicenter trial on the antiproliferative effect of lanreotide, interferon alfa, and their combination for therapy of metastatic neuroendocrine gastroenteropancreatic tumors – the International Lanreotide and Interferon Alfa Study Group. J Clin Oncol. 2003;21:2689–96.
Janson ET, Kauppinen HL, Oberg K. Combined alpha- and gamma-interferon therapy for malignant midgut carcinoid tumors. A phase I-II trial. Acta Oncol. 1993;32:231–3.
Frank M, Klose K, Wied M, et al. Combination therapy with octreotide and alpha-interferon: effect on tumor growth in metastatic endocrine gastroenteropancreatic tumors. Am J Gastroenterol. 1999;94:1381–7.
Oberg K, Funa K, Alm G. Effects of leukocyte interferon on clinical symptoms and hormone levels in patients with mid-gut carcinoid tumors and carcinoid syndrome. N Engl J Med. 1983;309:129–33.
Oberg K, Eriksson B. The role of interferons in the management of carcinoid tumors. Acta Oncol. 1991;30:519–22.
Valimaki M, Jarvinen H, Salmela P, et al. Is the treatment of metastatic carcinoid tumor with interferon not as successful as suggested? Cancer. 1991;67:547–9.
Rinke A, Muller H, Schade-Brittinger C, et al. Placebo-controlled, double blind, prospective, randomized study on the effect of octreotide LAR in the control of tumor growth in patients with metastatic neuroendocrine midgut tumors: a report from the PROMID study group. J Clin Oncol. 2009;27:4656–63.
Moertel CG. Treatment of the carcinoid tumor and the malignant carcinoid syndrome. J Clin Oncol. 1983;1:727–40.
Moertel CG, Hanley JA. Combination chemotherapy trials in metastatic carcinoid tumor and the malignant carcinoid syndrome. Cancer Clin Trials. 1979;2:327–34.
Engstrom PF, Lavin PT, Moertel CG, et al. Streptozocin plus fluorouracil versus doxorubicin therapy for metastatic carcinoid tumor. J Clin Oncol. 1984;2:1255–9.
Sun W, Lipsitz S, Catalano P, et al. Phase II/III study of doxorubicin with fluorouracil compared with streptozocin with fluorouracil or dacarbazine in the treatment of advanced carcinoid tumors: Eastern Cooperative Oncology Group Study E1281. J Clin Oncol. 2005;23:4897–904.
Bukowski R, Tangen C, Peterson R, et al. Phase II trial of dimethyltriazenoimidazole carboxamide in patients with metastatic carcinoid. A Southwest Oncology Group study. Cancer. 1994;73:1505–8.
Bajetta E, Ferrari L, Procopio G, et al. Efficacy of a chemotherapy combination for the treatment of metastatic neuroendocrine tumors. Ann Oncol. 2002;13:614–21.
Moertel C, Kvols L, O’Connell M, et al. Treatment of neuroendocrine carcinomas with combined etoposide and cisplatin: evidence of major therapeutic activity in the anaplastic variants of these neoplasms. Cancer. 1991;68:227–32.
Fjallskog ML, Granberg DP, Welin SL, et al. Treatment with cisplatin and etoposide in patients with neuroendocrine tumors. Cancer. 2001;92:1101–7.
Ansell SM, Pitot HC, Burch PA, et al. A phase II study of high-dose paclitaxel in patients with advanced neuroendocrine tumors. Cancer. 2001;91:1543–8.
Kulke MH, Kim H, Clark JW, et al. A phase II trial of gemcitabine for metastatic neuroendocrine tumors. Cancer. 2004;101:934–9.
Kulke MH, Kim H, Stuart K, et al. A phase II study of docetaxel in patients with metastatic carcinoid tumors. Cancer Invest. 2004;22:353–9.
Kwekkeboom D, Bakker W, Kooij P, et al. 177Lu-DOTA, Tyr3 octreotate: comparison with [111In-DTPA] octreotide in patients. Eur J Nucl Med. 2001;28:1319–25.
Kwekkeboom DJ, de Herder WW, Kam BL, et al. Treatment with the radiolabeled somatostatin analog [177Lu-DOTA 0, Tyr3]octreotate: toxicity, efficacy, and survival. J Clin Oncol. 2008;26:2124–30.
Bushnell Jr DL, O’Dorisio TM, O’Dorisio MS, et al. 90Y-Edotreotide for metastatic carcinoid refractory to octreotide. J Clin Oncol. 2010;28:1652–9.
Terris B, Scoazec J, Rubbia L. Expression of vascular endothelial growth factor in digestive neuroendocrine tumors. Histopathology. 1998;32:133–8.
Yao JC, Phan A, Hoff PM, et al. Targeting vascular endothelial growth factor in advanced carcinoid tumor: a random assignment phase II study of depot octreotide with bevacizumab and pegylated interferon alpha-2b. J Clin Oncol. 2008;26:1316–23.
Hobday TJ, Rubin J, Holen K, et al. MC044h, a phase II trial of sorafenib in patients (pts) with metastatic neuroendocrine tumors (NET): a phase II consortium (P2C) study. J Clin Oncol. 2007;2007 ASCO Annual Meeting Proceedings Part I. 25:Abstract 4505.
Kulke MH, Lenz HJ, Meropol NJ, et al. Activity of sunitinib in patients with advanced neuroendocrine tumors. J Clin Oncol. 2008;26:3403–10.
Duran I, Kortmansky J, Singh D, et al. A phase II clinical and pharmacodynamic study of temsirolimus in advanced neuroendocrine carcinomas. Br J Cancer. 2006;95:1148–54.
Yao JC, Phan AT, Chang DZ, et al. Efficacy of RAD001 (everolimus) and octreotide LAR in advanced low- to intermediate-grade neuroendocrine tumors: results of a phase II study [erratum appears in J Clin Oncol. 2008;26(34):5660]. J Clin Oncol. 2008;26:4311–8.
Kulke MH, Stuart K, Enzinger PC, et al. Phase II study of temozolomide and thalidomide in patients with metastatic neuroendocrine tumors. J Clin Oncol. 2006;24:401–6.
Kelsen DP, Buckner J, Einzig A, et al. Phase II trial of cisplatin and etoposide in adenocarcinomas of the upper gastrointestinal tract. Cancer Treat Rep. 1987;71:329–30.
Bukowski RM, Johnson KG, Peterson RF, et al. A phase II trial of combination chemotherapy in patients with metastatic carcinoid tumors. A Southwest Oncology Group Study. Cancer. 1987;60:2891–5.
Valkema R, De Jong M, Bakker WH, et al. Phase I study of peptide receptor radionuclide therapy with [In-DTPA]octreotide: the Rotterdam experience. Semin Nucl Med. 2002;32:110–22.
Anthony LB, Woltering EA, Espenan GD, et al. Indium-111-pentetreotide prolongs survival in gastroenteropancreatic malignancies. Semin Nucl Med. 2002;32:123–32.
Otte A, Herrmann R, Macke HR, et al. Yttrium 90 DOTATOC: a new somatostatin analog for cancer therapy of neuroendocrine tumors. Schweiz Rundsch Med Prax. 1999; 88:1263–8.
Paganelli G, Zoboli S, Cremonesi M, et al. Receptor-mediated radiotherapy with 90Y-DOTA-D-Phe1-Tyr3-octreotide. Eur J Nucl Med. 2001;28:426–34.
Waldherr C, Pless M, Maecke HR, et al. The clinical value of [90Y-DOTA]-D-Phe1-Tyr3-octreotide (90Y-DOTATOC) in the treatment of neuroendocrine tumours: a clinical phase II study. Ann Oncol. 2001;12:941–5.
Waldherr C, Pless M, Maecke H, et al. Tumor response and clinical benefit in neuroendocrine tumors after 7.4 GBq 90Y-DOTATOC. J Nucl Med. 2002;43:610–6.
DeJong M, Valkema R, Jamar F, et al. Somatostatin-receptor targeted radionucleotide therapy of tumors: preclinical and clinical findings. Semin Nucl Med. 2002;32:133–40.
Teunissen JJ, Kwekkeboom DJ, de Jong M, et al. Endocrine tumours of the gastrointestinal tract. Peptide receptor radionuclide therapy. Best Pract Res Clin Gastroenterol. 2005; 19:595–616.
Virgolini I, Britton K, Buscombe J, et al. In- and Y-DOTA-lanreotide: results and implications of the MAURITIUS trial. Semin Nucl Med. 2002;32:148–55.
Kwekkeboom DJ, Teunissen JJ, Bakker WH, et al. Radiolabeled somatostatin analog [177Lu-DOTA0, Tyr3]octreotate in patients with endocrine gastroenteropancreatic tumors. J Clin Oncol. 2005;23:2754–62.
Yao JC, Zhang JX, Rashid A, et al. Clinical and in vitro studies of imatinib in advanced carcinoid tumors. Clin Cancer Res. 2007;13:234–40.
Hobday T, Holen K, Donehower R, et al. A phase II trial of gefitinib in patients with progressive metastatic neuroendocrine tumors: a phase II consortium study. J Clin Oncol. 2006;2006 ASCO Annual Meeting Proceedings 24:A4043.
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Kulke, M.H. (2011). Management of Metastatic Carcinoid Tumors. In: Yao, J., Hoff, P., Hoff, A. (eds) Neuroendocrine Tumors. Current Clinical Oncology. Humana Press. https://doi.org/10.1007/978-1-60327-997-0_8
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