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Surgical treatment of mid-gut carcinoid tumors

Abstract

Coincident with medical antitumor treatment of 138 patients suffering from mid-gut carcinoid tumors, 51 patients were subjected to surgery with the principal aims of removing primary tumors and debulking mesenteric or liver metastases. Sixteen patients had previously been operated with intestinal resection or, when the tumors had been considered inexcisable, with intestinal bypass or laparotomy alone. Apart from exhibiting symptoms related to the carcinoid syndrome, the majority (approximately 60%) of the 51 patients had generally intermittent, subileus-like abdominal pain and weight loss. In 18 patients, these symptoms were pronounced and associated with intestinal obstruction or severe malnutrition. Computed tomography and arteriography efficiently demonstrated mesenteric and liver metastases. At laparotomy, the primary intestinal tumors were small, mainly less than 1 cm in diameter, and they were multiple in 39% of the patients. Mesenteric metastases measuring up to 12 cm in diameter were present in 86% of the patients. These metastases were frequently associated with a pronounced mesenteric and retroperitoneal fibrosis causing fixation, angulation, and obstruction of the bowel as well as incipient intestinal gangrene in 8 patients. In all but 6 patients, the primary tumors could be removed by comparatively limited intestinal resections although bulky mesenteric metastases were often dissected from the mesenteric vessels. Liver metastases, found in 49% of the patients, were generally bilateral and multiple, and major hepatic metastases were resected in 6 patients. The results support a role for surgery also in the more compromised patients with mid-gut carcinoid tumors and that such intervention may be associated with considerable symptomatic relief and substantial periods of survival.

Résumé

Parmi 138 patients traités par chimiothérapie pour tumeurs carcinoïdes intestinales, 51 ont eu une résection de leur tumeur primitive ou une chirurgie de réduction des métastases mésentèriques ou hépatiques. Seize patients avaient déjà été opérés d'une résection intestinale ou, quand on avait considéré les tumeurs comme inextirpables, d'une dérivation intestinale ou d'une laparotomie exploratrice. Mis à part les symptômes en rapport avec le syndrome carcinoïde, la plupart (60%) des 51 patients se plaignaient en général d'une douleur abdominale intermittente semblable à celle de l'occlusion intestinale et une perte de poids. Chez 18 patients ces symptômes étaient aigus et associés à une occlusion intestinale ou à une malnutrition sévère. Tomodensitométrie et artériographie ont été employés pour mettre en évidence les métastases du mésentère et du foie. A la laparotomie, les tumeurs intestinales primitives étaient petites, avec en général moins d'un cm de diamètre, et il y en avait plusieurs chez 39% des patients. Des métastases du mésentère mesurant plus de 12 cm de diamètre étaient présentes chez 86% des patients. Ces métastases était souvent associées à une importante fibrose mésentérique et rétropéritonéale provoquant adhérences, angulation et occlusion de l'intestin et un début de gangrène intestinale chez 8 patients. Chez tous les patients sauf 6, nous avons pu enlever les tumeurs primitives avec une résection de l'intestin relativement limitée alors qu'il existait de grosses métastases du mésentère, souvent dissociables des vaisseaux mésentériques. Les métastases du foie, retrouvées chez 49% des patients, étaient en général bilatérales et multiples, et, chez 6 patients, réséquables. Nos résultats parlent en faveur de la chirurgie même chez les patients avec des tumeurs carcinoïdes de l'intestin, même évoluées, et confirment que cette intervention peut être associée à d'importantes améliorations symptomatiques et à des périodes de survie conséquentes.

Resumen

Coincidente con el tratamiento médico antitumoral de 138 pacientes con tumores carcinoides del intestino medio, 51 pacientes fueron sometidos a cirugía con el propósito principal de remover los tumores primarios y disminuir la masa tumoral de metástasis mesentéricas o hepáticas. Dieciseis pacientes habían sido operados previamente con realización de resección intestinal o, cuando el tumor fue considerado no resecable, derivación intestinal o sólo laparatomía. Además de los síntomas relacionados con el síndrome carcinoide, la mayoría (60%) de los 51 pacientes presentó dolor abdominal intermitente y pérdida de peso, en 18 casos estos síntomas fueron severos y aparecieron asociados con obstrucción intestinal o con malnutrición severa. La tomografía computadorizada y la arteriografía demonstraron bien las metástasis mesentéricas y hepáticas. En la laparotomía los tumores intestinales primarios aparecieron como de tamaño pequeño, la mayoría de menos de un centimetro de diámetro, y múltiples en 39% de los casos. Metástasis mesentéricas hasta de 12 cm de diámetro ocurrieron en 86% de los pacientes. Tales metástasis con frecuencia aparecieron asociadas con marcada fibrosis mesentérica y retroperitoneal, produciendo fijación, angulación, y obstructión del intestino, así como gangrena intestinal incipiente en ocho pacientes. En todos los pacientes, menos en 6, se pudo resecar los tumores primarios mediante resecciones intestinales relativamente limitadas, aunque tumores muy voluminosos tuvieron que ser disecados de los vasos mesentéricos. Las metástasis hepáticas, presentes en 49% de los pacientes, generalmente fueron bilaterales y múltiples; en 6 pacientes se efectuó la resección de metástasis hepáticas mayores. Los resultados dan apoyo a la conducta de tratamiento quirúrgico también para los pacientes más comprometidos con tumores carcinoides del intestino medio y demuestran que la intervención puede resultar en considerable mejoría sintomática y sustanciales períodos de supervivencia.

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References

  1. Godwin, II, J.D.: Carcinoid tumors: An analysis of 2837 cases. Cancer36:560, 1975

    Google Scholar 

  2. Thompson, G.B., van Heerden, J.A., Martin, Jr., J.K., Schutt, A.J., Illstrup, D.M., Carney, J.A.: Carcinoid tumors of the gastrointestinal tract: Presentation, management, and prognosis. Surgery98:1054, 1985

    Google Scholar 

  3. Norheim, I., Öberg, K., Theodorsson-Norheim, E., Lindgren, P.G., Lundqvist, G., Magnusson, A., Wide, L., Wilander, E.: Malignant carcinoid tumors. An analysis of 103 patients with regard to tumor localization, hormone production, and survival. Ann. Surg.206:115, 1987

    Google Scholar 

  4. Mårtensson, H., Nobin, A., Sundler, F.: Carcinoid tumors in the gastrointestinal tract—An analysis of 156 cases. Acta Chir. Scand.149:607, 1983

    Google Scholar 

  5. åker, L., Lamke, L.-O., Smeds, S.: Follow-up of 102 patients operated on for gastrointestinal carcinoid. Acta Chir. Scand.151:469, 1985

    Google Scholar 

  6. Moertel, C.G., Sauer, W.G., Dockerty, M.B., Baggenstoss, A.H.: Life history of the carcinoid tumor of the small intestine. Cancer14:901, 1961

    Google Scholar 

  7. Welch, J.P., Malt, R.A.: Management of carcinoid tumors of the gastrointestinal tract. Surg. Gynecol. Obstet.145:223, 1977

    Google Scholar 

  8. Eckhauser, F.E., Argenta, L.C., Strodel, W.E., Wheeler, R.H., Bull, F.E., Appelman, H.D., Thompson, N.W.: Mesenteric angiopathy, intestinal gangrene, and midgut carcinoids. Surgery90:720, 1981

    Google Scholar 

  9. Moertel, C.G., Hanley, J.A.: Combination chemotherapy trials in metastatic carcinoid tumors and the malignant carcinoid syndrome. Cancer Clin. Trials2:327, 1979

    Google Scholar 

  10. Chernicoff, D., Bukowski, R.M., Groppe, Jr., C.W., Hawlett, J.S.: Combination chemotherapy for islet cell carcinoma and metastatic carcinoid tumors with 5-fluorouracil and streptozotocin. Cancer Treat. Rep.63:795, 1979

    Google Scholar 

  11. Öberg, 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.309:129, 1983

    Google Scholar 

  12. Öberg, K., Norheim, I., Lind, E., Alm, G., Lundqvist, G., Wide, L., Jonsdottir, B., Magnusson, A., Wilander, E.: Treatment of malignant carcinoid tumors with human leukocyte interferon: Long-term results. Cancer Treat. Rep.70:1297, 1986

    Google Scholar 

  13. Thulin, L., Samnegard, H., Tydén, G., Long, D., Effendic, S.: Efficacy of somatostatin in a patient with carcinoid syndrome. Lancet2:43, 1978

    Google Scholar 

  14. Kvols, L.K., Moertel, C.G., O'Connell, M.J., Schutt, A.J., Rubin, J., Hahn, R.G.: Treatment of the malignant carcinoid syndrome. Evaluation of a long-acting somatostatin analogue. N. Engl. J. Med.315:663, 1986

    Google Scholar 

  15. Kvols, L.K., Buck, M.: Chemotherapy of metastatic carcinoid and islet cell tumors. A Review. Am. J. Med.82[Suppl. 5B]:77, 1987

    Google Scholar 

  16. Öberg, K., Norheim, I., Lundqvist, G., Wide, L.: Cytotoxic treatment in patients with malignant carcinoid tumors: Response to streptozotocin—alone or in combination with 5-FU. Acta Oncol.26:429, 1987

    Google Scholar 

  17. Öberg, K., Persson, U.M., Alm, G., Eriksson, B.: Long-term treatment with alpha-interferons of patients with malignant carcinoid tumors-The six year experience. In The Biology of the Interferon System, Y. Kawade, S. Kobayashi, editors, Amsterdam, Elsevier Science Publishers, 1988, pp. 219–225

    Google Scholar 

  18. Strodel, W.E., Talpos, G., Eckhauser, F., Thompson, N.: Surgical therapy for small-bowel carcinoid tumors. Arch. Surg.118:391, 1983

    Google Scholar 

  19. Warner, T.F., O'Reilly, G., Power, G.: Carcinoid diathesis of the ileum. Cancer43:1900, 1979

    Google Scholar 

  20. Bancks, N.H., Goldstein, H.M., Dodd, G.D.: The roentgenologic spectrum of small intestinal carcinoid tumors. Am. J. Roentgenol.123:274, 1975

    Google Scholar 

  21. Andersson, T., Eriksson, B., Hemmingsson, A., Lindgren, P.G., Öberg, K.: Angiography, computed tomography, magnetic resonance imaging and ultrasonography in detection of liver metastases from endocrine gastrointestinal tumours. Acta Radiol.28:535, 1987

    Google Scholar 

  22. Andersson, T., Eriksson, B., Lindgren, P.G., Wilander, E., Öberg, K.: Percutaneous ultrasonography-guided cutting biopsy from liver metastases of endocrine gastrointestinal tumors. Ann. Surg.206:728, 1987

    Google Scholar 

  23. Goldstein, H.M., Miller, M.: Angiographic evaluation of carcinoid tumors of the small intestine: The value of epinephrine. Radiology114:23, 1975

    Google Scholar 

  24. Christensen, S.C., Stage, J.G., Henriksen, F.W.: Angiography in the diagnosis of carcinoid syndrome. Scand. J. Gastroenterol.53[Suppl.]:111, 1979

    Google Scholar 

  25. Siegel, R.S., Kuhns, L.R., Borlaza, G.S., McCormick, T.L., Simmons, J.L.: Computed tomography and angiography in ileal carcinoid tumor and retractile mesenteritis. Radiology134:437, 1980

    Google Scholar 

  26. McCarthy, S.M., Stark, D.D., Moss, A.A., Goldberg, H.I.: Computed tomography of malignant carcinoid disease. J. Comput. Ass. Tomogr.8:846, 1984

    Google Scholar 

  27. Cockey, B.M., Fishman, E.K., Jones, B., Siegelman, S.S.: Computed tomography of abdominal carcinoid tumor. J. Comput. Ass. Tomogr.9:38, 1985

    Google Scholar 

  28. Horsley, B.L., Baker, R.R.: Fibroplastic response to intestinal carcinoid. Am. Surg.36:676, 1970

    Google Scholar 

  29. Funa, K., Papanicolaou, V., Juhlin, C., Heldin, C.-H., Rastad, J., Åkerström, G., Öberg, K.: Platelet-derived growth factor B-type receptors are expressed on connective tissue cells in carcinoid tumors (unpublished data)

  30. Anthony, P.P., Drury, R.A.B.: Elastic vascular sclerosis of mesenteric blood vessels in argentaffin carcinoma. J. Clin. Pathol.23:110, 1970

    Google Scholar 

  31. Warner, T.F., O'Reilly, G., McLee, G.A.: Mesenteric occlusive lesion and ileal carcinoids. Cancer44:758, 1979

    Google Scholar 

  32. Knowlessar, O.D., Law, D.H., Sleisinger, M.H.: Malabsorption syndrome associated with metastatic carcinoid tumor. Am. J. Med.27:673, 1959

    Google Scholar 

  33. Martin, Y.K.: Carcinoid syndrome. In Common Problems in Endocrine Surgery, J.A. van Heerden, editor, Chicago, Year Book Medical Publishers, Inc., 1989, pp. 251–257

    Google Scholar 

  34. Gillett, D.J., Smith, R.C.: Treatment of the carcinoid syndrome by hemihepatectomy and radical excision of the primary lesion. Am. J. Surg.128:95, 1974

    Google Scholar 

  35. Martin, J.K., Moertel, C.G., Adson, M.A., Schutt, A.J.: Surgical treatment of functioning metastatic carcinoid tumors. Arch. Surg.118:537, 1983

    Google Scholar 

  36. Zeitels, J., Naunheim, K., Kaplan, E.L., Strauss, F.: Carcinoid tumors. A 37-year experience. Arch. Surg.117:732, 1982

    Google Scholar 

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Supported by the Swedish Cancer Society.

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Makridis, C., Öberg, K., Juhlin, C. et al. Surgical treatment of mid-gut carcinoid tumors. World J. Surg. 14, 377–383 (1990). https://doi.org/10.1007/BF01658532

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Keywords

  • Liver Metastasis
  • Intestinal Obstruction
  • Como
  • Carcinoid Tumor
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