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Wiseman GA, Kvols LK. Therapy of neuroendocrine tumors with radiolabeled MIBG and somatostatin analogues. Semin Nucl Med 1995; 25:272-8. [PMID: 7570046 DOI: 10.1016/s0001-2998(95)80016-6] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The increased understanding of the neuroendocrine tumors at a cellular and molecular level has led to the development of new radiopharmaceuticals for imaging. Two of the imaging agents include 131I metaiodobenzylguanidine (131I-MIBG) and 111In-DTPA-D-Phe1-octreotide (111In-pentetreotide) each having specific localization in certain neuroendocrine tumors. The selective uptake of these radiopharmaceuticals by the tumor cells has generated interest in potential use for targeted radiotherapy for neuroendocrine tumors. 131I-MIBG has been used to treat patients with pheochromocytoma, neuroblastoma, carcinoid tumors, medullary thyroid carcinoma, and paragangliomas. The tumor responses have been variable with the most encouraging results being in patients with pheochromocytoma. The dose-limiting toxicity has been thrombocytopenia or granulocytopenia. 111In-pentetreotide has been used as therapy in only a few patients and has resulted in objective evidence of tumor responses. A therapeutic agent using a somatostatin analogue will most likely require radiolabeling with a beta- or possibly an alpha-emitting radionuclide to achieve significant and durable tumor responses.
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Connolly HM, Nishimura RA, Smith HC, Pellikka PA, Mullany CJ, Kvols LK. Outcome of cardiac surgery for carcinoid heart disease. J Am Coll Cardiol 1995; 25:410-6. [PMID: 7829795 DOI: 10.1016/0735-1097(94)00374-y] [Citation(s) in RCA: 150] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES The hypothesis was that cardiac surgery for symptomatic carcinoid heart disease in conjunction with adjunctive therapy could improve the long-term outlook of patients with carcinoid heart disease. BACKGROUND Patients with carcinoid heart disease have a dismal prognosis; most die of progressive right heart failure within 1 year after onset of symptoms. Improved therapies for the systemic manifestations of the carcinoid syndrome have resulted in symptomatic improvement and prolonged survival in patients without heart disease. METHODS Twenty-six patients with symptomatic carcinoid heart disease underwent valvular surgery. Preoperative clinical, laboratory, Doppler echocardiographic and hemodynamic factors were evaluated. The survival of the surgical group was compared with that of a control group of 40 medically treated patients. RESULTS There were nine perioperative deaths (35%), primarily from postoperative bleeding and right ventricular failure. Of the 17 surgical survivors, 8 were alive at a mean of 28 months of follow-up. The postoperative functional class of the eight surviving patients was substantially improved. Late deaths were primarily due to hepatic dysfunction caused by metastatic disease. The only predictor of operative mortality (p = 0.03) was low voltage on preoperative electrocardiography (limb lead voltage < or = 5 mm). Predictors of late survival included a lower preoperative somatostatin requirement and a lower preoperative urinary 5-hydroxy-indoleacetic acid level. There was a trend toward increased survival for the surgical group compared with the control group. CONCLUSIONS Because new therapies have improved survival in patients with the malignant carcinoid syndrome, cardiac involvement has become a major cause of morbidity and mortality. Valve surgery is the only definitive treatment. Although cardiac surgery carries a high perioperative mortality, marked symptomatic improvement occurs in survivors. Surgical intervention should therefore be considered when cardiac symptoms become severe.
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Que FG, Nagorney DM, Batts KP, Linz LJ, Kvols LK. Hepatic resection for metastatic neuroendocrine carcinomas. Am J Surg 1995; 169:36-42; discussion 42-3. [PMID: 7817996 DOI: 10.1016/s0002-9610(99)80107-x] [Citation(s) in RCA: 273] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Metastatic neuroendocrine malignancies frequently cause incapacitating endocrinopathies, and metastases predominant in the liver. Hepatic resection of metastases from such tumors is attractive because the natural history of neuroendocrine tumors is protracted, clinical severity of the endocrinopathy correlates with tumor volume, and local and intrahepatic growth characteristics often allow complete resection. PATIENTS AND METHODS To define the role of hepatic resection for metastatic neuroendocrine tumors, the records of 74 patients who underwent hepatic resection for such tumors between 1984 and 1992 were reviewed. Neuroendocrine tumors were classified by site of origin and clinical endocrinopathy. Survival, and type and duration of symptomatic response, were assessed as the major outcomes of this study. RESULTS There were 50 carcinoid, 23 islet-cell, and 1 atypical neuroendocrine tumors. Resections included 36 hemihepatectomies or extended hepatectomies and 38 nonanatomic resections. Thirty-eight primary tumors were resected concomitantly. Perioperative mortality was 2.7% and morbidity was 24%. Four-year survival was 73%. Overall postoperative symptomatic response rate was 90% with a mean duration of response of 19.3 months. CONCLUSIONS Hepatic resection for metastatic neuroendocrine malignancies is safe, provides effective palliation, and probably prolongs survival.
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Moertel CL, Reubi JC, Scheithauer BS, Schaid DJ, Kvols LK. Expression of somatostatin receptors in childhood neuroblastoma. Am J Clin Pathol 1994; 102:752-6. [PMID: 7801887 DOI: 10.1093/ajcp/102.6.752] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Somatostatin receptors are expressed on certain neural crest-derived tumors, including pancreatic islet cell and carcinoid tumors, medullary thyroid carcinomas, pheochromocytomas, and paragangliomas. The authors evaluated the expression of high affinity somatostatin receptors in childhood neuroblastoma using autoradiography techniques with the somatostatin analogue 125I-octreotide or 125I-[Leu8,D-Trp22,Tyr25]-SS-28 as the radioligand. Thirty tumors from 30 children with neuroblastoma were analyzed. Twenty-three of 30 tumors that were tested expressed somatostatin receptors. Correlation of somatostatin receptor expression with survival was statistically significant. The survival of those patients whose tumors expressed somatostatin receptors was of longer duration than that of patients whose tumors did not. This was an independent prognostic factor. Somatostatin receptors were expressed more frequently in tumor tissue from patients with lower stages of disease and in those with no evidence of N-myc amplification. Tumoral somatostatin receptors are expressed in a subgroup of patients with childhood neuroblastoma. Survival analysis in this group of patients indicates that somatostatin receptor expression is a favorable prognostic factor. This finding may have important implications for the therapy of children with this malignancy.
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Wiedenmann B, Ahnert-Hilger G, Kvols LK, Riecken EO. New molecular aspects for the diagnosis and treatment of neuroendocrine gastroenteropancreatic tumors. Ann N Y Acad Sci 1994; 733:515-25. [PMID: 7978902 DOI: 10.1111/j.1749-6632.1994.tb17302.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Gough DB, Thompson GB, Crotty TB, Donohue JH, Kvols LK, Carney JA, Grant CS, Nagorney DM. Diverse clinical and pathologic features of gastric carcinoid and the relevance of hypergastrinemia. World J Surg 1994; 18:473-9; discussion 479-80. [PMID: 7725731 DOI: 10.1007/bf00353739] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The etiology, prognosis, and optimal management of primary gastric carcinoids remain controversial. Records of 36 consecutive patients with gastric carcinoid (15 men) were reviewed retrospectively between 1975 and 1990. Follow-up was complete in 97% of cases. Mean age at diagnosis was 58.4 years (range 24-82 years). The clinical presentations included anemia (72%), pain (69%), and carcinoid syndrome (11%). Associated autoimmune and endocrine abnormalities were common and included atrophic gastritis (67%), pernicious anemia (58%), hypothyroidism (39%), diabetes (19%), Addison's disease (6%), and hyperparathyroidism (6%). Lesions were nonantral in 78%, involving only the corpus in 42%, the fundus in 28%, and only the antrum in 8%; 42% were multiple. Urinary 5-hydroxyindoleacetic acid (5-HIAA) and serum gastrin levels were elevated in 17% and 50% of those tested, respectively. Histologic examination revealed that 28% of lesions were > or = 2 cm, and 33% had liver metastases on presentation or developed them during follow-up. Eight patients (22%) died of tumor with a median survival of 39 months. The presence of metastases, atypical histology, serosal involvement, and size > 2 cm were adverse prognostic factors. In patients without hypergastrinemia (n = 6), 66% developed metastases, 60% had elevated 5-HIAA, and 50% died of carcinoid tumor. In sharp contrast, those patients with hypergastrinemia and "typical" gastric carcinoids (n = 15), metastases and death did not occur (p < 0.003 and p < 0.005, respectively, compared with eugastrinemic patients).(ABSTRACT TRUNCATED AT 250 WORDS)
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von der Ohe MR, Camilleri M, Kvols LK. A 5HT3 antagonist corrects the postprandial colonic hypertonic response in carcinoid diarrhea. Gastroenterology 1994; 106:1184-9. [PMID: 8174881 DOI: 10.1016/0016-5085(94)90008-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND/AIMS Carcinoid patients show a hypertonic colonic motor response postprandially. Ondansetron reduces postprandial colonic tone in health. It was hypothesized that ondansetron, a selective 5HT3 antagonist, corrects the colonic motor response to eating in carcinoid diarrhea. METHODS The effects of ondansetron and placebo on fasting and postprandial colonic tone and motility in 10 patients with carcinoid diarrhea were compared using a manometry-barostat assembly positioned in the upper descending colon. RESULTS Fasting colonic tone and motility indices were similar in the placebo and ondansetron groups; ondansetron did not affect fasting motility. The placebo group showed a significant reduction in barostat balloon volume (signifying increased tone) from 207 +/- 29 mL (mean +/- SEM) during fasting to 106 +/- 14 mL postprandially (P = 0.01). With ondansetron, a tonic colonic response was induced postprandially (198 +/- 37 mL to 151 +/- 30 mL; P = 0.053). However, the increment in tone in the ondansetron group (23% +/- 7%) was significantly lower than in the placebo group (48% +/- 5%; P = 0.02) and was similar to that observed in untreated healthy subjects (24% +/- 3%). Postprandial manometric pressure activity increased significantly in the placebo group (P = 0.01); in the ondansetron group there was a trend (P = 0.09) to increased phasic activity. CONCLUSIONS Ondastetron reduces the postprandial colonic hypertonic response in carcinoid diarrhea to levels previously reported in health; further clinical studies of this class of antagonists in carcinoid diarrhea appear warranted.
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Wilkowske MA, Hartmann LC, Mullany CJ, Behrenbeck T, Kvols LK. Progressive carcinoid heart disease after resection of primary ovarian carcinoid. Cancer 1994; 73:1889-91. [PMID: 8137216 DOI: 10.1002/1097-0142(19940401)73:7<1889::aid-cncr2820730719>3.0.co;2-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Primary ovarian carcinoid tumors are uncommon, and carcinoid heart disease is a rare complication. Although carcinoid syndrome and carcinoid heart disease typically occur in the setting of metastatic carcinoid tumor, particularly involving the liver, this is not necessarily the case in patients with primary ovarian carcinoid tumors. After surgical resection of an ovarian carcinoid tumor, the prognosis is excellent; however, carcinoid heart disease can continue to progress. The following is a case report of a patient who, despite having complete resection of a primary ovarian carcinoid tumor, went on to develop progressive, debilitating carcinoid heart disease. This is an important scenario to recognize, because proper management and surgical intervention in carcinoid heart disease can be lifesaving.
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Edmonson JH, Long HJ, Kvols LK. Cytotoxic drugs plus subcutaneous granulocyte-macrophage colony-stimulating factor: can molgramostim enhance antisarcoma therapy? J Natl Cancer Inst 1994; 86:312-4. [PMID: 8158688 DOI: 10.1093/jnci/86.4.312] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
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Moertel CG, Johnson CM, McKusick MA, Martin JK, Nagorney DM, Kvols LK, Rubin J, Kunselman S. The management of patients with advanced carcinoid tumors and islet cell carcinomas. Ann Intern Med 1994; 120:302-9. [PMID: 8291824 DOI: 10.7326/0003-4819-120-4-199402150-00008] [Citation(s) in RCA: 216] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE To determine the effectiveness of hepatic artery occlusion alone and with sequenced chemotherapy for patients with hepatic-dominant metastases of islet cell carcinomas and carcinoid tumors. DESIGN Nonrandomized, observational study with follow-up from 2.5 to 10 years. PATIENTS 111 ambulatory patients referred to a multidisciplinary tertiary care center who had histologically proven islet cell carcinoma or carcinoid tumor and symptomatic measurable metastatic lesions in the liver or hormonal abnormalities or both. The patients were ambulatory but were having substantial symptoms because of their endocrine syndromes or their tumors. INTERVENTION All patients had hepatic artery occlusion done surgically or by catheterization and embolization. After this procedure, 71 patients were selected for chemotherapy with alternating two-drug regimens of doxorubicin plus dacarbazine and streptozocin plus fluorouracil. Main outcome measures of response to therapy were rates of tumor regression, rates of improvement in endocrine abnormalities, symptomatic improvement, and duration of favorable response. RESULTS Objective regressions were observed in 60% of patients treated with occlusion alone and in 80% with chemotherapy added. Regressions were associated with substantial or complete relief from the endocrine syndromes. With occlusion alone, the median duration of regression was 4.0 months and with chemotherapy added, it was 18.0 months. Any comparative inferences about the two treatment regimens must be guarded, because this was not a randomized trial and marked differences occurred in the distribution of prognostic factors between the patient groups. Side effects of arterial occlusion included fever, nausea, pain, and abnormalities in liver function. Side effects of chemotherapy included nausea, vomiting, leukopenia, and alopecia. CONCLUSIONS Hepatic arterial occlusion can frequently produce major regression of neuroendocrine tumors with relief from the hormonal syndromes. Sequential chemotherapy may improve the rate and duration of the regression.
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Earle JD, Foley JF, Wieand HS, Kvols LK, McKenna PJ, Krook JE, Tschetter LK, Schutt AJ, Twito DI. Evaluation of external-beam radiation therapy plus 5-fluorouracil (5-FU) versus external-beam radiation therapy plus hycanthone (HYC) in confined, unresectable pancreatic cancer. Int J Radiat Oncol Biol Phys 1994; 28:207-11. [PMID: 8270443 DOI: 10.1016/0360-3016(94)90159-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
From March 1981 to November 1987, 87 patients with histologically confirmed pancreatic adenocarcinoma, unresectable but confined to the pancreatic region, were randomized to two treatments. The standard treatment was 40-50 Gy external-beam radiation therapy (RT) to gross tumor plus potential microscopic tumor with a 5 Gy boost to gross tumor plus a 1.5-2.0 cm margin, using multiple fields and 5-fluorouracil (5-FU) 500 mg/m2/d intravenously by rapid infusion. The 5-FU was given each of the initial 3 days of each of three 20 Gy radiation courses. The experimental treatment used identical radiation fields, but the two Gy daily radiation fractions were administered in a continuous course to a total dose of 50 Gy. Hycanthone was administered 60 mg/m2 intravenously within 2 to 4 hr during each day of the 5-day course of infusions during the first and fifth weeks of radiation therapy. There was no statistically significant difference between treatment arms in survival (p = 0.82) or disease-free survival (p = 0.27). Seven percent of hycanthone-treated patients demonstrated hepatic toxicity which was usually mild in nature. There was, however, one death due to hepatic toxicity.
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Kvols LK. Somatostatin-receptor imaging of human malignancies: a new era in the localization, staging, and treatment of tumors. Gastroenterology 1993; 105:1909-11. [PMID: 7902824 DOI: 10.1016/0016-5085(93)91091-u] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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von der Ohe MR, Camilleri M, Kvols LK, Thomforde GM. Motor dysfunction of the small bowel and colon in patients with the carcinoid syndrome and diarrhea. N Engl J Med 1993; 329:1073-8. [PMID: 8371728 DOI: 10.1056/nejm199310073291503] [Citation(s) in RCA: 113] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND METHODS The pathophysiology of diarrhea in patients with the carcinoid syndrome is not understood. Possible causes include tumor production of neurohumoral substances, such as serotonin and substance P, which stimulate small-bowel and colonic motility, and intestinal abnormalities, such as lymphangiectasia and bacterial overgrowth. We undertook this study to determine whether carcinoid diarrhea is associated with abnormal motor function in the small intestine and colon. We measured the gastric, small-bowel, and colonic transit of radiolabeled solid residue and estimated the volume of the ascending colon in 16 patients with the carcinoid syndrome and diarrhea and 16 normal subjects. We also measured colonic tone and phasic pressure activity by intracolonic multilumen manometry and with an electronic barostat in seven patients and six normal subjects. RESULTS The patients with the carcinoid syndrome had elevated 24-hour urinary excretion of 5-hydroxyindoleacetic acid and elevated fasting plasma serotonin concentrations. Transit times in the small bowel and colon were two times (P < 0.001) and six times (P = 0.001) faster in the patients than in the normal subjects. The volume of the ascending colon was approximately 50 percent smaller in the patients than in the normal subjects (P < 0.001). The patients had normal fasting colonic tone; their mean postprandial colonic tone was markedly increased as compared with the values in the normal subjects (mean increase, 41 percent vs. 24 percent; P = 0.03). CONCLUSIONS Patients with the carcinoid syndrome who have diarrhea have major alterations in gut motor function that affect both the small intestine and colon.
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Carlson B, Johnson CD, Stephens DH, Ward EM, Kvols LK. MRI of pancreatic islet cell carcinoma. J Comput Assist Tomogr 1993; 17:735-40. [PMID: 8396599 DOI: 10.1097/00004728-199309000-00013] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE The purpose of this study is to report the spectrum of MR findings of pancreatic islet cell carcinoma. MATERIALS AND METHODS The MR scans of 33 patients with islet cell carcinoma were retrospectively reviewed. Magnetic resonance detected the primary tumor in 21 of 27 patients (78%) who had not had prior resection of their primary tumor. Mean tumor diameter was 7.1 cm (range 3.5-13.0 cm). RESULTS In all patients, the primary tumor on T1-weighted images (TR/TE = 250/15) was of signal intensity equal to or lower than that of the adjacent normal pancreas. The primary tumor on T2-weighted images (TR/TE = 2,000/> or = 100) was of signal intensity the same as or higher than fat in 18 of 21 patients (86%) and had mixed signal intensity in the other 3 (14%). Hepatic metastases were found in 28 of 33 patients (85%). Liver metastases were categorized as "usual" (variably circumscribed, homogeneous lesions of medium signal intensity on T2-weighted images) in 19 of 28 patients (68%), necrotic in 8 of 28 (29%), hemorrhagic in 3 of 28 (11%), and calcified in 1 of 28 (4%). Extrahepatic metastases were found in 18 of 33 patients (55%). CONCLUSION We conclude that MRI is an excellent modality for the diagnosis and routine follow-up of patients with islet cell carcinoma.
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Pyke CM, Lancaster BA, van Heerden JA, Kvols LK. Carcinoid syndrome secondary to a primary tumour in a Meckel's diverticulum. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1993; 63:732-4. [PMID: 8363487 DOI: 10.1111/j.1445-2197.1993.tb00503.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Foo ML, Gunderson LL, Nagorney DM, McLlrath DC, van Heerden JA, Robinow JS, Kvols LK, Garton GR, Martenson JA, Cha SS. Patterns of failure in grossly resected pancreatic ductal adenocarcinoma treated with adjuvant irradiation +/- 5 fluorouracil. Int J Radiat Oncol Biol Phys 1993; 26:483-9. [PMID: 8390422 DOI: 10.1016/0360-3016(93)90967-z] [Citation(s) in RCA: 135] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE Analyze patterns of failure, survival, and tolerance in patients with totally resected ductal adenocarcinoma of the pancreas treated with adjuvant irradiation alone or combined with chemotherapy. METHODS AND MATERIALS The records of 29 patients treated with radiotherapy following curative resection of pancreas cancer at the Mayo Clinic were retrospectively reviewed. Twenty-two (76%) patients underwent a subtotal pancreatectomy (Whipple procedure), six (21%) a total pancreatectomy, and one (3.5%) a distal pancreatectomy. Twenty-six (90%) had lesions located in the head of the pancreas and three (10%) were located either in the body or tail. Twelve (41%) of the tumors were histologic Grade 3, 15 (52%) Grade 2, and two Grade 1. Contiguous invasion of adjacent tissues or organs was found in fifteen patients (52%) and seventeen (59%) had lymph node involvement. Greater than 75% of patients received more than 45 Gy, with a median dose of 54 Gy, and twenty-seven (93%) patients received concomitant 5-fluorouracil chemotherapy. RESULTS The median survival was 22.8 months and the 2-year survival 48%. When survival was compared with that achieved with surgery alone in our institution, data suggested a doubling in both median and long-term survival with the addition of adjuvant treatment. Eighty-three percent of patients experienced tumor relapse with seventeen of 29 (59%) developing either liver metastases or peritoneal spread. In three patients, tumors recurred locally; one of one with microscopic residual disease after resection and two of 28 (7%) with negative margins (one of the two was treated with inadequate radiation portals). Patients tolerated adjuvant treatment with minimal acute toxicity consisting mostly of vomiting or nausea which, were controlled with medication in all patients. Chronic toxicity was acceptable; while 5 of 29 (17%) developed some form of possible treatment related complication, only one patient (3.5%) developed a small bowel obstruction. CONCLUSION These results corroborate data in previous studies which have shown a survival benefit when adjuvant irradiation plus 5-fluorouracil is used in patients with completely resected ductal adenocarcinoma of the pancreas. The patterns of failure indicate that post-operative adjuvant treatment can effectively control disease locally but that future survival improvements will be achieved only by reducing the incidence of liver and peritoneal metastases.
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Kvols LK, Brown ML, O'Connor MK, Hung JC, Hayostek RJ, Reubi JC, Lamberts SW. 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. [PMID: 8383865 DOI: 10.1148/radiology.187.1.8383865] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The purpose of this study was to evaluate the usefulness of a radiolabeled analog of somatostatin (iodine-123 octreotide) in the detection and localization of known carcinoid and islet cell tumors and to correlate tumor uptake with the presence or absence of somatostatin receptors. I-123 octreotide studies were performed in 28 patients. Whole-body and tomographic studies were performed over a 2-day period after injection. Twenty-two of the 28 patients underwent tumor biopsy, and samples were analyzed for the presence of somatostatin receptors. Tumors were best seen on scans obtained 1-4 hours after injection. Of the 28 patients, 22 had positive scans with uptake in tumors, three showed photon-deficient uptake in regions of known tumor, and three had negative scans. Seventeen patients in whom results of tumor biopsy were positive for somatostatin receptors had positive scans, and one patient in whom results of biopsy were negative for somatostatin receptors had a negative scan. Previously unsuspected lesions were detected on the I-123 octreotide scans in four of the 28 patients. I-123 octreotide appears to be a useful tracer for the localization of neuroendocrine tumors and, most likely, other soft-tissue tumors as well.
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Pellikka PA, Tajik AJ, Khandheria BK, Seward JB, Callahan JA, Pitot HC, Kvols LK. Carcinoid heart disease. Clinical and echocardiographic spectrum in 74 patients. Circulation 1993; 87:1188-96. [PMID: 7681733 DOI: 10.1161/01.cir.87.4.1188] [Citation(s) in RCA: 349] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The carcinoid syndrome is a rare cause of acquired valvular heart disease. Although the typical echocardiographic features of carcinoid heart disease are well recognized, this large series provides new information about unusual manifestations of the disease as well as the role of Doppler echocardiography. METHODS AND RESULTS Between 1980 and 1989, 132 patients with carcinoid syndrome underwent echocardiographic study. The echocardiographic, Doppler, and clinical features of the 74 patients (56%) with echocardiographic evidence of carcinoid heart disease are described. Among these patients, 97% had shortened, thickened tricuspid leaflets. Tricuspid regurgitation was present in all 69 patients with carcinoid heart disease who underwent Doppler examination, and it was of moderate or severe degree in 62 patients (90%). Severe tricuspid regurgitation was characterized by a dagger-shaped Doppler spectral profile with an early peak pressure and rapid decline. The pressure half-time was prolonged (mean, 116 msec), which is consistent with associated tricuspid stenosis. The pulmonary valve appeared thickened, retracted, and immobile in 36 patients (49%) and was diminutive to the extent of not being visualized in an additional 29 patients (39%). Among the 47 patients who underwent Doppler evaluation of the pulmonary valve, regurgitation was present in 81%, and stenosis was present in 53%. Left-sided valvular involvement was present in five patients (7%), four of whom had patent foramen ovale or carcinoid tumor involving the lung. Previously undescribed myocardial metastases were present in three patients (4%) and were confirmed by biopsy in each case. Small pericardial effusions were present in 10 patients (14%). Patients with and without echocardiographic evidence of carcinoid heart disease did not differ with regard to sex, age, location of the primary tumor, duration of diagnosis, or duration of symptoms of carcinoid syndrome. However, the mean pretreatment level of urinary 5-hydroxyindoleacetic acid was higher in patients with carcinoid heart disease than in patients without carcinoid heart disease (270 versus 131 mg/24 hrs, p < 0.001). The symptom of dyspnea was more prevalent among patients with carcinoid heart disease than in patients without the disease (54% versus 27%, p = 0.003); as expected, heart murmurs were also noted more frequently in patients with disease (92% versus 43%, p < 0.0001). Treatment regimens and response to therapy were similar in the two groups. Survival of patients with echocardiographic evidence of carcinoid heart disease was reduced compared with those without cardiac involvement (p = 0.0003). ECG and chest roentgenographic findings in patients with carcinoid heart disease were nonspecific. CONCLUSIONS The broad spectrum of carcinoid heart disease is detailed in this large series. This includes not only right-sided valvular lesions but also left-sided involvement, pericardial effusion, and myocardial metastases.
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Ganju V, Kvols LK. Molecular genetics of neuroendocrine tumors. Curr Opin Oncol 1993; 5:85-90. [PMID: 8427895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Neuroendocrine tumors are a group of malignancies that arise from primitive neuroectodermal cells. There is, however, considerable variation in the location and clinical behavior of these tumors. They are often difficult to distinguish from other malignancies and difficult to classify. Recent advances in molecular genetics have attempted to resolve some issues regarding accurate diagnosis, classification into prognostic subgroups, and understanding of basic common mechanisms underlying the development of these tumors. Correlation of morphologic changes with molecular changes induced by some potential therapeutic differentiating agents may lead to more rational therapy for these malignancies.
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Abstract
Patients with metastatic carcinoid tumors and the malignant carcinoid syndrome have benefited immensely from diagnostic and therapeutic advances during the past decade. Magnetic resonance imaging and whole body scintigraphy with radiolabelled analogues of somatostatin have improved our ability to diagnose, detect, stage and follow response to therapy. Surgical, medical, and radiation therapy may all contribute to the management of these patients. This disease is variable in its presenting symptoms and the biologic behavior of the tumor. The spectrum of clinical manifestations varies depending upon the type and quantity of polypeptide hormones or biogenic amines being produced. Although the tumors are usually indolent in their growth, the more dedifferentiated or anaplastic tumors can be quite aggressive. Thanks to new treatments that are very effective in the subgroup of anaplastic neuroendocrine carcinomas it is vital to recognize this subset. As research scientists and clinicians we must be aware of the natural history of the disease in order to optimize each patient's treatment. This highly selective review focuses on studies performed in collaboration with Dr. Charles Moertel along with other colleagues at the Mayo Clinic, have done in the past few years.
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van Haelst-Pisani CM, Richardson RL, Su J, Buckner JC, Hahn RG, Frytak S, Kvols LK, Burch PA. A phase II study of recombinant human alpha-interferon in advanced hormone-refractory prostate cancer. Cancer 1992; 70:2310-2. [PMID: 1382829 DOI: 10.1002/1097-0142(19921101)70:9<2310::aid-cncr2820700916>3.0.co;2-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
To determine the efficacy of recombinant human leukocyte alpha-interferon (IFL-RA) in advanced hormone-refractory prostate cancer, the authors treated 40 patients with IFL-RA administered intramuscularly at a dose of 10 x 10(6) U/m2 three times weekly. Toxicity was substantial and necessitated at least a 50% dose reduction in all but five patients during the first 1-2 months of therapy. No responses were observed in patients with bone metastases, but complete and partial regression of nodal disease were observed in two patients with extraosseous disease (overall response rate, 5%; 95% confidence interval, 0.64-17.75%). The authors conclude that IFL-RA cannot be recommended at this dose and schedule in patients with advanced prostate cancer, but additional study of its use in patients with nodal disease may be warranted.
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O'Connor MK, Kvols LK, Brown ML, Hung JC, Hayostek RJ, Cho DS, Vetter RJ. Dosimetry and biodistribution of an iodine-123-labeled somatostatin analog in patients with neuroendocrine tumors. J Nucl Med 1992; 33:1613-9. [PMID: 1517834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
A modified method for the preparation of a radiolabeled analog of somatostatin (123I-octreotide) is described. The pharmacokinetics and dosimetry of this analog were evaluated in patients with neuroendocrine tumors. Thirty patients had multiple blood and urine samples and sequential anterior and posterior whole-body scintigraphy up to 40 hr postinjection of 123I-octreotide. Region of interest analysis of the whole-body images was used to determine organ and tumor doses. The 123I-octreotide was rapidly cleared from the blood with a T 1/2 of 10 min by the hepatobiliary system. By 40 hr, approximately 55% was eliminated in the feces. The gallbladder wall received the highest dose (0.48 rad/mCi), with other organs receiving doses of 0.12 rad/mCi or less. Tumors were identified in 25 of 28 satisfactory studies. Tumor doses ranged from 0.1 to 0.6 rad/mCi. Calculations with 131I instead of 123I indicated that the gallbladder wall would receive 2 rad/mCi, while average tumor doses would range from 0.9 to 5.0 rad/mCi. Iodine-123-octreotide is a useful agent for the visualization of neuroendocrine tumors. The rapid washout of this agent from tumors precludes the possibility of radiotherapy with 131I-octreotide in these patients.
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Knott-Craig CJ, Schaff HV, Mullany CJ, Kvols LK, Moertel CG, Edwards WD, Danielson GK. Carcinoid disease of the heart. Surgical management of ten patients. J Thorac Cardiovasc Surg 1992; 104:475-81. [PMID: 1495314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Between 1982 and 1989, 10 patients with carcinoid heart disease underwent tricuspid valve replacement with a mechanical prosthesis at our institution. Pulmonary valvectomy was performed in nine patients and pulmonary valve replacement with a pulmonary homograft was performed in one. Two patients had carcinoid tumor metastatic to the heart, involving the right atrium in one case and both ventricles in the other. One patient had concomitant coronary artery bypass with the saphenous vein, and one patient had a quadruple valve replacement for histologically proved carcinoid disease of all four valves. The 30-day mortality was 10% and the late mortality was 30%. The remaining six patients were alive 4, 4, 4, 7, 24, and 46 months postoperatively. A review of the English literature identified 28 additional patients who underwent tricuspid valve replacement for carcinoid heart disease. There was no significant difference in the survival of patients with a bioprosthesis versus a mechanical valve in the tricuspid position. The 4-year survival for the 38 patients undergoing tricuspid valve replacement for carcinoid heart disease was 48% +/- 13%. Symptomatic patients who have carcinoid heart disease and whose metastatic malignant disease is not an imminent threat to life should be offered valve replacement. Operating soon after the onset of increasing cardiac symptoms, before the often rapid deterioration in right ventricular failure, optimizes the benefits.
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Hook CC, Kimmel DW, Kvols LK, Scheithauer BW, Forsyth PA, Rubin J, Moertel CG, Rodriguez M. Multifocal inflammatory leukoencephalopathy with 5-fluorouracil and levamisole. Ann Neurol 1992; 31:262-7. [PMID: 1637134 DOI: 10.1002/ana.410310306] [Citation(s) in RCA: 120] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A cerebral demyelinating disease developed in 3 patients during adjuvant therapy with 5-fluorouracil and levamisole for adenocarcinoma of the colon. None of the patients had evidence of metastatic disease or prior neurological disease. The duration of chemotherapy before onset of neurological symptoms ranged from 15 to 19 weeks. The total dose of 5-fluorouracil was 9.7 to 15.7 gm. The total dose of levamisole was 2.7 to 3.75 gm. Two patients presented with a subacute (2-3 weeks) progressive decline in mental status and ataxia. The third patient had two unexplained episodes of loss of consciousness. In each, magnetic resonance imaging with gadolinium demonstrated prominent multifocal enhancing white matter lesions. Cerebral biopsy was performed stereotaxically in 2 patients. The morphological features were those of active demyelinating disease. The myelin loss was associated with numerous dispersed as well as vasocentric macrophages, sparing of axons, and perivascular lymphocytic inflammation. Electron microscopy confirmed the light microscopic findings. All 3 patients improved after cessation of chemotherapy and a short course of corticosteroid therapy. Our patients represent the first reported examples of an inflammatory leukoencephalopathy associated with the administration of 5-fluorouracil and levamisole. This syndrome may represent the pathological basis for 5-fluorouracil neurotoxicity, although we cannot completely exclude the role of levamisole.
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