Radioembolization for unresectable neuroendocrine hepatic metastases using resin 90Y-microspheres: early results in 148 patients. Am J Clin Oncol. 2008;31:271-279. [PMID: 18525307 DOI: 10.1097/coc.0b013e31815e4557]

Recommendations for management of patients with neuroendocrine liver metastases

Many management strategies exist for neuroendocrine liver metastases. These strategies range from surgery to ablation with various interventional radiology procedures, and include both regional and systemic therapy with diverse biological, cytotoxic, or targeted agents. A paucity of biological, molecular, and genomic information and an absence of data from rigorous trials limit the validity of many publications detailing management. This Review represents the views from an international conference, for which 15 expert working groups prepared evidence-based assessments addressing specific questions, and from which an independent jury derived final recommendations. The aim of the conference was to review the existing approaches to neuroendocrine liver metastases, assess the evidence on which management decisions were based, develop internationally acceptable recommendations for clinical practice (when evidence was available), and make recommendations for clinical and research endeavours. This report represents the final clinical statements and proposals for future research.

Towards new response criteria in neuroendocrine tumors: which changes in MRI parameters are associated with longer progression-free survival after radioembolization of liver metastases?

PURPOSE

To evaluate the association of therapy-related changes in imaging parameters with progression-free survival (PFS) of patients with unresectable liver metastases from neuroendocrine tumors (NETLMs).

MATERIALS AND METHODS

Forty-five radioembolized patients (median age: 62 years; range: 43-75) received a pre- and 3 months posttherapeutic magnetic resonance imaging (MRI) examination. The latter were evaluated for tumor size, arterial enhancement, and necrosis pattern. Influences of therapy-related changes on PFS were analyzed. Statistical analysis included Student's t-test, Wilcoxon test, Cox regression analysis, and Kaplan-Meier curves.

RESULTS

The median percentage decrease in sum of diameters was 9.7% (range: 43.9% decrease to 15.4% increase). Twenty-one patients (47%) showed increased necrosis. Three parameters were associated with significantly longer PFS: a decrease of diameter (hazard ratio [HR]: 0.206; 95% confidence interval [CI]: 0.058-0.725; P = 0.0139), a decrease in tumor arterial enhancement (HR: 0.143; 95% CI: 0.029-0.696; P = 0.0160), and an increase in necrosis after 3 months (HR: 0.321; 95% CI: 0.104-0.990; P = 0.0480). Multivariate analysis revealed that changes in diameter and arterial enhancement have complementary information and are associated independently with long PFS.

CONCLUSION

A decrease both in sum of diameters and arterial enhancement of metastases, as well as an increase in necrosis, are associated with significantly longer PFS after radioembolization.

Radioembolization with Yttrium-90 microspheres (SIRT) in pancreatic cancer patients with liver metastases: efficacy, safety and prognostic factors

OBJECTIVE

To analyze the clinical efficacy of (90)Y radioembolization in liver metastases from pancreatic cancer, to describe treatment toxicities and to identify biomarkers as predictors of outcome.

METHODS

Data from 19 pancreatic cancer patients (9 females/10 males) who had received (90)Y radioembolization for metastatic liver disease between 06/2004 and 01/2011 were analyzed retrospectively.

RESULTS

The median age at (90)Y radioembolization was 63 years (range 43-77). In 16 patients, previous palliative gemcitabine-based chemotherapy was given for metastatic disease. Objective response in the liver after (90)Y radioembolization was 47%. Median local progression-free survival in the liver was 3.4 months (range 0.9-45.0). Median overall survival (OS) was 9.0 months (range 0.9-53.0) and 1-year survival was 24%. Cox regression models for baseline biomarkers at (90)Y radioembolization revealed correlations of increased carbohydrate antigen 19-9 (p = 0.02) and C-reactive protein (p = 0.03) with shorter OS. Short-term adverse events (nausea, vomiting, fatigue, fever and abdominal pain) did not exceed grade 3. As long-term adverse events, liver abscesses, gastroduodenal ulceration, cholestasis and cholangitis, ascites and spleen infarction were observed.

CONCLUSION

(90)Y radioembolization is able to induce an encouraging local response rate of liver metastases of pancreatic cancer patients. Most short-term toxicities are manageable; however, patients should be followed up carefully for severe long-term toxicities.

Biliary tree gastrinomas in multiple endocrine neoplasia type 1 syndrome

AIM: To describe our patients affected with ectopic biliary tree gastrinoma and review the literature on this topic.

METHODS: Between January 1992 and June 2012, 28 patients affected by duodenopancreatic endocrine tumors in multiple endocrine neoplasia type 1 (MEN1) syndrome underwent surgery at our institution. This retrospective review article analyzes our experience regarding seventeen of these patients subjected to duodenopancreatic surgery for Zollinger-Ellison syndrome (ZES). Surgical treatment consisted of duodenopancreatectomy (DP) or total pancreatectomy (TP). Regional lymphadenectomy was always performed. Any hepatic tumoral lesions found were removed during surgery. In MEN1 patients, removal of duodenal lesions can sometimes lead to persistence or recurrence of hypergastrinemia. One possible explanation for this unfavorable outcome could be unrecognized ectopic localization of gastrin-secreting tumors. This study described three cases among the seventeen patients who were found to have an ectopic gastrinoma located in the biliary tree.

RESULTS: Seventeen MEN1 patients affected with ZES were analyzed. The mean age was 40 years. Fifteen patients underwent DP and two TP. On histopathological examination, duodeno pancreatic endocrine tumors were found in all 17 patients. Eighty-one gastrinomas were detected in the first three portions of the duodenum. Only one gastrinoma was found in the pancreas. The mean number of gastrinomas per patient was 5 (range 1-16). Malignancy was established in 12 patients (70.5%) after lymph node, liver and omental metastases were found. Three patients exhibited biliary tree gastrinomas as well as duodenal gastrinoma(s). In two cases, the ectopic gastrinoma was removed at the same time as pancreatic surgery, while in the third case, the biliary tree gastrinoma was resected one year after DP because of recurrence of ZES.

CONCLUSION: These findings suggest the importance of checking for the presence of ectopic gastrinomas in the biliary tree in MEN1 patients undergoing ZES surgery.

Diffusion-weighted imaging with acquisition of three b-values for response evaluation of neuroendocrine liver metastases undergoing selective internal radiotherapy

OBJECTIVES

To evaluate diffusion-weighted MRI with acquisition of three b-values and calculation of fractioned ADCs for response evaluation of neuroendocrine liver metastases undergoing selective internal radiotherapy (SIRT).

METHODS

Ten consecutive patients with neuroendocrine liver metastases underwent MRI before and following SIRT. Diffusion-weighted imaging included acquisition of the b-values 0, 50 and 800 s/mm(2) and calculation of ADC(50,800), ADC(0,50) and ADC(0,800) maps. According to therapy response, lesions were categorised into group A [≥20% reduction of the longest diameter (LD) in comparison to baseline MRI] and group B (<20% reduction of the LD).

RESULTS

Twelve out of 31 metastases were categorised as group A and 19 out of 31 metastases were categorised as group B. Pretherapeutic values of ADC(0,800) and ADC(50,800) did not differ significantly between the two groups; however, ADC(0,50) was 32% lower in group A (P = 0.049). ADC(0,800) and ADC(50,800) increased significantly after therapy in both groups, however, group differences were not statistically significant. Conversely, the increase in ADC(0,50) was about a factor of 7 larger in group A than in group B (P = 0.023).

CONCLUSIONS

Our study showed that the ADC(0,50) is a promising biomarker for response assessment of neuroendocrine liver metastases following SIRT.

KEY POINTS

• Diffusion-weighted MRI offers new information about neuroendocrine hepatic metastases. • Evaluation of perfusion and diffusion components requires fractioned apparent diffusion coefficients (ADCs). • Perfusion effects represented by ADC (0.50) can be observed in neuroendocrine metastases. • Pretherapeutic ADC (0.50) was significantly lower in metastases with a response ≥20%. • Such biomarkers may help evaluate liver metastases in patients undergoing therapy.

Y90-radioembolization of lung metastases via the bronchial artery: a report of 2 cases

We report successful Y90-radioembolization of the lung applying Y90-resin microspheres via the bronchial artery in two patients with diffuse colorectal and renal cancer metastases, respectively. The deposition of radioactive Y90-resin-microspheres was technically feasible and resulted in a reasonable absorbed dose in the tumors. However, open questions remain regarding dosimetry and safe dose exposure to the lung. The technique warrants thorough investigation before clinical use. A Phase I trial to evaluate safety and preliminary efficacy is under preparation.

Can imaging patterns of neuroendocrine hepatic metastases predict response yttruim-90 radioembolotherapy?

AIM: To evaluate the response to treatment in patients with neuroendocrine tumor liver metastases following yttrium-90 (⁹⁰Y) radioembolotherapy, as a function of image patterns at presentation for ⁹⁰Y radioembolotherapy.

METHODS: The study cohort consisted of patients with hepatic metastatic neuroendocrine tumors treated with ⁹⁰Y at our institution during a two-year time period. Hepatic metastases were evaluated on a pre-therapy study assessing relative arterial enhancement compared to liver, lesion size, necrosis of the lesion, and associated tumor burden in the liver. We used six response criteria: Response Evaluation Criteria in Solid Tumors (RECIST) size, World Health Organization (WHO) size, European Association for the Study of the Liver (EASL) necrosis guidelines, Choi size, Choi necrosis and combination of Choi size and necrosis.

RESULTS: About 65 lesions in 17 patients met study criteria and formed the cohort. Statistically significant response was found for lesions < 5 cm vs those ≥ 5 cm with RECIST (P = 0.04), WHO (P = 0.002) and combined Choi criteria (P = 0.02). Hyperenhancing lesions demonstrated greater response only with the Choi size criteria (P = 0.04). Lesions with ≤ 50% necrosis on the pre-scan had statistically significant greater response with the Choi necrosis criteria (P = 0.01). There was no statistical significance for response comparing lesions < 2 cm vs≥ 2 cm or in comparing the degrees of tumor burden.

CONCLUSION: Based on our findings in this study, it is suggested that initial imaging findings, as listed above, are not a good predictor of response to ⁹⁰Y radioembolization.

ACR Appropriateness Criteria radiologic management of hepatic malignancy

Management of hepatic malignancy is a challenging clinical problem involving several different medical and surgical disciplines. Because of the wide variety of potential therapies, treatment protocols for various malignancies continue to evolve. Consequently, development of appropriate therapeutic algorithms necessitates consideration of medical options, such as systemic chemotherapy; surgical options, such as resection or transplantation; and locoregional therapies, such as thermal ablation and transarterial embolization. The authors discuss treatment strategies for the 3 most common subtypes of hepatic malignancy treated with locoregional therapies: hepatocellular carcinoma, neuroendocrine metastases, and colorectal metastases. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Sunitinib malate as first-line treatment for an advanced, poorly differentiated pancreatic neuroendocrine tumor

Pancreatic neuroendocrine tumors (PNETs) are rare, accounting for approximately 2% of primary malignant tumors of the pancreas. Compared with common pancreatic ductal adenocarcinomas, they grow more slowly, are less invasive and have a better prognosis. At present, surgery is the preferred method of treatment of PNETs, and offers the only chance of a cure. However, owing to the occult onset of PNETs, once diagnosed they are often inoperable when the diagnosis is established, and the optimal treatment of patients with inoperable liver metastases remains uncertain. In recent years, targeted drug therapies have emerged and have proved effective in prolonging progression-free survival in patients with advanced well-differentiated PNETs, but hardly any progress has been made in the treatment of poorly differentiated PNETs. In the patient described in this report, who had a poorly differentiated PNET with multiple hepatic metastases and had refused cytotoxic chemotherapy, oral sunitinib malate treatment for 22 months with regular follow-ups proved tolerable and effective in significantly reducing the size of the intrahepatic masses.

A case of inoperable malignant insulinoma with resistant hypoglycemia who experienced the most significant clinical improvement with everolimus

Metastatic insulinomas may sometimes present with recurrent life-threatening hypoglycemia episodes. Such patients usually fail to respond to various therapeutic agents which causes constant dextrose infusion requirement. Herein, we present a resistant case of inoperable malignant insulinoma who was treated with many therapeutic agents and interventions including somatostatin analogues, Yttrium-90 radioembolization, everolimus, radiotherapy, and chemoembolization. Close blood sugar monitorization during these therapies showed the most favourable response with everolimus. Everolimus treatment resulted in rapid improvement of hypoglycemia episodes, letting us discontinue dextrose infusion and discharge the patient. However, experience with everolimus in such patients is still limited, and more precise data can be obtained with the increasing use of this agent for neuroendocrine tumours.

Initial outcome after selective intraarterial radionuclide therapy with yttrium-90 microspheres as salvage therapy for unresectable metastatic liver disease

PURPOSE

The aim of the study was to retrospectively evaluate the potential benefit on survival outcomes of selective intraarterial radionuclide therapy (SIRT) with Yttrium-90 microspheres as a salvage therapy in liver metastasis of different tumors.

MATERIAL AND METHODS

Sixty-one patients who had unresectable liver metastases from colorectal carcinoma (n=23), neuroendocrine tumor (NET; n=12), cholangiocarcinoma (n=9), and others (n=17) received yttrium-90 microspheres. All patients were treated in a salvage setting with an 11-month mean follow-up. Early metabolic treatment response was evaluated by 18F-Fluorodeoxyglucose positron emission tomography (FDG PET-CT) in the sixth week after treatment.

RESULTS

Of the 61 patients, 32 were alive at the end of the study; median overall survival (OS) was 17.0 ± 2.5 months (95% confidence interval: 11.9-22.0). A subset analysis of colorectal and noncolorectal groups demonstrated median OS rates of 14.0 ± 5.8 and 17.0 ± 4.8 months, respectively (p=0.543). The mean OS for patients with NET and cholangiocarcinoma was 29.0 ± 3.1 months and 17.7 ± 3.2 months, respectively (p=0.010). According to the early metabolic treatment response, the mean OS of responder and nonresponder groups was 32.0 ± 5.6 months and 11.4 ± 2.1 months, respectively (p=0.054). Eastern Cooperative Oncology Group performance status <1 (p=0.018) and chemotherapy-naive patients (p=0.008) showed significant correlation with survival.

CONCLUSION

SIRT is an effective treatment option for patients with metastatic liver disease in a salvage setting with acceptable toxicity.

The joint IAEA, EANM, and SNMMI practical guidance on peptide receptor radionuclide therapy (PRRNT) in neuroendocrine tumours

Peptide receptor radionuclide therapy (PRRNT) is a molecularly targeted radiation therapy involving the systemic administration of a radiolabelled peptide designed to target with high affinity and specificity receptors overexpressed on tumours. PRRNT employing the radiotagged somatostatin receptor agonists (90)Y-DOTATOC ([(90)Y-DOTA(0),Tyr(3)]-octreotide) or (177)Lu-DOTATATE ([(177)Lu-DOTA(0),Tyr(3),Thr(8)]-octreotide or [(177)Lu-DOTA(0),Tyr(3)]-octreotate) have been successfully used for the past 15 years to target metastatic or inoperable neuroendocrine tumours expressing the somatostatin receptor subtype 2. Accumulated evidence from clinical experience indicates that these tumours can be subjected to a high absorbed dose which leads to partial or complete objective responses in up to 30 % of treated patients. Survival analyses indicate that patients presenting with high tumour receptor expression at study entry and receiving (177)Lu-DOTATATE or (90)Y-DOTATOC treatment show significantly higher objective responses, leading to longer survival and improved quality of life. Side effects of PRRNT are typically seen in the kidneys and bone marrow. These, however, are usually mild provided adequate protective measures are undertaken. Despite the large body of evidence regarding efficacy and clinical safety, PRRNT is still considered an investigational treatment and its implementation must comply with national legislation, and ethical guidelines concerning human therapeutic investigations. This guidance was formulated based on recent literature and leading experts' opinions. It covers the rationale, indications and contraindications for PRRNT, assessment of treatment response and patient follow-up. This document is aimed at guiding nuclear medicine specialists in selecting likely candidates to receive PRRNT and to deliver the treatment in a safe and effective manner. This document is largely based on the book published through a joint international effort under the auspices of the Nuclear Medicine Section of the International Atomic Energy Agency.

Interventional oncologic approaches to liver metastases

Metastatic liver disease is the most common cause of death in cancer patients. Complete surgical resection is currently considered the only curative treatment, with only about 25% of patients being amenable to surgery. Therefore, a variety of interventional oncologic techniques have been developed for treating secondary liver malignancies. The aim of these therapies is either to allow patients with unresectable tumors to become surgical candidates, provide curative treatment options in nonsurgical candidates, or improve survival in a palliative or even curative approach. Among these interventional therapies are transcatheter therapies such as portal vein embolization, hepatic artery infusion chemotherapy, transarterial chemoembolization, and radioembolization, as well as interstitial techniques, particularly radiofrequency ablation as the most commonly applied technique. The rationale, application and clinical results of each of these techniques are reviewed on the basis of the current literature. Future prospects such as gene therapy and immunotherapy are introduced.

Management of pancreatic neuroendocrine tumors

Pancreatic neuroendocrine tumors account for 1% to 2% of pancreatic neoplasms and may occur sporadically or as part of a hereditary syndrome. Patients may present with symptoms related to hormone secretion by functional tumors or to locally advanced or metastatic nonfunctional tumors. Asymptomatic pancreatic neuroendocrine tumors are increasingly detected incidentally during abdominal imaging performed for other reasons. The management of localized pancreatic neuroendocrine tumors is surgical resection. Hepatic metastases are common and their management involves a variety of liver-directed therapies, which should be tailored according to extent of disease, symptoms, presence of extrahepatic metastases, and patient performance status.

Systemic treatment in unresectable metastatic well-differentiated carcinoid tumors: consensus results from a modified delphi process

OBJECTIVES

This study aimed to develop expert consensus for the use of systemic treatments for unresectable metastatic well-differentiated (grade 1-2) carcinoid tumors using the RAND/UCLA modified Delphi process.

METHODS

After a comprehensive literature review, 404 patient scenarios addressing the use of systemic treatments for carcinoid tumors were constructed. A multidisciplinary panel of 10 physicians assessed the scenarios as appropriate, inappropriate, or uncertain (on a 1-9 scale) or as an area of disagreement before and after an extended discussion of the evidence.

RESULTS

Experts were medical and surgical oncologists, interventional radiologists, and gastroenterologists. Among rated scenarios, disagreement decreased from 14% before the meeting to 4% after. Consensus statements about midgut carcinoids included the following: (1) Somatostatin analogs are appropriate as first-line therapy for all patients; (2) In patients with uncontrolled secretory symptoms, it is appropriate to increase the dose/frequency of octreotide long-acting repeatable up to 60 mg every 4 weeks or up to 40 mg every 3 weeks as second-line therapy for refractory carcinoid syndrome. Other options may also be appropriate. Consensus was similar for non-midgut carcinoids.

CONCLUSIONS

The Delphi process provided a structured methodological approach to assist clinician experts in reaching consensus on the appropriateness of specific medical therapies for the treatment of advanced carcinoid tumors.

The Treatment of Liver Metastases in Patients with Neuroendocrine Tumors in 2012

Neuroendocrine tumors (NETs) comprise a heterogeneous group of tumors that form a distinct entity. Approximately 75-80% of patients present with liver metastases at the time of their diagnosis, and 20%-25% will develop these lesions in the course of their disease. The presence of secondary deposits in the liver significantly increases the morbidity and mortality in these patients. The only potentially curative treatment is the surgical resection of the primary tumor and hepatic lesions. However, only 10% of patients presents under ideal conditions for that approach. Several techniques aimed at localized liver lesions have been applied also with interesting results in terms of survival and symptom control. The same has been demonstrated with new systemic therapies (target therapies). However, these are still under study, in order to define their true role in the management of these patients. This paper intends to address, in a general way, the various treatment options in patients with liver metastases from neuroendocrine tumors.

Pancreatic neuroendocrine tumors

Pancreatic neuroendocrine tumors (pancreatic NETs) are rare, low- to intermediate-grade neoplasms thought to arise from the pancreatic islets. Recent advances in pathology and our understanding of the biological behavior of this group of tumors has resulted in changes in their nomenclature and how we treat them. This review puts into perspective our current understanding of pancreatic NETs in terms of their incidence, pathology, and management.

Pancreatic neuroendocrine tumors: biology, diagnosis,and treatment

Pancreatic neuroendocrine tumors (PNETs), a group of endocrine tumors arising in the pancreas, are among the most common neuroendocrine tumors. The genetic causes of familial and sporadic PNETs are somewhat understood, but their molecular pathogenesis remains unknown. Most PNETs are indolent but have malignant potential. The biological behavior of an individual PNET is unpredictable; higher tumor grade, lymph node and liver metastasis, and larger tumor size generally indicate a less favorable prognosis. Endocrine testing, imaging, and histological evidence are necessary to accurately diagnose PNETs. A 4-pronged aggressive treatment approach consisting of surgery, locoregional therapy, systemic therapy, and complication control has become popular in academic centers around the world. The optimal application of the multiple systemic therapeutic modalities is under development; efficacy, safety, availability, and cost should be considered when treating a specific patient. The clinical presentation, diagnosis, and treatment of specific types of PNETs and familial PNET syndromes, including the novel Mahvash disease, are summarized.

Neuroendocrine tumours of the small intestine

The prevalence of intestinal neuroendocrine tumours, also known as carcinoid tumours, has increased significantly over the past three decades. Tumours of the distal small intestine (midgut) are often indolent, but are characterized by a high potential to metastasize to the small-bowel mesentery and liver. Patients with distant metastases are prone to development of the carcinoid syndrome, a constellation of symptoms which includes flushing, diarrhoea, and valvular heart disease. The carcinoid syndrome is caused by secretion of serotonin and other vasoactive substances into the systemic circulation. Treatment options for metastatic intestinal NETs have expanded in recent years. Of particular importance has been the development of somatostatin-analogue therapies. Somatostatin analogues were originally introduced for palliation of the carcinoid syndrome; however recent clinical trials have demonstrated that they can exert an inhibitory effect on tumour growth. Other novel agents targeting the VEGF and mTOR pathways have recently been evaluated in phase III trials, however their role in the management of small-intestinal NETs remains controversial. This article examines the biological characteristics of small intestinal NETs, summarizes current guidelines on classification, staging and grading, and reviews developments in locoregional and systemic therapy.

Integrating radioembolization into the treatment paradigm for metastatic neuroendocrine tumors in the liver

Surgical resection of hepatic metastases from neuroendocrine tumors (mNETs) is controversial because the potential survival benefit of this intervention must be balanced against the risk of surgical morbidity and mortality. In patients with unresectable mNETs in the liver, radioembolization has been used to treat tumors from a range of primary sites, including carcinoid and islet cell carcinomas as well as nonfunctional, asymptomatic tumors. Initial clinical studies and retrospective studies on a large cohort of patients indicate that radioembolization is well tolerated and highly effective in achieving a durable hepatic tumor response and ameliorating symptoms. Radioembolization using Yttrium-90 ((90)Y)-labeled resin or glass microspheres offers effective disease control and possible improved quality of life and thus merits consideration as an option for both functional and nonfunctional mNETs. Benefits of this intervention seem to extend from use in early lines of treatment to salvage of refractory disease. Radioembolization also offers a potential somatostatin analog-sparing effect in symptomatic disease.

Carcinoid and other neuroendocrine tumors of the colon and rectum

Neuroendocrine tumors (NETs) are found throughout the intestinal tract and arise from the Kulchitsky cells located in the crypts of Lieberkühn. They are classified by site of origin and by degree of differentiation, with well-differentiated lesions representing those tumors formerly referred to as carcinoid tumors. The focus of this review is NETs of the appendix, colon, and rectum. The clinical presentation of these tumors is dependent on the primary site and many are discovered incidentally, either during screening or during the investigation of nonspecific abdominal complaints. Treatment is primarily via surgical removal as the response to chemotherapy has been traditionally poor. A noted exception to this has been with treatment of the carcinoid syndrome, which occurs almost exclusively in patients with liver metastases and is due to the release of bioactive peptides and amines directly into the systemic circulation. The use of somatostatin congeners to block the release of these substances has greatly ameliorated the devastating symptoms of this condition. Postresection follow-up is advocated, but specific recommendations are lacking an evidentiary basis. NETS, particularly those of the small bowel, colon, and appendix, are seen in association with other synchronous or metachronous malignancies, often of the gastrointestinal tract. However, the utility of subsequent screening and surveillance is unproven.

Therapy of metastatic pancreatic neuroendocrine tumors (pNETs): recent insights and advances

Neuroendocrine tumors (NETs) [carcinoids, pancreatic neuroendocrine tumors (pNETs)] are becoming an increasing clinical problem because not only are they increasing in frequency, but they can frequently present with advanced disease that requires diagnostic and treatment approaches different from those used in the neoplasms that most physicians are used to seeing and treating. In the past few years there have been numerous advances in all aspects of NETs including: an understanding of their unique pathogenesis; specific classification systems developed which have prognostic value; novel methods of tumor localization developed; and novel treatment approaches described. In patients with advanced metastatic disease these include the use of newer chemotherapeutic approaches, an increased understanding of the role of surgery and cytoreductive methods, the development of methods for targeted delivery of cytotoxic agents, and the development of targeted medical therapies (everolimus, sunitinib) based on an increased understanding of the disease biology. Although pNETs and gastrointestinal NETs share many features, recent studies show they differ in pathogenesis and in many aspects of diagnosis and treatment, including their responsiveness to different therapies. Because of limited space, this review will be limited to the advances made in the management and treatment of patients with advanced metastatic pNETs over the past 5 years.

Yttrium-90 microsphere radioembolization for treatment of lung cancer hepatic metastases

Because stage 4 lung cancer is associated with dismal 5-year survival rates, new treatment approaches targeting extrapulmonary disease are necessary. Yttrium-90 microsphere radioembolization is an emerging treatment for metastatic hepatic malignancies that results in high tumor response rates and extended patient survival. To date, application of this therapy toward management of lung cancer hepatic metastases has not been extensively described. Herein, we present 2 cases of effective yttrium-90 radioembolization for treatment of lung cancer hepatic metastases, and emphasize the potential coadjuvant value of this procedure in patients with advanced-stage lung cancer and liver-dominant metastatic disease.

Radioembolization and chemoembolization for unresectable neuroendocrine liver metastases - a systematic review

This review examines the clinical efficacy and safety of the use of hepatic arterial chemoembolization, bland embolization and radioembolization in the treatment of unresectable neuroendocrine tumor liver metastases (NETLM). Response to treatment, survival outcome and toxicity were examined in this review of 37 studies comprising 1575 patients. These therapies are safe and effective in the treatment of NETLM. Prospective clinical trials to compare the relative efficacy and toxicity are warranted.

Radionuclide therapy beyond radioiodine

For decades, Iodine-131 has been used for the treatment of patients with thyroid cancer. In recent years, increasingly, other radiopharmaceuticals are in clinical use in the treatment of various malignant diseases. Although in principle these therapies-as in all applications of radionuclides-special radiation protection measures are required, a separate nuclear medicine therapy department is not necessary in many cases due to the lower or lack of gamma radiation. In the following article, four different radionuclide therapies are more closely presented which are emerging in the last years. One of them is the "Peptide Receptor Radionuclide Therapy," the so-called PRRT in which radiolabeled somatostatin (SST)-receptor(R) ligands are used in patients with neuroendocrine tumors. On the basis of radiolabeled antibodies against CD20-positive cells, the so-called radioimmunotherapy is used in the treatment of certain forms of malignant lymphoma. In primary or secondary liver tumors, the (90)Y-labeled particles can be administered. Last but not the least, the palliative approach of bone-seeking radiopharmaceuticals is noted in patients with painful bone metastases.

Pancreatic neuroendocrine and carcinoid tumors: what's new, what's old, and what's different?

Well-differentiated neuroendocrine tumors (NETs) can be subdivided into carcinoid and pancreatic NETs (panNETs). Recently, two therapies have been FDA approved for progressive well-differentiated pancreatic NETs but have not been submitted for use in carcinoid tumors (Yao, Shah, Ito, et al. N Engl J Med 364:514-23, 2011••; Raymond, Dahan, Raoul, et al. N Engl J Med 364:501-13, 2011••). The first is sunitinib (Sutent(®), Pfizer, Inc.), an orally administered, multitargeted receptor kinase inhibitor. The second targeted agent is everolimus (Afinitor(®), Novartis Pharmaceuticals), a mammalian target of rapamycin (mTOR) inhibitor (Yao, Shah, Ito, et al. N Engl J Med 364:514-23, 2011••). Both agents demonstrated improved progression-free survival but can also result in non-trivial toxicities and therefore, should only be considered in patients with progressing or symptomatic pancreatic NET. This review will discuss "new" NET therapies and provides an overview of liver directed and "older" cytotoxic treatment options. We also briefly outline "what's different" by describing a recent genetics report identifying genetic mutations in panNETs. Such a discovery could potentially be used to stratify treatment and such studies are currently being investigated.

Neuroendocrine pancreatic tumors: guidelines for management and update

Pancreatic neuroendocrine tumors (PanNETs) are a diverse group of rare neoplasms. Commonly referred to as islet cell tumors, PanNETs are classified as functional or nonfunctional depending on their production of specific pancreatic endocrine hormones (e.g. insulin, gastrin, glucagon, and others) and association with the resultant clinical syndromes. While most PanNETs are sporadic, syndromic patients, in particular those with multiple endocrine neoplasia type 1 (MEN-1) and von Hippel Lindau (VHL), are at increased risk of developing these tumors. Recent investigations of patients with sporadic and syndromic PanNETs have elucidated critical pathways in tumor development, such as mammalian target of rapamycin (mTOR) signaling and its downstream growth factors such as vascular endothelial growth factor (VEGF). Prognosis ranges from favorable for localized, low-grade neoplasms to poor for advanced, high-grade tumors. Regardless of the stage at presentation, surgery is the first-line therapy for patients with disease amenable to surgical resection. We favor formal pancreatectomy with conventional lymph node sampling for the vast majority of patients, either through open or laparoscopic techniques. Those with insulinomas, however, may be candidates for enucleation. Cytoreductive surgery is also recommended for patients with locoregional recurrences or hepatic metastases. Regional adjuvants such as radiofrequency ablation (RFA), transarterial chemoembolization (TACE), and others are often employed in an attempt to palliate symptoms and prolong survival. Unfortunately, cytotoxic chemotherapy has been largely ineffective in treating patients with PanNETs. The somatostatin analogue octreotide, however, has been effective in palliating symptoms and slowing the progression of disease. Other promising systemic agents, including sunitinib and everolimus, have targeted critical PanNET signaling pathways. In summary, surgery remains the principal therapeutic strategy for patients with PanNETs, but continued research may identify more robust systemic therapies for those with advanced disease.

Treatment options for unresectable neuroendocrine liver metastases

Hepatic metastases develop in 85% of patients with gastroenteropancreatic neuroendocrine tumors. Radical surgery, which involves resection of the primary and liver metastases, is the mainstay of treatment, with 60-70% 5-year survival and 35% 10-year survival rates. However, less than 15% of neuroendocrine tumor liver metastases (NETLMs) are resectable, owing either to multifocality or the inability to preserve sufficient parenchyma following resection. This article deals with the therapeutic modalities available for nonresectable liver metastases, and the therapeutic options available for management of nonresectable NETLMs are discussed. Targeted therapies for NETLMs include hepatic artery embolization, transcatheter arterial chemoembolization, radiolabeled/drug-eluting microspheres, radiofrequency ablation, cryoablation and phenol injection. Hepatic artery embolization/transcatheter arterial chemoembolization is associated with 75-100% symptom relief and an objective tumor response varying from 33 to 80%. Other modalities, such as biotherapy, peptide receptor therapy and chemotherapy, target both the primary and metastatic disease. Their effects on NETLMs as a subgroup have not been evaluated. Various therapeutic options are available for the treatment of unresectable NETLMs. Most offer significant symptomatic relief, with only a few comparative studies showing survival benefit. Most of the available evidence is based on retrospective and prospective case series rather than randomized controlled trials. Well-designed studies on existing treatment modalities and the search for newer therapeutic options are required.

Surgical resection of hepatic metastases from neuroendocrine neoplasms: a systematic review

BACKGROUND

Neuroendocrine tumours (NET) most commonly metastasize to the liver. Hepatic resection of NET hepatic metastases (NETHM) has been shown to improve symptomology and survival.

METHODS

A systematic review of clinical studies before September 2010 was performed to examine the efficacy of hepatic resection for NETHM. As a secondary end-point, the impact of treatment on safety and symptomology were determined and prognostic variables were identified. The quality of each study was also assessed using predefined criteria incorporating 9 characteristics. Clinical outcome was synthesized through a narrative review with full tabulation of results of all included studies.

RESULTS

Twenty-nine included reported survival outcomes with a median 3-, 5- and 10-year overall survival of 83% (range, 63-100%), 70.5% (range, 31-100%), and 42% (range, 0-100%), respectively. The median progression-free survival (PFS) was 21 months (range, 13-46 months) and median 1-,3-,5- and 10-year PFS of 63% (range, 50-80 %), 32% (range, 24-69%), 29% (range, 6-66%) and 1% (range, 0-11%), respectively. Poor histologic grade, extra-hepatic disease and a macroscopically incomplete resection were associated with a poor prognosis. Studies reported a median rate of symptomatic relief from surgery in 95% of patients (range, 50-100%).

CONCLUSION

Hepatic resection for NETHM provides symptomatic benefit and is associated with favourable survival outcomes although the majority of patients invariably develop disease progression.

Liver-directed therapies in liver metastases from neuroendocrine tumors of the gastrointestinal tract

Presence of liver metastases in neuroendocrine tumors is a major factor altering both quality of life and prognosis. Surgery is recognized as the sole curative treatment. When it is not possible, radiological directed therapies are crucial, particularly in liver metastases from the small bowel. Thermal ablative therapies as radiofrequency ablation and microwave are alternative treatments alone or in combination with surgery. Hepatic artery embolization or chemoembolization, as radioembolization, has been shown to have good clinical, biochemical, and morphological responses when liver burden does not permit ablative therapies. However, technical issues are multiple and there is no randomized study to compare their efficacy. The choice of management depends on liver burden and metastases pattern, but also on origin of the primary tumor, tumor differentiation, and tumor proliferative activity. These patients should benefit of a multidisciplinary management to limit morbidity and mortality.

Comprehensive review of the diagnosis and treatment of biliary tract cancer 2012. Part II: multidisciplinary management

Biliary tract cancers (gallbladder cancer, intra- and extra-hepatic cholangiocarcinoma and selected periampullary cancers) accounted for 12,760 new cases of cancer in the USA in 2010. These tumors have a dismal prognosis with most patients presenting with advanced disease. Early, accurate diagnosis is essential, both for potential cure where possible and for optimal palliative therapy in all others. This review examines the currently available and emerging technologies for diagnosis and treatment of this group of diseases.