eMedicine Specialties > Radiology > Gastrointestinal

Carcinoid, Gastrointestinal: Follow-up

Author: Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, LRCP, Chairman of Medical Imaging, Professor of Radiology, NGHA, King Fahad National Guard Hospital, King Abdulaziz Medical City, Riyadh, Saudi Arabia
Coauthor(s): Sumaira MacDonald, MBChB, PhD, MRCP, FRCR, Lecturer, Sheffield University Medical School; Endovascular Fellow, Sheffield Vascular Institute; David Sherlock, MBBS, FRCS, Consulting Staff, Department of Surgery, North Manchester General Hospital, Christie Hospital
Contributor Information and Disclosures

Updated: Apr 2, 2008

Intervention

  • As with other neuro-endocrine tumors, the natural history of GI carcinoids is widely variable. Often, however, patients develop numerous small, relatively slow-growing liver metastases over a period of many years
  • Carcinoids secrete a variety of potent hormones, particularly when they metastasize to the liver. Control of symptoms resulting from carcinoid syndrome is the primary object of therapy, because the lifespan of patients is long regardless of treatment. When the disease becomes resistant to pharmacologic agonists and systemic chemotherapy, patients usually benefit from hepatic arterial embolization (HAE).16 Objective response rates of 70% and symptomatic response rates of 90-100% have been reported with embolization of islet and carcinoid liver metastases. Polyvinyl alcohol, Gelfoam, or coils can be used to embolize the arteries. Polyvinyl alcohol particles are preferred at the author's institution.
  • The ideal technique would be minimally invasive, have little effect on normal liver, and be readily repeatable
  • Embolization partly fulfills these criteria, and some of the best published results are from repeated embolizations
  • Transarterial chemo-embolization (TACE) is not associated with a higher degree of toxicity than is HAE.16,17 TACE demonstrates trends toward improvement in time to progression, symptom control, and survival.
  • Targeted radionuclide therapy with90 Y-DOTA Tyr3-octreotide (90 Y-DOTATOC) is another promising technique used to achieve cytoreduction.
  • Radiofrequency (RF) ablation fulfills all the desired criteria.18 RF can be used to reduce hormone secretion and/or tumor load.
  • Aggressive cytoreduction can reverse somatostatin-analogue resistance and reduce drug requirements. Cytoreduction followed by octreotide analogues can be the best way to achieve prolonged symptom control.19

Medicolegal Pitfalls

  • Complications of hepatic embolization include nontarget embolization, intestinal ischemia, splenic infarction, cholecystitis, infection, and hepatic insufficiency.
  • Nontarget embolization occurs in as many as 5.3% of patients.

Special Concerns

  • With multiple carcinoid liver metastases, only part of the liver at a time should be embolized, because embolization of multiple metastases may incur a carcinoid crisis, which can be fatal.
  • At the author's institution, embolization is usually performed in 1 lobe at a time.
  • Appropriate antibiotic coverage has reduced the incidence of liver abscess to 2%.
 
Acknowledgments

Ramesh Chandra Raja, MBChB, FRCR, Consulting Staff, Department of Radiology, Rochdale Healthcare NHS Trust, contributed to this article.



More on Carcinoid, Gastrointestinal

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Imaging: Carcinoid, Gastrointestinal
Follow-up: Carcinoid, Gastrointestinal
Multimedia: Carcinoid, Gastrointestinal
References
Further Reading
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References

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  2. Berger MW, Stephens DH. Gastric carcinoid tumors associated with chronic hypergastrinemia in a patient with Zollinger-Ellison syndrome. Radiology. Nov 1996;201(2):371-3. [Medline]. [Full Text].

  3. Ho AC, Horton KM, Fishman EK. Gastric carcinoid tumors as a consequence of chronic hypergastrinemia: spiral CT findings. Clin Imaging. Jul-Aug 2000;24(4):200-3. [Medline].

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  5. Gibril F, Reynolds JC, Lubensky IA, et al. Ability of somatostatin receptor scintigraphy to identify patients with gastric carcinoids: a prospective study. J Nucl Med. Oct 2000;41(10):1646-56. [Medline].

  6. Kimura T, Sakahara H, Higashi T, et al. [Imaging of somatostatin receptor using 111In-pentetreotide]. Kaku Igaku. Apr 1996;33(4):447-52. [Medline].

  7. Kwekkeboom DJ, Lamberts SW, Habbema JD, et al. Cost-effectiveness analysis of somatostatin receptor scintigraphy. J Nucl Med. Jun 1996;37(6):886-92. [Medline]. [Full Text].

  8. Orjollet-Lecoanet C, Menard Y, Martins A, et al. [CT enteroclysis for detection of small bowel tumors]. J Radiol. Jun 2000;81(6):618-27. [Medline]. [Full Text].

  9. Fruauff A, Irwin GA, Williams HC, et al. CT demonstration of gastric carcinoid. AJR Am J Roentgenol. Jun 1987;148(6):1276-7. [Medline].

  10. Tsai TL, Changchien CS, Hu TH, et al. Demonstration of gastric submucosal lesions by high-resolution transabdominal sonography. J Clin Ultrasound. Mar 2000;28(3):125-32. [Medline].

  11. Adolph JM, Kimmig BN, Georgi P, et al. Carcinoid tumors: CT and I-131 meta-iodo-benzylguanidine scintigraphy. Radiology. Jul 1987;164(1):199-203. [Medline]. [Full Text].

  12. Hoegerle S, Altehoefer C, Ghanem N. Whole-body 18F dopa PET for detection of gastrointestinal carcinoid tumors. Radiology. Aug 2001;220(2):373-80. [Medline]. [Full Text].

  13. Koopmans KP, Neels OC, Kema IP, et al. Improved staging of patients with carcinoid and islet cell tumors with 18F-dihydroxy-phenyl-alanine and 11C-5-hydroxy-tryptophan positron emission tomography. J Clin Oncol. Mar 20 2008;26(9):1489-95. [Medline].

  14. Adams S, Baum R, Rink T. Limited value of fluorine-18 fluorodeoxyglucose positron emission tomography for the imaging of neuroendocrine tumours. Eur J Nucl Med. Jan 1998;25(1):79-83. [Medline].

  15. Bousen E, Reuter SR. Mesenteric angiography in the evaluation of inflammatory and neoplastic disease of the intestine. Radiology. Dec 1966;87(6):1028-36. [Medline].

  16. Sharma KV, Gould JE, Harbour JW, et al. Hepatic arterial chemoembolization for management of metastatic melanoma. AJR Am J Roentgenol. Jan 2008;190(1):99-104. [Medline].

  17. Mukherjee E, Mukherji D, Jayawardene SA, et al. Tumor lysis syndrome and acute renal failure--an increasing spectrum of presentations. Clin Nephrol. Sep 2007;68(3):186-9. [Medline].

  18. Eriksson J, Stålberg P, Nilsson A, et al. Surgery and radiofrequency ablation for treatment of liver metastases from midgut and foregut carcinoids and endocrine pancreatic tumors. World J Surg. Mar 7 2008;[Medline].

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Keywords

gastrointestinal carcinoid, GI carcinoid, gastrointestinal tumor, GI tumor, argentaffin tumors, argentaffinoma, enterochromaffin cells of Kulchitsky, carcinoid syndrome

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Contributor Information and Disclosures

Author

Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, LRCP, Chairman of Medical Imaging, Professor of Radiology, NGHA, King Fahad National Guard Hospital, King Abdulaziz Medical City, Riyadh, Saudi Arabia
Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, LRCP is a member of the following medical societies: American Institute of Ultrasound in Medicine, Royal College of Physicians, Royal College of Physicians and Surgeons of the United States, Royal College of Radiologists, and Royal College of Surgeons of England
Disclosure: Nothing to disclose.

Coauthor(s)

Sumaira MacDonald, MBChB, PhD, MRCP, FRCR, Lecturer, Sheffield University Medical School; Endovascular Fellow, Sheffield Vascular Institute
Sumaira MacDonald, MBChB, PhD, MRCP, FRCR is a member of the following medical societies: British Medical Association, Royal College of Physicians, and Royal College of Radiologists
Disclosure: Nothing to disclose.

David Sherlock, MBBS, FRCS, Consulting Staff, Department of Surgery, North Manchester General Hospital, Christie Hospital
Disclosure: Nothing to disclose.

Medical Editor

John L Haddad, MD, Clinical Associate Professor, Department of Radiology, Weill Medical College of Cornell University; Director of Body MRI, Department of Radiology, Methodist Hospital in Houston
John L Haddad, MD is a member of the following medical societies: American College of Radiology, American Medical Association, and Radiological Society of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Udo P Schmiedl, MD, PhD, Clinical Professor, Department of Radiology, University of Washington; Consulting Staff, Swedish Medical Center, University of Washington Medical Center, Seattle Radiologists
Udo P Schmiedl, MD, PhD is a member of the following medical societies: American College of Radiology and Radiological Society of North America
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

John Karani, MBBS, FRCR, Consulting Staff, Department of Radiology, King's College Hospital, London
Disclosure: Nothing to disclose.

 
 
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