SURVIVAL OF PATIENTS WITH DISSEMINATED MIDGUT CARCINOID-TUMORS AFTER AGGRESSIVE TUMOR REDUCTION

Sixty-four consecutive patients with disseminated midgut carcinoids se re treated during an 8-gear period according to a single clinical prot ocol aimed at aggressive tumor reduction by surgery alone or with subs equent hepatic artery embolization. All patients had markedly elevated urinary 5-hydroxyindoleacetic acid (5-HIAA) levels (581 +/- 79 mu mol /24 h) and hormonal symptoms. Fourteen patients (22%) reached anatomic and biochemical cure by surgery alone. At follow-up, the mean 5-HIAA levels were still normal after 69.0 +/- 6.2 months; two patients had d ied from unrelated causes. With the introduction of somatostatin recep tor scintigraphy, subclinical disease was diagnosed in 7 of these 14 p atients. Forty patients with bilobar hepatic disease underwent emboliz ation in combination with octreotide. In this group, 5-HIAA levels wer e still reduced by 55% after 71 +/- 11 months of follow-up, and the 5- year survival was 56%, estimated from the total death hazard function. After embolization, two subgroups could be identified with marked dif ferences in their long-term response to treatment. Ten patients were n ot embolized owing to complicating diseases. The 5-year survival for t he entire series was 58%. A significantly increased risk of cardiovasc ular deaths was seen, which underlines the importance of total surviva l analysis in a disease with multiple hormonal effects. It is conclude d that an active surgical approach must be recommended to patients wit h the midgut carcinoid syndrome. In patients with bilobar hepatic dise ase, embolization combined with octreotide treatment markedly reduced the 5-HIAA excretion and suggested a prolonged 5-year survival.