Carcinoid case presentation and discussion: the American perspective.

The rationale underlying an aggressive approach in the management of some carcinoid patients is explained and illustrated by the presented case of a middle-aged man with advanced classic typical midgut carcinoid. The patient exhibited somatostatin receptor scintigraphy-positive massive liver metastases, carcinoid syndrome, severe tricuspid and pulmonic cardiac valve disease with congestive heart failure, ascites and malnutrition. He had been treated for several years with supportive medications and biotherapy including octreotide and alpha interferon but his tumor eventually progressed and his overall condition was markedly deteriorated when he first sought more aggressive treatment. This consisted of prompt replacement of both tricuspid and pulmonic valves, followed by hepatic artery chemoembolus (HACE) injection and then surgical tumor debulking including excision of the primary tumor in the small intestine. In addition, radiofrequency ablation was utilized to reduce the volume of metastases in the liver. Prophylactic cholecystectomy was also performed and a biopsy of tumor was submitted for cell culture drug resistance testing. This was followed by systemic chemotherapy utilizing the drug (docetaxel) which the in vitro studies suggested as most likely to be effective. His excellent response to this succession of treatments exemplifies the successful application of aggressive sequential multi-modality therapy.