DK Sennik,1 JL Bacon, 1 K Foster, 1 V Lewington2 and S Zachariah1
1. East Surrey Hospital, Redhill, Surrey. 2. Royal Marsden Hospital, Sutton, Surrey
We present the case of an 84 year old lady who presented with a history of intermittent abdominal pain, bloating and diarrhoea. She was noted to have rectal bleeding and a colonoscopy procedure demonstrated a 3cm polypoidal growth in the caecum which was confirmed at histology as well differentiated carcinoid. A 24 hour urinary 5HIAA collection was elevated at 106 µmol/24hrs (normal 15-75). She underwent debulking surgery with partial colectomy. At laparotomy, the tumour was noted to be locally invasive with liver secondaries. She was commenced on somatostatin analogue therapy with lanreotide 60mg monthly and Urine 5HIAA levels improved to normal. Two years later she presented with anorexia, nausea, weight loss and abnormal liver function tests (obstructive picture). A computed tomography (CT) scan of the abdomen showed a mass at the head of the pancreas consistent with metastatic carcinoid tumour. An endoscopic retrograde cholangio-pancreatography (ERCP) procedure was performed with stent insertion which relieved the obstructive jaundice.
The patient was then referred for radionuclide therapy. Indium ocreotide and mIBG scans were performed which demonstrated focal intense uptake consistent with metastases in the right iliac fossae (site of primary tumour), liver, pancreas and supraclavicular fossae. The patient was commenced on Yttrium DOTATOC therapy (90Y-1,4,7,10-tetraazacyclododecane-N,N’,N’’,N’’’-tetraacetic acid [DOTA]0, Tyr3 octreotide). The main risks of therapy were of myelosuppression and nephrotoxicity. Prophylactic amino acids were used for renal protection and the treatment had few side effects. Therapy is usually associated with complete or partial remission in 10-30% of patients and duration of therapy response of more than 2 years. In our patient, post therapy images revealed regression of the somatostatin receptor positive disease. We plan to discuss the mechanism of action, evidence-base and efficacy of such therapy in inoperable or metastatic neuroendocrine tumours.