Following or in parallel with tumor resection, medical therapy was administered in five patients, based on clinical experience. Importantly, under treatment with SSAs, the disease stabilized in 3 patients, in one patient the primary tumor, the metastatic lymph MG132 DMSO nodes and the liver metastases regressed and completely disappeared (Figure (Figure11 and Table Table1),1), whereas in another patient, pegylated interferon �� was added to the SSA and induced disease stabilization. In none of the twenty patients with metastatic GCA1 was disease progression observed over a mean follow-up period of 54 mo. Figure 1 Computed tomography and 68Ga-DOTATOC-PET-Computed tomography images before and during treatment with somatostatin analogue (sandostatin LAR 30 mg/mo).
Pathologic uptake in the gastric and hepatic lesion (A + B) adjacent lymphadenopathy and liver lesion … Based on the results of our study, metastatic GCA1 do exist, are extremely rare, and carry a good overall prognosis. Metastatic spread appears to be related to a tumor size of �� 1 cm, and therefore endoscopic ultrasound evaluation is recommended in such patients. Elevated Ki-67 index of tumor proliferation, as well as high serum gastrin levels, represent additional risk factors for metastatic disease. Endoscopic resection and/or subtotal gastrectomy are recommended by the ENETS guidelines in all patients with gastric carcinoids of �� 1 cm; however, in our personal opinion[21], SSAs might be considered as possible treatment in order to lower the elevated gastrin levels, suppress ECL cell hyperplasia, and obviate the need for surgical excisions, particularly in patients with multiple or relapsing tumors, as well as in those with metastatic disease of the liver.
Treatment with SSAs could be theoretically continued as long as gastrin/CGA levels are suppressed, in parallel with disease stabilization observed on regular endoscopic follow-up. However, this approach is still problematic by the lack of controlled trials, the high cost of these drugs as well as the limited accessibility to SSAs in some areas. Although the potential role of SSAs (��cold�� SSAs, as monthly injections, or radioactive ��hot�� SSAs, PRRT) cannot be denied – it remains still controversial and it has to be confirmed in larger studies. Moreover, surgical procedures should be most probably performed only in patients in whom total tumor excision can be expected.
Therefore, in these patients, endoscopic surveillance (as well as repeated oncological surveillance by imaging in metastatic cases) is the most important measure. Prospective multicenter randomised studies, including larger number of patients, would be optimal for definition of the best therapeutic approach, the duration of treatment and its efficacy in terms of long-term Cilengitide survival.