Hepatic artery chemoembolization in 122 patients with metastatic carcinoid tumor: Lessons Learned
Mark Bloomston1, Osama Al-Saif1, Bryan Palmer1, Manisha Shah2, E. Christopher Ellison1, Gregory Guy3, Edward W. Martin1; 1Surgery, Ohio State University, Columbus, OH; 2Medicine, Ohio State University, Columbus, OH; 3Radiology, Ohio State University, Columbus, OH
Background: HACE is the procedure of choice in the management of metastatic carcinoid. We reviewed our experience to identify potential factors that influence response to therapy and survival. Methods: The records of 122 consecutive patients with metastatic carcinoid tumor undergoing HACE between 1992 and 2005 were reviewed. Kaplan-Meier Survival curves were constructed and compared by log-rank analysis. Cox Proportional Hazards Analysis was applied to pre-HACE variables of age, gender, comorbidity, location of primary tumor, resection of primary, tumor differentiation, presence of carcinoid syndrome, presence of extrahepatic disease, and serum pancreastatin ≥5,000 pg/ml to identify factors predictive of decreased survival. Results: Median follow-up for all living patients was 22 months. HACE was undertaken for symptom palliation in 83% or to reduce tumor burden in 17%. Complications occurred in 23% with periprocedural mortality of 5%. Reduction in the size and/or number of lesions by CT was seen in 82% with stabilization of disease in 11% and progression in 6%. Median duration of CT response was 13 months. Significant improvement in symptoms was documented in 80% for a median duration of 11 months. HACE resulted in complete normalization of serum pancreastatin in 14% with a greater than 20% reduction in another 66%. Median overall survival was 33.3 months after HACE with median progression-free survival of 10 months. Post-procedure complication and the lack of symptom improvement, pancreastatin reduction, or CT response were associated with decreased overall survival (p<0.05). Of all pre-HACE variables analyzed, only pancreastatin level ≥5,000 was associated with decreased survival by multivariate analysis. These patients had greater periprocedural mortality and were less likely to experience significant reduction in pancreastatin following HACE (table). Conclusion: This report represents the largest experience with HACE in the management of unresectable carcinoid metastases. Though safe, it should be approached cautiously in patients with significant tumor burden as evidenced by pancreastatin levels ≥5,000. We do not recommend whole-liver embolization in these patients but prefer a staged approach to each side of the liver. HACE offers good control of tumor burden, hormone levels, and symptoms related to carcinoid metastases resulting in long-term survival.
| Pre-HACE pancreastatin (pg/mL) | <5,000 | ≥5,000 |
| Periprocedural mortality | 1.6% | 10.3%* |
| >20% pancreastatin reduction after HACE | 94% | 71%† |
| Median survival (months) | 40.7 | 22.9† |
*p=0.07 vs. pre-HACE pancreastatin <5,000 †p<0.05 vs. pre-HACE pancreastatin <5,000
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