What are the treatment options for mesenteric carcinoid?

Treatment of Mesenteric Carcinoid

Surgical resection of mesenteric carcinoid tumors with extensive mesenteric lymphadenectomy is the primary treatment approach, even in the presence of liver metastases, to prevent progression that would otherwise endanger the small bowel and to potentially improve survival. 1

Pathophysiology and Clinical Importance

Mesenteric carcinoid tumors are typically metastases from small intestinal primary carcinoids. These metastases have significant clinical importance because:

• They cause sclerosis with vascular compromise of the associated small bowel
• They can lead to pain, malabsorption, and even death
• Mesenteric fibrosis (desmoplasia) causes shrinkage and fixation of the mesentery
• Entrapped blood vessels may lead to arterial and venous ischemia 1

Surgical Management

Primary Approach

• Resection of the primary tumor and extensive resection of associated mesenteric lymph nodes 1
• Surgical approach is recommended even in the presence of liver metastases 1
• Resection of mesenteric metastases can dramatically alleviate symptoms and possibly prolong survival 1

Considerations for Mesenteric Fibrosis

• Resection of fibrotic tissue should be considered, even in a metastatic setting, if quality of life is significantly impaired (and reasonable prognosis exists) 1
• Surgery carries risk of short bowel syndrome but may offer symptomatic relief 1
• Despite stage IV disease, surgery remains a valid option but must be agreed upon in a Neuroendocrine Tumor Multidisciplinary Team meeting 1

Medical Management

Somatostatin Analogs

• Octreotide is indicated for symptomatic treatment of patients with metastatic carcinoid tumors 2
• Dosage range of 100 mcg to 600 mcg daily in 2-4 divided doses during initial 2 weeks of therapy 2
• Long-term therapy with somatostatin analogs may help alleviate symptoms and stabilize disease 3

Considerations for Prophylactic Procedures

• If long-term somatostatin analog therapy is anticipated, prophylactic cholecystectomy should be considered during initial surgery due to increased risk of gallstones 1, 4

Multidisciplinary Approach

Nutritional Support

• Early and sustained dietetic input is needed to optimize nutritional status and prevent malnutrition 1
• Long-term home parenteral nutrition is a valid alternative to surgery if surgical risks are too high 1

Pain Management

• Abdominal pain requires close collaboration between pain and palliative care teams and dietitians 1

Special Considerations

Surgical Timing

• Limited emergency small bowel resection for an obstructing carcinoid tumor can be followed at a later date by more definitive elective surgery 1

Debulking Surgery

• Debulking procedures may improve quality of life even when complete resection is not possible 5
• Removal of mesenteric metastases may prevent intestinal obstruction and ischemia 6

Monitoring and Follow-up

• Regular follow-up with CT scans and chromogranin A measurements is recommended 4
• Biochemical monitoring should include 5-HIAA and chromogranin A every 3-6 months 4

Pitfalls and Caveats

• Mesenteric fibrosis is difficult to predict; there is no specific blood marker and imaging may not identify subtle fibrosis 1
• Peptide receptor radionuclide therapy can exacerbate obstruction in 22-30% of patients, requiring steroids and surgery 1
• The impact of somatostatin analogue therapy on fibrotic processes remains unclear 1
• Carcinoid tumors are associated with an increased risk of developing other cancers, so new unexplained symptoms should prompt investigations for other GI cancers 1

By addressing both the primary tumor and mesenteric metastases through aggressive surgical management, patients with mesenteric carcinoid can experience significant symptom relief and potentially improved survival outcomes.