Code	Authors	Title
(B1)	Adler et al.	Combination Therapy with Lithium Chloride and Valproic Acid: A Novel Treatment for Gastrointestinal Neuroendocrine Tumors
(B2)	Gaur et al.	Identification of Activate Signaling Pathways in Gastrointestinal Neuroendocrine Tumors
(B3)	Giandomenico et al.	Novel markers for midgut carcinoid tumors identified by gene expression profiling
(B4)	Greenblatt et al.	Anti-Proliferative Effects of Histone Deacetylase Inhibitors in Carcinoid Cancer Cells
(B5)	Harris et al.	Nuclear Localization of a Long Interspersed Nuclear Element – 1 Protein in Neuroendocrine and Breast Tumors
(B6)	Kunnimalaiyaan et al.	Targeting Glycogen Synthase Kinase-3 (GSK-3) as a Therapy for Neuroendocrine Tumors
(B7)	Leu et al.	GPCR ExtraCellular Loop 2 Provides Human Somatostatin Receptor Subtype Specificity for Antibody Recognition and Elicits Agonist-Like Actions Upon Antibody Binding
(B8)	Nasir et al.	Novel Progression-associated Genes in Primary Pancreatic Endocrine Tumors
(B9)	Pitt et al.	P13 Kinase-Akt Pathway Inhibition Suppresses Carcinoid Tumor Cell Growth and Neuroendocrine Marker Production

B1

Combination Therapy with Lithium Chloride and Valproic Acid:
A Novel Treatment for Gastrointestinal Neuroendocrine Tumors

Joel T. Adler, BA, Muthusamy Kunnimalaiyaan, PhD, and Herbert Chen, MD, FACS
Endocrine Surgery Research Laboratories, Department of Surgery, University of Wisconsin
Corresponding Author: Herbert Chen, MD, FACS H4/750 Clinical Science Center 600 Highland Ave.
Madison, WI 53792 Phone: (608) 263-1387 Fax: (608) 263-7652 Email: chen@surgery.wisc.edu

BACKGROUND: Gastrointestinal (GI) neuroendocrine (NE) tumors frequently present with debilitating symptoms and hepatic metastases. Because conventional cancer treatments are largely ineffective against NE tumors, there is an urgent need for new therapeutic approaches. In the human GI NE cell line BON, valproic acid (VPA) has been shown to inhibit growth, upregulate Notch-1, and decrease NE markers. Moreover, lithium chloride is known to inhibit the growth of NE tumor cells in vitro. We hypothesized that lower-dose combination therapy could achieve similar growth inhibition to that of either drug alone.

METHODS: BON cells were treated with varying combinations of 0-20 mM lithium chloride and 0-3 mM VPA for up to 4 days. Western analysis was used to measure NE tumor markers achaete-scute complex-like 1 (ASCL-1) and chromogranin A (CgA). Growth was measured by a methylthiazolyldiphenyl-tetrazolium bromide (MTT) cellular proliferation assay. Western analysis was used to determine the mechanism of growth regulation.

RESULTS: A dose-dependent decrease in ASCL-1 and CgA with the combination of 20 mM lithium and 1-3 mM VPA was observed. Furthermore, VPA increased the amount of Notch-1 protein. The combination of 20 mM lithium and 2 mM VPA was as effective at growth inhibition as 3 mM VPA at 6 days. The levels of both p21 and p27 increased, suggesting that the growth inhibition is through cell cycle arrest.

CONCLUSIONS: Combination therapy in BON cells with VPA and lithium chloride effectively reduces growth through cell cycle arrest, upregulates Notch-1, and suppresses NE tumor markers. Significantly, these effects were achieved with lower doses when used in combination than when each drug was used alone. With the prospect of equal efficacy and decreased toxicity to patients, this approach may prove useful in the treatment of GI NE tumors.

B2

Identification of Activated Signaling Pathways
in Gastrointestinal Neuroendocrine Tumors

Puja Gaur, George van Buren, Nikolaos A Dallas, Ling Xia, Michael J. Gray, Fan Fan, Shaija Samuel, Misty Woodall, James C. Yao, and Lee M. Ellis. Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77230, USA. pujagaur@hotmail.com.

Background: Neuroendocrine tumors (NETs) are rare tumors that are refractory to chemotherapy. One strategy to treat metastatic or locally advanced NETs is to identify specific pathways that are activated and that can be targeted with drugs currently in development. The purpose of this study was to 1) establish new gastrointestinal (GI) NET cell lines from patient specimens, 2) identify activated molecular pathways involved in tumor progression, and 3) attempt to target a specific pathway.

Methods: NET surgical specimens from four patients with liver metastases [primary ileal carcinoid (n=2), pancreatic NET (n=1), and islet cell (n=1)] were harvested following resection in order to establish new NET cell lines. These cell lines, in addition to two established NET cell lines (BON and CNDT 2.5.5), were systematically evaluated for activation of molecular pathways (Western blot analyses). Initial screening demonstrated activation of Src signaling; thus, cells were treated with PP2, a Src family kinase inhibitor, and cell number was evaluated by MTT assay.

Results: Four new cell lines were established and their NET origin was confirmed by documentation of serotonin secretion and specific NET markers. All cell lines expressed activated Src, mTOR, Akt, and Erk. BON cells were unique in that this was the only NET cell line expressing all studied targets including EGFR, IGF-1R, cMET, FAK, and RON. Treatment with PP2 in all NET cell lines led to a decrease in cell number (p<0.01).

Conclusion: Molecular profiles of multiple GI NET cell lines demonstrated a number of intracellular signaling intermediates that were constitutively activated, including Src, whereas activation of growth factor receptors was rare. Preliminary studies demonstrated that Src inhibition inhibited in vitro growth; therefore, further studies are being done to assess Src inhibition in vivo.

B3

Novel Markers for Midgut Carcinoid Tumors
Identified by Gene Expression Profiling

Justyna Leja1, Ahmed Essaghir2, Kjell Öberg3, Thomas H. Tötterman1, George Vasmatzis4, Magnus Essand1, Jean-Baptiste Demoulin2, Valeria Giandomenico1

Purpose: To identify genes with expression relatively specific to midgut carcinoid cells and genes with differential expression between primary carcinoid tumors and liver metastases.

Experimental Design: Three specimens from primary midgut carcinoids and three from carcinoid liver metastases were analyzed by Affymetrix microarrays. Three specimens from normal mucosa of the ileum and three from scraped off cells of the outer mucosal layer were used as normal tissue reference. Microarray data were validated by quantitative real-time PCR on microdissected tumor cells and by immunohistochemistry.

Results: Significance Analysis of Microarrays (SAM) revealed that 94 genes are significantly higher expressed in tumor than normal material. These include GRIA2, SPOCK1, PNMA2, and SERPINA10, which we believe represent novel markers for carcinoids. Hierarchical clustering revealed high similarity between primary lesions and tumor metastases. However, CXCL14 and NKX2-3 are expressed to a lower level in carcinoid liver metastases than in primary carcinoid tumors and might therefore play a role in tumor progression.A bioinformatics method based on Expressed Sequence Tag (EST) data base analysis of our microarray data identified 50 tissue-specific genes of which GPR112 and OR51E1 encode proteins associated with the plasma membrane and therefore are potential targets for antibody-based diagnosis and therapy.

Conclusions: Our microarray and advanced bioinformatics analyses provide a comprehensive list of genes that are preferentially expressed in midgut carcinoid cells. This list of genes comprises a rich source from which novel therapeutic targets and novel diagnostic serum biomarkers can be selected to guide future research on innovative treatments.

1Division of Clinical Immunology, Rudbeck Laboratory, Uppsala University, Uppsala, SE-75185, Sweden
2Université Catholique de Louvain, de Duve Institute, Brussels, B-1200, Belgium
3Department of Endocrine Oncology, University Hospital, Uppsala, SE-75185, Sweden
4Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA

B4

Anti-Proliferative Effects of
Histone Deacetylase Inhibitors in Carcinoid Cancer Cells

David Yu Greenblatt, MD, Max A. Cayo, BS, Renata Jaskula-Sztul, PhD, Li Ning, MD, Muthusamy Kunnimalaiyaan, PhD, and Herbert Chen, MD, FACS
Institution:Endocrine Surgery Research Laboratories, Department of Surgery and Paul P. Carbone Comprehensive Cancer Center, University of Wisconsin, Madison, WI
Address correspondence to: Herbert Chen, MD, Section of Endocrine Surgery, Department of Surgery, 600 Highland Avenue, Madison, WI 53792-3236; email: chen@surgery.wisc.edu; fax: (608) 263-7652

Background: Carcinoid tumors frequently metastasize and cause debilitating symptoms due to secretion of various hormones. Complete surgical resection is often impossible because of widespread disease, and conventional anticancer therapies such as radiation and chemotherapy are ineffective, indicating the need for new treatments. Histone deacetylase inhibitors (HDAC-Is) increase histoneacetylation, thereby altering chromatin structure and modulating gene transcription. We hypothesized that HDAC-Is may inhibit the growth of carcinoid cancer cells.

Methods: Human gastrointestinal and pulmonary carcinoid cancer cells were treated with two HDAC-Is, valproic acid (VPA) and suberoyl bis-hydroxamic acid (SBHA), and cell proliferation was measured using the MTT assay. The mechanism of growth inhibition was established with Western blotting and flow cytometry. After HDAC-I treatment, changes in Notch1 signaling and tumor marker expression were analyzed with immunoblotting. RNA interference was used to confirm that the effects of HDAC-Is are mediated by Notch1. Finally, a mouse tumor xenograft model was used to assess the anti-proliferative effects of HDAC-I therapy in vivo.

Results: HDAC-I treatment of carcinoid cells resulted in a dose-dependent inhibition of tumor cell growth. Western blot analysis demonstrated an increase in cell cycle inhibitors p21 and p27 and a decrease in cyclin D1 with HDAC-I treatment. Flow cytometry confirmed that the mechanism of the growth inhibition is cell cycle arrest. Furthermore, protein levels of the neuroendocrine tumor marker chromogranin A were suppressed by VPA and SBHA. These effects of HDAC-Is on carcinoid cell growth and tumor marker expression were associated with an increase in Notch1 protein, and transfection with Notch1 small-interfering RNA blocked these effects. Importantly, VPA suppressed growth of carcinoid tumors in vivo.

Conclusions: The HDAC-Is VPA and SBHA activate Notch1 signaling in carcinoid tumor cells and inhibit cancer cell growth by inducing cell cycle arrest. HDAC-Is are a potential new type of treatment for carcinoid tumor disease.

B5

Nuclear Localization of a Long Interspersed Nuclear Element-1 Protein
in Neuroendocrine and Breast Tumors

Chris R. Harris1,2 ,Robin Normart1, Qifeng Yang2,3,4, Elizabeth Stevenson, Bruce G. Haffty2,3, Shridar Ganesan2, Carlos Cordon-Cardo5, Arnold J. Levine2,6, and Laura H. Tang7

Background: Within healthy human somatic cells, retrotransposition by long interspersed nuclear element-1 (also known as LINE-1 or L1) is thought to be held in check by a variety of mechanisms, including DNA methylation, RNAi, and occlusion of L1 proteins from the cell nucleus. We tested for expression of L1-ORF1 protein within various clinical cancer specimens and cancer cell lines.

Methods / Results: Although this protein has previously been thought to be cytoplasmic, we discovered that several human cell lines localize L1-ORF1p to the nucleus and/or to the nucleolus. L1-ORF1p expression was detected in nearly all breast tumors that we examined, and the protein was also present in a high percentage of ileal carcinoids, bladder, and pancreatic neuroendocrine tumors, as well as in a smaller percentage of prostate and colorectal tumors. Tumors generally demonstrated cytoplasmic L1-ORF1p; however, in certain neuroendocrine and breast cancers, L1-ORF1p was nuclear. Patients with breast tumors displaying nuclear L1-ORF1p had a greater incidence of both local recurrence and distal metastases, and also showed poorer overall survival when compared to patients with tumors displaying cytoplasmic L1-ORF1p.

Conclusions: These data suggest that expression of L1-ORF1p is widespread in many cancers, and that redistribution from cytoplasm to nucleus could be an important event during breast and neuroendocrine tumorigenesis. High expression and nuclear localization of L1-ORF1p may result in a higher rate of L1 retrotransposition, which could increase genomic instability.

1The Verto Institute, New Brunswick, NJ
2Cancer Institute of New Jersey, University of Medicine and Dentistry of New Jersey, New Brunswick, NJ USA
3Department of Radiation Oncology, Robert Wood Johnson Medical School, New Brunswick, NJ USA
4Department of Breast Surgery, Qilu Hospital, Shandong University, Jinan 250012, P.R. China.
5Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY USA
6The Institute for Advanced Study, Princeton, NJ USA
7Memorial Sloan Kettering Cancer Center, Department of Pathology, York Ave, New York, NY USA

B6

Targeting Glycogen Synthase Kinase-3 (GSK-3)
As a Therapy for Neuroendocrine Tumors

Muthusamy Kunnimalaiyaan, PhD, Mary A Ndiaye, BS, and Herbert Chen, MD, FACS
Endocrine Surgery Research Laboratory, Department of Surgery, University of Wisconsin
Corresponding Author: Muthusamy Kunnimalaiyaan, Ph.D, K4/623 Clinical Science Center 600 Highland Ave Madison, WI 53792 Phone: (608) 265-3749 Fax: (608) 263-8613 Email: kunni@surgery.wisc.edu

Background: Neuroendocrine tumors (NETs), such as carcinoids and medullary thyroid cancer (MTC), frequently metastasize to the liver resulting in an inoperable condition, which emphasizes the need for development of other forms of therapy. Recently, we have shown that inactivation of glycogen synthase kinase-3β (GSK-3β) in MTC cells by lithium and other GSK-3β inhibitors resulted in a significant reduction in growth, both in vitro and in vivo. However, it is not known if growth inhibition by GSK-3β inactivation can be observed in other NET cells.

Methods: Carcinoid (BON and H727) cells were treated with GSK-3β inhibitors such as lithium, SB216763, and AR4011 or with siRNA against GSK-3, and a standard cellular proliferation assay was performed. Cell lysates were analyzed for chromogranin A (CgA) and serotonin levels. Nude athymic mice were injected with BON cells (106 subcutaneously and tumors were developed. BON xenograft mice were treated with lithium (283mg/Kg Bwt) or saline (control) by intra-peritoneal injection every two days for twenty days. Tumor volume was measured at four day intervals and the percent change was calculated.

Results: Cellular proliferation assay showed a dose dependent decrease in NET cell growth with increasing concentrations of GSK-3β inhibitors. SiRNA against GSK-3 also showed growth reduction compared to non-specific siRNA treatment in carcinoid cells. Lysates from cells treated with siRNA or GSK-3β inhibitors showed significant decreases in CgA and serotonin. A fifty-four percent reduction in tumor volume was observed in lithium treated mice compared to control treatment, indicating that lithium also reduces tumor growth in vivo.

Conclusions: GSK-3 plays a direct role in NET cell proliferation and marker activation. Based on these studies, a clinical trial using lithium, a non-competitive inhibitor of GSK-3 with a well established safety profile, has been initiated at our institution for patients with NET disease.

B7

GPRC ExtraCellular Loop 2 Provides Human Somatostatin Receptor Subtype Specificity
for Antibody Recognition and Elicits Agonist-Like Actions Upon Antibody Binding

Frank Leu and Minesh Nandi
Verto Institute LLC, 195 Little Albany Street, New Brunswick, NJ 08901

Background: The human somatostatin receptors (hSSTR) belong to class A of the seven-transmembrane
G protein–coupled receptors (GPCR), which is rhodopsin-like and includes the β2 adrenergic receptor. hSSTR are primarily known to be coupled to the Gαi protein and have five subtypes, namely subtypes 1, 2, 3, 4 and 5. These membrane receptors are modulated by the brain-gut peptide somatostatin and, upon receptor activation, they negatively regulate neuroendocrine tumor proliferation and small peptides and hormone secretions. In particular, hSSTR subtypes 2 and 5 are overexpressed in neuroendocrine tumors and have been used as both diagnostic and therapeutic targets. The extracellular loop 2 (ECL2) region of GPCR is postulated to work as an inactivating “lid” and can provide the ligand binding specificity among the seven-transmembrane GPCR. This is becoming increasingly clear in light of the β2 adrenergic receptor structures recently solved and reported in Nature and Science (November 2007). According to the β2 adrenergic receptor structure, it is suggestive that the binding of these hSSTR subtype specific antibodies to the ECL2 could destabilize the disulfide bond between ECL2 and transmembrane 3 (TM3), and this disturbance then can transduce to and activate the receptors by disrupting the electrostatic force (ionic lock) that holds the TM3 and TM6 close.

Methods: In our study, to examine hSSTR-ECL2’s importance in receptor activation, we generated subtype specific hSSTR 1, 2, 3, 4 and 5 antibodies against the ECL2 region.

Results: Subsequently the anti-hSSTR2, 3 and 5 antibody binding resulted in agonist-like responses in the neuroendocrine tumor BON cells, such as cellular growth inhibition (MTS assay), cell cycle arrest (Flow cytometry using the propidium iodide DNA stain), inhibition of serotonin release (Serotonin EIA) and decrease in the cAMP accumulation (Perkin Elmer’s Lance kit).

Conlusions: Collectively, the abovementioned results suggest that anti-hSSTR antibodies are agonist-like as a result of ECL2 binding.

B8

Novel Progression-associated Genes
in Primary Pancreatic Endocrine Tumors

Aejaz Nasir, Susan M McCarthy, Emily Zeringer*, Gregory C Bloom, Steven Eschrich, Dung-Tsa Chen, Nancy M Gardner, Mike Gruidl, Nelly-Adriana T Nasir, Jonathan Strosberg, Pamela Hodul, Steven A Enkemann, Deepak Agrawal, Eric Blair*, Domenico Coppola, Mokenge P Malafa, Timothy J Yeatman, Larry K Kvols.
Department of Interdisciplinary Oncology, Divisions of Anatomic Pathology, Neuroendocrine Cancer Research, GI Oncology, Molecular Oncology, Biostatistics & Bioinformatics, Moffitt Cancer Center & Research Institute, Tampa, FL, USA. *Applied Biosystems, Inc., USA

Background: Pancreatic endocrine tumors/carcinomas (PETs/PECAs) are clinically challenging neoplasms. Once metastatic, they result in significant drop in patient survival. Therefore, an assay based on progression-associated genes may have significant prognostic and therapeutic implications in personalized management of these patients.

Methods: We selected 6 frozen metastatic-primary (MP)-PECAs from 6 patients (mean age 59 years, 3/3 M/F), 5 frozen non-metastatic-primary (NMP)-PETS from 5 other patients (mean age 66 years, 3/2 M/F). All tumors were macro-dissected to achieve 80-98% tumor enrichment. The tumor RNA samples were run on Affymetrix U133 plus 2.0 chip. The data were RMA normalized. The genes differentially expressed between MP-PECAs and NMP-PETs were identified by t-test. ‘Candidate-progression-genes’ were selected by considering p-values, fold change, gene function/class, pathway analysis using MetacoreTMfrom GeneGo and extensive literature search. RNA was extracted from independent test sets of archival PETs/PECAs using ‘RecoverAll’ kit (AB). Validation of microarray data was based on: A) Immunohistochemistry and B) Real-time-PCR using TaqMan low-density arrays. After normalizing with 3 endogenous control genes specific for PETs/PECAs, the real-time-PCR data were analyzed using SDS 2.3 software.

Results: 54 transcripts were differentially expressed between MP-PECAs and NMP-PETs, using p-value <0.01 and fold-change values >1.2/>1.5/>2/>4 (54/25/10/1 gene respectively). Among these CD24-antigen, insulin-receptor, SERPIN A1, SMURF1 and RNF43 were notably upregulated, while palladin, protocadherin 9, RUNX1T1, ST14 and PDGFRL were downregulated. Based on validation of a number of our novel candidate-progression-genes on the original frozen and independent test sets of archival MP-PECAs and NMP-PETs, we are developing a Real-time-PCR-based ‘PET progression assay.
Conclusion: Using gene expression profiling on unique tumor sets, we have identified a novel set of genes that may predict progression in PETs/PECAs based on a Real-time-PCR-based ‘PET progression assay. Such assay will offer potential prognostic and therapeutic utility as a part of ‘personalized management’ of PET/PECA patients.

B9

PI3 Kinase-Akt Pathway Inhibition Suppresses Carcinoid Tumor Cell Growth and Neuroendocrine Marker Production

Susan C. Pitt, MD, Muthusamy Kunnimalaiyaan, PhD, and Herbert Chen, MD
Department of Surgery, University of Wisconsin, Endocrine Surgery Research Laboratory, 600 Highland Avenue, CSC H4/750, Madison, WI 53792

Background: Aberrant activation of the PI3 Kinase-Akt pathway contributes to tumorigenesis by promoting tumor cell proliferation while suppressing apoptosis. In human carcinoid tumors, we have previously shown that various signal transduction pathways regulate cellular differentiation, growth, and neuroendocrine (NE) marker production. In addition, human carcinoid tumor cells are known to express endogenously high levels of active, phosphorylated Akt. Therefore, we hypothesized that inhibition of the PI3 Kinase-Akt pathway would result in the suppression of carcinoid tumor cell growth and NE marker production.

Methods: Human gastrointestinal (GI) carcinoid BON cells were treated with the PI3 kinase inhibitor LY294002 (0-100μM) or solvent (DMSO) for six days, and cellular growth was measured by MTT assay. Whole cell extracts were isolated from BON cells after treatment with the same concentrations of LY294002 for a two day time period. Western analyses were performed for active, phosphorylated Akt, total Akt, and the NE markers human achaete-scute homolog1 (ASCL1) and chromogranin A (CgA).

Results: Treatment of BON cells with LY294002 led to a significant dose-dependent decrease in tumor cell proliferation (76.1%). We also observed a dose-dependent reduction in the levels of the active, phosphorylated Akt, illustrating successful inhibition of the PI3 Kinase-Akt pathway. No effect was seen on total Akt. Furthermore, LY294002 treatment diminished ASCL1 and CgA expression proportional to the degree of Akt inhibition.
Conclusion: PI3 Kinase-Akt pathway inhibition by LY294002 suppresses human carcinoid tumor cell growth and NE marker production in vitro. Moreover, activation of PI3 Kinase-Akt signaling appears to play an essential role in both carcinoid tumor cell survival and NE hormone generation. As a result, the development of novel therapeutic interventions targeting components of this critical signal transduction pathway may enhance the treatment and palliation of patients with carcinoid tumors.

Code	Authors	Title
(C1)	Adler et al.	Isolated Adrenal Mass in Patients with History of Cancer: Remember Pheochromocytoma
(C2)	Anthony et al.	Phase II Open-Label Clinical Trial of Vatalanib (PTK/ZK) in Patients with Progressive Neuroendocrine Cancer
(C3)	Arbogast et al.	Retrospective Review of Clinical Response of Metastatic Neuroendocrine Tumors to Treatment with Streptozocin/Capecitabine
(C4)	Christante et al.	Hepatic Artery Chemoinfusion with Embolization for Neuroendocrine Cancer with Progressive Hepatic Metastases Despite Octreotide Therapy
(C5)	Coppola et al.	Activation of the Serine/Threonine Protein Kinase AKT in Neuroendocrine Tumors of the Gastrointestinal Tract
(C6)	Cundiff et al.	Acute Decreases in Plasma Octreotide Levels in Carcinoid Patients Receiving Chronic Octreotide LAR
(C7)	Dagohoy et al.	Population Based Study of Islet Cell Carcinoma
(C8)	Frauenhoffer et al.	Efficacy of Temozolomide-Based Therapy in Neuroendocrine Tumors
(C9)	Hallenbeck et al.	Pharmacokinetics of Intravenously Administered SVV-001 (NTX-010) in a Phase I Trial of Patients with Solid Tumors of Neuroendocrine Differentiation
(C10)	Hallenbeck et al.	Phase I Trial of Seneca Valley Virus (NTX -010), A Newly Discovered Systemically Deliverable Oncolytic Picornavirus, in Patients with Solid Tumors with Neuroendocrine Features
(C11)	Jacobs et al.	mTOR Inhibition with RAD001 Among Patients with Refractory Hypoglycemia Due to Advanced Malignant Insulinomas
(C12)	Johnson et al.	Whole Blood “Platelet Serotonin” Compared with Urine 5 Hydroxyindole Acetate in Carcinoid Syndrome
(C13)	Lesage et al.	Assessment of the Effect of Lanreotide Autogel® on Tumor Progression-free Survival in Patients with Non-Functioning Entero-Pancreatic Endocrine Tumor
(C14)	Lyons, III et al.	Metastatic Carcinoid Causing Encasement of the Mesenteric Vasculature Should Not Preclude Cytoreduction
(C15)	Lyons, III et al.	Application of Sentinel Lymph Node Mapping in Abdominal Carcinoid Tumors
(C16)	Mares et al.	One Hundred Years After “Carcinoid” : Epidemiology of and Prognostic Factors for Neuroendocrine Tumors in 35,825 Cases in the United States
(C17)	Michael et al.	Phase I Trial of 90Y-DOTA-tyr3 – Octreotide in Children and Young Adults with Neuroendocrine and Other Somatostatin Receptor Positive Solid Tumors
(C18)	Phan et al.	Final Results of a Randomized Phase II Study of Depot Octreotide with Bevacizumab and PEG Interferon α-2b
(C19)	Pinchot et al.	ACTH-Producing Pituitary Carcinoma with Refractory Cushing’s Disease and Hepatic Metastases: A Thorough Review of the World Literature
(C20)	Pingpank et al.	Impact of High-Dose Melphalan (MEL) Administered via Hepatic Arterial Infusion for Patients with Unresectable Hepatic Metastases from Neuroendocrine Tumors (MNET)
(C21)	Ruutiainen et al.	Chemoembolization and Bland Embolization of Neuroendocrine Tumor
(C22)	Ryan et al.	Assessment of Reorganized Healthcare Delivery for Neuroendocrine Tumor (NET) Patients in the Post-Katrina Era
(C23)	Shafir et al.	Prognostic Value of Expression of Vascular Growth Factors in Carcinoid Disease
(C24)	Strosberg et al.	Survival Analysis of 90 Metastatic Pancreatic Endocrine Carcinomas
(C25)	Strosberg et al.	Clinicopathologic Analysis of Well, Moderately and Poorly-differentiated Metastatic Gastroenteropancreatic Neuroendocrine Tumors (GEP-NETs)
(C26)	Strosberg et al.	Survival Analysis of 146 Metastatic Neuroendocrine Carcinomas of the Small Intestine and Proximal Colon (Mid-Gut Carcinoids)
(C27)	Withdrawn	Withdrawn
(C28)	Zanzi et al.	Experience with PET F-18-F-DOPA for Imaging of Neuroendocrine Tumors

C1

Isolated Adrenal Mass in Patients with History of Cancer:
Remember Pheochromocyta

Joel T. Adler, BA, Eberhard Mack, MD, FACS, and Herbert Chen, MD, FACS
Section of Endocrine Surgery, Department of Surgery, University of Wisconsin

Background: The adrenal gland has the highest rate of metastasis for any organ. With a history of cancer, an isolated adrenal mass is usually thought to be a metastasis. While a hormonal workup to rule out a functional tumor is recommended, some question its yield. This study was conducted to determine the incidence of functional adrenal lesions in this patient population.

Methods: At a single institution, there were 115 patients with an isolated adrenal mass who underwent adrenalectomy. Patient records were retrospectively analyzed for history of cancer, type of adrenal lesion, and other diagnostic parameters.

Results: Thirty-three (29%) patients had a history of cancer. There were 20 (61%) males and 13 (39%) females with a mean age of 58±2 years. 20 (61%) had adrenal metastases, 8 (24%) had pheochromocytomas, and 5 (15%) had adenomas unrelated to previous cancers. Hypertension was the most common presenting symptom associated with pheochromocytoma (p = 0.002), and both renal cell carcinoma and non-small cell lung cancer were associated with metastatic lesions (p = 0.01). Compared to metastases, pheochromocytoma was associated with a smaller size on computed tomography (CT) scan (2.9±0.2 cm vs. 6.1±0.9 cm, p = 0.003). All pheochromocytomas were diagnosed pre-operatively and given adequate alpha blockade.

Conclusions: Nearly 1 in 4 isolated adrenal masses in patients with a history of cancer were found to be pheochromocytomas. Combined with an ambiguous clinical presentation, the high incidence of pheochromocytoma in this series encourages a thorough workup in these patients. The potential dangers of intervention in this setting are grave; thus, in patients with an isolated adrenal mass and history of cancer… remember pheochromocytoma.

C2

Phase II Open-Label Clinical Trial of Vatalanib (PTK/ZK)
in Patients with Progressive Neuroendocrine Cancer

Lowell Anthony, Maria Chester, Stacy Michael, Thomas O'Dorisio, Sue O'Dorisio

Background: Vatalanib inhibits vascular endothelial growth factor receptor (VEGFR) by binding to the intracellular kinase domain of all 3 VEGFRs. Neuroendocrine tumors (NETs) express VEGF receptors. To determine vatalanib’s efficacy/tolerability in NET patients, a trial was performed.

Methods: Eligibility criteria included patients with metastatic NE cancer and had rising biochemical markers on somatostatin analogs. Eligible patients had measurable lesions, KPS > 60%, normal hematologic, renal and hepatic functions. Patients on octreotide therapy were on stable LAR doses (≤ 30mg/month). Initial dosing of vatalanib was 1,250 mg daily. Biochemical responses within 90 days were the primary response criteria. Secondary endpoints included changes in partial responses and safety.

Results: Sixteen patients were enrolled between 5/20/05 to 9/24/07. Ten patients are evaluable for efficacy and 15 patients are evaluable for safety. One patient continues on therapy 15 months after study entry. One patient withdrew consent; 1 patient died of disease within 5 days of study entry; 1 patient was allergic to vatalanib. Four patients required a 10-28 day discontinuation for rising SGOT/SGPT, alkaline phosphatase and Grade2 proteinuria. Resumption of vatalanib at 1,000 mg daily was well tolerated in 1 pt and 750 mg in another. One patient developed carcinoid crises with fever, flushing, rising 5-HIAA accompanied by Grade 2 proteinuria. Grade 1 nausea occurred in 14 patients with antiemetics required for 2 pts. Divided vatalanib dosing resulted in less nausea in these 2 patients. A partial (>50% decrease in 5-HIAA) biochemical response was observed in 3 patients. The observed radiographic (CT scans) and scintigraphic (OctreoScan®) responses in 10 patients have shown progressive disease in 1 and stable/minimal response in 9. Accrual continues.

Conclusions: Vatalanib is well tolerated in the majority of patients and results in a 30% biochemical partial response rate in NET patients with rising biochemical markers on stable somatostatin analog therapy.

C3

Retrospective Review of Clinical Response of Metastatic Neuroendocrine
Tumors to Treatment with Streptozocin/Capecitabine.

Daria Arbogast, RN, CNP, MSN, AOCN, APRN-BC, Manisha H. Shah, M.D.

Background: Cytotoxic chemotherapy has very limited role in controlling well/moderately differentiated neuroendocrine carcinomas (NEC). Response rates of streptozocin and 5-flurouracil chemotherapy in NEC is typically less than 10%. Capecitabine is oral pro-drug for 5-FU but its response in NEC is unknown.

Methods: Retrospective review of 12 patients with progressive metastatic NEC from 2004-2007 treated with streptozocin 400mg/m2 IV weekly on days 1, 8, 15, and 22 and capecitabine 1200mg/m2 orally in divided doses administered days 1-14 of 28 day cycle. Responses assessed with CT/MRI imaging and tumor markers levels.

Results: Among 12 patients, median age was 46 (36-68, range) with ECOG PS of 0-2. Primary tumor was in pancreas (n=7) small bowel (n=3) but all pts had liver metastasis. Five pts had concurrent octreotide therapy. Total of 68 cycles with median of 4 (range, 1-14) were administered. Grade 3 memory/ataxia was seen in 1 pt that reversed fully upon discontinuation of therapy. Common grade 1-2 AEs included nausea, fatigue, dysgusia and handfoot syndrome. Among nine response-assessable pts, three (33%) had minor response (23-30% reduction in sum of longest diameter of index lesions), five (55%) had stable disease and one had progression (11%). All pts with SD or MR also showed improvement in cancer related symptoms. Among 8 marker assessable pts, 6 had decreased peptide markers, range 24 to 81% reduction.

Conclusion: Combination streptozocin/capecitabine is well tolerated in patients with progressive metastatic carcinoid/islet cell tumors and results in controlling tumor burden, tumor markers and cancer-related symptoms. Given the encouraging anti-tumor activity, this combination therapy should be tested in a phase II clinical trial.

C4

Hepatic Artery Chemoinfusion with Embolization for Neuroendocrine Cancer
With Progressive Hepatic Metastases Despite Octreotide Therapy

Dara Christante, MD, SJ Pommier, PhD, Babak Givi, MD, R Pommier, MD

Background: Hepatic metastases from neuroendocrine cancer dramatically reduce survival. Therefore, these metastases represent important targets for intervention. An optimal approach to hepatic metastases has been difficult to define and the advent of octreotide alters the interpretation of earlier therapeutic interventions. We hypothesize that our combination of hepatic artery chemoinfusion with embolization provides clinical benefit to patients not amenable to cytoreduction who are already receiving maximized octreotide therapy.

Methods: Patients with a neuroendocrine cancer and hepatic metastasis were treated with hepatic artery chemoinfusion and embolization when they demonstrated radiological hepatic progression despite octreotide therapy. The protocol entailed four monthly 5-day cycles of 5-fluorouracil via hepatic artery infusion with embolization after the final 2 cycles. Patients were excluded from embolization if they had overwhelming liver tumor burden. Response was defined as radiological regression on CT or symptomatic improvement. Progression-free and disease-specific survival rates were calculated using the Kaplan-Meier method.
Results: Seventy-seven patients were treated with 13 receiving only chemoinfusion. Median follow-up time from the date of diagnosis was 57 months. Thirty-day mortality was 6.5%. Regression was observed in 58% and stabilization in 24%, for an overall response rate of 82%. Median progression-free survival was 19 months. Median disease-specific survival from the date of diagnosis was 74 months and 34 months from the first treatment. One-year survival from the initial therapy was 78%, 2-year survival was 62% and 5-year survival was 24%. Overall disease-specific survival from the date of diagnosis was 88% at 2 years and 59% at 5 years.

Conclusions: This protocol yielded over 2.5 years of post-treatment survival for the majority and 5 years of survival for nearly a quarter of patients who had progression of extensive hepatic disease despite octreotide. Combining chemoinfusion with embolization offers a high probability of clinical benefit to patients who otherwise have severely limited therapeutic options.

C5

Activation of the Serine Thronine Protein Kinase AKT
in Neurendocrine Tumors of the Gastrointestinal Tract

Ghayouri Masoumeh, M.D. (1); Farah Khalil, M.D.; David Boulware, M.S. (3); Aejaz Nasir, M.D. (1,2); Barbara Centeno, M.D.; Mokenge Malafa, M.D. (2); Jonathan Strosberg, M.D. (2); Larry Kvols, M.D. (2); Domenico Coppola, M.D. (1,2)

Background: AKT has been identified as a major regulator of cell proliferation, tumorigenesis and regulator of apoptosis. In this study, we evaluated the incidence of AKT activation in a subset of neuroendocrine tumors (NET) and its correlation to clinical pathological parameters.

Methods: A subset of 46 NET of the gastrointestinal tract was selected for evaluation. The tissue slides were stained with a mouse monoclonal antiphospho-AKT antibody using the avidin-biotin-complex method.

Results: The patients, 26M and 20F, had an average age of 61 years (range between 34 and 81 years old). Most of the tumors were from the small (18) and large bowel (8), and they included 16 pancreatic neuroendocrine tumors. The tumor size ranged between 11.5 and 0.2 cm (mean 4.5). Seventeen tumors were well differentiated, 15 moderately differentiated, and 14 poorly differentiated. Activation of AKT was detected in 59% (27/46) of cases. In 37% (17/46) of tumors the pAKT was weak, and in 22% (10/46) of them was moderate. Strong pAKT was nor seen in any of the tumor studied, and 41% (19/46) of NET were pAKT negative. No statistical correlation was found between pAKT score and tumor grade (p-value=0.72), tumor size (p-value=0.72), and presence of metastases (p-value=0.52).

Conclusions: This study shows for the first time, increasing activation of AKT in a subset of neuroendocrine tumors of the GI tract. This finding suggests a role of p-AKT in NET carcinogenesis and provides a rationale for using p-AKT inhibitor API-2/triciribine as an alternative adjuvant treatment, in a subset of these tumors.

Divisions of Anatomic Pathology (1),Gastrointestinal Oncology (2), Biostatistics and Drug Discovery (3), Department of Interdisciplinary Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida

C6

Acute Decreases in Plasma Octreotide Levels
in Carcinoid Patients Receiving Chronic Octreotide LAR

Cundiff JA1 Woltering, EA1, Salvo, VA.1, O’Dorisio, TM2, Lyons, J. III1, Li, G3, Zhou, Y3, Go, VLW3, Vinik, AI4, Mamikunian, P5, and Mamikunian, G5

Background: Octreotide is commonly used to treat patients with neuroendocrine tumors (NETS). Previous reports show that octreotide LAR dose and patient body weight affect plasma octreotide concentrations. Historically, nadir plasma octreotide values were approximately 1,250, 2,500, 5,000 and 11,000 pg/ml for LAR doses of 10, 20, 30 and 60 mg/month, respectively. Recently, patients who had exhibited excellent long-term symptom control on stable doses of LAR have become more symptomatic and their plasma octreotide levels have decreased over time.

Hypothesis: We hypothesized that patients currently receiving LAR have lower plasma drug levels than patients receiving the same drug /dose in the past. We also hypothesized that continuous infusion subcutaneous administration of octreotide would correct these low plasma levels.

Methods: From November 2004 until July 2007 trough plasma octreotide levels were determined in 86 patients on long-term octreotide LAR therapy at doses of 30, 60 or 120 mg/month. Changes in plasma drug levels were analyzed over time using random effects models. Nineteen (19) additional patients had drug levels prospectively collected in a controlled manner to confirm our observations.

Results: Current plasma octreotide levels for octreotide LAR doses of 30, 60 and 120 mg/month are approximately 2,200, 5,200 and 6,500 pg/ml respectively, representing a decrease of approximately 50-70% compared to expected plasma levels. The decrease in octreotide levels over time with the 30 and 60 mg/month LAR doses are highly statistically significant (p-value= 0.0067, 0.0149, respectively).

Eight patients were prospectively given 30mg/month of octreotide by continuous subcutaneous infusion and their mean octreotide levels were twice as high as those achieved by identical doses given as LAR.

Conclusions: Current plasma octreotide values are significantly (50-70%) lower than previously reported for 30, 60 and 120 mg/month LAR doses. These decreases in plasma octreotide levels may be responsible for increasing symptoms in NETS patients. Serial plasma octreotide value measurements should be used to determine if increasing symptoms or tumor growth are associated with sub-optimal octreotide levels. Continuous subcutaneous infusions of octreotide will provide significantly higher plasma drug concentrations than those achieved by identical LAR dosing.

The Louisiana State University Health Sciences Center, New Orleans, LA¹, The University of Iowa, Iowa City IO², The University of California Los Angeles, CA³, East Virginia Medical School Norfolk, VA⁴ and Inter Science Institute, Inglewood, CA⁵

C7

Population Based Study of Islet Cell Carcinoma

Cecile Dagohoy, Colleen Leary, Alexandria Phan, Asif Rashid, Manal Hassan,Douglas B. Evans, James C. Yao

Background: In this study, we examine the epidemiology, natural history, and prognostic factors impacting survival duration for islet cell carcinoma using population based registries.

Methods: The Surveillance, Epidemiology, and End Results (SEER) Program database (1973 – 2003 release April 2006) was used to identify cases of islet cell carcinoma using histology codes and tumor site.

Results: 1,310 (619 women and 691 men) cases with a median age of 59 years were identified. The annual age-adjusted incidence in the periods covered by SEER 9 (1973-1991), SEER 13 (1992-1999), and SEER 17 (2000-2003) were 0.16, 0.14, and 0.12 per 100,000 respectively. The estimated 28-year limited duration prevalence on January 1, 2003 in the United States was 2,705 cases. Classified by SEER stage, localized, regional, and distant stages corresponded to 14%, 23% and 54% of cases. The median survival was 38 months. By stage, median survival for patients with localized, regional, and distant disease were 124 (95% CI, 80-168) months, 70 (95% CI, 54 – 86) months, and 23 (95% CI, 20 - 26) months respectively. By multivariate Cox proportional modeling, stage (P < 0.001), primary tumor location (P = .04), and age at diagnosis (P < 0.001) were found to be significant predictors of survival.

Conclusion: Islet cell carcinomas account for approximately 1.3% of cancers arising in the pancreas. Most patients have advanced disease at the time of diagnosis. Despite its reputation of being indolent, survival of patients with advanced disease remains only 2 years. Development of novel therapeutic approaches is needed.

C8

Efficacy of Temozolomide-Based Therapy in Neuroendocrine Tumors

Christine Frauenhoffer, Susanne Hooshmand, Matthew H Kulke, Dana-Farber Cancer Inst., Boston, MA

Background: Temozolomide is an oral alkylating agent that has recently been shown to have activity in neuroendocrine tumors. To better define the antitumor activity of temozolomide, we performed a retrospective analysis of neuroendocrine tumor patients at our institution who had received temozolomide-based therapy.

Methods: Neuroendocrine tumor patients who had received temozolomide-based therapy were identified either through review of clinical trial records or through an IRB-approved protocol in which patients provided informed consent for the use of medical records and clinical outcome data for medical research purposes. Medical records were used to obtain demographic and treatment information. Radiologic response was measured according to RECIST. OS and PFS were calculated using the Kaplan-Meier method.

Results: 101 patients received temozolomide-based therapy. Patient characteristics were as follows: M:F=51:50; median age 57 years; treatment regimen temozolomide/thalidomide (44), temozolomide/bevacizumab (52), temozolomide/xeloda (1), temozolomide alone (4); median time from diagnosis of metastatic disease 19.5 mos, prior treatment regimens 0: ³1=44:57. Fifty-three patients had pancreatic neuroendocrine tumors and 44 had carcinoid tumors. No significant differences in tumor response rates were observed based on type of temozolomide regimen or whether the patients had received treatment as part of one of the formal, prospective studies. Prior systemic treatment also did not appear to significantly influence overall response rates. 18/53 (34%) patients with pancreatic neuroendocrine tumors experienced partial responses to therapy, 1/44 (2%) patients with carcinoid experienced a tumor response, and 1/4 (25%) patients with pheochromocytoma/paraganglioma responded to treatment. Median progression-free and overall survival times were 9 months and 23.6 months, respectively, in pancreatic neuroendocrine tumor patients receiving temozolomide. In the treated carcinoid patients, progression-free survival was 7.25 months and median overall survival was 18 months.

Conclusion: Temozolomide is active in pancreatic neuroendocrine tumors but appears to have less activity in carcinoid tumors.

C9

Pharmacokinetics of Intravenously Administered SVV-001 (NTX-010)
in a Phase I Trial of Patients with Solid Tumors of Neuroendocrine Differentiation

Kevin Burroughs2, Seshidhar Reddy2 Charles M. Rudin1, John R. Neefe2, Lawrence Garbo3, Joe Stephenson3, David Loesch3, Daniel Von Hoff3, David Smith3, Donald Richards3, Paul Conkling3, Carlos Alemany3, Barbara Coleman1, and Paul Hallenbeck2

Background: Seneca Valley Virus (SVV-001/NTX-010) is a newly discovered, replication-competent picornavirus with natural oncolytic selectivity towards human tumor cells of neuroendocrine differentiation, including small cell lung cancer, carcinoid and pediatric solid tumors.

Methods: Neotropix initiated a Phase 1 dose-escalation study in May, 2006, for patients with solid tumors with neuroendocrine features. Virus was administered as a single intravenous infusion over one hour. Five dose levels were planned at log increments from 107 to 1011 vector particles/kg. The objective of the trial was to determine a recommended dose for phase 2. As part of this trial, viral kinetics in serum and in four other compartments—urine, stool, sputum and nasal swab--and neutralizing antibodies in serum were monitored to assess NTX-010 replication and clearance and host immunity to the virus. Viral load in serum was monitored using a cell-based infectivity assay and a quantitative real-time RT-PCR assay. Anti-viral host immunity was monitored in serum using a cell-based virus neutralization assay.

Results: Eighteen patients with small cell carcinoma, carcinoid or other neuroendocrine tumors expressing neuroendocrine markers were enrolled. An interim safety analysis was conducted in November, 2007, and these patients form the population for the current report. Varying patterns of serum kinetics of NTX-010 were observed. In all but two patients, NTX-010 was detected in serum with kinetics consistent with viral replication in these patients. All patients followed for at least 30 days cleared virus from all compartments and developed a detectable serum neutralization response to NTX-010 with an observed dose-dependent trend in the rate and amplitude of the response.

Conclusion: Viral kinetics are consistent with NTX-010 replication in most patients with tumors with neuroendocrine features and all patients followed for at least 30 days cleared virus from all compartments. All patients developed high titers of neutralizing antibody.
¹Johns Hopkins University, Baltimore, MD USA
²Neotropix, Inc., Malvern, PA USA

³US Oncology, Houston, TX USA

C10

Phase 1 Trial of Seneca Valley Virus (NTX-010):
A Newly Discovered Systematically Deliverable Oncolytic Picornavirus,
in Patients with Solid Tumors with Neuroendocrine Features

Charles M. Rudin¹, John R. Neefe2, Lawrence Garbo³, Joe Stephenson³, David Loesch³, Daniel Von Hoff³, David Smith³, Donald Richards3, Paul Conkling³, Carlos Alemany³, , Barbara Coleman¹, Kevin Burroughs², Seshidhar Reddy², Paul Hallenbeck²

Background: NTX-010 is a novel replication-competent picornavirus with selective tropism for cancers with neuroendocrine features. Antitumor efficacy from intravenous administration of NTX-010 was demonstrated in 13/13 murine models and no dose limiting toxicity in animals was seen at doses up to 1014 vp/kg.

Methods: Neotropix is conducting a Phase 1 intravenous delivery, dose-escalation study in patients with advanced solid tumors expressing neuroendocrine markers. Dose escalation was planned in log increments from 107 vector particles/kg to 1011.

Results: Dose escalation progressed such that 3 patients were treated at dose level 4 (1010) without dose limiting toxicity. No therapy-related AEs above grade 2 were observed. Six patients that had recurrent and widely metastatic small cell carcinoma and life expectancy of ≥ 3 months were treated at 107 vector particles/kg. Three/six small cell patients died in 120 days or less with far-advanced disease as documented at autopsy while one patient is stable 6 months after treatment. Twelve patients that had carcinoid or neuroendocrine-marker-positive tumors other than small cell and had life expectancy of ≥ 6 months were treated from doses ranging from 107 vector particles/kg to 1010. The non–small-cell patients, tolerated therapy well. While no patients had objective evidence of tumor response by the standard criteria 6/12 had signs of clinical benefit including improved symptoms, prolonged stability of good performance status or work status, or improvement in biochemical markers.

Conclusions: NTX-010 is a novel first-in-class anticancer virus with selective tropism for tumors with neuroendocrine features. Safety and signs of clinical benefit in the non-small cell group encourage further investigation of the possibility that objective response will occur at the higher dose levels. Small cell patients may have to be treated at an earlier time in their course and as anticipated higher doses are likely required to elicit objective responses.
¹Johns Hopkins University, Baltimore, MD USA
²Neotropix, Inc., Malvern, PA USA

³US Oncology, Houston, TX USA

C11

mTOR Inhibition With RAD001 Among Patients
with Refractory Hypoglycemia Due to Advanced Malignant Insulinomas

Carmen Jacobs, Mathew Kulke, Emily K. Bergsland, James C. Yao

Purpose: Malignant insulinomas are rare endocrine neoplasms of the pancreas. While progress has been made in the diagnosis and management of patients with localized insulinomas, management of refractory hypoglycemia among patients with unresectable malignant disease remains a challenge.

Method: We examined the clinical course and biochemical parameters of 4 patients with malignant insulinoma and refractory hypoglycemia treated with oral mTOR inhibitor RAD001 at 10 mg per day. Patients 1 and 2 were treated on a single center phase II study of RAD001 and octreotide LAR in advanced low grade neuroendocrine tumors. Patients 3 and 4 were treated on a multi-center phase II study of RAD001 in advanced pancreatic neuroendocrine tumors after failure of chemotherapy.

Results: Three patients achieved complete resolution of hypoglycemic symptoms. The fourth achieved significant improvements manifested by decreased requirements for dextrose infusion. This was associated with a decrease in plasma insulin and an increase in glucose/insulin ratio at week-4 in all patients. However, glucose control continued despite an increase in plasma insulin at week-12 in patients 3 and 4. By RECIST criteria, there were 2 PR, and 2 SD. Progression-free survival duration were 16 months, 17+ months, 6+ months, and 6+ months. Treatment was well tolerated. Grade 3/4 adverse events included a single grade 3 oral apthous ulceration. In addition, 1 patient had grade 2 pneumonitis that improved following a short course of corticosteroid.

Conclusion: In summary, mTOR inhibition with RAD001 in patients with malignant insulinoma and refractory hypoglycemia resulted in improvements in glycemic control and evidence of anti-tumor activity.

C12

Whole Blood "Platelet Serontonin" compared with
Urine 5-Hydroxyindole Acetate in Carcinoid Syndrome

Lambro Johnson, Brett McWhinney and Alan Clague. Pathology Queensland, Royal Brisbane Hospital, Brisbane, Queensland, Australia 4029

Background: Despite earlier evidence1 for the greater diagnostic utility of platelet serotonin (plt5-HT) over urine 5-hydroxyindoleacetate (u5-HIAA) in carcinoid syndrome, the test is not routinely used, possibly due to technical difficulties. We developed a robust assay for serotonin in whole blood (related to the platelet count as "apparent platelet serotonin")2 which facilitates routine testing, with over 3800 assays performed.

The aim was to o compare plt5-HT with u5-HIAA in carcinoid syndrome.

Methods: plt5-HT was assayed in acetonitrile extracts of whole blood by RP-HPLC/ECD2; u5-HIAA in 24 hr collections by RP-HPLC/fluorimetry. Paired results were analyzed using a statistical procedure which only requires clinical characterization of patients with positive results.3

Results: 326 patients (new and reassessed following treatment) had both tests performed. 236 were below both cutoffs (-/-) and were not investigated further. Of 90 patients positive by one or both tests (+/-, -/+ or +/+), 55 were classified "carcinoid" on histological or historical criteria, 35/90 as "non-carcinoid". 51 carcinoids were positive by plt5-HT but only 40 by u5-HIAA; the false positives were 11 and 24 respectively. The two tests gave contradictory results for 19 carcinoids and for 35 non-carcinoids, with elevated plt5-HT/normal u5-HIAA (+/-) more often associated with carcinoids (P<0.02, chi-square 3), and normal plt5-HT/elevated u5-HIAA (-/+) with non-carcinoids (P<0.04). In 6 carcinoids highly abnormal plt5-HT levels were associated with normal u5-HIAA, whereas only 2 carcinoids with normal plt5-HT had significantly elevated u5-HIAA. No non-carcinoids were positive by both tests.

Conclusions: Our results are consistent with the original studies1 showing plt5-HT to be more sensitive, specific, and convenient than u5-HIAA. Wider application of robust assays may dispel current doubts about the role of platelet serotonin in carcinoid syndrome, and clarify the significance of some surprising discrepancies between the two tests in assessing serotonin secretion by these tumours.

Meijer WG, Kema IP et al Clin Chem 2000;46:1588-1596

Johnson LA and Clague A Clin Biochem Revs 1999;37:93

Schatzkin A et al Am J Epidemiol 1987;125:627-678

C13

Assessment of the effect of lanreotide Autogel® on tumor progression-free
Survival in patients with non-functioning entero-pancreatic endocrine tumour

Catherine Lesage ¹, Nilani Liyanage ¹ & Martyn Caplin ² on behalf UK NETS / ENETS ¹Ipsen Research&Development, Paris, France; ²Royal Free Hospital, London, UK

Background: Somatostatin analogs (SSA) are the treatment of choice for symptoms associated with neuroendocrine tumors (NETs) of a carcinoid type, but their anti-tumoral activity and effect on survival have not been fully assessed. The aim was to assess progression free survival (PFS) in patients with low grade NETs comparing high dose Lanreotide Autogel® (lan-ATG) vs. placebo.

Methods: In collaboration with UK NETS and ENETS, a randomized, double-blind, placebocontrolled study of lan-ATG 120mg for 96 weeks is underway in 13 countries to assess its impact on tumor PFS in 200 patients with well or moderately differentiated nonfunctioning entero-pancreatic endocrine tumors. Since prior tumor progression status and previous therapies may influence study outcome, patients are stratified at randomization according to their presence or absence to minimise any imbalance. The primary endpoint is time to either disease progression (using RECIST criteria) or death, occurring within 96 weeks of first study treatment. Two CT scans are made during screening to assess tumor progression, and repeated after 12, 24, 36, 48, 72 & 96 weeks. Secondary endpoints include proportions of patients alive & without progression at 48 & 96 weeks, time to progression, Quality of Life, plasma chromogranin A, safety & pharmacokinetic parameters.

Results: By end November 2007, 51 patients were included in the study in 25 centres. Preliminary baseline demographic data on the first 26 patients (18 males and 8 females with a mean age of 63± 9.52 years) show that 13 tumors originate in pancreas, 5 in midgut, 2 in duodenum, and 6 with unknown primary site. Thus far all patients had stable tumor at entry. Final results are expected in 2011.

Conclusion: This study is designed to provide valuable information about the anti-tumoral activity & effect on survival of lan-ATG.

C14

Metastatic Carcinoid Causing Encasement of the
Mesenteric Vasculature Should Not Preclude Cytoreduction

John M. Lyons, III, Erica Lindholm, Lowell B. Anthony, Yi-Zarn Wang, Eugene A. Woltering, J. Philip Boudreaux, LSU School of Medicine, New Orleans, LA

Background: Malignant tumors encasing the mesenteric vasculature have been previously considered unresectable by traditional surgical standards. We hypothesized that carcinoid tumors with mesenteric vascular encasement (MVE) could be successfully and safely resected in order to maximize surgical cytoreduction in patients with locally advanced disease.

Methods: We reviewed the available medical records of carcinoid patients who underwent cytoreductive surgery from January 2001 to June 2007 by the LSUHSC Neuroendocrine Tumor Group.

Results: 29 cytoreductive operations included surgical decompression of MVE. All (100%) patients who were seen within 90 days of surgery had improvement of some or all of their preoperative symptoms. Mean weight loss following surgery was 12 lbs (range 0-30 lbs). No (0%) patients who were narcotic-free preoperatively required chronic narcotic use following the first postoperative visit. 2 (50%) of 4 patients on preoperative narcotics stopped taking these medications postoperatively. Median follow up time was 246 days (range 15-1303). 3 (10%) postoperative complications required reoperation: 1(4%) wound dehiscence, 1(4%) postoperative bleed, and 1(4%) enterocutaneous fistula. 1(4%) death was observed resulting in an overall survival of 96% at 1 year.

Conclusion: Resection of metastatic carcinoid causing MVE provides improvements in symptoms and an acceptable morbidity and mortality rate. Tumor-derived MVE should be resected when encountered in patients with carcinoid, and the presence of MVE alone should not preclude carcinoid patients from undergoing cytoreductive surgery.

C15

Application of Sentinel Lymph Node Mapping in Abdominal Carcinoid Tumors

John M. Lyons, III, Erica Lindholm, Lowell B. Anthony, J. Philip Boudreaux,
Eugene A. Woltering, Yi-Zarn Wang, LSU School of Medicine, New Orleans, LA

Background: Sentinel lymph node (SLN) sampling is an effective technique to identify metastatic lymph nodes. We hypothesized that sentinel lymph node mapping would improve identification of metastatic lymph nodes in patients with locally advanced carcinoid tumors of the bowel.

Method: Fifteen patients undergoing resection for carcinoid had 5cc of methylene blue dye injected into their subserosal bowel wall peritumorally. Blue nodes were sent to pathology either separately or as part of a larger mass of clinically positive nodes.

Results: Blue sentinel nodes were identified in 13 (87%) of 15 patients. Of these 13, 5 patients. sentinel nodes (38%) were positive for metastasis. 4 (31%) had positive sentinel nodes identified in a lymph node basin that was already considered clinically positive, while 1 patient (7.7%) had a positive sentinel node identified in a basin that was clinically negative. Nine patients were found to have bulky, clinically evident, mesenteric lymph node disease. In eight (89%) of these nine patients, the blue dye was noted to first ravel proximal and distal to the area of injection along the longitudinal axis of the bowel prior to entering a draining mesenteric lymph node basin. All bowel walls that demonstrated longitudinal blue dye spread (100%) were found to have multiple intraluminal tumors, and the longitudinal distance traversed by the blue dye corresponded to the length of bowel grossly involved in the disease process. Using blue dye to demarcate the extent of resection enabled the ileocecal valve (ICV) to be spared in 4 (80%) of 5 patients who had terminal ileal primaries.

Conclusion: This technique may allow surgeons to more accurately gauge the amount of bowel to resect and to better predict which patients do not require ICV resection in cytoreductive operations for carcinoid. Preventing unnecessary resection will likely limit the risk of short gut syndrome that is often associated with extensive surgery. SLN mapping may also provide an alternative explanation for the development of multiple intramural tumors: this may be a result of local advancement following lymph node metastasis rather than the de novo development of multiple primary tumors.

C16

One Hundred Years After “Carcinoid”: Epidemiology of and Prognostic Factors
for Neuroendocrine Tumors in 35,825 Cases in the United States

Jeannette E. Mares, Alexandria Phan, Manal Hassan, Cecile Dagohoy, Colleen Leary, Asif Rashid, Douglas B. Evans, James C. Yao

Purpose: Neuroendocrine tumors (NETs) are considered rare tumors and can produce a variety of hormones. In this study, we examined the epidemiology of and prognostic factors for NETs, since a thorough examination of neither had previously been performed.

Methods: The Surveillance, Epidemiology, and End Results (SEER) Program registries were searched to identify NET cases from 1973 to 2004. Associated population data were used for incidence and prevalence analyses.

Results: We identified 35,618 patients with NETs. We observed a significant increase in the annual age-adjusted incidence of NETs from 1973 (1.09/100,000) to 2004 (5.25/100,000). Using the SEER 9 registry data, we estimated the 29-year limited-duration prevalence of NETs on January 1, 2004, to be 9263. Also, the estimated 29-year limited-duration prevalence in the United States on that date was 103,312 cases (35/100,000). The most common primary tumor site varied by race; with the lung being the most common in white patients, and the rectum being the most common in Asian/Pacific Islander, American Indian/Alaskan Native, and black. Additionally, survival duration varied by histologic grade. In multivariate analysis of patients with well-differentiated to moderately differentiated NETs, disease stage, primary tumor site, histologic grade, sex, race, age, and year of diagnosis were predictors of outcome (P < .001).

Conclusion: We observed increased incidence of NETs and increased survival durations over time, suggesting that NETs are more prevalent than previously reported. Clinicians need to be become familiar with the natural history and patterns of disease progression which are characteristic of these tumors.

C17

Phase I Trial of 90Y-DOTA-tyr3-Octreotide in Children and Young Adults with Neuroendocrine and Other Somatostatin Receptor Positive Solid Tumors

Stacy Michael, ARNP1, Yusef Menda, MD2, Geetika Khanna, MD2, David Bushnell, MD2, Mark Madsen, PhD2, Mary Connally, PhD4, John Babich, PhD5, Thomas O’Dorisio, MD3, and M Sue O’Dorisio, MD, PhD1

Background: Neuroendocrine tumors are considered to be rare in children and young adults. However, metastatic NET was the most common diagnosis in subjects referred to the University of Iowa Children’s Hospital for a Phase I trial of 90Y-DOTA-tyr3-Octreotide.

Methods: The dose/toxicity trial was initiated at 30 mCi/m2 and escalated to 50 mCi/m2 with concomitant Aminosyn II infusion. Subjects received 3 cycles of treatment, 6 weeks apart. Eligibility criteria included: age 2-25 yrs; recurrent or progressive malignancy with at least one Octreoscan+ lesion; bone marrow cellularity >40%; GFR >80 ml/min/m2; no radiation therapy for 3 months; no chemotherapy for 30 days. Incidence and prevalence of NET and neuroblastoma in children and young adults were analyzed from 1973-2004 SEER data base.

Results: Thirteen subjects completed 3 cycles. Diagnoses included gastrinoma (3), foregut carcinoid (3), neuroblastoma (2), paraganglioma (2), MENIIb, anaplastic astrocytoma, and choroid plexus carcinoma. There were no dose limiting toxicities. Five subjects (38%) had a PR; four subjects had a positive response; four subjects had stable disease. Four subjects withdrew from the study after one cycle and had progressive disease within 6 weeks.

Incidence of neuroblastoma in 2004 was 800 while NET was <100. Prevalence of neuroblastoma on 1/1/04 was 500 compared to 6500 NET in the same age group. The most common NET in this age group is appendiceal carcinoid, followed by bronchial carcinoid, and metastatic NET with unknown primary.

Conclusions: The incidence of neuroblastoma is 8 fold higher than NET in children and young adults. On the other hand, the prevalence of NET is more than 10 fold higher than neuroblastoma. Based on intent to treat, 53% of children and young adults with metastatic NET had a positive response to 90Y-DOTA-tyr3-Octreotide and there were no dose limiting toxicities with doses up to 50 mCi/m2.

¹ Departments of Pediatrics; ²Radiology; ³Internal Medicine at the University of Iowa

⁴Boehringer Pharmaceuticals, ⁵Molecular Insight Pharmaceuticals

C18

Final Results of a Randomized Phase II Study

of Depot Octreotide with Bevacizumab and PEG Interferon α-2b.

Alexandria Phan,¹ Paulo M. Hoff,² Chusilp Charnsangavej,³ Sai-Ching J. Yeung,⁴ Kenneth Hess,⁵ Chaan Ng,3 James L. Abbruzzese,1 Jaffer A. Ajani¹, and James C. Yao,¹

Background: Effective systemic therapy for advanced carcinoid is lacking. The combination of bevacizumab (BVZ), and PEG Interferon alpha-2b (PEGI) was evaluated among patients with metastatic or unresectable carcinoid tumors.

44 patients on stable doses of octreotide were randomly assigned to 18 weeks of treatment with BVZ or PEGI. At disease progression (PD) or at the end of 18 weeks (whichever occurred earlier), patients received BVZ plus PEGI until progression. Functional CT scans were performed to measure effect on tumor blood flow.

Results: In the BVZ arm, 4 (18%) achieved confirmed partial response (PR), 17 (77%) had stable disease (SD), and 1 (5%) had PD. In the PEGI arm, 15 (68%) had SD, and 6 (27%) PD. Progression free survival (PFS) rates after 18 weeks of monotherapy were 95% in BVZ versus 68% on the PEGI arm. The overall median PFS for all 44 patients is 63 weeks. Compared to paired baseline measurements on functional CT scans, we observed a 49% (P < 0.01) and 28% (P < 0.01) decrease in tumor blood flow at day-2 and week-18 among patients treated with BVZ. No significant changes in tumor blood flow were observed following PEGI. PEGI treatment was associated with decrease in plasma bFGF (P = 0.04) and increase in plasma IL-18 (P < 0.01). No significant changes in bFGF or IL-18 following treatment with BVZ.

Conclusions: BVZ therapy resulted in objective responses, reduction of tumor blood flow and longer PFS in patients with carcinoid than PEGI.

Departments of Gastrointestinal Medical Oncology,1 Diagnostic Imaging,3 General Internal Medicine, Ambulatory Treatment & Emergency Care4 and Biostatistics and Applied Mathematics,5 The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030; and Centro de Oncologia, Sao Paulo, Brazil2

C19

ACTH-Producing Pituitary Carcinoma with Refractory Cushing’s Disease and
Hepatic Metastases: A Thorough Review of the World Literature

Scott N. Pinchot, MD, Rebecca Sippel, MD, and Herbert Chen, MD, FACS, Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, Madison, WI

Background: Pituitary carcinomas are rare neuroendocrine tumors affecting the adenohypophysis, representing only 0.1-0.2% of all pituitary tumors. The hallmark of these lesions is the demonstration of distant metastatic spread. To date, few well-documented cases have been reported in the literature. We report the case of a fatal pituitary carcinoma evolving within two years from an adrenocorticotrophic hormone (ACTH)-secreting macroadenoma and review the global literature regarding this rare neuroendocrine tumor.

Case Details and Course: A 59-year-old woman presented with complaints of progressive diplopia and fatigue. Evaluation of the patient revealed mild hyperprolactinemia and magnetic resonance imaging (MRI) showed a 2.8cm pituitary mass. The patient underwent endoscopic transnasal resection of the tumor in 2003. Pathologic examination revealed an ACTH-producing pituitary adenoma with extension into the respiratory mucosa. The patient completed a course of external beam radiation and did well for several months. She later presented in early 2004 with elevated urinary cortisol levels suggestive of pituitary Cushing’s disease. A repeat MRI revealed a marked increase in the size of the residual pituitary mass. The patient underwent tumor debulking via a right frontotemporal orbitozygomatic approach with subsequent postoperative stereotactic radiosurgery in late 2004. Despite these procedures, the patient showed rapid local progression of the tumor and refractory Cushing’s disease. Bilateral adrenalectomy was performed several months later to control the patient’s symptoms; intraoperatively, hepatic metastases consistent with pituitary carcinoma were discovered. Ultimately, the patient died from her pituitary carcinoma 27 months after the development of her first neurological symptoms and just 1 month following the development of metastases.

Conclusion: Unlike reports from the literature, the latency period between adenoma and carcinoma was quite abbreviated in our patient (9.5 years vs. 26 months). Additionally, this case represents one of the few well-documented cases in the literature of pituitary carcinoma with refractory Cushing’s disease and the development of hepatic metastases.

C20

Impact of High-Dose Melphalan (MEL) administered via Hepatic Arterial Infusion for Patients with Unresectable Hepatic Metastases from Neuroendocrine Tumors (MNET)

James F. Pingpank, Jr., MD, Richard E. Royal, MD, Steven K. Libutti, MD, Udai S. Kammula, MD, H. Richard Alexander, Jr., MD, Bradford J. Wood, MD, Anthony W. Kam, MD, Susan E. Ohl, RN, BSN, Bryan H. Emery, RN, BSN

Background: Patients with MNET to liver are faced with multiple treatment strategies including resection, ablation, and a variety of regional therapies. Treatment options for patients with diffuse hepatic disease are more limited, however. We present results utilizing high-dose MEL via two generations of hepatic arterial infusion and extracorporeal perfusion for patients with unresectable MNET.

Methods: Between 10/1993 and 7/2007 39 patients with unresectable MNET underwent isolated hepatic perfusion (IHP) with MEL (1-2 mg/kg, n=18) or percutaneous hepatic perfusion (PHP) with Mel (1.5-3.5 mg/kg, n=21). IHP included hepatic isolation at laparotomy with inflow via a cannula in the gastroduodenal artery and outflow via a cannula in the isolated retrohepatic vena cava (IVC). PHP consisted of a 30 minute hepatic artery infusion of melphalan via a percutaneously placed catheter with hepatic venous hemofiltration using a double balloon catheter (Delcath Systems, Inc.) positioned in the retrohepatic IVC. Patients were followed for toxicity, radiographic response, and hepatic progression-free (HPFS) and overall survival (OS). HPFS and OS probabilities were calculated by Kaplan-Meier.

Results: There were 24 males and 15 females (mean age: 50 yr [range: 15-76]) with unresectable MNET (median # metastases: 26 [range: 3-50]; median % liver replaced by tumor: 22). There was 3 operative/treatment-related mortality (2.6%). There were 21 responses in 33 evaluable pts (64%). For the 33 pts with evidence of treatment effect (minor, partial, or complete response), HPFS was 24 months (range: 3-42+). For all treated patients, median OS was 52 months and 5-yr survival was 50%.

Conclusions: IHP and PHP with MEL results in marked tumor regression and prolonged HPFS and OS in patients with high hepatic tumor burden from MNET.

C21

Chemoembolization and Bland Embolization
of Neuroendocrine Tumor Metastases to the Liver^*

Alexander T. Ruutiainen, BA, Michael C. Soulen, MD, Catherine M. Tuite, MD, Timothy W.I. Clark, MD,
Jeffrey I. Mondschein, MD, S. William Stavropoulos, MD, Scott O. Trerotola, MD

Purpose: To assess the toxicity and efficacy of chemoembolization and bland embolization in patients with neuroendocrine tumor metastases to the liver.

Methods: A total of 67 patients underwent 219 embolization procedures: 23 patients received primarily bland embolization with PVA with or without iodized oil and 44 primarily received chemoembolization with cisplatin, doxorubicin, mitomycin-C, iodized oil, and polyvinyl alcohol. Clinical, laboratory, and imaging follow-up was performed 1 month after completion of therapy and every 3 months thereafter. Patients with disease relapse were treated again when feasible. Toxicity was assessed according to National Cancer Institute Common Toxicity Criteria for Adverse Events, version 3.0. Efficacy was assessed by clinical and morphologic response. Time to progression (TTP), time to treatment failure, and survival were estimated by Kaplan–Meier analysis.

Results: Ten of 67 patients (15%) were lost to follow-up. The mortality rate at 30 days was 1.4%. Toxicities of grade 3 or worse in severity occurred after 25% of chemoembolization procedures and 22% of bland embolization procedures (odds ratio, 1.2; 95% CI, 0.4–4.0). Mean length of stay was 1.5 day in both groups. Rates of freedom from progression at 1, 2, and 3 years were 49%, 49%, and 35% after chemoembolization and 0%, 0%, and 0% after bland embolization (log-rank test, P = .16). Among the subgroup with carcinoid tumors, the proportions without progression were 65%, 65%, and 52% after chemoembolization and 0%, 0%, and 0% after bland embolization (log-rank test, P = .08). Patients treated with chemoembolization and bland embolization experienced symptomatic relief for means of 15 and 7.5 months, respectively (P = .14). Survival rates at 1, 3, and 5 years after therapy were 86%, 67%, and 50%, respectively, after chemoembolization and 68%, 46%, and 33%, respectively, after bland embolization (log-rank test, P = .18).

Conclusions: Chemoembolization was not associated with a higher degree of toxicity than bland embolization. Chemoembolization demonstrated trends toward improvement in TTP, symptom control, and survival. Based on these results, a multicenter prospective randomized trial is warranted.

^*This material has been previously published in JVIR 2007 18(7) 847-55 and was presented in an oral format by A.T.R. at the 2006 meeting of the Society of Interventional Radiology in Toronto

C22

Assessment of Reorganized Healthcare Delivery for
Neuroendocrine Tumor (NET) Patients in the Post-Katrina Era

Pamela Ryan, R.N. ¹, Philip Boudreaux, M.D.², Eugene Woltering, M.D.², Yi-Zarn Wang, M.D. ², Leigh Anne Burns, M.S. ², Ann-Porter Uhlhorn, R.N. ¹ Lowell Anthony, M.D. ²

Background: Naturally occurring disasters create societal turmoil forcing change. On 08/29/2005, Hurricane Katrina devastated the U.S. Gulf Coast and resulted in major reorganization of healthcare for NET patients. Ochsner/LSU created a multidisciplinary NET clinic consolidating medical/surgical care from 4 clinic/hospital locations pre-Katrina to 1 post-Katrina. To assess the impact of this change, we hypothesized that patients receiving both pre- and post-Katrina care, would perceive their care as improved post-hurricane.

Methods: To test our hypothesis, a survey method using subjects as their own control, was performed. Inclusion criteria included those patients receiving multi-disciplinary care in both eras. A blinded questionnaire using the Likert scale was created to evaluate change in 8 areas. This Likert scale ranged from 1 to 5 (1=excellent, 2=very good, 3=good, 4= fair, 5=poor). Means, standard deviations (S.D.) and differences were calculated. Student’s two-tail t-Test was used to establish statistical significance (p<0.05).

Results: Twenty patients met the inclusion criteria with 15 surveys analyzed:

Subject	Era	Mean		S. D.	Difference	p value
		(N=15)			Pre-Post	Pre vs Post
1. Scheduling	Pre-K	1.6	0.83		0.33	0.136
	Post-K	1.3	0.46
2. Timely Apointment*	Pre-K	1.7	0.82		0.40	0.028
	Post-K	1.3	0.46
3. Time for Opinions	Pre-K	1.5	0.99		0.27	0.104
	Post-K	1.3	0.59
4. Registration Process*	Pre-K	2.2	1.37		0.86	0.034
	Post-K	1.4	0.50
5. Access to Location*	Pre-K	2.5	1.13		1.07	0.010
	Post-K	1.5	0.74
6. Overall Clinic Experience*	Pre-K	1.9	1.10		0.87	0.010
	Post-K	1.1	0.26
7. Response to Phone Inquiries*	Pre-K	2.0	1.07		0.60	0.033
	Post-K	1.4	0.74
8. Time spent in clinic	Pre-K	1.7	0.91		0.38	0.068
	Post-K	1.3	0.62

                 _^*p<0.05

Conclusions: NET patients perceived improvement in their care favoring the post-Katrina model with statistical significance reached in 5 (timely appointments, registration process, access to location, overall clinic experience, and phone inquiries) of the 8 areas queried.

¹Ochsner Medical Center-Kenner, Kenner, LA, 70065

²LSUHSC New Orleans, Kenner LA 70065

C23

Prognostic Value of Expression of
Vascular Growth Factors in Carcinoid Disease
Shafir, M.K. M.D., Warner, R.P., M.D.

Background: Vascular growth factors such as VEGF (vascular endothelial growth factor ) and angiogenesis/CD31 have been reported as unfavorable criteria in biological behaviour of malignant tumors by promoting progression and metastasis. The formation of capillary neovascularization in the tumors facilitates the local tumor growth. Thus, shorter disease free survival has been inferred for a variety of malignancies.

Objectives: the purpose of this study is to determine the value of VEGF and angiogenesis/CD31 in carcinoid disease and attempt to correlate their expression with clinical outcomes.

Methods: 22 patients with carcinoids were studied. There were 12 females and 10 males, age ranging from 30 to 78 ( mean: 52 ). All patients were operated on by one surgeon and surgical specimens of primary tumors, metastatic lymph nodes and/or liver metastases were submitted fresh for evaluation of expression of VEGF and CD/31. Postoperatively long acting octreotide, chemotherapy and 90Yttrium were administered according to the treating physician’s decision based on the individual findings.

Results: Follow up mean of 16 months, 13 months for patients with objective response, 16 months for patients with stable disease and 19 months for patients with progressive disease. VEGF was found to be overexpressed in 38% of patients with objective response vs. 63% in patients with stable disease and 32% of patients with progressive disease. Angiogenesis/CD31 was overexpressed in 40% of patients with objective response vs 35% of patients with stable disease and 44% of patients with progressive disease.

Conclusion: Our series does not demonstrate a clear correlation between prognosis and clinical behaviour. In contrast with reports of higher overexpression of VEGF andCD31 associated with poorer outcome in several other malignancies, in our limited study we could not reach the same conclusion. Further studies with larger number of patients seems warranted.

C24

Survival Analysis of 90 Metastatic Pancreatic Endocrine Carcinomas

Jonathan Strosberg MD,Nancy Gardner PhD, Larry Kvols MD, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida

Background: Pancreatic endocrine carcinomas (PECAs) are uncommon, with an annual incidence of less than 1 per 100,000. Approximately half are metastatic at initial diagnosis. Studies of chemotherapy and hepatic artery embolization have described median survival durations of approximately 2-3 years from onset of treatment. Overall survival from time of diagnosis of metastases has never been reported in a large cohort of patients.

Methods: We evaluated all cases of metastatic PECAs seen at the H. Lee Moffitt Cancer Center between the years 1999 and 2003, measuring survival duration from time of diagnosis of metastatic disease. Poorly differentiated (anaplastic) carcinomas were excluded. Kaplan-Meier estimates were used to calculate overall survival (median and 5-year), with log-rank analysis of clinical, pathologic and demographic prognostic factors.

Results: Ninety cases of metastatic PECAs were identified. The median overall survival was 70 months (95% CI 59-81 months). 5-year survival rate was 56% (95% CI 45%-66%). 56 tumors (62%) were unassociated with a hormonal syndrome (non-functional). The liver was the predominant site of metastases in 98% of cases. Treatments included chemotherapy (81% of patients), octreotide (65%), hepatic artery embolization (44%), peptide receptor radiotherapy (30%), and cytoreductive hepatic surgery (30%). Age, gender and tumor type (functional vs. non-functional) did not impact prognosis. Tumor grade was highly prognostic, with a median survival of 86 months for well differentiated tumors versus only 22 months for moderately differentiated tumors (p<0.0001).

Conclusions: Median overall survival is 70 months (5.8 years) among patients with metastatic pancreatic endocrine carcinomas. 5-year survival is 56%. This prolonged survival duration may reflect the impact of multi-modality treatments. Tumor grade (well vs. moderately differentiated) represents a highly significant prognostic factor.

C25

Clinicopathologic Analysis of Well, Moderately and Poorly-differentiated
Metastatic Gastroenteropancreatic Neuroendocrine Tumors (GEP-NETs)

Jonathan Strosberg, MD, Domenico Coppola, MD, Aejaz Nasir, MD, Nancy Gardner, PhD, Larry Kvols, MD

Background: The pathologic grading of neuroendocrine tumors relies on mitotic rate, necrosis, pleomorphism and Ki-67 index. Using these criteria, neuroendocrine tumors are often classified as “well”, “moderately” or “poorly differentiated.” But although this nomenclature is conventionally employed by pathologists, it is not well-defined in the field of GEP-NETs. In particular, “moderately-differentiated” GEP-NETs are not recognized as a distinct category, and the clinical behavior of these tumors has not been described. Our grading of GEP-NETs relies primarily on cell morphology and mitotic index, with well-differentiated tumors displaying monomorphic appearance and rare mitoses (<2/10HPF), poorly-differentiated tumors consisting of pleomorphic cells or small “oat cells” with a high mitotic index (>10/HPF), and moderately-differentiated tumors displaying intermediate morphology and mitotic rate. We hypothesize that the classification of neuroendocrine tumors into the above-listed categories carries prognostic value.

Methods: We performed a chart analysis of patients with metastatic GEP-NETs seen at the Moffitt Cancer Center between 1999-2005, selecting all patients with “poorly differentiated” and “moderately differentiated” tumors and randomly selecting an equivalent number of patients with the more common “well differentiated” tumors. The primary endpoint was overall survival. Other features examined included sites of metastases, radiotracer uptake on pentetreotide scintigraphy, and elevations in biochemical hormone markers.

Results: A total of 83 cases were analyzed (28 well-differentiated, 28 moderately-differentiated tumors, and 27 poorly- differentiated tumors). Overall survival correlated strongly with histological classification. At 24 months, rates of overall survival were 100% among patients with well-differentiated, 57% with moderately differentiated, and 22% with poorly differentiated tumors (p<0.001). De-differentiation of tumors was associated with a lower rate of pentetreotide scan positivity, decreased rates of hormone secretion and more extensive spread of metastatic disease.

Conclusions: The classification of GEP-NETs into three histologic grades correlates strongly with survival. “Moderately differentiated” tumors should be recognized as a distinct prognostic category of GEP-NETs.

C26

Survival Analysis of 146 Metastatic Neuroendocrine Carcinomas of the
Small Intestine and Proximal Colon (Mid-Gut Carcinoids)

Jonathan Strosberg MD, Larry Kvols MD, Nancy Gardner PhD, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA

Background: Gastrointestinal neuroendocrine carcinomas are heterogeneous neoplasms that vary in mortality according to location of primary tumor and stage of disease. Past analyses of survival derive primarily from the SEER registry and suggest a trend towards improving longevity among patients with metastatic mid-gut neuroendocrine carcinomas (5-year survival of 50% in the 1990s versus 36% in the 1970s -1980s). We hypothesize that newer treatment modalities have yielded further improvements in survival rates.

Methods: We evaluated all cases of metastatic neuroendocrine carcinomas of the mid-gut (distal small intestine and proximal colon) seen at the H. Lee Moffitt Cancer Center between 1999 and 2003, measuring survival from time of diagnosis of distant metastatic disease. Median survival and 5-year survival rates (absolute and relative) were estimated using Kaplan-Meier methodology. We also assessed the impact of various clinical and demographic prognostic factors.

Results: 146 cases of metastatic mid-gut neuroendocrine carcinomas were identified, the majority originating in the terminal ileum. A large majority of cases (83%) were associated with the carcinoid syndrome. Median overall survival was 103 months (95% CI 88-118 months). The 5-year absolute survival rate was 75% (95% CI 67%-81%) and the relative survival rate was 82%. Common sites of metastatic disease included liver (90%), retroperitoneum (24%), and bone (24%). Most patients (91%) received octreotide therapy. Other medical treatments included hepatic artery embolization (45%), chemotherapy (28%) and peptide receptor radiotherapy (15%). Primary tumor resection was performed in 69% of cases, and hepatic cytoreductive surgery in 22% of cases. Age at diagnosis was highly prognostic for survival (p<0.0001).

Conclusions: Median overall survival is 103 months (8.5 years) among patients with metastatic mid-gut neuroendocrine carcinomas. This prolonged survival duration may reflect the impact of multi-modality treatments. Age at diagnosis represents a highly significant prognostic factor.

C27

Withdrawn

C28

Experience with PET F-18-F-DOPA for Imaging
of Neurodendocrine Tumors

Italo Zanzi, Richard RP Warner, Barry Babchyck, Yana Studentsova, David Bjelke, Thomas Chaly

Background: Localization of neuroendocrine tumors (NETs) allows effective treatment, but frequently is limited despite availability of multiple imaging techniques. Several studies have shown promising results using F-18-F-DOPA (FDOPA). Most of those included substantially large tumors. We performed PET with FDOPA to assess the feasibility of imaging mostly small tumors that were considered equivocal or not detected on some conventional imaging modalities, such as In-111 octreotide, CT scans, MRI, or FDG/PET.

Methods: Sixteen patients (11 female/5 male, age range 27-77 years, median 50) with appropriate symptoms and/or chemical markers suspicious of NET were studied. Carbidopa was administered prior to FDOPA injection in the 5 subjects most recently studied. Whole body imaging was obtained one hour following 6.8±1.6 mCi of FDOPA IV injection. Images were analyzed using visual observation.

Results: Diagnoses at referral were carcinoid (n=8), NET (n=4), pheochromocytoma (n=2), MEN IA (n=1), and paraganglioma (n=1). In 4 patients FDOPA scans disclosed more regions of increased FDOPA accumulation than those revealed with In-111-pentetreotide. In 3 subjects, PET demonstrated foci of FDOPA accumulation where no somatostatin receptor positive lesions were observed with pentetreotide scan. No abnormally increased tracer uptake was identified on FDOPA images of the remaining 9 subjects; in 8 of them the In-111pentetreotide or I-123-MIBG scans (two patients) were also negative. In one patient, a photopenic lesion at the base of the skull on FDOPA/PET was imaged on pentetreotide study and was reported as arachnoid cyst on MRI.

Conclusions: This initial study demonstrated a limited but encouraging value of PET/FDOPA in localization of NETs in this inhomogeneous tumor population, mostly with small tumors. Nevertheless, when other imaging modalities fail to localize NETs, a common clinical problem, PET/FDOPA may provide relevant information, as noted in 7 patients. Further studies are planned to assess the benefit of carbidopa in enhancing tumor visualization.

2008 Abstract Poster Criteria

The aim of the annual NANETS abstract poster session is to provide an avenue for investigators to network and present their most recent advancements in all areas of carcinoid and other neuroendocrine tumor (NET) disease research. Due to the complexity of these rare diseases and the limited funding resources, the main objective of this event is to encourage collaboration among physicians, allied healthcare, researchers and institutions and increase their interest to pursue both clinical and basic research in the field of NETS. In addition, this program will offer the participants an opportunity to explain their findings to a wide cross section of people with a varied understanding of genetics, pathology, molecular and cell biology.

Goals of Session

· To transfer basic research into effective, low toxicity targeted therapies.

· To yield new insights about molecular pathways which are altered in carcinoid and other NET disease progression.

· To explore the clinical benefit of various drug and interventional techniques in patients with advanced unresectable neuroendocrine tumors.

· To encourage collaboration with other research institutes to optimize current technologies and identify new methods, systems and reagents for the development of potential drug treatments.

· To clarify the genetic particularities and explore the causes of carcinoid and other neuroendocrine tumors.

· To increase comprehensive, systematic, and ongoing analyses of cell signaling and receptor mutations in NET diseases.

· To provide the medical community with new research results and inform them about the potential funding opportunities and possibilities in the field of NETS research.

· To establish and promote a network whose primary objective is to promote new research in the area of diagnosis and therapy of neuroendocrine tumor diseases.

· To educate the carcinoid and NET advocacy community about how the investment in basic and clinical research is leading to new, more effective treatments.