2245 Thoracic Neuroendocrine Tumor With Hepatic Metastases: An Ideal Case for Radioembolization

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INTRODUCTION: This rare case of a thoracic neuroendocrine tumor (NET) metastasizing to the liver is meant to bring attention to the lag in diagnosis until symptoms from the metastases become discernible. It also acknowledges recent literature on radioembolization efficacy in disease control rate as well as symptom resolution for NET with liver metastases, in particular. CASE DESCRIPTION/METHODS: A 56-year-old male patient with cirrhosis secondary to hepatitis C s/p treatment presented with RUQ abdominal pain, fever, chills, and fatigue. Labs show elevated AST/ALT/ALP of 64/72/227, respectively. A CT abdomen and MRCP demonstrated a cirrhotic liver with multiple hypodense ill-defined hepatic lesions with portocaval lymphadenopathy. An EGD discovered 4 non-bleeding esophageal varices and hypertensive portal gastropathy (Figure 2). EUS-guided liver and periportal lymph node biopsies returned positive for a high grade poorly differentiated metastatic NET with greater than 50% positive for KI-67. Octreotide scan was negative. PET scan indicated the primary source as possibly thoracic given mediastinal involvement. Currently, patient is receiving cycles of carboplatin and etoposide. DISCUSSION: NETs arise from neurological and hormonal cells within any organ system and are classified by their anatomical location. Incidence is 5/100,000 with total prevalence 35/100,000, with the highest proportion reported in African Americans. Genetically, they are associated with MEN1, VHL, and tuberous sclerosis. Symptoms are present for 5-7 years before finally being diagnosed and include abdominal pain, diarrhea and fatigue. They are detected sooner if they are functional tumors that secrete hormones, such as serotonin, causing carcinoid syndrome. A majority, however, are non-secretory or non-functional and found incidentally. For diagnosis and staging, a CT or MRI and Ki-67 IHC staining. An octreotide scan is sensitive for a well-differentiated NET, whereas a PET scan is more sensitive for poorly differentiated or high grade tumors. Treatment entails laparoscopic removal or debulking, local hepatic ablation via radiofrequency, cryotherapy or electroporation, or embolization of the hepatic artery. For those with metastases or poor surgical candidates, chemotherapy with cisplatin and streptozocin are widely used. A recent study showed that radioembolization for NETs with hepatic metastases had a 91% disease control rate and 79% had resolution of NET-related symptoms.