The role of surgery in patients with advanced midgut carcinoid tumours

64 consecutive patients with disseminated midgut carcinoids were treated over 8 years by active intervention. Their 5-year survival was 57.5%. 14 (22%) attained anatomical and biochemical cure by surgery alone. Their mean 5-hydroxindoleacetic acid (5-HIAA) levels were still normal after 69 +/- 6.2 months of follow-up. Subclinical disease was diagnosed in 7/14 patients using somatostatin receptor scintigraphy; subsequent re-exploration of 6 led to scintigraphically proven cure in 5. 40 patients with bilobar hepatic disease underwent embolisation in combination with octreotide; their 5-HIAA levels were still reduced by 55% after 71 +/- 10 months of follow-up and their estimated 5-year survival was 56%. More specifically, those with good radiological response on computerised tomography (>50%) had a pronounced reduction of 5-HIAA levels (81%) and low mortality, while those with poor radiological volume reduction had a limited reduction of 5-HIAA levels (28%) and a much higher mortality (death by tumour or cardiovascular disease). 10 patients were not embolised due to complicating diseases and had a very poor 5-year survival. The increased risk of cardiovascular death underlines the importance of total survival analysis in patients suffering from a disease with multiple hormonal effects.