Endocrine Abstracts

A 55 year old lady presented to our hospital in 1991 with a year's history of diarrhoea, weight loss and abdominal pain. On examination, she had 5cm hepatomegaly. Serum gastrin was elevated (148 pmol per litre NR < 40), as was GAWK (276 pmol per litre NR < 150). Basal gastric acid secretion was increased (39 mmol per hour NR < 5). CT abdomen showed multiple hepatic metastases, confirmed to be neuroendocrine in origin on biopsy. There were no clinical or biochemical features of MEN I. She commenced omeprazole, which was gradually increased to maximal doses, providing some symptomatic relief.

We use selective hepatic embolisation, using polyvinyl alcohol, to palliate symptoms from metastatic neuroendocrine tumours. In 1992, she underwent a left hepatic artery embolisation, which was uncomplicated. However, a right hepatic artery embolisation several months later, was complicated by a hepatic abscess, requiring percutaneous drainage and intravenous antibiotics. Subsequently, her symptoms improved and omeprazole was reduced. Serum gastrin levels fell to 42 pmol per litre, associated with a significant reduction in size of hepatic metastases. By 1998, her symptoms again worsened, although hepatic metastases remained static in size. She commenced Lanreotide 30 milligrammes intramuscularly every 2 weeks and Creon. Initially this controlled her symptoms. However, subsequently she deteriorated. A third hepatic embolisation was performed, also complicated by a subhepatic abscess. Post-embolisation, metastases in the right lobe of the liver were smaller. However, technical difficulties had precluded embolisation of some metastases supplied by the right inferior phrenic artery. Post-embolisation, her symptoms were only moderately improved.

In 2004, her diarrhoea had become increasingly intolerable, despite maximal medical therapy, with increased size of several hepatic metastases. A further, more extensive hepatic embolisation was performed. This was well tolerated, without complications. Her diarrhoea stopped and she was able to discontinue Lanreotide. Consistent with her clinical improvement, several hepatic metastases had reduced in size. This case illustrates that multiple hepatic embolisations may effectively relieve symptoms in metastatic gastrinomas.