Less than 10% of patients have solitary or dominant lesions which are amenable for surgical resection (10). Other modalities used to treat liver metastases include radiofrequency ablation, liver embolisation, transplantation, radioactive labelled octreotide and meta-iodobenzylguanidine (MIBG) (2,42). Radiofrequency ablation which is being increasingly used, can induce necrosis of lesions up to 3-4 cm in size but, is not very effective for lesions close to major vessels. Significant and

sustained symptom relief as well as reduction in tumour markers can be achieved if greater than 90% of tumour volume has been ablated or excised (52). Almost all patients who had Inhibitors,research,lifescience,medical curative liver resection will develop new metastases which typically show Inhibitors,research,lifescience,medical slow progression and are unusually tenacious; imaging even with specific methods such as octreotide scan and 5-HTP PET may fail to detect disease progression. Medical treatment Somatostatin is a peptide that inhibits the secretion

of a number of hormones (growth hormone, insulin, glucagon and gastrin) (53) and a significant proportion of GICTs (>80%) have been shown to express somatostatin receptors on their cell surfaces. As a result, somatostatin analogues (Octreotide and Lanreotide) as well as interferons have been used to effectively palliate Inhibitors,research,lifescience,medical the symptoms of carcinoid syndrome in up to 70% of patients, to provide tumour reduction in around 5% of patients and to stabilise the disease Inhibitors,research,lifescience,medical (an average of three years) in approximately half of the patients (40,54,55). These analogues can be Fluorouracil cost self-administered thrice daily (50-150 µg) through subcutaneous injections and furthermore, longer acting formulations with the convenience of once monthly injections are also available (54). The side effects

of octreotide treatment are gallstone formation and pancreatic insufficiency whereas those patients receiving interferons Inhibitors,research,lifescience,medical report more adverse effects including flu-like symptoms, chronic fatigue and autoimmune reactions. Chemotherapy has yielded limited success in the treatment of GICTs and tend to be more effective in patients with aggressive variants for (such as neuroendocrine carcinomas), in which a cisplatin/etoposide-based regime has been reported to achieve up to 60% response rate (56). External beam radiotherapy has been shown to have a role in the treatment of locally unresectable disease and in the effective palliation of bone and central nervous system metastases (57). Role of multi-disciplinary team Patients with carcinoid tumours require multiple modalities of treatment and a dedicated multi-disciplinary team (MDT) to co-ordinate the management and follow up is essential. In view of the relatively low incidence of these tumours and for optimum use of resources, these MDTs need to be centralised and based in regional tertiary centres (8).