7 x 9.0 cm) (Figure 1A and ​and1B).1B). A biopsy specimen of the mass was consistent with metastatic neuroendocrine carcinoma. The chromogranin A level was 468 ng/mL (normal ≤ 36.4 ng/mL). The patient’s case was reviewed in our multidisciplinary tumor board and he was considered potentially resectable. Subsequently, in August 2007, he underwent surgical resection of segments II and III of the liver and intraoperative

examination revealed that the tumor was located in these two segments. Figure 1 Figure 1A and 1B showing large left lobe liver metastases with increased activity on Octreoscan Pathologic examination of the specimen demonstrated an encapsulated, 8 x 8 x 6.5 cm well-differentiated neuroendocrine tumor Inhibitors,research,lifescience,medical morphologically consistent with

metastatic carcinoid to liver. The resection margins were negative and lymphovascular invasion was Inhibitors,research,lifescience,medical identified. Immunohistochemical staining was positive for chromogranin and synaptophysin and negative for insulin, glucagon, serotonin, calcitonin, bombexin, TTF and CDX-2 (Figure 2). The Ki-67 immunostain showed a low proliferative activity. The patient had an uneventful post-operative course. Approximately 1 month after resection, his serum chromogranin A level was 19 ng/mL (normal ≤ 15 ng/mL) and repeat OSI 906 octreotide scan again demonstrated non-specific increased activity in the right lower lung. Seventeen months after the surgical resection, octreotide scan demonstrated Inhibitors,research,lifescience,medical increased activity in the right lobe of the liver, skull, humerus and ribs in addition to persistent uptake in the Inhibitors,research,lifescience,medical right lower lung. The CT scan demonstrated innumerable hypodense lesions in both hepatic lobes. Therapy was commenced with the long acting somatostatin analogue (Octreotide LAR) monthly with initial stable disease. After nine months of therapy with Octreotide LAR, he developed progressive disease, with rise in the serum chromogranin from Inhibitors,research,lifescience,medical 340 to 2980 (normal ≤ 36.4 ng/mL) and increased uptake of octreotide in the bones on Octreoscan in addition

to progressive disease in the liver. (Figure 3A and ​and3B3B) Figure 2 A. Well encapsulated tumor (H&E, 100x); B. The tumor is composed by uniform and polygonal cells with scant eosinophilic cytoplasm and coarsely granular chromatin (H&E, 400x); C. Tumor cells show diffuse and strong cytoplasmic Thymidine kinase immunoreactivity … Figure 3 Figure 3A and 3B showing diffuse metastases in the liver with increased activity on Octreoscan He was started on modified FOLFOX 6 (5-FU, 400 mg/m(2) bolus infusion, followed by Leucovorin 400 mg/m(2) and Oxaliplatin 85 mg/m(2) given in “Y” over 2 hours followed by 5 FU 2,400 mg/m(2) continuous infusion over 46 hours) plus bevacizumab in addition to Octreotide LAR and zolendronic acid in October 2009, with achievement of partial response by RECIST criteria, as noted on the CT scan obtained after 9 and 18 cycles of chemotherapy (Fig 4A and ​and4B4B respectively) The serum chromogranin A level decreased to 424 by December 2010.