Medical Challenge Question 9 Cancer

An 82 year old caucasian man comes to the office with complaints of increasing fatigue, abdominal pain, decreased appetite, and a 4.5-kg (10-lb) weight loss over the last month. He does not have cough, dyspnea, or chest pain. The patient has no medical history and takes no medications. The patient is a lifelong nonsmoker, 1 pack per day since age 21.

On examination, temperature is 97.4 degrees, blood pressure is 130/80 mm Hg, pulse rate is 84/min, and respiration rate is 12/min. Abdominal examination demonstrates hepatomegaly while the remainder of the examination is unremarkable.

Laboratory results show serum alkaline phosphatase level of 234 U/L, total bilirubin level is 2.1 mg/dL, and creatinine level is 0.8 mg/dL.

Then a CT scan of the abdomen and pelvis with contrast demonstrates multiple liver metastases with 40% liver replacement and several metastases in the pelvic bones and ribs. Next a CT-guided needle biopsy is performed. The liver biopsy reveals a high-grade poorly differentiated neuroendocrine cancer. Finally a chest CT scan shows no evidence of tumor.

Which of the following is the most appropriate treatment?

A. Start radiation therapy for bone metastases
B. Start radio frequency ablation of liver metastases
C. Start platinum-based systemic chemotherapy
D. Use octreotide
E. Perform hepatic artery embolization

References:

Reidy DL, Tang LH, Saltz LB. Treatment of advanced disease in patients with well-differentiated neuroendocrine tumors. Nat Clin Pract Oncol. 2009 Mar;6(3):143-52. PMID: 19190591