The treatment was well tolerated, and he experienced NCI-CTC grade 2 tinnitus with sensorineural hearing impairment that did not require treatment; grade 2 mucositis, anemia and neutropenia. He also had grade 1 thrombocytopenia, proteinuria and peripheral sensory neuropathy. He had no grade 3 or 4 adverse events. Upon the development of grade

2 tinnitus, the treatment with modified FOLFOX 6 was delayed for two weeks to enable full audiology and otolaryngology evaluation. On occasion the patient had treatment delays for personal reasons. In February 2011 Inhibitors,research,lifescience,medical restaging imaging studies demonstrated progressive disease in the liver and bones and he was switched to everolimus. Figure 4 Figure 4A and 4B showing a sustained response in the liver after 9 and 18 cycles of FOLFOX + Bevacizumab Inhibitors,research,lifescience,medical Discussion Bronchial carcinoid tumors are neuroendocrine neoplasms of foregut origin which are generally considered low grade neoplasms. These tumors usually present with respiratory symptoms such as cough, wheezing, hemoptysis, and recurrent pneumonias (3)-(5). Carcinoid tumors HA-1077 mouse greater than 5mm in diameter are classified as typical or atypical based on the mitotic activity and necrosis. Typical features include mitotic activity in fewer than 2 cells per 10 HPF and absence of Inhibitors,research,lifescience,medical focal necrosis. Atypical features include

greater mitotic activity and punctuate necrosis (3),(5),(6). Metastasis to regional lymph nodes occurs in less than 15% of typical bronchial carcinoids, but may be present in 30% to 50% of atypical tumors (4),(5). Certain features, like extension along the bronchial tree, may increase the risk of metastasis of typical bronchial carcinoids (7) Peripheral tumors with typical features are preferably removed Inhibitors,research,lifescience,medical with a large wedge or segmental resection, whereas more radical procedures, such as lobectomy with lymph node sampling, bi-lobectomy, sleeve resection, or pneumonectomy, are often chosen for central or atypical carcinoids. The long-term postoperative survival is 83% to 96% for typical carcinoids Inhibitors,research,lifescience,medical and 31% to 79% for atypical carcinoids (4)-(6).

Resection of metastasis may have a curative role in neuroendocrine cancers, however, about 90% of patients with liver metastases have bilateral and multifocal hepatic metastases and only 10-25% of patients have tumors that are sufficiently localized to allow for a curative resection (1),(8). In selected patients with resectable liver metastases, surgery provides both a symptomatic Fossariinae relief and a potential survival benefit (5-year actuarial survival of 18% to 29% without surgery, increasing to 50% to 79% after resection) (8),(9). Despite the multifocal and unresectable nature of many patients with liver metastases, the clinical course can be prolonged and debilitating with pain due to progressive increase in liver size and development of carcinoid syndrome in patients with hormonally active cancers (8).