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Randomised trial of irinotecan versus fluorouracil by continuous infusion fluorouracil failure in patients with metastatic colorectal cancer. Irinotecan combined with fluorouracil compared with fluorouracil alone as first-line treatment for metastatic colorectal cancer: a multicentre randomised trial. Leucovorin and fluorouracil with or without oxaliplatin as firstline treatment in advanced colorectal cancer. Long-term survival of patients with unresectable colorectal cancer liver metastases following infusional chemotherapy with 5-fluorouracil, leucovorin, oxaliplatin and surgery. Advanced colorectal cancer: results from the latest raltitrexed comparative study. Proc Am Soc Clin Oncol 2000; 20:494 (abstract) 9 Management of neuroendocrine tumours Ian Pope and Graeme J Poston Neuroendocrine gastrointestinal tumours are derived from the neuroendocrine cell system. These tumours have widely differing clinical presentations that reflect both their organ of origin and syndromes related to excess hormone production. The neuroendocrine gastrointestinal tumours are divided into two main groups, carcinoid tumours and endocrine pancreatic tumours. The first part of this chapter considers the clinical presentation and metastatic potential of primary neuroendocrine tumours. Given the rarity of these tumours, the experience of treatment of liver metastases from individual tumours is limited. Most studies combine carcinoid tumours derived from various organs of origin together with pancreatic endocrine tumours. The second part of this chapter is therefore devoted in general to the diagnosis and management of neuroendocrine hepatic metastases, albeit from a wide variety of primary tumours. Neuroendocrine tumours: historical perspective the diffuse neuroendocrine system was first described by Feyrter in 1938 (diffuse endokrine epithelail organe). Multiple small tumours were observed at autopsy in the distal ileum of two patients. Microscopic examination revealed the absence of glandular structures, suggesting development of these tumours from epithelial cells within the glands of Leiberkuhn. The first case of metastatic disease, and indeed the carcinoid syndrome, was described by Ranson in 1890 who reported a patient with ileal carcinoma and multiple liver metastases who experienced diarrhoea and dyspnoea after eating. As described today, the diffuse neuroendocrine system includes all neuronal and endocrine cells that share a common phenotype characterized by simultaneous expression of general neuroendocrine markers and cell type specific regulatory peptides.

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The actual diaphragmatic muscle is obscured by the reverberation that occurs at the level of the diaphragm-lung interface. Diaphragmatic muscle is clearly visible only when there is simultaneous pleural and peritoneal effusion. Identification of the esophagus at the esophageal hiatus is more difficult due to air in the stomach and lung. A, On the lateral radiograph the cardiac size and shape are normal for a dog of narrow thoracic conformation. A, On the ventrodorsal radiograph fat density can be seen in the cranial mediastinum (arrows) and also outlines the caudal mediastinum (arrows). B, the density ventral to the cardiac silhouette on the lateral radiograph represents fat in the ventral mediastinum. There is an indentation in the cranial ventral margin of the cardiac silhouette at the site of the interventricular groove (open arrow). Pulmonary structures are identified easily with calcification present within some bronchial walls. The size and shape of the cardiac silhouette are normal for a dog with intermediate thoracic conformation. However, because of the size of this space and the small amount of fluid that it contains, it is not visible radiographically. The cardiac silhouette appears enlarged; however, it is normal for a dog of wide thoracic conformation. A and B, the cranial mediastinum also appears widened, but this dog is obese and the mediastinal widening represents an accumulation of fat. B, On the ventrodorsal radiograph fat also is seen within the caudal mediastinum (closed arrows). The accumulation of fat also is responsible for the separation of the lungs from the thoracic wall in the caudal portion of the thorax (open arrows). A B Chapter Two the Thorax 43 within this potential space, or fibrosis, or calcification of the pleura will make the pleural space visible. When the direction of the x-ray beam is parallel to an interlobar fissure, it may be radiographically evident as a thin linear tissue density. The locations of the interlobar fissures within the thorax are fairly consistent and these should be examined specifically. Fat may accumulate beneath the parietal pleura in obese animals and be visible (see Fig. The pleural space width may be accentuated on an expiratory radiograph in a normal animal.

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