Treatment Options

Ochsner believes no one treatment regimen can successfully manage all patients at all stages of their disease. Many, if not most, patients will derive benefit from a combined approach, considering all therapeutic options, both non-surgical and surgical. Ochsner strives to offer the most effective treatment options for its patients that utilize the combined experiences of medical oncology, surgical oncology, transplantation, nutrition and research. This list is not meant to be inclusive, but illustrative of some of the options we recommend.

Medical Management

In arena of medical management, Ochsner Medical Center – Kenner offers the following:

• Targeted therapies
• Chemotherapy options
• Clinical trials
• Investigative agents
• Naturally occurring anti-tumor agents
• Biotherapies, such as somatostatin analogs, sandostatin and interferons
• Nutritional optimization

Chemoembolization
A chemoembolization involves a catheter that is placed into the liver through an artery. The tumor-bearing area is then injected with a combination of chemotherapeutic agents and a clotting agent to limit the spread of the agent and to occlude the blood supply to the area.

Radiotherapy
Radiotherapy involves microscopic, radioactive beads that are delivered to tumor-infected area, usually within the liver through a catheter that has been inserted into an artery.

Targeted radiolabeled somatostatin analogs and MIBG therapy
This targeted analog procedure involves an intravenous injection of radioactive octreotide or MIBG, usually in high doses, in an effort to bind and irradiate the tumor-infected area.

Radiofrequency Ablation
This ablation procedure involves a probe that is placed inside a tumor using ultrasound guidance and high-frequency radio waves in an effort to destroy the tumor. The procedure can be performed percutaneously, laparoscopically or as part on an open operation.

Aggressive Surgery
Some patients are eligible for more aggressive approaches that surgically remove or destroy as much tumor as feasible. Patients might also be candidates for laparoscopic liver resections or other minimally-invasive procedures. Specifically, open procedures may include radiofrequency ablation, resections of the liver, pancreas, diaphragm, lung, resection of the primary tumor, involved lymph nodes or other involved organs. However, sometimes the blood supply to certain organs is encased in tumors. But that can be successfully peeled away from these vessels by Ochsner’s surgeons, thus improving the blood flow and making the patient eligible for an aggressive approach. In certain cases, patients with extensive tumor burdens may need to undergo staged procedures in order to limit any surgical trauma. As such, each operation is individually planned in concert with input from Ochsner’s entire team.

Neoprobe-guided Surgery
In some cases where tumors are difficult to locate, Ochsner utilizes radio-guided surgeries, which rely on a handheld gamma probe known as a neoprobe. This device is used in surgery after the patient has received a dose of a radioactive substance, such as octreoscan dye or MIBG, to assist in finding and removing tumors.

Transplantation
Liver transplantation is sometimes an option in selected patients with slow-growing tumors confined to the liver. Visit Ochsner's Multi-Organ Transplant Institute to find out more about liver transplantation.

NanoKnife

Ochsner Medical Center-Kenner is the first hospital in the south Louisiana region to be equipped with a surgical device called a NanoKnife that is used to eliminate malignant tumors.

“There are only about a dozen of these devises in use in the entire country. In the last year, we have used the NanoKnife in about 50 patients, treating over 100 malignant tumors and we have been extremely pleased by the results,” says J. Philip Boudreaux, MD, FACS, Professor of Surgery, LSU Health Sciences Center, at the combined LSU/Ochsner-Kenner’s Neuroendocrine Tumor Program.

Patient Benefits

Prior to acquisition of the NanoKnife, the primary method for destroying most malignant tumors that could not be removed employed a microwave-energy device which literally cooked the tumor until it was dead. The problem was that if the tumor was located next to a crucial blood vessel or structure within an organ, such as within the liver or pancreas, the microwave cooked that vital structure also. Thus, tumors that were located in critical areas could not be treated for fear of collateral damage to important vital organs, until, that is, the advent of the NanoKnife.

How The NanoKnife Works

The NanoKnife, which isn’t in actuality a knife at all, uses very high electric voltage dispensed in fractions of a second at very low currents (hence the reference to nanoseconds) to destroy tumors. Patients feel no pain from the procedure and their recoveries are relatively quick when the procedure can be performed non-invasively in selected patients.

Neuroendocrine Tumor Program

Meet Our Team

With more than 50 years of combined experience, the staff of this hospital-based-program works with referring physicians and their patients to help with diagnosis and disease management decisions.

Physicians

	J. Philip Boudreaux, MD, FACS Professor of Surgery, LSUHSC Neuroendocrine – Carcinoid Tumors/ Surgical Oncology / Transplant / General Surgery
	Juan Gimenez, MD Interventional Radiology
	Susan Gunn, MD Pulmonary Services - Lung Cancer
	Daniel Raines, MD Assistant Professor of Gastroenterology, LSUHSC, Section Chief of Gastroenterology
	T. Ramcharan, MD, FACS Associate Professor of Surgery, LSUHSC Neuroendocrine Surgery, Hepatic/Pancreatic Surgery, Minimally Invasive Surgery
	Robert Ramirez, DO, FACP Hematology / Oncology Thoracic Oncology, Lung Carcinoid
	Eugene Woltering, MD, FACS The James D. Rives Professor of Surgery and Neurosciences Section Chief of Surgical Oncology and Endocrinology Director of Surgical Research, LSUHSC Neuroendocrine – Carcinoid Tumors

Support Staff

	Kendal Thomas Director of Oncology
	Pam Ryan, BSN, RN Nurse Navigator - Neuroendocrine Tumor Program
	Cynthia Hart, BS, RN Supervisor, Neuroendocrine Clinical Coordinator
	Elizabeth Neupert, RN Neuroendocrine Clincial Coordinator
	Whitney Steele, LPN Neuroendocrine Clincial Coordinator
	Amber Cheesebrough Clinic Services Coordinator
	Kaci C. Gisclair, BA Medical Assistant
	Donna Riley Medical Assistant
	Terre Carter, BA, RN Chemo Infusion
	Christine Duke, BS, RN Chemo Infusion
	Kelly Herrmann Chemo Infusion
	Renee Jenkins Research Associate
	Jeanine Latham Dietician
	Karen Hymel Patient Access Representative
	Marlene Mandella Patient Access Representative
	Mary "Jennie" Ricks Administrative Secretary

Nutrition Information

Ochsner believes nutrition is an important part of disease management. Many patients have significant issues with weight loss, diarrhea, abdominal pain or simply have questions about which foods to avoid and which ones to emphasize. The nutrition team at Ochsner Health Center – Kenner includes an oncology nutritionist who has a special focus on the needs of patients with neuroendocrine tumors.

Nutrition and Cancer Treatment

Many patients with cancer including Neuroendocrine tumors have nutritional problems requiring specific dietary plans. The medical team will provide information and set nutritional goals on an individual basis to address these concerns. Here at Ochsner Kenner's Neuroendocrine Program, achieving a good nutritional regiment is an important component of your treatment. We look forward to working with you. If you know you have a problem or concern regarding your nutritional status or habits please discuss with the nurse at the time of the appointment so they can set up time for you to meet with the Registered Dietitian during your appointment. You may contact us at 504-464-8500 or 1-866-91-ZEBRA.

Nutrition Resources

Obtaining optimal nutrition during treatment has become a strong component of current cancer treatments. A good nutritional status of a patient can mean the difference in the patient's outcomes in several areas of treatment including radiation and chemotherapy. A goal of our team is to provide support as a resource in the areas of treatment, as well as prevention and research related to nutrition. One problem with information related to nutrition is accessing usable information that is based on scientific findings. The resources provided on this website list are considered beneficial to both people affected by cancer and those involve in the care of health care cancer patients. Below is a list of organizations and resources providing information related to nutrition and activity for people involved in the care of cancer patients:

Cancer Nutrition Info, LLC - This site is dedicated to ONE goal: Providing up-to-date, comprehensive, and scientifically sound information about nutrition and cancer. This is our passion! We want to give individuals living with cancer and cancer survivors, as well as their family, friends, and health care providers, unbiased information on nutrition and cancer. This information can be used to make the best choices for promoting healing from cancer.

The National Cancer Institute - US National Institute of Health is a leading resource in all areas of cancer providing one of the most complete sources and topics relating not only to patient care but also prevention, research and activities related to cancer. Information is also available by calling 1-800-4-CANCER. ( 1-800-422-6237 ) The representative in Louisiana is Dana Feist.

The NCI is also the provider of this site providing direct access to Eating Hints for Cancer Patients.

The American Cancer Society is a vital partner and resource in the area of cancer. They provide not only information and funding for research, they also reach into the communities through out Louisiana providing services which help to bridge many of the disparities related to the care of the people affected by cancer. If you scroll down to more resources you can click on food and Fitness. This page will provide nutrition and activity related to prevention of cancer and tools to help achieve a healthy diet and lifestyle. Information is also available by calling 1 800-ACS-2345 or 1-866-228-4327 for TTY.

Sloan-Kettering professional resource for Herbs, botanicals, and other products.

The Wellness Community (TWC) is a international not for profit organization founded by Harold Benjamin Ph. D. using The Patient Active concept providing education, support, and hope for people affected by cancer. Clicking on cancer information; then clicking on side affect management accesses the nutrition information. You then will scroll down to maximizing your health and well-being and click on nutrition and hydration.

Healthcastle is a website with the purpose of being a one stop site for reliable nutrition information and was established by Gloria Tsang R.D when a friend was diagnosed with cancer. It is run by volunteer Registered Dietitians. Healthcastle focus is preventative health but also provides information and tips for nutrition during treatment. This is a very user friendly website and has a free nutrition forum.

The American Dietetic Association is the professional association for registered dietitians. Registered Dietitians participate in all areas of nutrition from prevention to treatment. They provide the health team with vital knowledge regarding nutrition and disease. This site provides access to scientific based information and programs for general population and health care professionals.

Cookbook - Eating Well through Cancer by Holly Clegg and Gerald Meletello, published: April 2001
For ordering information: (800) 548-2537 www.wimmerco.com
The problems associated with nutrition can be associated with many factors related to cancer patient's present nutritional status, previous surgeries and treatments. It is important to ask your physician for information regarding patients concerns related to nutrition or ask him to provide a consult to a Registered Dietitian familiar with the practice of caring for cancer patients.

Research/Clinical Trials

• A Study of Human Tumor Angiogenesis Using a Fibrin-Thrombin Clot Model - open to accrual
• CP13-0710: A Phase 2, Multicenter, Two-Tier Study of IMC-A12 in Combination With Depot Octreotide in Patients With Metastatic, Well- or Moderately-Differentiated Carcinoid or Islet Cell Carcinoma - closed to accrual
• 68Ga-DOTATATE PET Scan Imaging in Patients with Neuroendocrine Tumors - open, not yet accruing
• Alliance A021202: Prospective Randomized Phase II Trial of Pazopanib vs Placebo in Patients with Progressive Carcinoid Tumors - open to accrual
• ECOG E2211 A Randomized Phasae II Study of Temozolomide and Capecitabine in Patients with Advanced Pancreatic Neuroendocrine Tumors - open to accrural
• A prospective, randomized, double-blind, multi-center, phase 2 study of the efficacy and safety of lanreotide autogel/depot 120mg vs placebo for tumor control in patients with well differentiated, advanced lung or thymus neuroendocrine tumors - open to accrual
• ECOG EAY131 Molecular Analysis for Therapy Choice (MATCH) - temporarily closed to accrural
• A Phase 3, prospective, randomized, double-blind, multi-center, study of the efficacy and safety of lanreotide autoget/depot 120mg plus best supportative care for tumor control in subjects with well differentiated, metastatic and /or unresectable typical or atypical lung neuroendocrine tumors - open to accrual

For more information on Clinical trials, go to clinicaltrials.gov.

Books

Neuroendocrine Tumors - A Comprehensive Guide to Diagnosis and Management: 4th edition
Inter Science Institute 2009

Neuroendocrine Tumors - A Comprehensive Guide to Diagnosis and Management
Inter Science Institute 2006

Articles

2015

• Adjuvant Intraoperative Post-Dissectional Tumor Bed Chemotherapy- A Novel Approach in Treating Midgut Neuroendocrine Tumors. J Gastrointest Oncol.
• Theranostics With I-131/I-123 Meta-Iodobenzylguanidine (MIBG) in Stage IV Advanced Malignant Neuroendocrine Tumors. Pancreas
• Combination Capecitabine/Temozolomide in Patients with Neuroendocrine Tumors (NETs): A Single Institution Review. J Clin Onc.
• Reappraisal of Lymphatic Mapping for Midgut Neuroendocrine Patients Undergoing Cytoreductive Surgery. Pancreas
• In vitro chemotherapy profiling of well-differentiated midgut neuroendocrine tumors (NETs) based on individual patient tumor biomarkers analysis. Pancreas.

2014

• Transition of a pancreatic neuroendocrine tumor from ghrelinoma to insulinoma: a case report
• Size Hx Characteristics of LN material
• Surg Treatment Rectal
• Variation in SB Length
• A Single Institution’s Experience with Surgical Cytoreduction of Stage IV, Well-Differentiated, Small Bowel Neuroendocrine Tumors
  • Journal of American College of Surgeons

2013

• Cocoon Formation
• I-125 MB Sentinel LN ID BrCa
• Plasma 5HIAA

2012

• Prospective evaluation of the value of previst counseling
• Prospective Evaluation of PPI use
• Cervical and Upper Mediastinal LN- Wang

2011

• Radioguided Exploration Facilitates Surgical Cytoreducation of NETS, July 2011
• Pipeline Drugs in NETs, May 2011
• Validation of NKA Assays in the US and Europe
• Surgery for GEPNETS
• Do Primary NET and Metastasis Have Same Characteristics
• Carcinoid syndrome and perioperatiave anesthetic considerations

2010

• Nutrition and Gastroenteropancreatic Neuroendocrine Tumors
  • Endocrinology and Metabolism Clinics of North America, December 2010, Volume 34, Number 4
• The Role of Angiogenesis in Neuroendocrine Tumors
  • August 2010
• Resolution of Pulsatile Tinnitus Following an Upper Mediastinal Lymph Node Resection
  • Southern Medical Association, April 2010
• 90Y-Edotreotide for Metastatic Carcinoid Refractory to Octreotide
  • Journal Of Clinical Oncology • Volume 28, Number 10, April 1 2010
• Development of a Highly Sensitive and Specific Carboxy-Terminal Human Pancreastatin Assay to Monitor Neuroendocrine Tumor Behavior
  • Pancreas Journal 2010
• A Prospective Trial on the Effect of Body Mass Index and Sex on Plasma Octreotide Levels in Patients Undergoing Long-Term Octreotide LAR Therapy
  • Pancreas Journal 2010
• Neuroendocrine tumors (NETS): Current Recommendations for Diagnosis and Surgical Management
  • Endocrinology and Metabolism Clinics of North America 2010
• The Effect of AlloDerm On the Initiation and Growth of Human Neovessels
  • Laryngoscope 2010

2009

• Staged Second-Look Laparoscopy to Evaluate Ischemic Bowel
  • Journal of the Society of Laparoendoscopic Surgeons, October 2009
• Lymphatic Mapping Helps to Define Resection Margins for Midgut Carcinoid
  • Surgery, September 2009
• Review From somatostatin to octreotide LAR: Evolution of a Somatostatin Analogue
  • Current Medical Research & Opinion, December 2009
• Biochemical Testing for Neuroendocrine Tumors
  • Pancreas, November 2009
• In Vitro Chemoresistance Testing in Well-Differentiated Carcinoid Tumors
  • Annuals of Surgical Oncology, January 2009
• Metronomic Dosing Enhances The Anti-Angiogenic Effect of Epothilone B
  • J Surg Res, 2009
• Percutaneous localisation of pulmonary nodules prior to video-assisted thoracoscopic surgery using methylene blue and TC-99
  • European Journal of Cardio-thoracic Surgery, July 2009
• Sweet leaf tea extract shows real promise in preventing cancer recurrence
  • Louisiana Agriculture, Summer 2009
• The Role of VEGF Pathways in Human Physiologic and Pathologic Angiogenesis
  • Journal of Surgical Research -, 1–11 (2009)

2008

• Clinical Value of Monitoring Plasma Octreotide Levels
  • Pancreas • Volume 37, Number 1, July 2008
• Safety and Efficacy of Radionuclide Therapy with High-Activity In-111 Pentetreotide in Patients with Progressive Neuroendocrine Tumors
  • Cancer Biotherapy & Radiopharmaceuticals Volume 23, Number 3, 2008

2007

• The Safety and Efficacy of a Dietary Herbal Supplement and Gallic Acid for Weight Loss
  • Journal of Medicinial Food 2007
• A Phase I/II Trial of 125I Methylene Blue for One-Stage Sentinel Lymph Node Biopsy
  • Annals of Surgery • Volume 245, Number 2, February 2007
• Antiangiogenic Effect of a Chinese Sweet Leaf Tea Extract in Experimental Corneal Neovascularization
  • Pharmaceutical Biology 2007. Vol. 45. No. 1

2006

• Use of Plasma Octreotide Levels to Guide Sandostatin® LAR Dosing
  • US Oncological Disease 2006
• Validation of Serum Versus Plasma Measurements of Chromogranin A Levels in Patients With Carcinoid Tumors
  • Lippincott Williams & Wilkins 2006
• Development of a Human Cardiac Tissue-Based Angiogenesis Model
  • Journal of Surgical Research 2006
• Gallic Acid is Partially Responsible for the Antiangiogenic Activities of Rubus Leaf Extract
  • John Wiley & Sons, Ltd. 2006

2005

• Effect of Octreotide LAR Dose and Weight on Octreotide Blood Levels in Patients With Neuroendocrine Tumors
  • Pancreas • Volume 31, Number 4, November 2005
• Surgical Treatment of Advanced-Stage Carcinoid Tumors
  • Annals of Surgery • Volume 241, Number 6, June 2005
• Black Raspberry Extract and Fractions Contain Angiogenesis Inhibitors
  • American Chemical Society 2005

2002

• Cytoreductive Surgery in Patients with Advanced-Stage Carcinoid Tumors
  • The American Surgeon August 2002 Vol. 68
• Somatostatin Analogs Inhibit Neonatal Retinal Neovascularization
  • Elsevier Science Ltd. 2002

2001

• Growing vascular endothelial cells express somatostatin subtype 2 receptors
  • British Journal of Cancer 2001

National NET Treatment Guidelines

• Consensus Guidelines for the Management and treatment of Neuroendocrine Tumors
  • Published in 2013, as a compliment to the 2010 Guidelines
• NANETS Consensus Guidelines for the Diagnosis of Neuroendocrine Tumor
• NANETS Treatment Guidelines –Well-Differentiated Neuroendocrine Tumors of the Jejunum, Ileum, Appendix, and Cecum
• NANETS Treatment Guidelines –Pheochromocytoma, Paraganglioma, and Medullary Thyroid Cancer
• NANETS Treatment Guidelines –Well-Differentiated Neuroendocrine Tumors of the Thorax (Includes Lung and Thymus)
• NANETS Treatment Guidelines –Well-Differentiated NETs of the Distal Colon and Rectum
• The NANETS Consensus Guidelines for the Diagnosis and Management of Poorly Differentiated (High-Grade) Extrapulmonary Neuroendocrine Carcinomas
• The Pathologic Classification of Neuroendocrine Tumors – A Review of Nomenclature, Grading, and Staging Systems
• NANETS Treatment Guidelines – Well-Differentiated Neuroendocrine Tumors of the Stomach and Pancreas

Outcomes at Ochsner

Our program has a very aggressive approach to the treatment of NET especially small bowel NETS. We attempt to reduce these tumors and have become experts in the resection of nodal metastases especially those that displace or encase the superior mesenteric artery. Following surgery we evaluate individual tumor characteristics to try and match postoperative therapies to individual tumor characteristics.

Our program has:

• Best survival 5, 10 & 20 year survival reported in world's literature to date*
• consulted with over 2400 new neuroendocrine tumor patients
• performed over 1000 neuroendocrine tumor debulking surgeries
• performed over 100 MIBG therapies on neuroendocrine tumor patients
• performed over 350 liver directed therapies on neuroendocrine tumor patients

Patient Survival Statistics

Expert Multi-Specialty Care Makes a Difference in Your Survival Compared to the National Average

Survival of Stage IV, Well-Differentiated NETS

The NOLA Nets Program is an affiliation between LSU & Ochsner Medical Center - Kenner

SEER is the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute, who works to provide information on cancer statistics in an effort to reduce the burden of cancer among the U.S. population.

*"A single Institution's Experience with Surgical Cytoreduction of Stage IV, Well- Differentiated, Small Bowel Neuroendocrine Tumors"
Boudreaux, Wang, et al. J Am Coll Surg 2014; 218:837-845.

Gallium 68 Scan Study

Our office is now offering the Ga 68 scan, which offers higher resolution imaging of neuroendocrine tumors.

The New Orleans Neuroendocrine Tumor Specialists at Ochsner Medical Center – Kenner have launched the Gallium 68 Scan Study to test the effectiveness of this diagnostic tool to detect neuroendocrine tumors.

Study Location

Ochsner - Kenner is the only site from Louisiana through the Florida Panhandle to offer this groundbreaking diagnostic tool in a clinical trial.

Gallium 68 Scan Benefits

Neuroendocrine tumors (NET) are a rare type of tumor that is characterized as slow-moving and can originate in the stomach, thymus, lungs, pancreas, duodenum, jejunum, ileum, colon or rectum. Once a NET is diagnosed, patients undergo a series of medical tests which may include Computed Tomography (CT), PET/CT, Magnetic Resonance Imaging (MRI) and Octeo Scan.

This study requires additional testing using the Gallium 68 scanner, an imaging scanner that uses positron emitting radiopharmaceuticals to show tumor development. The objective of this trial is to show that this type of scan offers a clearer image and greater tumor detail. The Gallium 68 results are then compared to the imaging results from the original scans to determine the best course of treatment.

“We hope this study will prove that the Gallium 68 Scan offers patients and their physicians a better diagnostic option to detect these rare tumors earlier, thus potentially saving more lives,” said Dr. Richard Campeau, Professor of Radiology (Nuclear Medicine) and Principal Investigator of the study. “To have this national study right here in our community shows the strength of our program, the quality of our care and our reputation as a leader in this specialized field.”

Study Criteria

The Gallium 68 Scan Study inclusion criteria includes:

Known diagnosis of classical neuroendocrine tumor, such as medullary thyroid cancers, typical or atypical (bronchial, thymic or gastrointestinal) carcinoid tumors, pancreatic neuroendocrine tumors, patients with neuroendocrine metastases from an unknown primary tumor, or patients with clinical “carcinoid syndrome” and elevated blood markers (e.g. chromogranin A, plasma serotonin levels, etc.) characteristic of neuroendocrine tumors with no known primary tumor site.

• At least 18 years of age
• Able to provide informed consent
• Karnofsky score greater than 50
• Females of childbearing potential must have a negative pregnancy test at screening/baseline