Ninety-five percent of all carcinoids are found in the appendix, rectum, or small intestine. 9 The remainder arise outside of the intestinal tract (., in the ovary or testis). In general, the larger the primary tumor, the greater the likelihood of metastasis, which provides prognostic implications. 9 Carcinoids of the appendix and rectum rarely manifest with the carcinoid syndrome. Forty percent to 50% of patients with carcinoids of the small intestine or proximal colon have manifestations of the carcinoid syndrome. 10 Tumors that secrete their hormonal product into the portal venous system do not cause flushing, because the released amines are inactivated by the liver. In contrast, liver metastases may escape hepatic inactivation and deliver their product directly into the systemic circulation, hence causing flushing. 9 Pulmonary or ovarian carcinoids release pharmacologic products directly into the venous circulation, bypassing the portal system, and can therefore cause symptoms without metastasizing to the liver. 1,10
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Gynecomastia is a common adverse effect of bicalutamide (Casodex) therapy that may prompt some men to discontinue prostate cancer treatment. Tamoxifen has been recommended as a preventive agent for gynecomastia in these patients. A double-blind study of 282 men randomized to receive 20 mg of tamoxifen once per day with bicalutamide or bicalutamide alone found that after six months, gynecomastia and breast pain were significantly reduced in men who received tamoxifen ( versus percent in the control group). 41 An Italian randomized controlled trial of 80 participants also found that 20 mg of tamoxifen once per week is as effective as 20 mg once per day. 42