The anesthetic significance of serotonin secreting carcinoid tumors

Gastrointestinal carcinoid tumors: current management strategies

BACKGROUND

Carcinoid or neuroendocrine tumors of the gastrointestinal tract, although characteristically indolent, are also quite heterogeneous both with respect to histologic and endocrine features and with respect to clinical presentation and behavior.

PURPOSE

This study was undertaken to review and summarize the current literature on classification controversies, site-specific carcinoid presentation and behavior, and diagnostic and management strategies for primary and advanced carcinoid tumors and the carcinoid syndrome.

RESULTS

For carcinoid tumors, oncologic results depend on the location of the primary tumor, extent of locoregional and metastatic disease, functioning status of the tumor, and the feasibility of complete surgical extirpation. Whereas favorable survival rates are typically observed for appendiceal and rectal primaries, less favorable rates are often observed for colonic and ileal tumors. A search for additional tumors is generally advised because multiple carcinoids and second neoplasms are not uncommon. Because of the indolent nature of the tumor and because these therapies have been shown to improve quality and quantity of life, otherwise fit patients with advanced carcinoid disease should be treated with aggressive medical and surgical therapies. Development of a malignant carcinoid syndrome indicates the presence of a functionally active carcinoid tumor and portends a poor prognosis.

CONCLUSION

Gastrointestinal carcinoids, although malignant, behave differently from other carcinomas. Results are highly variable and must be individualized according to the site of the primary tumor, extent of spread, and general condition of the patient. A prolongation of quality life can often be accomplished through aggressive medical and surgical therapies.

Carcinoid syndrome and intravenous cyproheptadine

The anaesthetic management of a patient with the carcinoid syndrome is reported. Important cardiovascular complications occurred immediately after tracheal intubation and during manipulation of metastases. Hypertensive crises were controlled with intravenous cyproheptadine, although hypotension and drowsiness were observed due to its use.

Somatostatin, anaesthesia, and the carcinoid syndrome. Peri-operative administration of a somatostatin analogue to suppress carcinoid tumour activity

A patient with carcinoid syndrome on long-term antiserotonin therapy with parachlorophenylalanine, experienced a flushing attack with hypotension during the prophylactic administration of aprotonin prior to the induction of anaesthesia. When she was subsequently prepared with a long-acting somatostatin analogue, octreotide (Sandostatin, Sandoz SMS 201-995), plasma levels of tumour-released hormones were reduced and anaesthesia for resection of hepatic metastases was uneventful. The advantages of an anaesthetic approach based on inhibition of carcinoid tumour activity, rather than antagonism of released hormones, are discussed.

Circulation, respiration and serotonin levels in carcinoid patients during neurolept anaesthesia

Release of hormones peri-operatively in patients with metastatic carcinoids may lead to severe circulatory and respiratory disturbances. Fourteen patients with liver metastases were studied during 16 operations with a modified neurolept anaesthesia in order to evaluate the central haemodynamic and respiratory functions as well as plasma serotonin levels. The premedication in five patients was supplemented with levopromazine. During the 11 operations performed on patients not pretreated with levopromazine, no major significant fluctuations in circulatory or respiratory functions were recorded although big variations in serotonin plasma levels were measured. In the patients treated with levopromazine, however, significant changes were observed in heart rate, mean pulmonary artery pressure, cardiac index, and left and right ventricular stroke work especially during flushing episodes. However, these changes did not correlate with the changes in plasma serotonin levels. Modified neurolept anaesthesia without levopromazine pretreatment combined with careful monitoring seems to be a safe procedure for carcinoid patients. Using this type of anaesthetic procedure only one major complication occurred in connexion with 16 major operations and then in the postoperative period.

Acute carcinoid syndrome: a complication of flexible fiberoptic bronchoscopy

We report the case of a patient with functioning bronchial carcinoid tumor found as a solitary nodule. Acute carcinoid syndrome developed during transbronchial biopsy, and life-threatening hypotension occurred during operation. We emphasize that carcinoid tumors should be considered in the differential diagnosis of solitary nodules, and such a complication should be kept in mind when endobronchial or transbronchial biopsy is performed.

Severe hypertension and flushing in a patient with a non-metastatic carcinoid tumour. Hypertension and flushing with a solitary carcinoid tumour

A case of multiple endocrine adenopathy type I associated with a solitary carcinoid tumour is described. During anaesthesia and characteristic syndrome consisting of hypertension, tachycardia and flushing occurred. The possible mechanism for this are discussed.

Ketamine-diazepam anaesthesia in a patient with carcinoid syndrome

The use of ketamine in patients with carcinoid syndrome is controversial because of the catecholamine response to this agent. Prior administration of diazepam modifies the catecholamine response to ketamine and may make its use in such patients safe. The successful use of a diazepam-ketamine technique for anaesthesia of a patient with malignant carcinoid syndrome and associated tricuspid valve disease who underwent laparotomy and hepatic artery ligation is described. The theoretical advantages of safe ketamine anaesthesia in carcinoid patients are discussed and the relevant literature reviewed. To the authors' knowledge the successful use of ketamine anaesthesia in carcinoid syndrome has not previously been reported.

Anaesthesia for an unusual carcinoid metastasis

The intra-operative course of a patient found to have a metastatic serotonin-secreting carcinoid tumour in the orbit is reported. No prophylactic or intra-operative therapy was necessary during the administration of enflurane anesthesia. This case demonstrates again the wide spectrum of clinical responses observed among patients with this disease.

Bronchial carcinoid with osteoblastic metastases

Bony metastases in association with a lesion in the lung are usually regarded as secondary to bronchial carcinoma. This is generally true when the metastases are osteolytic. However, in the presence of a solitary lung lesion with osteoblastic metastases, the diagnosis of bronchial carcinoid should be considered. The following case illustrates this point.

Carcinoid syndrome: its relevance to the anaesthetist

This paper presents the pathology, pharmacophysiology and therapy of the carcinoid syndrome. Forty reports from the literature are reviewed and the anaesthetic management of the patients is discussed. The carcinoid syndrome is a rare multihumoral endocrine disease. Secretions may be stimulated by certain anaesthetic and surgical manoeuvres and produce undesirable, and occasionally fatal, cardiovascular and respiratory complications. A radical surgical approach to the disease is current. Anaesthetists may therefore be involved in the management of these patients more frequently than before. The implication of both serotonin and bradykinin in the pharmacophysiology of this disease allows a more rational approach to the treatment of complications occurring during anaesthesia. However, other, as yet undiscovered vasoactive substances, may be involved.

Anaesthetic considerations in bronchial adenoma

The patient with bronchial adenoma can present a puzzling diagnostic dilemma as well as challenging problems in anaesthetic management. Several aspects are reviewed in this report. Diagnostically these include chest roentgenographic findings and unique pulmonary function test. Problems in anaesthetic management include possible development of acute carcinoid syndrome, as this tumour is usually of the carcinoid variety. In addition, the tumour may act as a ball valve, causing uneven ventilation of affected lung with expiratory air trapping. Several factors may necessitate prolonged bronchial blockage during anaesthesia. These include a friable mass which may bleed profusely upon manipulation, infected and atelectatic parenchymal tissue beyond the obstruction, copious volumes of purulent secretions, and one lung ventilation during resection.

Bronchial adenoma and the carcinoid syndrome

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