Anesthesia for patients with carcinoid syndrome

Small bowel neuroendocrine tumours - casting the net wide

PURPOSE OF REVIEW

Our aim is to provide an overview of small bowel neuroendocrine tumours (NETs), clinical presentation, diagnosis algorithm and management options. We also highlight the latest evidence on management and suggest areas for future research.

RECENT FINDINGS

Dodecanetetraacetic acid (DOTATATE) scan can detect NETs with an improved sensitivity than when compared with an Octreotide scan. It is complimentary to small bowel endoscopy that provides mucosal views and allows the delineation of small lesions undetectable on imaging. Surgical resection is the best management modality even in metastatic disease. Prognosis can be improved with the administration of somatostatin analogues and Evarolimus as second-line therapies.

SUMMARY

NETs are heterogenous tumours affecting most commonly the distal small bowel as single or multiple lesions. Their secretary behaviour can lead to symptoms, most commonly diarrhoea and weight loss. Metastases to the liver are associated with carcinoid syndrome.

A case of metastatic neuroendocrine disease and cholecystitis: surgical remedy and management of carcinoid crisis

The report presents a case of a 70-year-old male with a known mesenteric neuroendocrine tumour and metastases to the liver diagnosed with acute cholecystitis. During surgery, the patient developed a carcinoid crisis with mixed distributive and cardiogenic shock involving systemic vasodilation and arrhythmia. During surgical procedures, carcinoid crisis can be precipitated by tumours that secrete a pathological shower of vasoactive mediators. Somatostatin analogues are utilized to control carcinoid syndrome and are routinely used peri-operatively. However, no standard infusion regimen exists. The case raises the suggestion that metastatic liver neuroendocrine disease may confound the diagnosis of cholecystitis, complicates the management of acute surgical presentations and highlights the need for agreement on octreotide therapy for surgical patients with carcinoid tumours.

Outcomes and periprocedural management of cardiac implantable electronic devices in patients with carcinoid heart disease

BACKGROUND

Carcinoid heart disease (CHD) is a rare complication of hormonally active neuroendocrine tumors that often requires surgical intervention. Data on cardiac implantable electronic device (CIED) implantation in patients with CHD are limited.

OBJECTIVE

The purpose of this study was to evaluate the experience of CIED implantation in patients with CHD.

METHODS

Patients with a diagnosis of CHD and a CIED procedure from January 1, 1995, through June 1, 2020, were identified using a Mayo Clinic proprietary data retrieval tool. Retrospective review was performed to extract relevant data, which included indications for implant, procedural details, complications, and mortality.

RESULTS

A total of 27 patients (55.6% male; mean age at device implant 65.6 ± 8.8 years) with cumulative follow-up of 75 patient-years (median 1.1 years; interquartile range 0.4-4.6 years) were included for analysis. The majority of implanted devices were dual-chamber permanent pacemakers (63%). Among all CHD patients who underwent any cardiac surgery, the incidence of CIED implantation was 12%. The most common indication for implantation was high-grade heart block (66.7%). Device implant complication rates were modest (14.8%). No patient suffered carcinoid crisis during implantation, and there was no periimplant mortality. Median time from implant to death was 2.5 years, with 1-year mortality of 15%.

CONCLUSION

CHD is a morbid condition, and surgical valve intervention carries associated risks, particularly a high requirement for postoperative pacing needs. Our data suggest that CIED implantation can be performed relatively safely. Clinicians must be aware of the relevant carcinoid physiology and take appropriate precautions to mitigate risks.

A prospective study of carcinoid crisis with no perioperative octreotide

BACKGROUND

Carcinoid crises, defined as the sudden onset of hemodynamic instability in patients with neuroendocrine tumors undergoing operation, are associated with significantly increased risk of postoperative complications. Octreotide has been used prophylactically to reduce crisis rates as well as therapeutically to treat crises that still occur. However, studies using octreotide still report crisis rates of 3.4% to 35%, leading to the questioning of its efficacy.

METHODS

Patients with neuroendocrine tumors undergoing operation between 2017 to 2020 with no perioperative octreotide were prospectively studied. Clinicopathologic data were compared by χ² test for discrete variables and by Mann-Whitney U test for continuous variables.

RESULTS

One hundred and seventy-one patients underwent 195 operations. Crisis was documented in 49 operations (25%), with a mean duration of 3 minutes. Crisis was more likely to occur in patients with small bowel primary tumors (P = .012), older age (P = .015), and carcinoid syndrome (P < .001). Those with crises were more likely to have major postoperative complications (P = .003).

CONCLUSION

Completely eliminating perioperative octreotide resulted in neither increased rate nor duration compared with previous studies using octreotide. We conclude perioperative octreotide use may be safely stopped, owing to inefficacy, though the need for an effective medication is clear given continued higher rates of complications.

A Challenging Case of Carcinoid Crisis in a Patient With Neuroendocrine Tumor

The critical state of circulatory collapse and hypoperfusion that results in end-organ damage has been called shock. Carcinoid crisis is a rare cause of shock, which is difficult to identify in the presence of infection. It occurs due to the release of vasoactive amines into the systemic circulation following an inciting event. In the presence of a neuroendocrine tumor, carcinoid crisis should be suspected in case of resistant shock. Herein, we report a rare case of carcinoid crisis, in which a quick response to the somatostatin analog therapy, octreotide, was helpful to confirm the diagnosis.

Carcinoid Syndrome and Hyperinsulinemic Hypoglycemia Associated with Neuroendocrine Neoplasms: A Critical Review on Clinical and Pharmacological Management

The carcinoid syndrome (CS) and hyperinsulinemic hypoglycemia (HH) represent two of the most common clinical syndromes associated with neuroendocrine neoplasms (NENs). The former is mainly related to the serotonin secretion by a small bowel NEN, whereas the latter depends on an insulin hypersecretion by a pancreatic insulinoma. Both syndromes/conditions can affect prognosis and quality of life of patients with NENs. They are often diagnosed late when patients become strongly symptomatic. Therefore, their early detection and management are a critical step in the clinical management of NEN patients. A dedicated and experienced multidisciplinary team with appropriate therapeutic strategies is needed and should be encouraged to optimize clinical outcomes. This review aims to critically analyze clinical features, evidence and treatment options of CS and HH and therefore to improve their management.

Octreotide for resuscitation of cardiac arrest due to carcinoid crisis precipitated by novel peptide receptor radionuclide therapy (PRRT): A case report

Peptide receptor radionuclide therapy (PRRT) is an effective treatment for metastatic carcinoid tumours but can precipitate a carcinoid crisis through release of stored bioamines. Cardiac arrest is an uncommon manifestation of carcinoid crisis and has never been reported as a complication of PRRT. We report a case of a 58-year old female who suffered from cardiac arrest following PRRT for metastatic carcinoid tumour. She was successfully resuscitated using intravenous octreotide following 22 min of failure to resuscitate with a standard advanced cardiac life support protocol. Following resuscitation, severe carcinoid heart disease was diagnosed, and the patient subsequently underwent successful surgical valve replacement. Although there is no trial evidence, considering pharmacological rationale and successful outcome in this case, we suggest early administration of intravenous octreotide during resuscitation of patients suffering cardiac arrest post PRRT for carcinoid disease and recommend preventive strategies.

Β-Adrenergic agonist administration is not associated with secondary carcinoid crisis in patients with carcinoid tumor

BACKGROUND

Patients with carcinoid tumors are at risk for profound intraoperative hypotension known as carcinoid crisis, which catecholamines are traditionally believed to trigger. However, data supporting this are lacking.

METHODS

Anesthesia records were retrospectively reviewed for carcinoid patients treated with vasopressors. Hemodynamics for those with crisis were compared between those who received β-adrenergic agonists (B-AA) versus those who did not.

RESULTS

Among 293 consecutive operations, 58 were marked by 161 crises. There was no significant difference in the incidence of paradoxical hypotension with B-AA compared to non-B-AA (p = 0.242). The maximum percent decrease in mean arterial pressure following drug administration was significantly greater in those patients treated with non-B-AA than with B-AA (31.6% vs. 12.5%, p < 0.0001). There were no differences in crisis duration (p = 0.257) or postoperative complication rate (p = 0.896).

CONCLUSIONS

β-Adrenergic agonist use was not associated with paradoxical hypotension, prolonged carcinoid crisis, or postoperative complications in patients with intraoperative carcinoid crisis.

A prospective study of the pathophysiology of carcinoid crisis

BACKGROUND

Sudden massive release of serotonin, histamine, kallikrein, and bradykinin is postulated to cause an intraoperative carcinoid crisis. The exact roles of each of these possible agents, however, remain unknown. Optimal treatment will require an improved understanding of the pathophysiology of the carcinoid crisis.

METHODS

Carcinoid patients with liver metastases undergoing elective abdominal operations were studied prospectively, using intraoperative, transesophageal echocardiography, pulmonary artery catheterization, and intraoperative blood collection. Serotonin, histamine, kallikrein, and bradykinin levels were analyzed by enzyme-linked immunosorbent assay.

RESULTS

Of 46 patients studied, 16 had intraoperative hypotensive crises. Preincision serotonin levels were greater in patients who had crises (1,064 vs 453 ng/mL, P = .0064). Preincision hormone profiles were otherwise diverse. Cardiac function on transesophageal echocardiography during the crisis was normal, but intracardiac hypovolemia was observed consistently. Pulmonary artery pressure decreased during crises (P = .025). Linear regression of preincision serotonin levels showed a positive relationship with mid-crisis cardiac index (r = 0.73, P = .017) and a negative relationship with systemic vascular resistance (r=-0.61, P = .015). There were no statistically significant increases of serotonin, histamine, kallikrein, or bradykinin levels during the crises.

CONCLUSION

The pathophysiology of carcinoid crisis appears consistent with distributive shock. Hormonal secretion from carcinoid tumors varies widely, but increased preincision serotonin levels correlate with crises and with hemodynamic parameters during the crises. Statistically significant increases of serotonin, histamine, kallikrein, or bradykinin during the crises were not observed.

[Asystole during surgery to manage small intestine cancer: are we dealing with anaphylaxis or carcinoid crisis]

Cardiac arrest in the operating room is a life-threatening event with multiple causes. We report the case of a 53-year old female patient with no particular past medical history scheduled for surgery to manage small intestine cancer. Twenty minutes after anesthetic induction the patient had asystole rapidly reversible after resuscitation measures. The association of face rash with chest rash gave rise to suspicion of late anaphylactic reaction. Rapid patient recovery allowed to resume surgical procedure. Tumor manipulation immediately caused a second severe bradycardia rapidly reversible after the administration of 0.5 mg atropine. Skin rush at the level of the face and the chest occurred again. This second complication immediately gave rise to suspicion of carcinoid crisis. Sandostatine was then administered. No other complication occurred, the patient spent 24 hours in the Intensive Care Unit receiving sandostatine infusion. Urinary 5-HIAA values were very high and histological examination of the surgical specimen confirmed carcinoid tumor. This study aims to highlight the rarity of this entity and the importance of suspecting carcinoid crisis in patients with intraoperative complications during anesthesia for small intestine tumor surgery.

Exercise cardiac magnetic resonance imaging with pulmonary artery catheter monitoring in carcinoid heart disease: a shift towards early intervention?

Neuroendocrine tumours are a rare malignancy, which can be complicated by a carcinoid syndrome and, in more rare cases, also valve destruction. The correct timing for surgical repair remains unknown. We report the first‐in‐men exercise cardiac magnetic resonance imaging with pulmonary artery catheter measurements in order to better understand the haemodynamic impact of isolated tricuspid valve insufficiency in a low symptomatic patient. Not pressure but volume overload is the key factor in the development of symptoms, as long as the right ventricular function is intact. Based on our findings, we referred the patient for tricuspid valve replacement. This case, together with the review of all carcinoid heart disease cases in our hospital (a large tertiary cardiology and oncology centre) since 2000, indicates a potential benefit for early intervention in carcinoid heart disease.

Prevention and management of carcinoid crises in patients with high-risk neuroendocrine tumours undergoing peptide receptor radionuclide therapy (PRRT): Literature review and case series from two Australian tertiary medical institutions

Peptide receptor radionuclide therapy (PRRT) is an important therapeutic option for somatostatin receptor (SSTR) positive metastatic and/or inoperable neuroendocrine tumours (NETs). However, in patients with poorly controlled carcinoid syndrome, it may lead to an acute flare of carcinoid symptoms or even carcinoid crisis. We report seven patients who received PRRT with (¹⁷⁷Lu-DOTA⁰, Tyr³) octreotate (¹⁷⁷Lu-octreotate-LuTate) across two Australian tertiary medical institutions who developed acute flare of carcinoid symptoms/carcinoid crisis during/after PRRT. Cases were identified as high-risk due to previous history of carcinoid crises, high tumour burden and markedly elevated tumour markers. We propose a protocol to prevent and manage severe carcinoid symptoms in high-risk patients treated with PRRT.

THE ROLE OF SURGERY IN A PATIENT WITH CARCINOID SYNDROME, COMPLICATED BY CARCINOID HEART DISEASE

A 55-year-old female patient was admitted for flushing and abdominal pain in the right upper quadrant. Her past medical history revealed high blood pressure and a recent echocardiography showed thickened appearance of tricuspid valve with coaptation defect and grade II tricuspid regurgitation. Contrast enhanced abdominal CT scan and MRI were subsequently performed and revealed a large macronodular liver mass, as well as other micronodular lesions disseminated in the liver parenchyma. CT guided biopsy from the main liver mass revealed neuroendocrine tumor of unknown origin (probably GI) with Ki-67 of 8%. Surgical exploration was decided. During laparotomy, the primary tumor was found in the proximal ileum and the patient underwent segmental enterectomy. Non-anatomical hepatectomy was also performed to remove the bulk of the tumor burden (more than 90%). Postoperative course was uneventful and the carcinoid syndrome relieved. At present, 15 months postoperatively, the patient is under treatment with somatostatin analogue for its antiproliferative effect, with good clinical, biochemical and tumoral control and stable heart disease. In patients with neuroendocrine liver metastases from unknown primary, surgical exploration could allow detection (and resection) of the primary tumor and surgical debulking of liver metastases to control carcinoid syndrome and carcinoid heart disease.

Pharmacology of Octreotide: Clinical Implications for Anesthesiologists and Associated Risks

Many patients presenting with a history of foregut, midgut neuroendocrine tumors (NETs) or carcinoid syndrome can experience life-threatening carcinoid crises during anesthesia or surgery. Clinicians should understand the pharmacology of octreotide and appreciate the use of continuous infusions of high-dose octreotide, which can minimize intraoperative carcinoid crises. We administer a prophylactic 500-μg bolus of octreotide intravenously (IV) and begin a continuous infusion of 500 μg/h for all NET patients. Advantages include low cost and excellent safety profile. High-dose octreotide for midgut and foregut NETs requires an appreciation of the pathophysiology involved in the disease, pharmacology, drug-drug interactions, and side effects.

Fatal Systemic Vasoconstriction in a Case of Metastatic Small-Intestinal NET

An increased release of serotonin secreted by ileal NETs is thought to be the major factor causing the carcinoid syndrome. However, in acutely arising carcinoid crisis also other vasoactive factors may lead to hazardous fluctuations in blood pressure and bronchial constriction. In rare cases, systemic vasoconstriction can be observed, probably caused by catecholamines or similar acting substances. Here, we report a fatal case of fulminant systemic vasoconstriction possibly caused by catecholamines in a patient with metastasized ileal NET. The vasospasm was detected by CT-angiography, and hemodynamic monitoring revealed a high systemic vascular resistance. Epinephrine, norepinephrine, and chromogranin A levels in plasma were elevated as was the urinary 5-hydroxyindoleacetic acid (5-HIAA). The cause of death was heart failure due to severe circulatory insufficiency. The progression of the tumor disease was confirmed by autopsy.

ENETS Consensus Guidelines for the Standards of Care in Neuroendocrine Tumors: Pre- and Perioperative Therapy in Patients with Neuroendocrine Tumors

Neuroendocrine tumors of the small intestine are the most common causes of the carcinoid syndrome. Carcinoid heart disease occurs in more than half of the patients with the carcinoid syndrome. Patients with carcinoid heart disease who need to undergo surgery should also undergo preoperative evaluation by an expert cardiologist. Treatment with long-acting somatostatin analogs aims at controlling the excessive hormonal output and symptoms related to the carcinoid syndrome and at preventing a carcinoid crisis during interventions. Patients with a gastrinoma require pre- and postoperative treatment with high doses of proton pump inhibitors. Patients with a glucagonoma require somatostatin analog treatment and nutritional supplementation. Patients with a VIPoma also require somatostatin analog treatment and intravenous fluid and electrolyte therapy. Insulinoma patients generally require intravenous glucose infusion prior to operation. In patients with localized operable insulinoma, somatostatin analog infusion should only be considered after the effect of this therapy has been electively studied.

Systemic Therapies for Advanced Gastrointestinal Carcinoid Tumors

Well-differentiated gastrointestinal neuroendocrine tumors (GINETs) tend to be slow growing, but treatment of advanced disease remains a challenge. Somatostatin analogues (SSAs) are considered standard therapy for carcinoid syndrome. SSAs delay tumor progression in advanced well-differentiated gastroenteropancreatic NETs. Cytotoxic chemotherapy and interferon play a limited role in the treatment of nonpancreatic GINETs. There is no standard approach to treatment of patients with disease progression. Identification of systemic agents with antitumor activity in advanced disease remains an unmet medical need. Enrollment to clinical trials is encouraged; potential therapeutic targets include the vascular endothelial growth factor and mammalian target of rapamycin signaling pathways.

Continuous infusion of octreotide combined with perioperative octreotide bolus does not prevent intraoperative carcinoid crisis

BACKGROUND

Operations and anesthesia in carcinoid patients can provoke carcinoid crises, which can have serious sequelae, including death. Prophylactic octreotide is recommended to prevent crises. Recommended prophylaxis regimens vary from octreotide long-acting repeatable to preoperative bolus to continuous octreotide infusion; however, efficacy data are lacking. We have shown previously that crises correlated with major complications and that octreotide long-acting repeatable and preoperative bolus failed to prevent crises. This study examines the impact of continuous octreotide infusion.

METHODS

A total of 127 patients (71% with liver metastases, 74% with carcinoid syndrome) who underwent 150 operations with continuous octreotide infusions were enrolled in this prospective case series. Our main outcome measures were the occurrence of intraoperative carcinoid crises and post-operative complications.

RESULTS

Crises occurred at a rate of 30% as compared with 24% in our previous series, which examined the impact of preoperative octreotide bolus. Crises were significantly associated with the presence of hepatic metastases (P = .02) or history of carcinoid syndrome (P = .006), although neither was required for crises. Prompt vasopressor treatment shortened the mean duration of hypotension to 8.7 minutes, compared with 19 minutes in our prior series. Crises no longer correlated with major complications (P = .481) unless instability persisted for greater than 10 minutes (P = .011).

CONCLUSION

Octreotide infusions do not prevent intraoperative crises. Patients without liver metastases or carcinoid syndrome can have intraoperative crises. Postoperative complications can be decreased by reducing the duration of crises. Further study is needed to determine how best to shorten hemodynamic instability during crises.

Anesthetic management of patients undergoing resection of carcinoid metastasis to the brain

BACKGROUND

Carcinoid tumors are derived from enterochromaffin cells and may release physiologically active compounds into the systemic circulation, leading to the development of carcinoid syndrome. Occasionally, these tumors metastasize to the brain, warranting biopsy or resection. In these surgical patients, the perioperative implications for anesthetic management are not heretofore defined in the indexed literature.

METHODS

Patients who had craniotomy for biopsy or resection of intracranial carcinoid tumors were retrospectively identified at a single medical center. Patient demographics, perioperative anesthetic management, adverse events, and outcome were summarized in this case series.

RESULTS

Eleven patients were identified; median age was 60 years (range = 42-78 years), and 45% were male. Immediately before surgery, 4 patients (36%) were receiving a somatostatin analog drug, and no patient had unchecked carcinoid syndrome. All patients received general anesthesia that included inhaled isoflurane and nitrous oxide, and all had invasive arterial blood pressure monitoring. One patient developed sustained hypotension after induction of anesthesia, likely related to hypovolemia and anesthetic drugs, but the possibility of carcinoid mediator release cannot be excluded. There were no other signs or symptoms of carcinoid syndrome in this or any other patient. Of all 11 patients, 10 (91%) experienced either significant disease progression (n = 2; 18%) or death (n = 8; 73%) from carcinoid disease, its sequelae, or an undetermined cause within 3 years after surgery. Of note, 3 of the deaths occurred shortly after surgery, on postoperative days 3, 7, and 8.

CONCLUSIONS

In our experience, carcinoid tumor metastasis to the brain-whether because of tumor makeup or prior treatment-is unlikely to produce symptoms of new-onset carcinoid syndrome intraoperatively; however, the risk cannot be completely excluded. Postsurgical prognosis was poor, both within the hospital and after hospital discharge.

Management of bronchial carcinoid: An anaesthetic challenge

Carcinoid tumours pose a great challenge to anaesthesiologist, especially if carcinoid syndrome is present. We report peri-operative management of a patient with carcinoid syndrome who underwent upper lobectomy. Pre-operative optimisation for 10 days before surgery with injection octreotide and administration on the day of surgery as per guidelines was followed (North American Neuroendocrine Tumour Society guidelines). Our main goals were to prevent mediator release, avoidance of triggering factors and management of peri-operative carcinoid crisis. During tumour handling patient developed carcinoid crisis which was effectively treated with intravenous bolus octreotide and increasing rate of infusion.

Carcinoid heart disease: current understanding and future directions

Carcinoid tumors are rare and aggressive malignancies. A multitude of vasoactive agents are central to the systemic effects of these tumors. The additional burden of cardiac dysfunction heralds a steep decline in quality of life and survival. Unfortunately, by the time carcinoid syndrome surfaces clinically, the likelihood of cardiac involvement is 50%. Although medical therapies such as somatostatin analogues may provide some symptom relief, they offer no mortality benefit. On the other hand, referral to surgery following early detection has shown increased survival. The prompt recognition of this disease is therefore of the utmost importance.

Octreotide LAR and bolus octreotide are insufficient for preventing intraoperative complications in carcinoid patients

BACKGROUND AND OBJECTIVES

Surgery in carcinoid patients can provoke a carcinoid crisis, which can have serious sequelae, including death. Octreotide prophylaxis is recommended to prevent carcinoid crisis, however there are few reports of outcomes and no large series examining its efficacy. We hypothesized that a 500 µg prophylactic octreotide dose is sufficient to prevent carcinoid crisis.

METHODS

Records of carcinoid patients undergoing abdominal operations during years 2007-2011 were retrospectively reviewed. Octreotide use and intraoperative and postoperative outcomes were analyzed.

RESULTS

Ninety-seven intraabdominal operations performed by a single surgeon were reviewed. Ninety percent of patients received preoperative prophylactic octreotide. Fifty-six percent received at least one additional intraoperative dose. Twenty-three patients (24%) experienced an intraoperative complication. Intraoperative complications correlated with presence of hepatic metastases but not presence of carcinoid syndrome. Postoperative complications occurred in 60% of patients with intraoperative complications versus 31% of those with none (P = 0.01).

CONCLUSIONS

Significant intraoperative complications occur frequently in patients with hepatic metastases regardless of presence of carcinoid syndrome and despite octreotide LAR or single dose prophylactic octreotide. Occurrence of such events correlates strongly with postoperative complications. Randomized controlled trials are needed to determine whether the administration of prophylactic octreotide is beneficial.

Practical guide to supportive care of patients with functional neuroendocrine tumors

Supportive care of patients with functional neuroendocrine tumors (NETs) has evolved to include the use of multiple targeted agents to control paraneoplastic states and newer surgical and interventional radiologic techniques to reduce tumor bulk. Challenges encountered by the clinician are the recognition of specific symptom complexes, selecting the relevant laboratory tests and radiologic/scintigraphic scans, and the timing of intervention(s). Individual variables such as the severity of symptoms in the context of primary and metastatic disease sites, tumor bulk, comorbidities, and previous treatment are factors determining the prioritization of specific treatment regimens for patients with functional NETs. Symptoms such as flushing, secretory diarrhea, hypercalcemia, hyper /hypoglycemia, hypercortisolism, and peptic ulcers should improve with decreasing the elevated amino acid and/or peptide levels produced by NETs. These paraneoplastic symptoms may be accompanied by complaints related to tumor burden such as fatigue, pain, early satiety, anorexia, weight loss, night sweats, and/or symptoms secondary to adverse drug effects such as mucositis, dysgeusia, diarrhea, rash, hypertension, and myelosuppression. Developing a comprehensive continuum of care plan early in disease management assists in controlling the presenting signs and symptoms, and in minimizing disease- and/or treatment-related side effects. This guide serves as a framework to manage the signs and symptoms of metastatic functional neuroendocrine tumors.

Recurrent Acute Severe Pulmonary Oedema as a Presentation of Carcinoid Crisis following Cardiac Surgery

This is a case report of a 75-year-old patient with a pelvic carcinoid tumour who had valve replacements and a patent foramen ovale repair. Her postoperative course was complicated by persistent symptoms related to the carcinoid tumour. Pathophysiology and management are reviewed. Cardiac surgery for carcinoid heart surgery has significantly high morbidity and mortality. Common complications include cardiovascular instability, bronchospasm, complete heart block, gastrointestinal hypermotility and acute kidney injury. Acute pulmonary oedema can be a presenting feature of a carcinoid crisis and should be suspected in the differential diagnoses of pulmonary oedema in carcinoid heart disease patients. Octreotide remains the mainstay of treatment. Doses of up to a maximum of 200 μg/hour can be used. There is emerging evidence that catecholamines can be used safely when used in conjunction with octreotide. Good analgesia is important in suppressing sympathetic stimulation.

Carcinoid syndrome and perioperative anesthetic considerations

Carcinoid tumors are uncommon, slow-growing neoplasms. These tumors are capable of secreting numerous bioactive substances, which results in significant potential challenges in the management of patients afflicted with carcinoid syndrome. Over the past two decades, both surgical and medical therapeutic options have broadened, resulting in improved outcomes. The pathophysiology, clinical signs and symptoms, diagnosis, treatment options, and perioperative management, including anesthetic considerations, of carcinoid syndrome are presented.

Small bowel tumors

Although rare, small bowel tumors may cause significant morbidity and mortality if left undetected. New endoscopic modalities allow full examination of the small bowel with improved diagnosis. However, isolated mass lesions may be missed by capsule endoscopy or incomplete balloon-assisted enteroscopy. Therefore the use of radiologic imaging and intraoperative enteroscopy for diagnosis should not be forgotten. Endoscopic resection of small bowel polyps and certain vascular tumors is possible but requires proper training. Advances in endoscopic tools are likely to broaden the endoscopic management of small bowel tumors. This article describes the general features of small bowel tumors, clinical presentation, and diagnostic tests followed by a description of the more common tumor types and their management.

The neuroendocrine tumors of the ileum

Neuroendocrine tumors arise from the diffuse neuroendocrine system and secrete several peptides and bioactive amines (serotonin, histamine, dopamine, norepinephrine, corticotropin, calcitonin, bradykinin, kalikrein, gastrin, cholecystokinin, prostaglandins). The most common occurrence site of neuroendocrine tumors is the ileum. The symptoms of small bowel carcinoids are represented by intermittent intestinal obstruction and carcinoid syndrome. Presence of the carcinoid syndrome usually indicates hepatic or retroperitoneal metastases. The typical carcinoid syndrome is characterized by flushing, diarrhea, nonspecific abdominal pain and bronchospasm. The diagnosis of small bowel tumors is often difficult due to their rarity and the nonspecific and variable nature of the presenting signs and symptoms. The most useful initial diagnostic test for the carcinoid syndrome is to measure 24-hour urinary excretion of 5-hydroxyindolacetic acid (5 HIAA), which is the end product of serotonin metabolism. Capsule endoscopy is a more recent diagnostic tool. Surgery is the radical form of curative therapy for carcinoid tumors. Numerous therapies are available for palliation including surgery, pharmacologic therapy, interventional radiologic therapy, embolization and chemoembolization of hepatic metastases, immunotherapy (Interferon alfa) and chemotherapy. We carefully reviewed the available literature on this topic before beginning our study.

Hormonal crises following receptor radionuclide therapy with the radiolabeled somatostatin analogue [177Lu-DOTA0,Tyr3]octreotate

Introduction

Receptor radionuclide therapy is a promising treatment modality for patients with neuroendocrine tumors for whom alternative treatments are limited. The aim of this study was to investigate the incidence of hormonal crises after therapy with the radiolabeled somatostatin analogue [¹⁷⁷Lu-DOTA⁰,Tyr³]octreotate (¹⁷⁷Lu-octreotate).

Materials and methods

All ¹⁷⁷Lu-octreotate treatments between January 2000 and January 2007 were investigated. Four hundred seventy-six patients with gastroenteropancreatic neuroendocrine tumors and three patients with metastatic pheochromocytoma were included for analysis.

Results

Four hundred seventy-nine patients received a total of 1,693 administrations of ¹⁷⁷Lu-octreotate. Six of 479 patients (1%) developed severe symptoms because of massive release of bioactive substances after the first cycle of ¹⁷⁷Lu-octreotate. One patient had a metastatic hormone-producing small intestinal carcinoid; two patients had metastatic, hormone-producing bronchial carcinoids; two patients had vasoactive intestinal polypeptide-producing pancreatic endocrine tumors (VIPomas); and one patient had a metastatic pheochromocytoma. With adequate treatment, all patients eventually recovered.

Conclusion

Hormonal crises after ¹⁷⁷Lu-octreotate therapy occur in 1% of patients. Generally, ¹⁷⁷Lu-octreotate therapy is well tolerated.

Carcinoid heart disease

Progress in the medical and surgical management of patients with carcinoid disease has resulted in improved symptoms and survival. Carcinoid heart disease remains a major cause of morbidity and mortality among patients with malignant carcinoid syndrome. Limited medical treatment options are available for patients with symptomatic carcinoid heart disease. At the Mayo Clinic (Rochester, MN), we have taken an aggressive approach to severe valvular dysfunction from carcinoid heart disease. Patients with severe carcinoid heart disease currently are referred for cardiac operation when they develop cardiac symptoms, ventricular dysfunction, or (rarely) in anticipation of hepatic surgery. Surgical outcome depends on patient age and functional class at the time of cardiac surgery. Despite metastatic disease that limits longevity, cardiac surgical survivors usually demonstrate dramatic improvement in functional capacity. Cardiac surgery should be considered early for patients with symptomatic carcinoid heart disease and controlled carcinoid symptoms. An experienced medical, surgical, and anesthetic team approach to the patient with carcinoid heart disease is critical in order to provide state of the art management.

Carcinoid heart disease

Carcinoid heart disease is a rare form of valvular heart disease. The management of these patients is complex, as the systemic malignant disease and the cardiac involvement have to be considered at the same time. Progress in the treatment of patients with carcinoid disease has resulted in improved symptom control and survival. Development and progression of carcinoid heart disease are associated with increased morbidity and mortality. In patients with severe cardiac involvement and well-controlled systemic disease, cardiac surgery has been recognized as the only effective treatment option. Valve replacement surgery may not only be beneficial in terms of symptom relief, but may also contribute to the improved survival observed over the past 2 decades in patients with carcinoid heart disease. Early diagnosis and early surgical treatment in appropriately selected patients may provide the best results. In this article, we review the current literature regarding the biology, diagnosis, treatment, and prognosis of carcinoid heart disease.

Carcinoid tumor and carcinoid syndrome

PURPOSE OF REVIEW

Carcinoid tumors secrete many different types of substances (e.g. serotonin, bradykinin) that may produce potentially fatal intraoperative reactions such as hypotension and bronchoconstriction. The most effective treatment for the deleterious cardiovascular and pulmonary effects of serotonin and bradykinin is octreotide, a somatostatin analogue. Carcinoid heart disease, which develops in the majority of patients with carcinoid syndrome, presents the anesthesiologist with more diagnostic and therapeutic dilemmas.

RECENT FINDINGS

The incidence of carcinoid tumors is much greater than previously recognized. New diagnostic techniques permit identification and localization of carcinoid tumors with greater accuracy. Short term and long term therapy with octreotide significantly improves survival and reduces the severity of 'carcinoid crises'. Echocardiographic studies have demonstrated a very high incidence of carcinoid heart disease (tricuspid and pulmonary insufficiency) in patients with carcinoid syndrome. Cardiac valve surgery is, consequently, becoming much more common in patients with carcinoid syndrome.

SUMMARY

More patients with carcinoid tumors and carcinoid syndrome are requiring anesthesia and surgery. Specific therapy with somatostatin analogues (octreotide) has replaced older less specific drugs (e.g. antihistamines) for the treatment of adverse effects caused by products of carcinoid tumors.

Successful palliation with octreotide of a neuroendocrine syndrome from malignant melanoma

We present a unique case of a neuroendocrine syndrome in a patient with Stage IV vaginal melanoma metastatic to the liver that was successfully palliated with octreotide. Similar to the carcinoid syndrome, the patient exhibited chronic diaphoresis, intermittent low-grade fevers, dizziness, nausea with vomiting, and hot flashes. The symptoms on admission of acute hypotension, acute exacerbation of abdominal pains, and intractable nausea with vomiting suggested a neuroendocrine crisis secondary to massive degranulation and hormone release. Consistent with our hypothesis, her plasma chromogranin A was found to be elevated. Octreotide was used successfully to palliate her symptoms. When the octreotide was stopped, all her symptoms returned. As the use of octreotide is gaining application in palliative care, this case highlights the effectiveness of its use in a select group of patients whose symptoms would be otherwise difficult to manage.

Anesthetic considerations in the multiple endocrine neoplasia syndromes

PURPOSE OF REVIEW

The multiple endocrine neoplasia (MEN) syndromes present a diverse array of challenges to the anesthesiologist. The tumors and their effects are often underdiagnosed and potentially discovered only when the patient is undergoing surgery for either a component of one of the syndromes or another procedure altogether. This can present the anesthesiologist with a life-threatening situation in the operating room. A thorough understanding of the syndromes, as well as management strategies, will enable the anesthesiologist to handle these patients.

RECENT FINDINGS

Advances in the pharmacologic armamentarium available to physicians have enabled patients with MEN, particularly those with the carcinoid syndrome or pheochromocytoma, to undergo surgery safely, with minimal morbidity and mortality.

SUMMARY

Awareness of the components of the MEN syndromes, as well as careful preoperative preparation, paves the way for a smooth anesthetic and postoperative course in these patients.

[Surgical treatment of gastric, enteric, and pancreatic endocrine tumors Part 1. Treatment of primary endocrine tumors]

Endocrine tumors (ET) of the digestive tract (formerly called neuroendocrine tumors) are rare. They are classified into two principal types: gastrointestinal ET's (formerly called carcinoid tumors) which are the most common, and pancreaticoduodenal ET's. Functioning ET's secrete polypeptide hormones which cause characteristic hormonal syndromes. The management of ET is multidisciplinary. Poorly-differentiated ET's have a poor prognosis and are treated by chemotherapy. Surgical excision is the only curative treatment of well-differentiated ET's. The surgical goals are to: 1. prolong survival by resecting the primary tumor and any nodal or hepatic metastases, 2. control the symptoms related to hormonal secretion, 3. prevent or treat local complications. The most common sites of gastrointestinal ET's ( carcinoids) are the appendix and the rectum; these are often small (<1 cm), benign, and discovered fortuitously at the time of appendectomy or colonoscopic removal. Ileal ET's, even if small, are malignant, frequently multiple, and complicated in 30-50% of cases by bowel obstruction, mesenteric invasion, or bleeding. The carcinoid syndrome (consisting of abdominal pain, flushing, diarrhea, hypertension, bronchospasm, and right sided cardiac vegetations) is caused by the hypersecretion of serotonin into the systemic circulation; it occurs in 10% of cases and is usually associated with hepatic metastases. More than half of the cases of pancreatic ET are non-functional. They are usually malignant and of advanced stage at diagnosis presenting as a palpable or obstructing mass or as liver metastases. Insulinoma and gastrinoma (cause of the Zollinger-Ellison syndrome) are the most common functional ET's. 80% are sporadic; in these cases, tumor size, location, and malignant potential determine the type of resection which may vary from a simple enucleation to a formal pancreatectomy. In 10-20% of cases, pancreaticoduodenal ET presents in the setting of multiple endocrine neoplasia (NEM type I), an autosomal-dominant genetic disease with multifocal endocrine involvement of the pituitary, parathyroid, pancreas, and adrenal glands. For insulinoma with NEM-I, enucleation of lesions in the pancreatic head plus a caudal pancreatectomy is the most appropriate procedure. For gastrinoma with NEM-I, the benefit of surgical resection for tumors less than 2-3 cm in size is not clear. The lesions are frequently small, multiple, and widespread and recurrence is frequent after excision. The long-term prognosis is nevertheless fairly good. But the eventual development of liver metastases which are the most common cause of mortality still argues for an aggressive surgical approach in the early stages of the disease.

Remifentanil and anaesthesia for carcinoid syndrome

Carcinoid syndrome creates many challenges during anaesthesia, including hypertension, hypotension and bronchospasm. These challenges are less common and less severe after the routine use of octreotide. We describe the use of remifentanil as part of the anaesthetic management of a 67-yr-old man undergoing resection of a carcinoid tumour of the terminal ileum. The combination of perioperative octreotide administration, intraoperative remifentanil infusion and sevoflurane anaesthesia, with postoperative epidural analgesia proved satisfactory. We review the recent literature and suggest that remifentanil is a useful addition to the armamentarium of the anaesthetist in the management of a patient with carcinoid syndrome.

Somatostatin analog therapy in treatment of gastrointestinal disorders and tumors

Long-acting octapeptide somatostatin analogs can effectively control symptoms resulting from excessive hormone release in patients with endocrine tumors of the gastrointestinal tract, provided that these tumors and metastases show a high expression of the somatostatin receptor subtype 2. The presence of this receptor subtype on these tumors can be demonstrated by in vitro studies, but also in vivo using 111In-pentetreotide scintigraphy. In a few studies, significant antiproliferative effects of these drugs on these tumors have also been demonstrated. The effectiveness of octapeptide somatostatin analogs in the management of chemotherapy- related and AIDS-related diarrhea and in reducing postoperative complications of pancreatic surgery have also been demonstrated. These drugs have been used to decrease the output of enterocutaneous pancreatic fistulas and are prophylactically used to prevent the development of these fistulas. Octapeptide somatostatin analog therapy is widely accepted for the initial management of acute variceal bleeding in cirrhotic patients. These drugs are currently also being evaluated for the treatment of advanced hepatocellular carcinoma and malignant intestinal obstruction. Radiotherapy with octapeptide somatostatin analogs coupled to radionuclides such as indium-111, yttrium-90, and lutetium- 177 is currently being studied in phase I-III trials.

Uneventful spinal anesthesia for a patient with carcinoid syndrome managed with long-acting octreotide

PURPOSE

To present a case of spinal anesthesia in a patient suffering from carcinoid syndrome undergoing an inguinal hernia repair. In the past, regional anesthesia was considered unacceptable in these patients because of the possibility of intraoperative hypotension, hypertension, or bronchospasm. Recently, however, the preoperative use of octreotide, the synthetic analogue of the naturally occurring hormone somastatin, has been found to prevent these complications. Nevertheless, it remains unclear whether the use of this drug in patients with carcinoid syndrome allows the possibility of regional anesthesia.

CLINICAL FINDINGS

We report the uneventful use of spinal anesthesia in a patient suffering from carcinoid syndrome treated with long-acting octreotide. With careful attention to volume status of the patient and low volume of local anesthetics (10 mg hyperbaric bupivacaine 0.5%) supplemented with intrathecal narcotics (fentanyl 20 micro g), we were able to prevent any episodes of intraoperative hypotension in this patient. Octreotide was available in the operating theatre in case of an emergency. One of the original aspects of this case report is that the patient received long-acting octreotide (once a month administration) instead of the usual daily dose. In addition this is one of the few reports of spinal anesthesia administered to a patient with carcinoid syndrome.

CONCLUSION

Preoperative octreotide may result in more favourable conditions for regional anesthesia in patients with carcinoid syndrome. However, further studies will be required to confirm the favourable outcome observed in this patient.

Carcinoid heart disease: a case report and literature review

We report a patient who presented for elective exploratory laparotomy, and resection of a pelvic mass, which was thought to be ovarian carcinoma. Intraoperative transesophageal echocardiography demonstrated right-sided valvular heart lesions, which suggested the diagnosis of carcinoid syndrome before a pathologic confirmation was obtained. This article discusses the classical presentation and anesthetic management of patients with carcinoid syndrome and emphasizes the importance of proper preoperative diagnosis and careful planning if the incidence and severity of the symptoms that this condition can provoke are to be reduced.