Carcinoid disease of the heart

Metastatic Midgut Carcinoid in the Myocardium

Metastasis of neuroendocrine tumor to the myocardium is rare. We present a case of 64-year-old woman, who presented initially with abdominal pain and large adnexal mass. The image-guided biopsy showed low-grade neuroendocrine tumor with Ki67 less than 2% within the ovarian tissue. CT staging revealed bilateral adnexal masses, liver metastases, and primary lesion in the terminal ileum. Octreoscan showed marked tracer uptake within the lower esophagus not related to obvious mass on CT scan; the echocardiography confirmed the presence of a 2.7 cm LV/LA mass. In this case, close correlation between ECHO and the octreoscan obviated need for myocardial biopsy.

⁶⁸Ga-DOTA-TOC-PET/CT detects heart metastases from ileal neuroendocrine tumors

Metastases from ileal neuroendocrine tumors (NETs) to the myocardium are rare and generally seen in patients with widespread metastatic NET disease. The objectives of this investigation were to describe the frequency of intracardiac metastases in ileal NET patients examined by (68)Ga-DOTA-TOC-PET/CT and to describe the cases in detail. All (68)Ga-DOTA-TOC-PET/CT examinations performed at the Karolinska University Hospital since 2010 until April 2012 were reviewed. In all, 128 out of 337 examinations were in patients with ileal NETs. Four patients had seven myocardiac metastases, yielding a frequency of 4.3 % in patients with ileal NETs. One patient had cardiac surgery while three were treated with somatostatin analogs. The cardiac metastases did not affect the patients' activity of daily life. (68)Ga-DOTA-TOC-PET/CT is an established imaging modality in identifying cardiac metastases in ileal NETs. Prospective studies are needed to confirm the true clinical value of (68)Ga-DOTA-TOC-PET/CT in detecting cardiac metastases in both ileal and non-ileal NETs.

Primary insular carcinoid of the ovary with carcinoid heart disease: Unfavourable outcome of a case

INTRODUCTION

Primary ovarian carcinoid is a very rare disease. Carcinoid heart disease occurs in about one-third of patients with carcinoid syndrome. Cardiac involvement may be a cause of death in this syndrome.

PRESENTATION OF CASE

We presents the unfavourable outcome of a 78-year-old woman admitted to the hospital complaining severe dyspnea and peripheral oedemas. Because of the presence of a large pericardial effusion with compression of cardiac chambers, an evacuative pericardiocentesis was performed. Computed tomography showed a solid pelvic mass with ascites. She underwent a complete surgical staging. Histological findings revealed an insular carcinoid stage IA. Three weeks later she was readmitted to the hospital and echocardiography demonstrated a right tricuspid valvular involvement with stenosis and severe regurgitation with a 2 cm masses in the posterior mitral leaflet. Hemoculture was positive for Staphylococcus aureus. Patient was not suitable for surgical intervention and decease due to sepsis and because secondary complications of the mitral endocarditis.

DISCUSSION

High level of 5-HIAA has a rule in the development and progression of the carcinoid heart syndrome and could lead the right tricuspid valvular involvement. In the case we presented the bacterial endocarditis worsened the cardiac functions and the clinical conditions before she deceased.

CONCLUSION

Ovarian primary carcinoid tumors are very rare tumors that require appropriate preoperative diagnosis. Even if survival is usually excellent, when carcinoid syndrome with heart involvement is present, a high level of attention is mandatory to prevent and limit damage caused by the vasoactive amine secreted by the tumor.

Surgery for carcinoid heart disease: current outcomes, concerns and controversies

Cardiac involvement in patients with carcinoid disease is a well-recognized pathology. Early reports described right-sided heart involvement. More recently, both right- and left-sided heart disease have been reported. Progress of the treatment of carcinoid disease is leading to an increase in the number of patients presenting for surgery to treat valvular dysfunction. owing to improvements in the prognosis of the basic disease, valve replacement surgery is now a reasonable option in patients with severe valvular dysfunction. This article provides an overview of carcinoid heart disease with an emphasis on current outcomes, concerns and controversies associated with the surgical management of this disease.

Management of patients undergoing multivalvular surgery for carcinoid heart disease: the role of the anaesthetist

BACKGROUND

The management of patients with carcinoid heart disease poses two major challenges for the anaesthetist: carcinoid crisis and low cardiac output secondary to right ventricular (RV) failure. Carcinoid crises may be precipitated by the administration of catecholamines and histamine-releasing drugs.

METHODS

We analysed a series of 11 patients [six males, median (range) age 60 (42-73) yr] with severe symptomatic carcinoid heart disease who underwent multivalve surgery (right-sided valves, n=8; right- and left-sided valves, n=3) between 2001 and 2007.

RESULTS

All patients received octreotide intraoperatively [650 (300-1050) microg] to prevent carcinoid symptoms and vasoplegia. Those patients on a greater preoperative octreotide regime required additional intraoperative octreotide [median (range) dose 320 (300-850) vs 750 (650-1050) mug]. Similarly, the use of greater doses of aprotinin (> 5 KIU) was associated with greater requirements for octreotide [475 (300-700) vs 750 (320-1050) microg] and higher glucose levels (> or =8.5 mmol litre(-1)). Catecholamines were generally required in those patients who presented with a worse New York Heart Association functional class. Overall mortality was 18% (n=2) and only one episode of mild intraoperative carcinoid crisis was observed.

CONCLUSIONS

Carcinoid crisis and RV failure still remain the primary challenges for the anaesthesiologist while managing patients with carcinoid heart disease. Our study supports the administration of catecholamines to wean patients off cardiopulmonary bypass, particularly in the presence of myocardial dysfunction. Those patients on higher octreotide dosages may require close intraoperative glucose monitoring. Despite high operative mortality, surgical outcome has been improved potentially due to earlier patient referral and better perioperative management.

Carcinoid heart disease

The carcinoid syndrome is usually evident when enterochromaffin (EC) cell-derived neuroendocrine tumors (carcinoids) metastasize to the liver. In addition to carcinoid symptomatology, about 40% of patients exhibit carcinoid heart disease (CHD) with fibrotic endocardial plaques and associated heart valve dysfunction. The mechanism behind CHD development is not fully understood, but serotonin (5-HT) is considered to be a major initiator of the fibrotic process. Most patients present with right-sided heart valve dysfunction since pulmonary and tricuspid valves lesions are the most common (>95%) cardiac pathology. Left-sided valvular involvement, and angina associated with coronary vasospasm occur in ~10% of subjects with CHD. Pathognomonic echocardiograpic features include immobility of valve leaflets and thickening and retraction of the cusps most commonly resulting in tricuspid valve regurgitation and pulmonary stenosis. Therapeutic options include cardioactive pharmacotherapy for heart failure and, in selected individuals, cardiac valve replacement. Previously valve replacement was reserved for advanced disease due to a perioperative mortality of >20% however in the last decade, technical advances as well as an earlier diagnosis have decreased surgical mortality to <10% and valve replacements are undertaken more frequently. A recent analysis of 200 cases demonstrated an increase in median survival from 1.5 years to 4.4 years in the last two decades. Although the improved prognosis might also reflect the increased use of surgical cytoreduction, hepatic metastatic ablative therapies and somatostatin analogs a robust correlation between diminution of circulating tumor products and an increased long-term survival in CHD has not been rigorously demonstrated.

Carcinoid pulmonary valvulopathy evaluated by real-time 3-dimensional transthoracic echocardiography

A 55-year-old woman with carcinoid valvular heart disease was referred for consideration of right-sided valve replacement. By transthoracic 2-dimensional and Doppler echocardiography, there was severe tricuspid regurgitation and mild right ventricular dysfunction. The pulmonary valve was thickened with annular constriction and severe regurgitation. Real-time 3-dimensional transthoracic echocardiography provided an en face view of pulmonary valve from the right ventricular outflow perspective, not obtainable by routine 2-dimensional echocardiography. Three-dimensional echocardiography may play an incremental role for the preoperative assessment of the pulmonary valve in patients with carcinoid heart disease.

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.

Quadruple Valve Involvement in a Patient With Severe Carcinoid Heart Disease

We report on the case of a 48-year-old male patient suffering from a severe carcinoid heart disease with involvement of the four valves. The primary carcinoid tumor was diagnosed in the ileum. The patient developed a moderate stenosis and severe insufficiency of the tricuspid valve, a severe insufficiency of the pulmonary valve, and a moderate insufficiency of the mitral and aortic valves. Ultimately, a stentless pulmonary valve replacement was performed, as well as a tricuspid valve replacement with a pericardial prosthesis and aortic and mitral valve plasty. The patient recovered well and he was discharged from hospital on day 10.

Metastatic carcinoid tumor of the heart

Although carcinoid heart disease has been well described in the literature, metastatic implantation in the heart is rare. We describe a 79-year-old man with no previous history of cancer who presented with progressive dyspnea. He was found to have a septal implantation of a previously undiagnosed metastatic carcinoid tumor. He underwent successful resection with an uneventful postoperative course.

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.

Surgical pathology of carcinoid heart disease: a study of 139 valves from 75 patients spanning 20 years

OBJECTIVE

To quantitate the pathologic features of carcinoid plaques in a relatively large number of surgical specimens from a single institution.

PATIENTS AND METHODS

Medical records, operative reports, and surgical specimens were reviewed from all patients with carcinoid heart disease who underwent cardiac valvular surgery at Mayo Clinic, Rochester, Minn, between 1980 and 2000.

RESULTS

The study group included 75 patients (45 men, 30 women) who ranged in age from 26 to 78 years (mean, 59 years). From these 75 patients, 139 valves had been excised surgically (73 tricuspid, 55 pulmonary, 6 mitral, 5 aortic). Pure regurgitation was the most common dysfunctional state of the tricuspid valve (80% [60/75]), mitral valve (97% [32/33]), and aortic valve (96% [23/24]). The pulmonary valve was more often both stenotic and insufficient (52% [37/71]) than purely regurgitant (30% [21/71]). In all cases, valve dysfunction was attributed to the presence of carcinoid plaques, which caused both thickening and retraction. Thickening was the result of both cellular proliferation and deposition of extracellular matrix. Proliferation of myofibroblasts was observed in all plaques and was mild in 49% (68/139) and moderate or severe in 51% (71/139). Extracellular matrix included collagen (in 99% of the 139 valves), myxoid ground substance (98% [136/139]), and elastin (20% [28/139]). Carcinoid plaques were also involved by neovascularization (94% [131/139]), chronic inflammation (94% [131/139]), and mast cell infiltration (64% [89/139]). Severe thickening was attributable primarily to collagen deposition in tricuspid valves and to myofibroblast proliferation and myxoid matrix in pulmonary valves.

CONCLUSIONS

Among patients undergoing valvular surgery for carcinoid heart disease, tricuspid and pulmonary valves represented 92% of the excised valves (128/ 139). Although numerous cellular and extracellular features were common to the carcinoid plaques, variability in their relative expression produced appreciable differences in the histologic appearance among the plaques.

Carcinoid heart disease and carcinoid syndrome: successful surgical treatment

Tumor debulking can greatly improve quality of life for patients with malignant carcinoid syndrome, but hepatic cytoreduction is confounded by carcinoid heart disease, which can cause postsinusoidal portal hypertension, thereby increasing the risk of death from hemorrhage during hepatic resection. We describe a patient with metastatic carcinoid syndrome and carcinoid heart disease who had repair of his carcinoid heart disease and, after improvement of right-sided heart function, had successful hepatic debulking of carcinoid metastases.

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 heart disease. Correlation of high serotonin levels with valvular abnormalities detected by cardiac catheterization and echocardiography

BACKGROUND

Although serotonin has been postulated as an etiologic agent in the development of carcinoid heart disease, no direct evidence for different ambient serotonin levels in cardiac and noncardiac patients has been reported to date.

METHODS AND RESULTS

The present study reviews our experience with 604 patients in the Duke Carcinoid Database. Nineteen patients with proven carcinoid heart disease (by cardiac catheterization and/or echocardiogram) were compared with the remaining 585 noncardiac patients in the database with regard to circulating serotonin and its principal metabolite, 5-hydroxyindole acetic acid (5-HIAA). No significant demographic differences existed between the cardiac and noncardiac groups; however, typical carcinoid syndrome symptoms (ie, flushing and diarrhea) were almost threefold more common in the cardiac group (P < .001). Compared with the noncardiac group, heart disease patients demonstrated strikingly higher (P < .0001) mean serum serotonin (9750 versus 4350 pmol/mL), plasma serotonin (1130 versus 426 pmol/mL), platelet serotonin (6240 versus 2700 pmol/mg protein), and urine 5-HIAA (219 versus 55.3 mg/24 h) levels. The spectrum of heart disease among the 19 patients showed a strong right-sided valvular predominance, with tricuspid regurgitation being the most common valvular dysfunction (92% by cardiac catheterization; 100% by echocardiogram).

CONCLUSIONS

These data suggest that serotonin plays a major role in the pathogenesis of the cardiac plaque formation observed in carcinoid patients.

Tricuspid valve replacement: porcine bioprostheses and mechanical prostheses

The clinical performance of tricuspid valve replacement with bioprostheses and mechanical prostheses was assessed in a series of 5,489 total valve replacement operations performed from 1975 to 1992. There were 97 (1.8%) tricuspid valve replacements in 94 patients (16 men, 78 women) with a mean age of 55.4 +/- 13.8 years. Bioprostheses (mean patient age, 55.9 +/- 14.1 years) were used in 83 operations and mechanical prostheses (mean patient age, 52.1 +/- 11.9 years) were used in 14 operations. There were 30 isolated tricuspid valve replacements and 67 tricuspid valve replacements incorporated in multiple valve replacements. The total cumulative follow-up was 360 patient-years (bioprostheses, 321 years; mechanical prostheses, 39 years) (96.8% complete). The mean follow-up was 3.7 years (bioprostheses, 3.9 years; mechanical prostheses, 2.8 years) (p = not significant). The early mortality was 14.4% (bioprostheses, 14.5%; mechanical prostheses, 14.3%) (p = not significant) (isolated replacement, 13.3%; multiple replacement, 14.9%). The late mortality was 9.2% per patient-year (isolated replacement, 12.2% per patient-year; multiple replacement, 7.9% per patient-year). The freedom from structural valve deterioration at 5 and 7 years was 100% for mechanical prostheses and 97.1% +/- 2.9% for bioprostheses (p = not significant). For isolated tricuspid valve replacement, the freedom from structural valve deterioration for bioprostheses was 90.9% +/- 8.7% at 5 years and at 7 years (p = not significant). For the mechanical prostheses, the freedom was 100%.(ABSTRACT TRUNCATED AT 250 WORDS)

Predictors of outcome of tricuspid valve replacement in carcinoid heart disease

The cardiac valvular surgical experience of patients in the Duke Carcinoid Database was reviewed to assess operative outcome. Of the 604 patients in the database, 19 patients with carcinoid heart disease were identified by cardiac catheterization or echocardiography, or both. Eight of these underwent tricuspid valve replacement surgery with bioprostheses (2 also had open pulmonic valvuloplasty). Compared with patients medically managed, surgically treated patients were similar with the exception that they had higher right atrial mean (17 +/- 6 vs 9 +/- 4 mm Hg, p = 0.03) and v-wave (27 +/- 6 vs 17 +/- 7 mm Hg, p = 0.04) pressures. Of the 8 surgical patients, 5 (63%) died within 30 days. Causes of death included tricuspid valve thrombosis, cerebral vascular accident, coagulopathy, renal failure, and intractable right heart failure. High comorbidity was present in all 8 patients. There was a weak trend (p = 0.17) toward lower Charlson comorbidity indexes in survivors (6.7 +/- 0.6) compared with nonsurvivors (7.6 +/- 0.9). Age was significantly lower (p = 0.036) in survivors (46 +/- 13 years) compared with nonsurvivors (69 +/- 4 years). Extended follow-up revealed 2 patients who survived beyond a decade. Review of 47 carcinoid valve replacement cases (Duke Carcinoid Database and 39 published cases) revealed a 30-day mortality of 56% for patients > 60 years of age, and 0% for those < or = 60 years of age (p < 0.0001). Although valve replacement surgery can afford prolonged palliation from carcinoid heart disease, it is associated with a significant mortality risk. Careful preoperative risk stratification by age and comorbidity may provide a means for optimal selection of surgical candidates.

Outcome of cardiac surgery for carcinoid heart disease

OBJECTIVES

The hypothesis was that cardiac surgery for symptomatic carcinoid heart disease in conjunction with adjunctive therapy could improve the long-term outlook of patients with carcinoid heart disease.

BACKGROUND

Patients with carcinoid heart disease have a dismal prognosis; most die of progressive right heart failure within 1 year after onset of symptoms. Improved therapies for the systemic manifestations of the carcinoid syndrome have resulted in symptomatic improvement and prolonged survival in patients without heart disease.

METHODS

Twenty-six patients with symptomatic carcinoid heart disease underwent valvular surgery. Preoperative clinical, laboratory, Doppler echocardiographic and hemodynamic factors were evaluated. The survival of the surgical group was compared with that of a control group of 40 medically treated patients.

RESULTS

There were nine perioperative deaths (35%), primarily from postoperative bleeding and right ventricular failure. Of the 17 surgical survivors, 8 were alive at a mean of 28 months of follow-up. The postoperative functional class of the eight surviving patients was substantially improved. Late deaths were primarily due to hepatic dysfunction caused by metastatic disease. The only predictor of operative mortality (p = 0.03) was low voltage on preoperative electrocardiography (limb lead voltage < or = 5 mm). Predictors of late survival included a lower preoperative somatostatin requirement and a lower preoperative urinary 5-hydroxy-indoleacetic acid level. There was a trend toward increased survival for the surgical group compared with the control group.

CONCLUSIONS

Because new therapies have improved survival in patients with the malignant carcinoid syndrome, cardiac involvement has become a major cause of morbidity and mortality. Valve surgery is the only definitive treatment. Although cardiac surgery carries a high perioperative mortality, marked symptomatic improvement occurs in survivors. Surgical intervention should therefore be considered when cardiac symptoms become severe.

Carcinoid heart disease: early failure of an allograft valve replacement

A woman who had carcinoid syndrome and carcinoid heart disease underwent tricuspid and pulmonary valve replacements with a xenograft and a cryopreserved allograft, respectively. Within 3 months of the operation severe pulmonary regurgitation and pulmonary hypertension refractory to medical therapy developed. Autopsy found the biomechanical tricuspid valve to be free of disease but the allograft in the pulmonary position was involved by carcinoid heart disease in a fashion similar to the excised native pulmonary valve.

Successful balloon dilatation of the pulmonary valve in carcinoid heart disease

Percutaneous balloon dilatation of the pulmonary valve resulted in long lasting benefit in a 40-year-old patient with carcinoid heart disease. Concomitant aggressive therapy for her metastatic carcinoid tumour may explain why the clinical outcome was better than previous reports.

Bronchial carcinoid tumors

Bronchial carcinoid tumors, termed (incorrectly) "bronchial adenomas" in the past, are uncommon pulmonary neoplasms. These tumors are currently classified as neuroendocrine in origin because of their potential to form and sometimes secrete a variety of chemical substances. Overall, approximately 75% of bronchial carcinoid tumors arise in the lobar bronchi, 10% occur in the main-stem bronchi, and 15% originate in the periphery of the lung. Well-differentiated carcinoid tumors constitute almost 90% of all bronchial carcinoids. Atypical carcinoid tumors have a higher malignant potential than do typical bronchial carcinoids. The carcinoid syndrome is rarely, if ever, associated with carcinoids limited to the tracheobronchial tree. Occasionally, Cushing's syndrome due to ectopic hormone production is caused by bronchial carcinoid tumors. More than 75% of bronchial carcinoids are detected on conventional posteroanterior chest roentgenograms. Computed tomography may help disclose small neoplasms that are occult on conventional roentgenography, particularly in the assessment of patients who have Cushing's syndrome due to ectopic hormone production. Pulmonary resection is the treatment of choice for bronchial carcinoids. The prognosis is related to the pathologic grade and stage of the tumor.

Carcinoid heart disease. Clinical and echocardiographic spectrum in 74 patients

BACKGROUND

The carcinoid syndrome is a rare cause of acquired valvular heart disease. Although the typical echocardiographic features of carcinoid heart disease are well recognized, this large series provides new information about unusual manifestations of the disease as well as the role of Doppler echocardiography.

METHODS AND RESULTS

Between 1980 and 1989, 132 patients with carcinoid syndrome underwent echocardiographic study. The echocardiographic, Doppler, and clinical features of the 74 patients (56%) with echocardiographic evidence of carcinoid heart disease are described. Among these patients, 97% had shortened, thickened tricuspid leaflets. Tricuspid regurgitation was present in all 69 patients with carcinoid heart disease who underwent Doppler examination, and it was of moderate or severe degree in 62 patients (90%). Severe tricuspid regurgitation was characterized by a dagger-shaped Doppler spectral profile with an early peak pressure and rapid decline. The pressure half-time was prolonged (mean, 116 msec), which is consistent with associated tricuspid stenosis. The pulmonary valve appeared thickened, retracted, and immobile in 36 patients (49%) and was diminutive to the extent of not being visualized in an additional 29 patients (39%). Among the 47 patients who underwent Doppler evaluation of the pulmonary valve, regurgitation was present in 81%, and stenosis was present in 53%. Left-sided valvular involvement was present in five patients (7%), four of whom had patent foramen ovale or carcinoid tumor involving the lung. Previously undescribed myocardial metastases were present in three patients (4%) and were confirmed by biopsy in each case. Small pericardial effusions were present in 10 patients (14%). Patients with and without echocardiographic evidence of carcinoid heart disease did not differ with regard to sex, age, location of the primary tumor, duration of diagnosis, or duration of symptoms of carcinoid syndrome. However, the mean pretreatment level of urinary 5-hydroxyindoleacetic acid was higher in patients with carcinoid heart disease than in patients without carcinoid heart disease (270 versus 131 mg/24 hrs, p < 0.001). The symptom of dyspnea was more prevalent among patients with carcinoid heart disease than in patients without the disease (54% versus 27%, p = 0.003); as expected, heart murmurs were also noted more frequently in patients with disease (92% versus 43%, p < 0.0001). Treatment regimens and response to therapy were similar in the two groups. Survival of patients with echocardiographic evidence of carcinoid heart disease was reduced compared with those without cardiac involvement (p = 0.0003). ECG and chest roentgenographic findings in patients with carcinoid heart disease were nonspecific.

CONCLUSIONS

The broad spectrum of carcinoid heart disease is detailed in this large series. This includes not only right-sided valvular lesions but also left-sided involvement, pericardial effusion, and myocardial metastases.

Metastatic carcinoid tumors and the malignant carcinoid syndrome

Patients with metastatic carcinoid tumors and the malignant carcinoid syndrome have benefited immensely from diagnostic and therapeutic advances during the past decade. Magnetic resonance imaging and whole body scintigraphy with radiolabelled analogues of somatostatin have improved our ability to diagnose, detect, stage and follow response to therapy. Surgical, medical, and radiation therapy may all contribute to the management of these patients. This disease is variable in its presenting symptoms and the biologic behavior of the tumor. The spectrum of clinical manifestations varies depending upon the type and quantity of polypeptide hormones or biogenic amines being produced. Although the tumors are usually indolent in their growth, the more dedifferentiated or anaplastic tumors can be quite aggressive. Thanks to new treatments that are very effective in the subgroup of anaplastic neuroendocrine carcinomas it is vital to recognize this subset. As research scientists and clinicians we must be aware of the natural history of the disease in order to optimize each patient's treatment. This highly selective review focuses on studies performed in collaboration with Dr. Charles Moertel along with other colleagues at the Mayo Clinic, have done in the past few years.