Treatment of a malignant bronchial carcinoid affecting the mediastinum and left atrium by radical two stage resection with cardiopulmonary bypass and somatostatin infusion

Shifting Paradigms in the Pathophysiology and Treatment of Carcinoid Crisis

Carcinoid crisis is a potentially fatal condition characterized by various symptoms, including hemodynamic instability, flushing, and diarrhea. The incidence of carcinoid crisis is unknown, in part due to inconsistency in definitions across studies. Triggers of carcinoid crisis include general anesthesia and surgical procedures, but drug-induced and spontaneous cases have also been reported. Patients with neuroendocrine tumors (NETs) and carcinoid syndrome are at risk for carcinoid crisis. The pathophysiology of carcinoid crisis has been attributed to secretion of bioactive substances, such as serotonin, histamine, bradykinin, and kallikrein by NETs. The somatostatin analog octreotide has been considered the standard of care for carcinoid crisis due to its inhibitory effect on hormone release and relatively fast resolution of carcinoid crisis symptoms in several case studies. However, octreotide's efficacy in the treatment of carcinoid crisis has been questioned. This is due to a lack of a common definition for carcinoid crisis, the heterogeneity in clinical presentation, the paucity of prospective studies assessing octreotide efficacy in carcinoid crisis, and the lack of understanding of the pathophysiology of carcinoid crisis. These issues challenge the classical physiologic model of carcinoid crisis and its common etiology with carcinoid syndrome and raise questions regarding the utility of somatostatin analogs in its treatment. As surgical procedures and invasive liver-directed therapies remain important treatment modalities in patients with NETs, the pathophysiology of carcinoid crisis, potential benefits of octreotide, and efficacy of alternative treatment modalities must be studied prospectively to develop an effective evidence-based treatment strategy for carcinoid crisis.

Somatostatin analogues do not prevent carcinoid crisis

BACKGROUND

Carcinoid crisis is a life-threatening syndrome of neuroendocrine tumors (NETs) characterized by dramatic blood pressure fluctuation, arrhythmias, and bronchospasm. In the era of booming anti-tumor therapeutics, this has become more important since associated stresses can trigger carcinoid crisis. Somatostatin analogues (SSTA) have been recommended for prophylactic administration before intervention procedures for functioning NETs. However, the efficacy is still controversial. The aim of this article is to review efficacy of SSTA for preventing carcinoid crisis.

MATERIALS AND METHODS

PubMed, Cochrane Controlled trials Register, and EMBASE were searched using 'carcinoid crisis' as a search term combining terms with 'somatostatin'; 'octreotide'; 'lanreotide' and 'pasireotide' until December 2013.

RESULTS

Twenty-eight articles were retrieved with a total of fifty-three unique patients identified for carcinoid crisis. The most common primary sites of NETs were the small intestine and respiratory tract. The triggering factors for carcinoid crisis included anesthesia/ surgery (63.5%), interventional therapy (11.5%), radionuclide therapy (9.6%), examination (7.7%), medication (3.8%), biopsy (2%) and spontaneous (2%). No randomized controlled trials (RCTs) were identified and two case-control studies were included to assess the efficacy of SSTA for preventing carcinoid crisis by meta-analysis. The overall pooled risk of perioperative carcinoid crisis was similar despite the prophylactic administration of SSTA (OR 0.44, 95% CI: 0.14 to 1.35, p=0.15).

CONCLUSIONS

SSTA was not helpful for preventing carcinoid crisis based on a meta-analysis of retrospective studies. Attentive monitoring and careful intervention are essential. Future studies with better quality are needed to clarify any effect of SSTA for preventing carcinoid crisis.

A pulmonary mass with invasion into the heart

We describe the case of a 58 year old woman who presented with bronchial atypical carcinoid found at surgery to invade the left atrium along the pulmonary veins. A right pneumonectomy and removal of a portion of the left atrium was performed. The patient made an excellent post operative recovery. Three years later she presented in acute respiratory failure secondary to local recurrence. This is first case described in which recurrence after resection of bronchial carcinoid metastatic to the heart is described.

Cardiopulmonary bypass as an adjunct for the noncardiac surgeon

The use of cardiopulmonary bypass (CPB) in noncardiac surgical settings has been increasingly developed and has greatly benefited noncardiac surgeon. A few years after the advent of CPB as well as profound hypothermic circulatory arrest in the early years, it was employed by neurosurgeons in cerebrovascular surgery and by general thoracic surgeons in carinal tumor resection. Indications for CPB were extended and modified year after year. It has facilitated not only the surgical management by surgeons of lesions that cannot be managed safely and effectively by conventional techniques, or conventional techniques carry significant risks to the patient, but also the preservation of the viability of multiple organ procurement, the practice of isolated limb perfusion for the treatment of malignancies of the extremities, and emergent cardiopulmonary resuscitation. Owing to the complications arising from CPB and profound hypothermic circulatory arrest, such as postoperative bleeding, coagulopathy, and neurologic deficits, efforts have been made to avoid these common hazards. Thus, innovative techniques including extracorporeal membrane oxygenation, percutaneous cardiopulmonary support, venovenous bypass, normothermic CPB, and minimally invasive approaches have emerged and played an important role as alternatives of standard CPB in decreasing morbidity and mortality and improving survival.

Giant bronchial carcinoid tumors: a multidisciplinary approach

BACKGROUND

Bronchial carcinoid tumors account for approximately 2% of all lung tumors. Although they were considered benign lesions, they are now categorized malignant, occasionally with poor prognosis. The clinical symptoms can be highly variable and are often present for many years before diagnosis. Whereas some carcinoids are entirely asymptomatic, others are accompanied by carcinoid or paraneoplastic syndromes.

METHODS

We describe the multidisciplinary management of a 34-year-old female patient with a massive actively secreting bronchial carcinoid tumor of the right lung. Furthermore, we provide a review of the literature regarding the operative treatment and the perioperative management of pulmonary carcinoid tumors with respect to surgical, anesthetic, radiologic, and pathologic considerations.

RESULTS

In the reported case, the first symptoms were chronic watery diarrhea, skin flushing, progressive shortness of breath, and increasing right shoulder pain. When the patient initially presented at our institution, the tumor had already reached an enormous size and it involved the right and left atrium as well as the atrial septum. Using an evidence-based, multidisciplinary approach the patient was treated successfully with extended surgical resection.

CONCLUSIONS

Carcinoid tumors are potentially curable even if they reach a significant size and thus an aggressive strategy is warranted. The management of such cases requires careful investigation, planning, and treatment with collaborative expertise provided by a multidisciplinary team. We demonstrated that this approach can lead to a favorable outcome in what first appeared to be a formidable and unresectable tumor.

Invasive carcinoid tumor of the heart

Carcinoid tumors have been described in almost every organ and may affect virtually every body system. Cardiac involvement manifesting as right-sided valvular disease is characteristic of the carcinoid syndrome; however, direct myocardial involvement is unusual. We present a case of an invasive carcinoid tumor whose primary manifestation was myocardial invasion.

Transoesophageal echocardiography and the intraoperative diagnosis of left atrial invasion by carcinoid tumour

A 41-yr-old woman with pulmonary carcinoid tumour presented for thoracotomy and lung resection. However, intraoperative transoesophageal echocardiography (TEE) revealed that the tumour had invaded the left atrium, and the planned resection was aborted to allow resection under cardiopulmonary bypass at a later date. Although the incidence of cardiac involvement by lung cancer at the time of pulmonary resection is unknown, transoesophageal echocardiography can be useful in identifying the extension of hilar lung tumours. This should preferentially be done preoperatively, but can be done intraoperatively as described in this case report.