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Koffas A, Toumpanakis C. Managing carcinoid heart disease in patients with neuroendocrine tumors. ANNALES D'ENDOCRINOLOGIE 2020; 82:187-192. [PMID: 33321109 DOI: 10.1016/j.ando.2020.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Carcinoid heart disease is a complex clinical entity frequently complicating the course of neuroendocrine tumors and carcinoid syndrome and is associated with significant morbidity and mortality. Although the pathogenesis of carcinoid heart disease remains poorly understood, it appears that the exposure to excessive circulating levels of serotonin contribute a key role, triggering a cascade of events that ultimately results in the development of plaque-like material on the endocardial surfaces of the valve leaflets. The occurrence of carcinoid heart disease may initially run an asymptomatic period, followed by the development of symptoms of congestive cardiac failure. The diagnosis of carcinoid heart disease is suspected by raised biomarkers, such as serum NT-pro-BNP and confirmed by imaging modalities, with echocardiogram being the gold standard to date. Carcinoid heart disease treatment remains challenging as in addition to cardiac dysfunction, tumor burden needs to be tackled with, hence requiring a multidisciplinary approach. Therapy comprises watchful waiting during the first initial stages of the disease; medications for heart failure; optimal control of serotonin secretion from the NET with pharmacotherapy, interventional means or even surgical techniques; and, in selected patients, cardiac valve replacement. The current review summarizes the literature on the diagnosis and management of carcinoid heart disease.
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Affiliation(s)
- Apostolos Koffas
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, Pond Street, London NW3 2QG, UK
| | - Christos Toumpanakis
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, Pond Street, London NW3 2QG, UK.
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Rindi G, Wiedenmann B. Neuroendocrine neoplasia of the gastrointestinal tract revisited: towards precision medicine. Nat Rev Endocrinol 2020; 16:590-607. [PMID: 32839579 DOI: 10.1038/s41574-020-0391-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2020] [Indexed: 02/06/2023]
Abstract
Over the past 5 years, a number of notable research advances have been made in the field of neuroendocrine cancer, specifically with regard to neuroendocrine cancer of the gastrointestinal tract. The aim of this Review is to provide an update on current knowledge that has proven effective for the clinical management of patients with these tumours. For example, for the first time in the tubular gastrointestinal tract, well-differentiated high-grade (grade 3) tumours and mixed neuroendocrine-non-neuroendocrine neoplasms (MiNENs) are defined in the WHO classification. This novel classification enables efficient identification of the most aggressive well-differentiated neuroendocrine tumours and helps in defining the degree of aggressiveness of MiNENs. The Review also discusses updates to epidemiology, cell biology (including vesicle-specific components) and the as-yet-unresolved complex genetic background that varies according to site and differentiation status. The Review summarizes novel diagnostic instruments, including molecules associated with the secretory machinery, novel radiological approaches (including pattern recognition techniques), novel PET tracers and liquid biopsy combined with DNA or RNA assays. Surgery remains the treatment mainstay; however, peptide receptor radionuclide therapy with novel radioligands and new emerging medical therapies (including vaccination and immunotherapy) are evolving and being tested in clinical trials, which are summarized and critically reviewed here.
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Affiliation(s)
- Guido Rindi
- Università Cattolica del Sacro Cuore, Rome, Italy.
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Bertram Wiedenmann
- Charité, Campus Virchow Klinikum and Charité Mitte, University Medicine Berlin, Berlin, Germany
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La Salvia A, Brizzi MP, Trevisi E, Parisi F, Muratori L, Atzeni F, Di Maio M, Scagliotti GV. Carcinoid heart failure in a duodenal neuroendocrine tumor: role of cardiac surgery in a challenging patient and brief review of the literature. Acta Oncol 2020; 59:315-319. [PMID: 31583924 DOI: 10.1080/0284186x.2019.1672891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Anna La Salvia
- Medical Oncology, Department of Oncology, University of Turin, Azienda Ospedaliera Universitaria San Luigi, Orbassano, Turin, Italy
| | - Maria Pia Brizzi
- Medical Oncology, Department of Oncology, University of Turin, Azienda Ospedaliera Universitaria San Luigi, Orbassano, Turin, Italy
| | - Elena Trevisi
- Medical Oncology, Department of Oncology, University of Turin, Azienda Ospedaliera Universitaria San Luigi, Orbassano, Turin, Italy
| | | | - Leonardo Muratori
- Medical Oncology, Department of Oncology, University of Turin, Azienda Ospedaliera Universitaria San Luigi, Orbassano, Turin, Italy
| | - Francesco Atzeni
- Cardiac Surgery, University of Turin, A.O. Ordine Mauriziano, Turin, Italy
| | - Massimo Di Maio
- Medical Oncology, Department of Oncology, University of Turin, A.O. Ordine Mauriziano, Turin, Italy
| | - Giorgio V. Scagliotti
- Medical Oncology, Department of Oncology, University of Turin, Azienda Ospedaliera Universitaria San Luigi, Orbassano, Turin, Italy
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Mujtaba SS, Clark S. Quadruple Valve Replacement for Carcinoid Heart Disease. Braz J Cardiovasc Surg 2019; 33:398-403. [PMID: 30184038 PMCID: PMC6122765 DOI: 10.21470/1678-9741-2017-0224] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 02/26/2018] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Carcinoid heart disease most frequently involves the tricuspid or, more rarely, the pulmonary valve and presents with right heart failure as 5-HT is metabolized by the lung. Left-sided valve involvement is quite rare. We describe our experience of 3 patients presenting with heart failure secondary to carcinoid heart disease affecting all four cardiac valves. There are only four previous isolated case reports in the literature. METHODS All three patients underwent quadruple valve replacement during a single operation. Right ventricular outflow tract reconstruction with a pericardial patch was performed in all patients. For 24 hours prior to surgery, all patients received intravenous octreotide, which continued in intensive care for at least 24 hours. RESULTS Mean cross-clamp and bypass times were 175 (range 164-197 minutes) and 210 (range 195-229 minutes) minutes, respectively. Mean intensive treatment unit (ITU) and inpatient stays were 2.3 (range 2-3 days) and 12 (range 9-16 days) days, respectively. One patient was reopened for bleeding 4 hours postoperatively from a ventricular pacing wire site. None required a permanent pacemaker postoperatively. There were no other complications in any patient. The quality of life was excellent at 6-16 months clinic follow-up as they were in NYHA 1. Postoperative echocardiography showed no paravalvular leaks and well-functioning prostheses in all cases. CONCLUSION Surgery to replace all four valves is feasible with excellent medium-term survival and a very low rate of complications. Patients with carcinoid heart disease should always be considered for surgery irrespective of the extent of valvular involvement.
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Affiliation(s)
- Syed Saleem Mujtaba
- Freeman Hospital Newcastle, United Kingdom of Great Britain and Northern Ireland
| | - Stephen Clark
- Freeman Hospital Newcastle, United Kingdom of Great Britain and Northern Ireland
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Khay K, Arous S, Bentaoune T, Drighil A, Habbal R. Carcinoid heart disease revealed by cyanosis with both right and left valvular involvement: a case report. J Med Case Rep 2018; 12:23. [PMID: 29386066 PMCID: PMC5791312 DOI: 10.1186/s13256-018-1574-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Accepted: 01/15/2018] [Indexed: 01/02/2023] Open
Abstract
Background Carcinoid heart disease is a frequent complication of carcinoid syndrome. It is related to the release by the carcinoid tumor and/or its metastases of bioactive substances such as serotonin. It is characterized by right-sided valvular involvement and can lead to right-sided heart failure. It is a prognostic factor of carcinoid syndrome. Case presentation We report the case of a 53-year-old African woman with an endocrine tumor of her small intestine complicated by carcinoid heart disease, revealed by right-sided heart failure. The diagnosis was confirmed by transthoracic echocardiography, which showed a severe tricuspid regurgitation with a patent foramen ovale, and by increased serum chromogranin A and urinary 5-hydroxyindoleacetic acid. Initially she was treated with medical therapy (furosemide and injection of somatostatin). Afterwards she was proposed for surgery. The evolution of her treatment was good. Conclusions Carcinoid syndrome is complicated in 60% of the cases of a heart disease, and is responsible for an important morbidity and mortality. The prognosis of patients with carcinoid heart disease has improved in recent years through somatostatin analogues and the cardiac surgery.
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Affiliation(s)
- Khadija Khay
- Department of Cardiology, Ibn Rushd University Hospital, Casablanca, Morocco
| | - Salim Arous
- Department of Cardiology, Ibn Rushd University Hospital, Casablanca, Morocco.
| | - Tarik Bentaoune
- Department of Cardiology, Ibn Rushd University Hospital, Casablanca, Morocco
| | - Abdenasser Drighil
- Department of Cardiology, Ibn Rushd University Hospital, Casablanca, Morocco
| | - Rachida Habbal
- Department of Cardiology, Ibn Rushd University Hospital, Casablanca, Morocco
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Yuan SM. Valvular Disorders in Carcinoid Heart Disease. Braz J Cardiovasc Surg 2017; 31:400-405. [PMID: 27982350 PMCID: PMC5144560 DOI: 10.5935/1678-9741.20160079] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 05/16/2016] [Indexed: 12/28/2022] Open
Abstract
Carcinoid heart disease is a rare but important cause of intrinsic right heart valve disorders leading to right heart failure. Occasionally, left-sided heart valves may also be involved. The characteristic cardiac pathological findings of carcinoid heart disease are endocardial thickening as a result of fibrous deposits on the endocardium. Echocardiographic examination and right heart catheterization are very useful for the diagnosis of the lesion. If more cardiac valves are affected, multiple valve replacement should be considered. The management of the pulmonary valve lesion depends on the extent of the diseased valve, either by valvulotomy, valvectomy, or valve replacement. Percutaneous valve implantations in the pulmonary and in the inferior vena cava positions have been advocated for high-risk patients.
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Affiliation(s)
- Shi-Min Yuan
- MMed, PhD. The First Hospital of Putian, Teaching Hospital, Fujian Medical University, Fujian Province, China
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Sagar VM, Steeds RP, Doshi SN, Shah T. Transcatheter valve implantation to inferior vena cava to control carcinoid symptoms. BMJ Case Rep 2017; 2017:bcr-2017-220888. [PMID: 29066637 PMCID: PMC5665334 DOI: 10.1136/bcr-2017-220888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2017] [Indexed: 11/04/2022] Open
Abstract
Severe carcinoid syndrome and carcinoid heart disease in neuroendocrine tumours can have a significant impact on a patient's quality of life and are a major cause of morbidity and mortality. We present a novel approach to managing a patient with medically uncontrollable carcinoid syndrome. Inferior and superior vena cava placement of transcatheter heart valves has been used to treat patients with right heart failure due to severe tricuspid and pulmonary regurgitation. However, this procedure has not been attempted to specifically reduce hormone secretion, primarily from the liver, in order to control carcinoid syndrome symptoms. We attempted this procedure in a patient with severe carcinoid disease and tricuspid regurgitation as a bridge to later definitive therapy. The procedure was technically successful, but did not improve carcinoid symptoms. The possible reasons for the failure are discussed here.
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Affiliation(s)
- Vandana M Sagar
- Department of Liver Medicine, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
| | - Richard P Steeds
- Department of Cardiology, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
| | - Sagar N Doshi
- Department of Cardiology, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
| | - Tahir Shah
- Department of Liver Medicine, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
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Diagnosing and Managing Carcinoid Heart Disease in Patients With Neuroendocrine Tumors: An Expert Statement. J Am Coll Cardiol 2017; 69:1288-1304. [PMID: 28279296 DOI: 10.1016/j.jacc.2016.12.030] [Citation(s) in RCA: 147] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 11/08/2016] [Accepted: 12/10/2016] [Indexed: 12/17/2022]
Abstract
Carcinoid heart disease is a frequent occurrence in patients with carcinoid syndrome and is responsible for substantial morbidity and mortality. The pathophysiology of carcinoid heart disease is poorly understood; however, chronic exposure to excessive circulating serotonin is considered one of the most important contributing factors. Despite recognition, international consensus guidelines specifically addressing the diagnosis and management of carcinoid heart disease are lacking. Furthermore, there is considerable variation in multiple aspects of screening and management of the disease. The aim of these guidelines was to provide succinct, practical advice on the diagnosis and management of carcinoid heart disease as well as its surveillance. Recommendations and proposed algorithms for the investigation, screening, and management have been developed based on an evidence-based review of the published data and on the expert opinion of a multidisciplinary consensus panel consisting of neuroendocrine tumor experts, including oncologists, gastroenterologists, and endocrinologists, in conjunction with cardiologists and cardiothoracic surgeons.
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Dalal A, Stone M. Intraoperative Management of Carcinoid Heart Disease for Valvular Surgery. J Cardiothorac Vasc Anesth 2016; 30:1046-9. [DOI: 10.1053/j.jvca.2015.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Indexed: 11/11/2022]
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