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Hack M, Bhamidipati CM. Management of carcinoid heart disease. Curr Probl Cancer 2024; 52:101128. [PMID: 39173543 DOI: 10.1016/j.currproblcancer.2024.101128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 05/22/2024] [Indexed: 08/24/2024]
Abstract
Carcinoid Heart Disease (CaHD) is defined as the constellation of all cardiac manifestations that occur in patients with carcinoid tumors. Cardiac manifestations are generally due to the paraneoplastic effects of vasoactive substances secreted by carcinoid tumors. These primarily cause cardiac valve dysfunction and resultant heart failure. Successful management of patients with CaHD requires a multidisciplinary team to address both the classical manifestations of carcinoid syndrome, as well as the additional manifestations of cardiac dysfunction. While the cornerstone of medical management for carcinoid syndrome are somatostatin analogs (SSAs), there is no evidence to suggest that the usage of SSAs influences the development or progression of CaHD. Additionally, while liver-directed therapies provide a survival benefit to symptomatic carcinoid syndrome patients with resectable disease, there are conflicting data on the survival benefit of hepatic resection among patients with CaHD. Cardiac surgery in patients with CaHD is a complex undertaking, and is the only definitive treatment for symptom management in CaHD with significant survival benefit for patients in advanced disease states. Two crucial surgical decisions to be made are determining which valve(s) should be replaced, and what prosthetic should be utilized. While challenging in this often medically frail population, cardiac surgery confers a survival benefit and should be pursued in cases of symptomatic CaHD or progressive right ventricular dysfunction.
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Affiliation(s)
- Madelaine Hack
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
| | - Castigliano M Bhamidipati
- Division of Cardiothoracic Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
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Namkoong J, Andraweera PH, Pathirana M, Munawar D, Downie M, Edwards S, Averbuj P, Arstall MA. A systematic review and meta-analysis of the diagnosis and surgical management of carcinoid heart disease. Front Cardiovasc Med 2024; 11:1353612. [PMID: 38572311 PMCID: PMC10987853 DOI: 10.3389/fcvm.2024.1353612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/11/2024] [Indexed: 04/05/2024] Open
Abstract
Introduction Carcinoid heart disease (CHD), a complication of carcinoid syndrome (CS), is a rare condition that can lead to right sided valvular heart disease and has been traditionally associated with a poor prognosis. We conducted a systematic review and meta-analysis to explore the accuracy of biomarkers and echocardiography in diagnosing CHD amongst patients who are already known to have neuroendocrine tumours and to assess whether surgical management of CHD leads to a reduction in mortality. Methods A systematic literature search of MEDLINE, EMBASE, EBM Reviews, Google Scholar, ClinicalTrials.gov was conducted. All studies on patients with carcinoid heart disease (CHD) reporting on biomarkers, echocardiographic and surgical outcomes were included. The National Heart, Lung, and Blood Institute quality assessment tool was used to assess the methodological study quality. Data analysis was performed using Stata Statistical Software and R Studio, and individual meta-analyses were performed for biomarkers, echocardiographic findings, and surgical outcomes. Results A total of 36 articles were included in the systematic review analysis. N terminal pro-brain natriuretic peptide (NTproBNP) and 5-hydroxyindole acetate (5-HIAA) levels were higher in patients with CHD compared with those without CHD. 32% of CS patients had echocardiographic evidence of cardiac involvement, of which 79% involved tricuspid valve abnormalities. Moderate-severe tricuspid regurgitation was the most common echocardiographic abnormality (70% of patients). However, these analyses had substantial heterogeneity due to the high variability of cardiac involvement across studies. Pooled surgical mortality for CHD was 11% at 1 month, 31% at 12 months and 56% at 24 months. When assessing surgical outcomes longitudinally, the one-month surgical results showed a trend towards more recent surgeries having lower mortality rates than those reported in earlier years, however this was not statistically significant. Discussion There is not enough data in current literature to determine a clear cut-off value of NTproBNP and 5-HIAA to help diagnose or determine CHD severity. Surgical management of CHD is yet to show significant mortality benefit, and there are no consistent comparisons to medical treatment in current literature.
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Affiliation(s)
- Jenny Namkoong
- Department of Cardiology, Lyell McEwin Hospital, SA Health, Elizabeth Vale, SA, Australia
| | - Prabha H. Andraweera
- Department of Cardiology, Lyell McEwin Hospital, SA Health, Elizabeth Vale, SA, Australia
- Adelaide Medical School, The University of Adelaide, North Terrace Adelaide, SA, Australia
| | - Maleesa Pathirana
- Department of Cardiology, Lyell McEwin Hospital, SA Health, Elizabeth Vale, SA, Australia
- Adelaide Medical School, The University of Adelaide, North Terrace Adelaide, SA, Australia
| | - Dian Munawar
- Department of Cardiology, Lyell McEwin Hospital, SA Health, Elizabeth Vale, SA, Australia
| | - Michael Downie
- SA Health Library Service, Lyell McEwin Hospital, SA Health, Elizabeth Vale, SA, Australia
| | - Suzanne Edwards
- Adelaide Medical School, The University of Adelaide, North Terrace Adelaide, SA, Australia
| | - Paula Averbuj
- Department of Cardiology, Lyell McEwin Hospital, SA Health, Elizabeth Vale, SA, Australia
| | - Margaret A. Arstall
- Department of Cardiology, Lyell McEwin Hospital, SA Health, Elizabeth Vale, SA, Australia
- Adelaide Medical School, The University of Adelaide, North Terrace Adelaide, SA, Australia
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Sharma A, Fierro ME, Pak S, Thallapureddy K, Awobajo M, Hui D, Otchere P. Late-stage diagnosis of carcinoid heart disease due to lack of access to health care. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2023; 9:28. [PMID: 37277819 DOI: 10.1186/s40959-023-00176-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 05/12/2023] [Indexed: 06/07/2023]
Abstract
Carcinoid syndrome (CS) is a unique constellation of symptoms caused by release of vasoactive substances from neuroendocrine tumors (Pandit et al., StatPearls, 2022). Neuroendocrine tumors are rare with an annual incidence of 2 in 100,000 people (Ram et al., 46:21-27, 2019). Up to 50% of patients with these tumors will develop carcinoid syndrome, which is characterized by symptoms caused by elevated levels of serotonin and most commonly include fatigue, flushing, wheezing, and non-specific gastrointestinal symptoms such as diarrhea and malabsorption (Pandit et al., StatPearls, 2022) (Fox et.al., 90:1224-1228, 2004). Over time, patients with carcinoid syndrome can develop carcinoid heart disease (CHD). CHD refers to the cardiac complications that occur when the vasoactive substances, such as serotonin, tachykinins, and prostaglandins, secreted from the carcinoid tumors. These complications most commonly include valvular abnormalities, but can also present as coronary artery damage, arrhythmias or direct myocardial injury (Ram et al., 46:21-27, 2019). While CHD is not typically an initial feature of carcinoid syndrome, it does eventually occur in up to 70% of patients with carcinoid tumors (Ram et al., 46:21-27, 2019) (Jin et.al., 146:65-73, 2021) (Macfie et.al., 224:665-669, 2022). CHD is associated with significant morbidity and mortality due to the risk of progressive heart failure (Bober et.al., 14:1179546820968101, 2020). In this case, we describe a 35-year-old Hispanic woman in South Texas with undiagnosed carcinoid syndrome for over 10 years that eventually progressed to severe CHD. In this patient's case, we emphasize how lack of access to healthcare resulted in delay of diagnosis, appropriate treatment, and worsened prognosis in this young patient.
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Affiliation(s)
- Aditi Sharma
- Department of Medicine, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, Texas, 78229, 210-567-7000, USA
| | - Maria E Fierro
- Department of Medicine, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, Texas, 78229, 210-567-7000, USA
| | - Stella Pak
- Department of Neurology, Albany Medical College, 43 New Scotland Ave, Albany, NY, 12208, 518-262-5521, USA.
| | - Keerthi Thallapureddy
- Department of Medicine, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, Texas, 78229, 210-567-7000, USA
| | - Moyosore Awobajo
- Department of Pathology, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, Texas, 78229, 210-567-7000, USA
| | - Dawn Hui
- Department of Cardio-Thoraic Surgery, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, Texas, 78229, 210-567-7000, USA
| | - Prince Otchere
- Department of Cardio-Oncology, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, Texas, 78229, 210-567-7000, USA
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Uema D, Alves C, Mesquita M, Nuñez JE, Siepmann T, Angel M, Rego JFM, Weschenfelder R, Rocha Filho DR, Costa FP, Barros M, O'Connor JM, Illigens BM, Riechelmann RP. Carcinoid Heart Disease and Decreased Overall Survival among Patients with Neuroendocrine Tumors: A Retrospective Multicenter Latin American Cohort Study. J Clin Med 2019; 8:jcm8030405. [PMID: 30909590 PMCID: PMC6463128 DOI: 10.3390/jcm8030405] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 03/14/2019] [Accepted: 03/19/2019] [Indexed: 01/22/2023] Open
Abstract
The background to this study was that factors associated with carcinoid heart disease (CHD) and its impacts on overall survival (OS) are scantly investigated in patients (pts) with neuroendocrine tumors (NETs). In terms of materials and methods, a retrospective multicenter cohort study was conducted of factors associated with CHD in advanced NET pts with carcinoid syndrome (CS) and/or elevated urinary 5-hidroxyindole acetic acid (u5HIAA). CHD was defined as at least moderate right valve alterations. The results were the following: Among the 139 subjects included, the majority had a midgut NET (54.2%), 81.3% had CS, and 93% received somatostatin analogues. In a median follow-up of 39 months, 48 (34.5%) pts developed CHD, with a higher frequency in pts treated in public (77.2%) versus private settings (22.9%). In a multivariate logistic regression, unknown primary or colorectal NETs (Odds Ratio (OR) 4.35; p = 0.002), at least 50% liver involvement (OR 3.45; p = 0.005), and being treated in public settings (OR 4.76; p = 0.001) were associated with CHD. In a Cox multivariate regression, bone metastases (Hazard Ratio {HR} 2.8; p = 0.031), CHD (HR 2.63; p = 0.038), and a resection of the primary tumor (HR 0.33; p = 0.026) influenced the risk of death. The conclusions were the following: The incidence of CHD was higher in pts with a high hepatic tumor burden and in those treated in a public system. Delayed diagnosis and limited access to effective therapies negatively affected the lives of NET patients.
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Affiliation(s)
- Deise Uema
- Division of Health Care Sciences Center for Clinical Research and Management Education Dresden, Dresden International University, 01067 Dresden, Germany.
| | - Carolina Alves
- Instituto do Cancer do Estado de Sao Paulo, Sao Paulo 01246-000, Brazil.
| | - Marcella Mesquita
- Instituto do Cancer do Estado de Sao Paulo, Sao Paulo 01246-000, Brazil.
| | - Jose Eduardo Nuñez
- Instituto do Cancer do Estado de Sao Paulo, Sao Paulo 01246-000, Brazil.
- Department of Clinical Oncology, AC Camargo Cancer Center, Sao Paulo 01509-900, Brazil.
| | - Tim Siepmann
- Division of Health Care Sciences Center for Clinical Research and Management Education Dresden, Dresden International University, 01067 Dresden, Germany.
| | - Martin Angel
- Instituto Alexander Fleming, C1426ANZ Buenos Aires, Argentina.
| | - Julian F M Rego
- Hospital Universitário Onofre Lopes, Natal 59012-300, Brazil.
| | | | | | | | - Milton Barros
- Department of Clinical Oncology, AC Camargo Cancer Center, Sao Paulo 01509-900, Brazil.
| | - Juan M O'Connor
- Hospital de Gastroenterología Bonorino Udaondo, C1264AAA Buenos Aires, Argentina.
| | - Ben M Illigens
- Division of Health Care Sciences Center for Clinical Research and Management Education Dresden, Dresden International University, 01067 Dresden, Germany.
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02114, USA.
| | - Rachel P Riechelmann
- Department of Clinical Oncology, AC Camargo Cancer Center, Sao Paulo 01509-900, Brazil.
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