NET Patient Foundation wallet card (example guidance)
The word ‘crisis’ has a wide range of meanings and it’s well used in the media to catch the reader’s attention. Lately, the terms ‘political crisis’, financial ‘crisis’ and ‘constitutional crisis’ appear almost daily in media headlines. In a previous life, the term ‘crisis management’ was used daily in the work I was undertaking as I went from problem to problem, dampening or putting out fires (….. that’s a metaphor!). Thinking back, my adrenaline (epinephrine), norepinephrine, and cortisol must have been very busy!
However, in the world of Neuroendocrine Tumours (NETs), ‘crisis’ has a very significant meaning and its very mention will make ears prick up. The word ‘crisis’ is normally spoken or written using the term ‘Carcinoid Crisis’ given this is the type of NET with which it has been mostly associated. However, I’ve studied and researched and it would appear that some form of ‘crisis’ might apply to other types of NETs. Perhaps this is another knock-on effect caused by the historical use of the word ‘Carcinoid’ to incorrectly refer to all NETs. In terms of ‘crisis’, maybe there should be a more generic NETs wide term? More on that later.
In the simplest of terms, it is a dangerous change in blood pressure, heart rate, and breathing (technical term – cardiopulmonary hemodynamic instability). On an operating table under anaesthetics or an invasive procedure such as liver embolization, this can actually be life threatening. Incidentally, this happens with many other types of conditions and it is the cause of the cardiopulmonary hemodynamic instability that is different with NET patients. For some, it could be a life or death situation
NETs can release a variety of ‘vasoactive peptides’ (hormones) in excess (e.g. serotonin, catecholamines, histamine). Under normal circumstances, these would just present as routine syndromes which may need to be controlled in most cases with somatostatin analogue treatment (Octreotide/Lanreotide). Excess amounts of these substances can cause both hypertension and hypotension (high and low blood pressure respectively). In extreme cases this can lead to what is known as a (carcinoid) crisis situation. It is said by one very well-known NET expert to “not to be something which happens randomly to all patients, it is usually linked to a medical procedure of some sort when you are having anaesthesia”. Dr Eric Liu also said “Luckily it is relatively uncommon”.
If you research this plus your own experience, you will know there are different ideas and ‘protocols’. However, they all mostly involve some pre-procedure infusion of a somatostatin analogue (normally Octreotide) – although I’d love to hear from anyone who has had Lanreotide as an alternative. Some doctors or hospitals are known to have ‘protocols’ and I’ve uploaded the one from the ISI NET book page 215 (Wang, Boudreaux, O’Dorisio, Vinik, Woltering, et al). Click here. Please note this is an example rather than a recommendation as this is something the NOLA team have developed for their own centre. In all the procedures I’ve had done in my local NET Centre, I have always been admitted the day before to receive what they describe as an ‘Octreotide Soak’.
I have seen some discussion about the difference between a severe attack of carcinoid syndrome and carcinoid crisis and it’s a really difficult area. Looking at Dr Liu’s definition, he said it was ‘usually’ linked to a procedure based scenario so I guess it could happen in a non-surgical scenario in extreme cases. Most people are effectively managed on monthly injections of Octreotide/Lanreotide but some people still need ‘rescue shots’ (top ups) where they are experiencing breakthrough symptoms. When I was symptomatic (syndromic), I would regularly flush in stressful situations but that was definitely syndrome rather than crisis. Check out my video explaining how I felt. It’s worth reading something called the 5 E’s of Carcinoid Syndrome, probably useful to other types of NETs as I’m sure there is some overlap. There is a very important point in my ‘5 E’s’ blog about dental treatment which involves the use of dental based anaesthetics. Additionally there is advice for users of ‘Epi Pens’. You also need to derisk these situations.
The ISI Book Link above (here for convenience), does state “regardless of tumor type, all NETs should be pre-treated with Octreotide for protection against crisis“. I know that certain non-carcinoid NET patients can also be treated by somatostatin analogues as they too can be subject to the effects of excess secretion of certain vasoactive peptides. I recently read an article about a person with a Pheochromocytoma (a less common NET that comes from the chromaffin cells of the adrenal medulla and secretes catecholamines). The person had what was described as an ‘Intraoperative Hypertensive Crisis’ that appeared to be caused by her tumour type rather than the sort of incident that might occur in a standard surgery. Hypertension (high blood pressure) can be a symptom of Pheochromocytoma so you can see the problem with surgery and other procedures. An interesting issue with this type of NET is that after surgery, the patient is at risk for hypotension (low blood pressure) from venous dilation caused by the sudden withdrawal of catecholamines.
I highly suspect there are many examples from the NET world beyond the ‘carcinoid’ subtype of NETs and I’ve already given you one above. I’ll update this blog as I discover other examples. In the meantime, make sure you ask your medical team about ‘crisis protection’ if you are to undergo any surgical or invasive medical procedure.
Do we need to rename the term ‘Carcinoid Crisis’? Probably!
Thanks for listening
Ronny
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