Carcinoid syndrome

Carcinoid syndrome
Classification and external resources
Serotonin
ICD-10	E34.0
ICD-9	259.2
ICD-O:	M8240/3-8245
DiseasesDB	2040
MedlinePlus	000347
eMedicine	med/271
MeSH	[1]

Carcinoid syndrome refers to the array of symptoms that occur secondary to carcinoid tumors.^[1]

Carcinoid tumors are discrete, yellow, well-circumscribed tumors that can occur anywhere along the gastrointestinal tract and in the lung. They most commonly affect the appendix, ileum, and rectum. Carcinoids are tumors of neuroendocrine nature, that originate in the cells of the neuroendocrine system and are characterized by production of serotonin (5-hydroxytryptamine; 5-HT). Although quite rare with 15 cases/1,000,000 population, carcinoid tumors account for 75% of gastrointestinal endocrine tumors.

Clinical presentation

The carcinoid syndrome occurs in approximately 10% of carcinoid tumors^[2] and becomes manifest when vasoactive substances from the tumors enter the systemic circulation escaping hepatic degradation. This is the case when carcinoid tumors metastasize to the liver or they arise for example in the bronchus.

The most important clinical finding is flushing of the skin, usually of the head and the upper part of thorax.^[3] Secretory diarrhea and abdominal cramps are also characteristic features of the syndrome. When the diarrhea is intensive it may lead to electrolyte disturbance and dehydration. Other associated symptoms are nausea, and vomiting. Bronchoconstriction affects a smaller number of patients and often accompanies flushing.

About 50% of patients have cardiac abonormalities, caused by serotonin-induced fibrosis of the tricuspid and pulmonary valves. Elevated levels of circulating serotonin have been associated with cardiac failure, due to fibrous deposits on the endocardium. These deposits are thought to be responsible for the fibrous degeneration of the valve apparatus. "TIPS" is an acronym for Tricuspid Insufficiency, Pulmonary Stenosis (fibrosis of tricuspid and pulmonary valves).

Abdominal pain is due to desmoplastic reaction of the mesentery or hepatic metastases.

Pathophysiology

Carcinoid tumors produce the vasoactive substance, serotonin. It is commonly, but incorrectly, thought that serotonin is the cause of the flushing. The flushing results from secretion of kallikrein, the enzyme that catalyzes the conversion of kininogen to lysyl-bradykinin. The latter is further converted to bradykinin, one of the most powerful vasodilators known. Other components of the carcinoid syndrome are diarrhea (probably caused by serotonin), a pellagra-like syndrome (probably caused by diversion of large amounts of tryptophan from synthesis of the vitamin B3, niacin, to the synthesis of 5-hydroxyindoles including serotonin), fibrotic lesions of the endocardium, particularly on the right side of the heart resulting in insufficiency of the tricuspid valve and, less frequently, the pulmonary valve and, uncommonly, bronchoconstriction. The pathogenesis of the cardiac lesions and the bronchoconstriction is unknown, but the former probably involves activation of serotonin 5-HT2B receptors by serotonin. When the primary tumor is in the gastrointestinal tract, as it is in the great majority of cases, the serotonin and kallikrein are inactivated in the liver; manifestations of carcinoid syndrome do not occur until there are metastases to the liver or when the cancer is accompanied by liver failure (cirrhosis). Carcinoid tumors arising in the bronchi may be associated with manifestations of carcinoid syndrome without liver metastases because their biologically active products reach the systemic circulation before passing through the liver and being metabolized.

In most patients, there is an increased urinary excretion of 5-HIAA (5-hydroxyindoleacetic acid), a degradation product of serotonin.

Diagnosis

With a certain degree of clinical suspicion, diagnosis is made primarily by measuring plasma levels of the secreted glycoprotein Chromogranin A, supported by measuring the 24 hour urine levels of 5-HIAA (5-hydroxyindoleacetic acid), a breakdown product of serotonin. Patients with carcinoid syndrome usually excrete >25 mg of 5-HIAA per day. For localization of both primary lesions and metastasis, the initial imaging method is Octreoscan, where ¹¹¹Indium labelled somatostatin analogues (octreotide) are used in scintigraphy for detecting tumors expressing somatostatin receptors. Median detection rates with octreoscan are about 89%, in contrast to other imaging techniques such as CT scan and MRI with detection rates of about 80%. Usually on CT scan, one will note a spider-like/crab like change in the mesentery due to the fibrosis from the release of serotonin. PET scans, which evaluate for increased metabolism of glucose, may also aid in localizing the carcinoid lesion or evaluating for metastases.

Localization of tumour

Tumour localization may be extremely difficult. Barium swallow and follow-up examination of the intestine may occasionally show the tumour. Capsule video endoscopy has recently been used to localize the tumour. Often laparotomy is the definitive way to localize the tumour.

Primary site of a carcinoid cancer of gut, secondaries are also visible on the mesentry

Treatment

For symptomatic relief of carcinoid sydrome:

• octreotide (a somatostatin analogue that neutralizes serotonin and decreases urinary 5-HIAA)
• methysergide maleate (antiserotonin agent but not used because of serious side effect of retroperitoneal fibrosis)
• cyproheptadine (an antihistamine drug)

Alternative treatment for qualifying candidates:

• Surgical resection of tumor and chemotherapy (5-FU and doxorubicin)

Prognosis

Prognosis varies from individual to individual. It ranges from a 95% 5 year survival for localized disease to an 80% 5 year survival for those with liver metastases. The average survival time from the start of octreotide treatment has increased to about 12 years.

Synonyms

• Thorson-Bioerck syndrome
• Argentaffinoma syndrome
• Cassidy-Scholte sydrome
• Flush syndrome

References

See also

• Carcinoid
• Kulchitsky cells