PRRT is an important therapeutic option in neuroendocrine tumours that works through binding of lutetium-177-DOTA-octreotate (Lutate) to somatostatin receptor positive neuroendocrine tumours. However, it may lead to initial worsening of carcinoid symptoms or even carcinoid crises. This case series aims to summarise interventions to prevent and manage carcinoid crises precipitated by Lutate therapy.
Methods and outcomes:
We report a series of six high-risk patients who received Lutate treatment across two Australian tertiary medical institutions. Cases were identified as high-risk due to a previous history of carcinoid crisis, either spontaneously or secondary to tumour manipulation.
All patients were premedicated with histaminergic and serotonergic blockade as well as corticosteroids. Current guidelines recommend withholding somatostatin analogues (SSAs) prior to Lutate due to potential interference with receptor targeting and therapeutic effects. Long-acting SSA was ceased four weeks prior to Lutate and regular short-acting octreotide was commenced in four out of six patients. Two patients continued SSA administration during Lutate due to uncontrollable baseline symptoms and high tumour burden.
Five patients experienced carcinoid symptoms following their procedures, and all five were symptomatic (flushing, diarrhoea, haemodynamic instability) within 12 hours of Lutate infusion. Treatment varied from regular subcutaneous octreotide to octreotide infusions (50-100microg/hour). Three patients required intensive care unit admissions, and one required vasopressors due to severe hypotension. There were no mortalities within 30 days of PRRT administration.
These cases highlight the need to develop standardised protocols to prevent and manage severe carcinoid symptoms in high-risk patients treated with PRRT.