Introduction: Perioperative mortality of patients who undergo heart valve surgery for carcinoid heart valve disease (CHVD) has been observed to be high (510%). We investigated whether peptide receptor radiotherapy (PRRT) with Lutetium-177 Dotatate can be used safely in patients with neuroendocrine neoplasms (NEN) and CHVD and if there is an associated survival advantage by reducing overall exposure of the valves to high doses of vasoactive peptides.
Method: A retrospective case notes review was performed on 18 NEN patients (mean age 60 years, 9 female), who underwent heart valve surgery between 2003 and 2017 for CHVD.
Results: All patients were treated with somatostatin receptor antagonists and underwent cardiac valvular surgery (mean two valves replaced) and three benefitted from additional coronary bypass grafting. Ten patients underwent surgery alone: in this group, the time from surgery to progression was mean 14 months (S.D. 13.5 months). Nine were treated with PRRT in addition to surgery (mean three cycles). Six underwent surgery with PRRT on progression. Time to progression from surgery to first PRRT was mean 25.1 months (S.D. 23.6 months). Two patients had PRRT pre- and post-operatively, after one cycle PRRT, undergoing surgery 68 and 101 days post PRRT. One patient received PRRT with surgery planned. All PRRT patients were pre-dosed with 5% arginine plus 5% lysine, 1 litre intravenous, over four hours. No patients developed peri-treatment cardiac complications. Average time from surgery to last follow up/death was 41 months (679) in the surgery+lutetium group and in the surgery only group 17 months (124). There were no deaths within the 30-day post-operative period. Nine patients died, five in the surgery+lutetium group and four in the surgery only group, all at greater than one year post-surgery. One death, in the non-PRRT group, was due to progression of CHVD.
Discussion: PRRT is safe in the setting of CVHD: in patients with controlled heart failure, PPRT can be use in the pre- and post-valve surgery period. There appears to be a survival benefit of having PRRT. Further evidence for PRRT in the neo-adjuvant setting prior to cardiothoracic surgery is required.
02 Dec 2019
UK and Ireland Neuroendocrine Tumour Society