Carcinoid crisis in Lutetium-177-Dotatate therapy of neuroendocrine tumors: an overview of pathophysiology, risk factors, recognition, and treatment

Purpose: Lutetium-177-Dotatate (Lutathera^®) is a combined radionuclide-peptide that is FDA-approved for the treatment of well-differentiated, somatostatin receptor-positive, gastroenteropancreatic neuroendocrine tumors. Carcinoid crisis is a rare, but potentially life-threatening risk of this radiopharmaceutical, of which prompt recognition and treatment is essential to reducing morbidity. This manuscript provides an overview of the topic to promote awareness of this adverse event, with emphasis on early recognition and management. In addition, we present our institution's experience with Lutetium-177-Dotatate-associated complications across a five-year period.

Methods: A literature review of lutetium-177-dotatate therapy and its potential implication of carcinoid crisis was performed. Additionally, a review of our institution's experience is presented.

Results: The incidence of carcinoid crisis induced by Lutetium-177-Dotatate therapy is estimated to range between 1 and 2% of treatment recipients. Those who have tumors located within the midgut, higher tumor burden, and the presence of metastasis have an increased risk of developing carcinoid crisis, among other risk factors. Carcinoid crisis is most often encountered within 12-48 h of receiving the first treatment dose, with the most common symptoms being nausea/vomiting, flushing, and diarrhea.

Conclusion: Carcinoid crisis is a rare but potentially life-threatening complication of Lutetium-177-Dotatate therapy. Knowledge of risk factors and prompt recognition of symptoms is essential to successful treatment, with early initiation of intravenous octreotide serving a critical step in reducing morbidity of this adverse event.