Sandostatin Desensitization

Abstract

Purpose: Currently there are no guidelines to manage patients with carcinoid tumors who would benefit from sansdostatin but are unable to tolerate it. We attempt a desensitizing strategy in such patients. Methods: 49-year old white male was evaluated for a history of painless jaundice of 1-week duration. He reported facial flushing, lasting years. Asymptomatic otherwise, and had no other significant personal or family history or physical examination findings other than facial flushing. Work up revealed distension of the gall bladder and dilatation of the common bile duct (CBD) (1.9 cm), hepatic ducts and a 3.5 cm hypodense lesion in the head of the pancreas. Patient underwent multiple endoscopic retrograde cholangiopancreatographies (ERCP) with stent placement; CBD biopsies and brushings did not reveal malignancy. Subsequent CT scan of the abdomen revealed multiple 10–15 mm ill-defined hepatic lesions and increased fullness in the pancreatic head. Biopsy of the pancreas revealed a low-grade neuroendocrine tumor of the pancreas head and neck. Octreotide uptake was noted in the head and neck of the pancreas and two hepatic lesions. Patient had an elevated chromogranin-A level of 6. While the patient was waiting for surgery (whipple procedure), he was started on sandostatin 150 mcg SQ bid, to be continued for 2 weeks, followed by long acting sandostatin once every month. However, patient reported severe nausea, vomiting, diarrhea, abdominal cramps after each dose of 150 mcg and was challenged a few days apart with 3 doses. There is no literature to guide management of these patients in terms of strategies for desensitizing patients as sandostatin can cause disease stabilization as well as minimize anesthesia complications during the peri-operative period and ultimately benefit the patient. We attempted a trial of gradually increasing the dose of sandostatin, starting at less than 1/3rd of the recommended dose, at 25 mcg subcutaneously (SQ) twice a day. Results: As the patient tolerated the dose, it was doubled every 3 days to eventually reach a dose that is within the lower range of recommended for achieving steady state concentrations. Upon reaching the targeted dose of 150 mcg SQ bid, he tolerated it without the intial severe gastrointestinal effects. Following this he was given a long acting sandostatin LAR injection of 20 mg deep intramuscularly, which he tolerated well, with some relief of his flushing as well. Conclusion: There are no guidelines to manage patients with carcinoid tumors who are unable to tolerate sandostatin. We report a desensitizing strategy that can be useful in such patients and situations where sandostatin is indicated for therapy of tumor (as a disease stabilizing agent) or for control of carcinoid symptoms.