Case Summary

A 55-year-old woman with a history of a neuroendocrine tumor (NET) of the lung with hepatic metastasis presents for breast conservation surgery for early-stage breast carcinoma.

This case illustrates a complex perioperative challenge: managing a patient with an established systemic malignancy undergoing curative-intent surgery for a second primary cancer. It highlights how anesthesiologists must integrate oncologic context, basic science, and perioperative risk modulation in their decision-making.

Oncological Context

This patient carries two primary malignancies.

The first is a pulmonary neuroendocrine tumor with hepatic metastases, representing advanced systemic disease. However, NETs often follow an indolent course, and patients may survive for years even with metastatic burden, particularly when therapies such as somatostatin analogs or peptide receptor radionuclide therapy (PRRT) are available.

The second is early-stage breast carcinoma. Surgery for this disease offers curative potential and long-term benefit. From a risk–benefit perspective, the relatively indolent course of the NET means that delaying or omitting surgery for breast cancer would deny the patient a chance at cure.

This balance can be thought of as follows: the NET is like a smouldering fire that can be controlled, while the breast cancer represents a new spark that could spread aggressively if not treated.

Preoperative Considerations

The preoperative evaluation should focus on three broad domains: functional status, hepatic involvement, and neuroendocrine activity.

Functional assessment includes performance status, nutrition, and cardiopulmonary reserve. Discussions with oncology are essential to clarify prognosis, therapeutic goals, and life expectancy.

Because the liver normally inactivates serotonin, histamine, and bradykinin secreted by NETs, the presence of hepatic metastases means these mediators may bypass first-pass metabolism and enter systemic circulation. This increases the risk of carcinoid syndrome. Preoperative laboratory testing should include liver function, coagulation profile, and synthetic markers such as albumin. Hepatic dysfunction also has important anesthetic pharmacology implications: metabolism of opioids, benzodiazepines, and muscle relaxants may be impaired. Drugs with extrahepatic metabolism such as atracurium, cisatracurium, and remifentanil are preferable.

Neuroendocrine activity may contribute to perioperative instability. Serotonin can cause vasoconstriction, bronchospasm, and diarrhea; kallikrein release may trigger bradykinin-mediated hypotension; and histamine release can result in flushing and bronchospasm. In addition, NETs secrete cytokines such as TNF-α and IL-6, which may exacerbate perioperative inflammation. Octreotide prophylaxis with a continuous infusion of 50–100 µg/h is recommended to suppress mediator release.

Anesthetic Considerations

Airway and pulmonary evaluation must consider prior lung resections and restrictive physiology, which reduce ventilatory reserve. For example, following lobectomy, tidal volume reserve is diminished, necessitating cautious opioid titration and avoidance of hypercarbia to limit pulmonary vascular load.

Liver metastases may alter drug clearance. Propofol is generally safe, but prolonged infusion may accumulate. Long-acting opioids and benzodiazepines should be avoided.

The major intraoperative risk is carcinoid crisis, a life-threatening event characterized by severe hypotension and bronchospasm. Triggers include surgical stress, anesthetic induction, histamine-releasing agents, and tumor manipulation. Drugs such as morphine, atracurium, succinylcholine, and ephedrine should be avoided. Safer alternatives include fentanyl, remifentanil, cisatracurium, and vasopressors such as phenylephrine or norepinephrine. Treatment consists of an immediate octreotide bolus (50–100 µg IV), discontinuation of the triggering stimulus, aggressive fluid resuscitation, and vasopressor support.

Breast conservation surgery can be conducted with either volatile anesthesia or total intravenous anesthesia. Regional techniques such as pectoral or serratus anterior plane blocks are useful for analgesia but should be avoided in the presence of coagulopathy or significant thrombocytopenia.

Intraoperative Monitoring

Standard ASA monitoring is sufficient for low-risk patients. Invasive arterial blood pressure monitoring should be considered in patients with symptomatic carcinoid syndrome, significant hepatic dysfunction, or a high risk of hemodynamic instability. Intraoperative glucose monitoring may also be warranted, as serotonin-producing NETs can cause hypoglycemia, and hepatic dysfunction may impair gluconeogenesis.

Postoperative Considerations

Pain management should emphasize multimodal approaches, including acetaminophen, regional techniques, and low-dose opioids such as fentanyl or remifentanil. NSAIDs should be avoided in patients with renal or hepatic impairment or coagulopathy.

Patients must be monitored for hepatic decompensation, which may manifest as ascites, encephalopathy, or worsening coagulopathy. For those with symptomatic carcinoid syndrome, octreotide should be continued for 24–48 hours postoperatively to prevent flare.

Specific Clinical Scenarios

In symptomatic carcinoid syndrome, octreotide infusion should be started before surgery, and histamine- or serotonin-releasing drugs avoided. Invasive monitoring is strongly recommended.

Patients with Child–Pugh B or C liver disease will have prolonged drug clearance, higher bleeding risk, and contraindications to regional anesthesia.

Patients with restrictive physiology following lung resection require lung-protective ventilation, cautious opioid titration, and avoidance of fluid overload.

Teaching Design

From a teaching standpoint, the anesthetic challenge can be summarized as follows: neuroendocrine tumors secrete mediators such as serotonin that can precipitate systemic instability. This manifests as vasospasm, bronchospasm, and hemodynamic collapse. The anesthesiologist must therefore avoid histamine-releasing drugs, maintain octreotide prophylaxis, and select anesthetics with extrahepatic metabolism.

Key Takeaways for Residents

This case should not be approached as a routine breast conservation surgery. It represents surgery for a curable malignancy in a patient with an indolent but systemic tumor. The key points are:

1. Always consider the risk of carcinoid crisis and keep octreotide immediately available.
2. Avoid drugs that release histamine or serotonin.
3. Use anesthetic agents that rely on extrahepatic metabolism.
4. Regional blocks are safe only if coagulation is preserved.
5. Surgery is justified because early breast cancer is curable, whereas NETs are often indolent.