Job title
Professor of gastroenterology and neuroendocrine tumours
Related services
Location
Biography
Prof Toumpanakis is a Professor at the medical school of University College London and has been awarded ‘top-teacher of the year’ in 2007, 2009, 2013, 2014, 2015 and 2016.
He graduated from Medical School-University of Athens, Greece, in 1994, obtained his specialty title in gastroenterology and hepatology in 2004, along with his PhD from University of Athens in 2007. He is the immediate past Chair of the European Neuroendocrine Tumour Society (ENETS) Advisory Board. He is the Senior Author of ENETS Guidance Paper 2022 of Carcinoid Syndrome and Carcinoid Heart Disease and co-author in other several ENETS guidelines' papers.
His sub-specialty is neuroendocrine (carcinoid) tumours (NETs), and he is considered as one of the international experts in that field. He has significant clinical experience in all types of gastro-entero-pancreatic, as well as bronchial NETs in all available treatment options.
Professor Toumpanakis's main interests, apart from general gastroenterology and endoscopy, include gastro-oesophageal reflux disease, celiac disease, chronic diarrhoea, inflammatory bowel disease and gastro-intestinal problems in patients with congenital immuno-deficiencies.
He lectures regularly in several international conferences and has published many original papers and reviews.
Languages
English
Greek
• ENETS Consensus Guidelines for the Standards of Care in Neuroendocrine Neoplasia: Peptide Receptor Radionuclide Therapy with Radiolabeled Somatostatin Analogues. Hicks RJ, Kwekkeboom DJ, Krenning E, Bodei L, Grozinsky-Glasberg S, Arnold R, Borbath I, Cwikla J, Toumpanakis C, Kaltsas G, Davies P, Hörsch D, Tiensuu Janson E, Ramage J Neuroendocrinology. 2017 Apr.
• ENETS Consensus Guidelines for Standard of Care in Neuroendocrine Tumours: Surgery for Small Intestinal and Pancreatic Neuroendocrine Tumours. Partelli S, Bartsch DK, Capdevila J, Chen J, Knigge U, Niederle B, Nieveen van Dijkum EJ, Pape UF, Pascher A, Ramage J, Reed N, Ruszniewski P, Scoazec JY, Toumpanakis C, Kianmanesh R, Falconi M;. Neuroendocrinology. 2017 Feb.
• Occipital Headache as Initial Manifestation of a Pancreatic Neuroendocrine Tumor. Tsoukalas N, Triantafyllidis A, Tolia M, Galanopoulos M, Kostakis ID, Demiri S, Toumpanakis C, Koumakis G.. Journal of gastrointestinal cancer. Mar 2017.
• The Impact of Radiological Response to Peptide Receptor Radionuclide Therapy on Overall Survival in Patients With Metastatic Midgut Neuroendocrine Tumors. Yalchin M, Oliveira A, Theocharidou E, Pencharz D, Navalkissoor S, Quigley AM, Walker M, Caplin M, Toumpanakis C.Clin Nucl Med. 2017;42(3):E135-E41.
• Early efficacy of and toxicity from lutetium-177-DOTATATE treatment in patients with progressive metastatic NET. Pencharz D, Walker M, Yalchin M, Quigley AM, Caplin M, Toumpanakis C, et al.Nucl Med Commun. 2017;38(7):593-600.
• Comparison of the Impact of Ga-68-DOTATATE and F-18-FDG PET/CT on Clinical Management in Patients with Neuroendocrine Tumors. Panagiotidis E, Alshammari A, Miehopoulou S, Skoura E, Naik K, Maragkoudakis E, Mohmaduvesh M, Al-Harbi M, Belda M, Caplin ME, Toumpanakis C, Bomanji J.J Nucl Med. 2017;58(1):91-6.
• Peptide Receptor Radionuclide Treatment and (131)I-MIBG in the management of patients with metastatic/progressive phaeochromocytomas and paragangliomas. Nastos K, Cheung VTF, Toumpanakis C, Navalkissoor S, Quigley AM, Caplin M, et al. J Surg Oncol. 2017;115(4):425-34.
• The Antiproliferative Role of Lanreotide in Controlling Growth of Neuroendocrine Tumors: A Systematic Review. Michael M, Garcia-Carbonero R, Weber MM, Lombard-Bohas C, Toumpanakis C, Hicks RJ. Oncologist. 2017;22(3):272-85.
• Evaluating lanreotide as maintenance therapy after first-line treatment in patients with non-resectable duodeno-pancreatic neuroendocrine tumours. Lepage C, Dahan L, Bouarioua N, Toumpanakis C, Legoux JL, Le Malicot K, et al. Dig Liver Dis. 2017;49(5):568-71.
• Diagnosing and Managing Carcinoid Heart Disease in Patients With Neuroendocrine Tumors An Expert Statement. Davar J, Connolly HM, Caplin ME, Pavel M, Zacks J, Bhattacharyya S, Cuthbertson D, Dobson R, Grozinsky-Glasberg S, Steeds R, Dreyfus G, Pellikka P, Toumpanakis C.J Am Coll Cardiol. 2017;69(10):1288-304.
• Progressive epigenetic dysregulation in neuroendocrine tumour liver metastasis. Karpathakis A, Dibra H, Pipinikas C, Feber A, Morris T, Francis JM, Oukrif D, Mandair D, Pericleous M, Mohmaduvesh M, Serra S, Ogunbiyi O, Novelli M, Luong TV, Asa SL, Kulke MH, Toumpanakis C, Meyer T, Caplin M, Beck S, Thirlwell C. Endocr Relat Cancer. 2017 Jan 3
• ENETS Consensus Guidelines Update for Neuroendocrine Neoplasm of the Jejunum and Ileum.Niederle B, Pape UF, Costa F, Gross D, Kelestimur F, Knigge U, Öberg K, Pavel M, Perren A,Toumpanakis C, O’Connor J, O’Toole D, Krenning E, Reed N, Kianmanesh R; all other Vienna Consensus Conference participants. Neuroendocrinology. 2016 Jan 12.
• Active Surveillance versus Surgery of Nonfunctioning Pancreatic Neuroendocrine Neoplasms ?2 cm in MEN1 Patients. Partelli S, Tamburrino D, Lopez C, Albers M, Milanetto AC, Pasquali C, Manzoni M, Toumpanakis C, Fusai G, Bartsch D, Falconi M. Neuroendocrinology. 2016 Jan 6.
• Consensus Guidelines for High Grade Gastro-Entero-Pancreatic (GEP) Neuroendocrine Tumours and Neuroendocrine Carcinomas (NEC).Garcia-Carbonero R, Sorbye H, Baudin E, Raymond E, Wiedenmann B, Niederle B, Sedlackova E,Toumpanakis C, Anlauf M, Cwikla J, Caplin M, O’Toole D, Perren A; all other Vienna Consensus Conference participants. Neuroendocrinology. 2016 Jan 5
• Consensus Guidelines for Neuroendocrine Neoplasms of the Appendix (Excluding Goblet Cell Carcinomas). Pape UF, Niederle B, Costa F, Gross D, Kelestimur F, Kianmanesh R, Knigge U, Öberg K, Pavel M, Perren A, Toumpanakis C, O’Connor J, Krenning E, Reed N, O’Toole D; all other Vienna Consensus Conference participants. Neuroendocrinology. 2016 Jan 5.
• The impact of 68Ga-DOTATATE PET/CT imaging on management of patients with neuroendocrine tumours: Experience from a national referral centre in the United Kingdom. Skoura E, Michopoulou S, Mohmaduvesh M, Panagiotidis E, Al Harbi M, Toumpanakis C, Almukhailed O, Kayani I, Syed R, Navalkissoor S, Ell PJ, Caplin ME, Bomanji J. J Nucl Med. 2016 Jan;57(1):34-40
• Hepatic artery embolization in advanced neuroendocrine tumors: Efficacy and long-term outcomes. Pericleous M, Caplin ME, Tsochatzis E, Yu D, Morgan-Rowe L, Toumpanakis C. Asia Pac J Clin Oncol. 2015 Dec 14.
• Phase III study of pasireotide long-acting release in patients with metastatic neuroendocrine tumors and carcinoid symptoms refractory to available somatostatin analogues. Wolin EM, Jarzab B, Eriksson B, Walter T, Toumpanakis C, Morse MA, Tomassetti P, Weber MM, Fogelman DR, Ramage J, Poon D, Gadbaw B, Li J, Pasieka JL, Mahamat A, Swahn F, Newell-Price J, Mansoor W, Öberg K. Drug Des Devel Ther. 2015 Sep 3;9:5075-86.
• Prognostic Impact of Novel Molecular Subtypes of Small Intestinal Neuroendocrine Tumor. Karpathakis A, Dibra H, Pipinikas C, Feber A, Morris T, Francis J, Oukrif D, Mandair D, Pericleous M, Mohmaduvesh M, Serra S, Ogunbiyi O, Novelli M, Luong T, Asa SL, Kulke M, Toumpanakis C, Meyer T, Caplin M, Meyerson M, Beck S, Thirlwell C. Clin Cancer Res. 2015 Jul 13. Chromogranin A as a predictor of radiological disease progression in neuroendocrine tumours. Rossi RE, Garcia-Hernandez J, Meyer T, Thirlwell C, Watkins J, Martin NG, Caplin ME, Toumpanakis C. Ann Transl Med. 2015 Jun;3(9):118.
• Goblet cell appendiceal tumors–management dilemmas and long-term outcomes. Rossi RE, Luong TV, Caplin ME, Thirlwell C, Meyer T, Garcia-Hernandez J, Baneke A, Conte D, Toumpanakis C. Surg Oncol. 2015 Mar;24(1):47-53.
• Accuracy and reproducibility of right ventricular quantification in patients with pressure and volume overload using single-beat three-dimensional echocardiography. Knight DS, Grasso AE, Quail MA, Muthurangu V, Taylor AM, Toumpanakis C, Caplin ME, Coghlan JG, Davar J.J Am Soc Echocardiogr. 2015 Mar;28(3):363-74.
• Diagnosis of polypoid portal hypertensive enteropathy due to superior mesenteric vein thrombosis by capsule endoscopy and double-balloon enteroscopy. Laskaratos FM, Toumpanakis C, Clark I, Wylie P, Bhagani S, Despott EJ. Endoscopy. 2014;46 Suppl 1 UCTN:E592-3.
• Role of interferon-alpha in patients with neuroendocrine tumors: a retrospective study. Mirvis E, Mandair D, Garcia-Hernandez J, Mohmaduvesh M, Toumpanakis C, Caplin M. Anticancer Res. 2014 Nov;34(11):6601-7
• Case report of multimodality treatment for metastatic parathyroid hormone-related peptide-secreting pancreatic neuroendocrine tumour. Rossi RE, Naik K, Navalkissoor S, Imber C, O’Beirne J, Toumpanakis C, Caplin ME. Tumori. 2014 Jul-Aug;100(4):153e-6e.
• Combination of Cross-Sectional and Molecular Imaging Studies in the Localization of Gastroenteropancreatic Neuroendocrine Tumors. Toumpanakis C, Kim MK, Rinke A, Bergestuen DS, Thirlwell C, Khan MS, Salazar R, Oberg K. Neuroendocrinology. 2014;99(2):63-74. Review.
• Circulating plasma and platelet 5-hydroxytryptamine in carcinoid heart disease: a pilot study. Bhattacharyya S, Jagroop A, Gujral DM, Hayward C, Toumpanakis C, Caplin M, Mikhailidis DP, Davar J. J Heart Valve Dis. 2013 May;22(3):400-7.
• Pancreatic adenocarcinoma in a patient with multiple endocrine neoplasia 1 syndrome. Karpathakis A, Pericleous M, Luong TV, Khoo B, Thirlwell C, Toumpanakis C, Caplin ME. Pancreas. 2013 May;42(4):725-6.
• A comparison of Ki-67 and mitotic count as prognostic markers for metastatic pancreatic and midgut neuroendocrine neoplasms.Khan MS, Luong TV, Watkins J, Toumpanakis C, Caplin ME, Meyer T. Br J Cancer. 2013 May 14;108(9):1838-4.
• Update on the role of somatostatin analogs for the treatment of patients with gastroenteropancreatic neuroendocrine tumors. Toumpanakis C, Caplin ME. Semin Oncol. 2013 Feb;40(1):56-68. Review. Appendiceal goblet cell carcinoid tumour: a case of unexpected lung metastasis. Pericleous M, Lumgair H, Baneke A, Morgan-Rowe L, E Caplin M, Luong TV, Thirlwell C, Gillmore R, Toumpanakis C. Case Rep Oncol. 2012 May;5(2):332-8.
• Gastric mixed adenoneuroendocrine carcinoma with a trilineage cell differentiation: case report and review of the literature. Pericleous M, Toumpanakis C, Lumgair H, Caplin ME, Morgan-Rowe L, Clark I, Luong TV. Case Rep Oncol. 2012 May;5(2):313-9.
• Guidelines for the management of gastroenteropancreatic neuroendocrine (including carcinoid) tumours (NETs).Ramage JK, Ahmed A, Ardill J, Bax N, Breen DJ, Caplin ME, Corrie P, Davar J, Davies AH, Lewington V, Meyer T, Newell-Price J, Poston G, Reed N, Rockall A, Steward W, Thakker RV, Toubanakis C, Valle J, Verbeke C, Grossman AB; UK and Ireland Neuroendocrine Tumour Society. Gut. 2012 Jan;61(1):6-32.
• Carcinoid tumors of the duodenum and the ampulla of Vater: current diagnostic and therapeutic approach in a series of 8 patients. Case series.Nikou GC, Toubanakis C, Moulakakis KG, Pavlatos S, Kosmidis C, Mallas E, Safioleas P, Sakorafas GH, Safioleas MC. Int J Surg. 2011;9(3):248-53.
• Long-term results of treatment of malignant carcinoid syndrome with prolonged release Lanreotide (Somatuline Autogel).Khan MS, El-Khouly F, Davies P, Toumpanakis C, Caplin ME. Aliment Pharmacol Ther. 2011 Jul;34(2):235-42.
• Risk factors for the development and progression of carcinoid heart disease.Bhattacharyya S, Toumpanakis C, Chilkunda D, Caplin ME, Davar J. Am J Cardiol. 2011 Apr 15;107(8):1221-6.
• Outcomes, risks and complications of cardiac surgery for carcinoid heart disease. Bhattacharyya S, Raja SG, Toumpanakis C, Caplin ME, Dreyfus GD, Davar J. Eur J Cardiothorac Surg. 2011 Jul;40(1):168-72.
• Use of molecular imaging to differentiate liver metastasis of colorectal cancer metastasis from neuroendocrine tumor origin.Desai K, Watkins J, Woodward N, Quigley AM, Toumpanakis C, Bomanji J, Caplin M. J Clin Gastroenterol. 2011 Jan;45(1):e8-11.
• “Chemotherapy with 5-fluorouracil, cisplatin and streptozocin for neuroendocrine tumours.Turner NC, Strauss SJ, Sarker D, Gillmore R, Kirkwood A, Hackshaw A, Papadopoulou A, Bell J, Kayani I, Toumpanakis C, Grillo F, Mayer A, Hochhauser D, Begent RH, Caplin ME, Meyer T.Br J Cancer. 2010 Mar 30;102(7):1106-12.
• “Features of Carcinoid Heart Disease Identified By Two- and ThreeDimensional Echocardiography and Cardiac Magnetic Resonance Imaging.”Bhattacharyya S, Toumpanakis C, Burke M, Taylor A, Caplin M, Davar J.Circ Cardiovasc Imaging. 2010 Jan;3(1):103-11
• “Management of gastroentero-pancreatic neuroendocrine tumors (GEP-NETs).”Desai KK, Khan MS, Toumpanakis C, Caplin ME.Minerva Gastroenterol Dietol. 2009 Dec;55(4):425-43.
• “Long-term results of patients with malignant carcinoid syndrome receiving octreotide LAR”.Toumpanakis C, Garland J, Marelli L, Srirajaskanthan R, Soh J, Davies P, Buscombe J, Caplin ME. Aliment Pharmacol Ther. 2009 Oct;30(7):733-40
• “A stepwise approach to the management of metastatic midgut carcinoid tumor.”Bhattacharyya S, Gujral DM, Toumpanakis C, Dreyfus G, Davidson BR, Davar J, Caplin ME.Nat Rev Clin Oncol. 2009 Jul;6(7):429-33.
• “Surgical management and palliative treatment in bronchial neuroendocrine tumours: a clinical study of 45 patients.”Srirajaskanthan R, Toumpanakis C, Karpathakis A, Marelli L, Quigley AM, Dusmet M, Meyer T, Caplin ME.Lung Cancer. 2009 Jul;65(1):68-73
• “Review article: future therapies for management of metastatic gastroenteropancreatic neuroendocrine tumours.” Srirajaskanthan R, Toumpanakis C, Meyer T, Caplin ME.Aliment Pharmacol Ther. 2009 Jun 1;29(11):1143-54
• “Two-dimensional electrophoretic analysis of nuclear matrix proteins in human colon adenocarcinoma”.Toumpanaki A, Baltatzis GE, Gaitanarou E, Seretis E, Toumpanakis C, Aroni K, Kittas C, Voloudakis-Baltatzis IE. Ultrastruct Pathol. 2009 Mar-Apr;33(2):83-91
• “Parathyroid Hormone-Related Peptide-Secreting Pancreatic Neuroendocrine Tumours: Case Series and Literature Review”. Srirajaskanthan R, McStay M, Toumpanakis C, Meyer T, Caplin ME. Neuroendocrinology 2009;89(1):48-55.
• Usefulness of N-terminal pro-brain natriuretic peptide as a biomarker of the presence of carcinoid heart disease.Bhattacharyya S, Toumpanakis C, Caplin ME, Davar J.Am J Cardiol. 2008 Oct 1;102(7):938-42
• “Alpha-fetoprotein and human chorionic gonadotrophin-beta as prognostic markers in neuroendocrine tumour patients”. Shah T, Srirajaskanthan R, Bhogal M, Toubanakis C, Meyer T, Noonan A, Witney-Smith C, Amin T, Bhogal P, Sivathasan N, Warner B, Hochhauser D, Caplin ME.Br J Cancer. 2008 Jul 8;99(1):72-7
• “The role of 99mTc-depreotide in the management of neuroendocrine tumours”. Shah T, Kulakiene I, Quigley AM, Warbey VS, Srirajaskanthan R, Toumpanakis C, Hochhauser D, Buscombe J, Caplin ME. Nucl Med Commun. 2008 May;29(5):436-40.
• “A review of thymic tumours”. Srirajaskanthan R, Toubanakis C, Dusmet M, Caplin ME. Lung Cancer. 2008 Apr;60(1):4-13.
• “Molecular Genetics in Gastroenteropancreatic Neuroendocrine Tumours”C. Toumpanakis, ME Caplin. Am J Gastroenterol 2008 Mar;103(3):729-32)
• “Analysis of 150 Patients with Carcinoid Syndrome seen in a Single Year at One Institution in the First Decade of the Twenty-First Century”Sanjeev Bhattacharyya, Christos Toumpanakis, Joseph Davar, Martyn E Caplin Am J Cardiol. 2008 Feb 1;101(3):378-81.
• “Lung scintigraphy with Non-specific Human Immunoglobulin G (99mTc – HIG) for the evaluation of Pulmonary Involvement in Connective Tissue Diseases: Correlation with Pulmonary Function Tests (PFTs) and High Resolution Computed Tomography (HRCT)”Ch. Kostopoulos, J. Koutsikos, C. Toubanakis, L.A Moulopoulos, Ch. Mamoulakis, M. Souvatzoglou, E. Gialafos, P.P. Sfikakis, Ch. Zerva, M. Mavrikakis, A. Leondi European Journal of Nuclear Medicine and Molecular Imaging 2008 Feb;35(2):343-51
• “Treatment of small intestinal disease in systemic sclerosis with octreotide : a prospective study in seven patients” George C. Nikou , Christos Toumpanakis , Christina Katsiari , Dionisios Charalambopoulos , Petros P. Sfikakis J Clin Rheumatol. 2007 Jun;13(3):119-2
• “Cytotoxic treatment including embolization and chemoembolization for neuroendocrine tumours” Christos Toumpanakis, Tim Meyer, Martyn E CaplinBest Clin Practice & Research Clinical Endocrinology and Metabolism 2007 Mar;21(1):131-44.
• “Goblet Cell Carcinoid Tumors (adenocarcinoid) of the Appendix”Christos Toumpanakis, Richard A. Standish, Elora Baishnab, Mark C. Winslet, Martyn E. Caplin.Dis Col Rectum 2007 Mar;50(3):315-22.
• “Gastrinomas associated with MEN-1 syndrome: new insights for the diagnosis and management in a series of 11 patients” Nikou GC, Toubanakis C, Nikolaou P, Giannatou E, Marinou K, Safioleas M, Karamanolis D.Hepatogastroenterology. 2005 Nov-Dec;52(66):1668-76.
• “Multimodality treatment of neuroendocrine tumors of the thymus” Dosios T, Nikou GC, Toubanakis C, Filippides T, Papachristou D. Thorac Cardiovasc Surg. 2005 Oct;53(5):305-9.
• “Disseminated aspergillosis mimicking hepatic veno-occlusive disease”. Daikos GL, Syriopoulou V, Aperis G, Toubanakis C, Petrikkos G, Demonakos M. Ann Intern Med. 2005 Aug 16;143(4):315-6
• “VIPomas: an update in diagnosis and management in a series of 11 patients”. Nikou GC, Toubanakis C, Nikolaou P, Giannatou E, Safioleas M, Mallas E, Polyzos A. Hepatogastroenterology. 2005 Jul-Aug;52(64):1259-65.
• “Current Diagnosis and Treatment of Gastrointestinal Carcinoids in a series of 101 patients : ?he significance of serum chromogranin-a , somatostatin receptor scintigraphy and somatostatin analogues.” Nikou GC, Lygidakis NJ, Toubanakis C, Pavlatos S, Tseleni-Balafouta S, Giannatou E, Mallas E, Safioleas M. Hepatogastroenterology. 2005 May-Jun;52(63):731
• “Carcinoid tumors of the appendix. Prognostic factors and evaluation of indications for right hemicolectomy” Safioleas MC, Moulakakis KG, Kontzoglou K, Stamoulis J, Nikou GC, Toubanakis C, Lygidakis NJ. Hepatogastroenterology. 2005 Jan-Feb;52(61):123
• “Successful Treatment of Chylous Pleural Effusion and Lymphedema in Yellow Nail Syndrome with Octreotide” K.Makrilakis , S.Pavlatos , G.Giannikopoulos , C.Toubanakis , N.Katsilambros Ann Intern Medicine 2004 Aug 3;141(3):246-7
• “Effect of octreotide administration on serum interleukin-6 (IL-6) levels of patients with acute oedematous pancreatitis” G.C.Nikou,E.Giamarellos-Bourboulis,P.Grecka,C.Toumpanakis ,G.Giannikopoulos , N.Katsilambros Hepatogastroenterology. 2004 Mar-Apr;51(56):599-602
• “Alteration of Systemic Endotoxemia over the course of Acute Edematous Pancreatitis” E.GiamarellosBourboulis,G.C.Nikou,M.Matsaggoura,C.Toumpanakis,P.Grecka,G.Giannikopoulos , N.Katsilambros Pancreatology. 2003;3(4):323-8.
• “Acute pancreatitis after long-term therapy with mesalazine , and hyperamylasemia associated with azathioprine in a patient with ulcerative colitis”C.Toubanakis,E.Batziou, N.Sipsas , G.Galanopoulos , M.Tzivras , A.Archimandritis European Journal of Gastroenterology & Hepatology 2003, 15: 933-934
• Changes of plasma levels of gastrointestinal peptides over the course of acute pancreatitis. Any significance for the pathophysiology and treatment of acute pancreatitis?Nikou GC, Giamarellos-Bourboulis EJ, Toumpanakis C, Arnaoutis TP, Kitsou E, Kyriaki D, Katsilambros N.Hepatogastroenterology. 2002 May-Jun;49(45):706-8.
• Acute pancreatitis after captopril treatment A.Iliopoulou , G.Giannakopoulos, H. Pagou, C. Toubanakis, T.Spiropoulos. Digest. Dis. Sci 46/9 ; 2001 : 1882-1883
• Replacement of the Pyloric Sphincter with the Ileocecal valve:An experimental study. G.Toubanakis , G.Economou , G.Karagianis , C.Toubanakis , B.Golematis The Mount Sinai Journal of Medicine , Vol. 67 , No 2 , Mar.2000, 152-158.
• Use of Pylorus for Preventing Ileostomy Complications». An Experimental Canine Study.Toubanakis G, Peveretos P, Toubanakis C, Golematis BC.Dis. Colon.Rectum , 1996 ,Mar;39(3): 266-9.
Prof Toumpanak's research interests in neuroendocrine tumours include biomarkers, mesenteric fibrosis, and carcinoid heart disease.