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Gastrinoma
The American Journal of Surgery 183 (2002) 666 – 667
Clinical image
Gastrinoma Thomas P. McIntyre, M.D., Kurt R. Stahlfeld, M.D.*, Harry W. Sell, Jr., M.D. Department of Surgery, Mercy Hospital of Pittsburgh, 1400 Locust St., Pittsburgh, PA 15232-4738, USA Manuscript received November 30, 2001; revised manuscript February 2, 2002
A 64-year-old man presented with a longstanding history of epigastric pain. Outside records indicated that the patient had a previous vagotomy and pyloroplasty for a bleeding duodenal ulcer. Esophagogastroduodenoscopy for the recurrent epigastric pain revealed severe espohagitis, duodenitis, and numerous duodenal ulcers. Fasting serum gastrin level was 725 pg/mL. Radiolabeled octreotide scan demonstrated a midepigastric lesion, most likely a gastrinoma (Fig. 1). Computed tomography showed a 1.5-cm lesion adjacent to the head of the pancreas (Fig. 2). Owing to a concomitant esophageal stricture, the patient was unable to swallow and his albumin dropped to 2.0g/dL. A nasoduodenal feeding tube was placed for nutritional supplementation. He was taken to the operating room where a mass adjacent to the superior border of the pancreas was resected (Fig. 3). Pathology confirmed a gastrinoma in a suprapancreatic lymph node. A postoperative fasting serum gastrin level was 44 pg/mL. He has subsequently undergone serial esophageal dilations and is tolerating a puree diet. Gastrinomas are neuroendocrine tumors that occur in 0.1% of all patients with peptic ulcer disease and 2% of patients with recurrent ulcer disease [1]. Approximately 25% of all gastrinomas are associated with multiple endocrine neoplasia type I [2]. Gastrinomas occur more commonly in males (3:1) and the average age at diagnosis is between 50 and 60 years. Most patients develop peptic ulcers and 43% have evidence of esophagitis. Owing to hypergastremia-induced diarrhea, malabsorption, and reflux-induced esophagitis and stricture, many patients are severely malnourished. Recent advances in endoscopic ultrasound and radiolabeled octreotide scanning have allowed * Corresponding author. Tel.: ⫹1-412-232-8097; fax: ⫹1-412-2328096. E-mail address: [email protected].
Fig. 1. A solitary lesion is seen on radiolabeled octreotide scan.
almost 90% of primary gastrinomas to be identified preoperatively. Although gastrinomas are found most frequently in the pancreas, as many as 20% are located in extrapancreatic sites [3]. Several of these cases clearly involve gastrinomas arising de novo in peripancreatic lymph nodes [3,4]. Surgery offers the only chance for cure and is the treatment of choice for localized disease.
0002-9610/02/$ – see front matter © 2002 Excerpta Medica, Inc. All rights reserved. PII: S 0 0 0 2 - 9 6 1 0 ( 0 2 ) 0 0 8 6 3 - 2
T.P. McIntyre et al. / The American Journal of Surgery 183 (2002) 666 – 667
667
References [1] Azimuddin K, Chamberlain RS. The surgical management of pancreatic neuroendocrine tumors. Surg Clin North Am 2001;81:511–25. [2] Orloff SL, Debas HT. Advances in the management of patients with Zollinger-Ellison syndrome. Surg Clin North Am 1995;75:511–23. [3] MacGillivray DC, Rushin JM, Zeiger MA, Shakir KM. The significance of gastrinomas found in peripancreatic lymph nodes. Surgery. 1991;109:558 – 62. [4] Farley DR, van Heerden JA, Grant CS, Thompson GB. Extrapancreatic gastrinomas. Surgical experience. Arch Surg 1994;129:506 –11.
Fig. 2. A 1.5-cm lesion is adjacent to the head of the pancreas (arrow) corresponding to the site on the octreotide scan.
Fig. 3. The surgical specimen is consistent with a gastrinoma in a suprapancreatic lymph node.
Clinical image
Gastrinoma Thomas P. McIntyre, M.D., Kurt R. Stahlfeld, M.D.*, Harry W. Sell, Jr., M.D. Department of Surgery, Mercy Hospital of Pittsburgh, 1400 Locust St., Pittsburgh, PA 15232-4738, USA Manuscript received November 30, 2001; revised manuscript February 2, 2002
A 64-year-old man presented with a longstanding history of epigastric pain. Outside records indicated that the patient had a previous vagotomy and pyloroplasty for a bleeding duodenal ulcer. Esophagogastroduodenoscopy for the recurrent epigastric pain revealed severe espohagitis, duodenitis, and numerous duodenal ulcers. Fasting serum gastrin level was 725 pg/mL. Radiolabeled octreotide scan demonstrated a midepigastric lesion, most likely a gastrinoma (Fig. 1). Computed tomography showed a 1.5-cm lesion adjacent to the head of the pancreas (Fig. 2). Owing to a concomitant esophageal stricture, the patient was unable to swallow and his albumin dropped to 2.0g/dL. A nasoduodenal feeding tube was placed for nutritional supplementation. He was taken to the operating room where a mass adjacent to the superior border of the pancreas was resected (Fig. 3). Pathology confirmed a gastrinoma in a suprapancreatic lymph node. A postoperative fasting serum gastrin level was 44 pg/mL. He has subsequently undergone serial esophageal dilations and is tolerating a puree diet. Gastrinomas are neuroendocrine tumors that occur in 0.1% of all patients with peptic ulcer disease and 2% of patients with recurrent ulcer disease [1]. Approximately 25% of all gastrinomas are associated with multiple endocrine neoplasia type I [2]. Gastrinomas occur more commonly in males (3:1) and the average age at diagnosis is between 50 and 60 years. Most patients develop peptic ulcers and 43% have evidence of esophagitis. Owing to hypergastremia-induced diarrhea, malabsorption, and reflux-induced esophagitis and stricture, many patients are severely malnourished. Recent advances in endoscopic ultrasound and radiolabeled octreotide scanning have allowed * Corresponding author. Tel.: ⫹1-412-232-8097; fax: ⫹1-412-2328096. E-mail address: [email protected].
Fig. 1. A solitary lesion is seen on radiolabeled octreotide scan.
almost 90% of primary gastrinomas to be identified preoperatively. Although gastrinomas are found most frequently in the pancreas, as many as 20% are located in extrapancreatic sites [3]. Several of these cases clearly involve gastrinomas arising de novo in peripancreatic lymph nodes [3,4]. Surgery offers the only chance for cure and is the treatment of choice for localized disease.
0002-9610/02/$ – see front matter © 2002 Excerpta Medica, Inc. All rights reserved. PII: S 0 0 0 2 - 9 6 1 0 ( 0 2 ) 0 0 8 6 3 - 2
T.P. McIntyre et al. / The American Journal of Surgery 183 (2002) 666 – 667
667
References [1] Azimuddin K, Chamberlain RS. The surgical management of pancreatic neuroendocrine tumors. Surg Clin North Am 2001;81:511–25. [2] Orloff SL, Debas HT. Advances in the management of patients with Zollinger-Ellison syndrome. Surg Clin North Am 1995;75:511–23. [3] MacGillivray DC, Rushin JM, Zeiger MA, Shakir KM. The significance of gastrinomas found in peripancreatic lymph nodes. Surgery. 1991;109:558 – 62. [4] Farley DR, van Heerden JA, Grant CS, Thompson GB. Extrapancreatic gastrinomas. Surgical experience. Arch Surg 1994;129:506 –11.
Fig. 2. A 1.5-cm lesion is adjacent to the head of the pancreas (arrow) corresponding to the site on the octreotide scan.
Fig. 3. The surgical specimen is consistent with a gastrinoma in a suprapancreatic lymph node.