- Email: [email protected]
Synchronous carcinoid tumor of the small bowel
Synchronous Carcinoid Tumor of the Small Bowel Deron J Tessier, MD, Eric Harris, MD, Daniel J Johnson, MD, FACS Mayo Clinic, Scottsdale, AZ
An 84-year-old woman was an outpatient for chronic abdominal pain for 1 year at another institution. She required 5 to 10 Percocet (Endo Pharmaceuticals, Chadds Ford, PA) per day to control her symptoms. She had no earlier abdominal operations and was otherwise healthy. Colonoscopy, esophagogastroduodenoscopy, and a small bowel series were reportedly normal. Dissatisfied with her care she presented to our institution. Gastroenterology and vascular surgery evaluated the patient for food fear and postprandial pain. Duplex of the mesenteric arteries, angiography, CT scan with contrast, colonoscopy, and esophagogastroduodenoscopy were nondiagnostic. Two months into her evaluation by our institution she presented to the emergency room with increased pain and signs of a partial small bowel obstruction. A small bowel barium study showed a high-grade stenosis of the mid-small bowel (A, large arrow). Proximal to this stenosis the bowel was dilated and had numerous filling defects (A, small arrows). Given the patient’s symptoms and small bowel study, she was taken to the
© 2002 by the American College of Surgeons Published by Elsevier Science Inc.
operating room for exploratory laparotomy. There were two strictures of the mid-small bowel. On palpation there were numerous hard, freely mobile masses within the dilated, proximal segment. The small bowel and mesentery were resected and sent for pathologic inspection. The bowel had numerous pills consistent with the reported Percocet the patient had been consuming (B). Microscopic analysis of the two stricture sites found carcinoid tumors. Retrospective analysis of the CT scan performed 2 months earlier demonstrated a loop of small bowel with numerous filling defects, initially interpreted as normal sigmoid colon (C). No distinct mass lesion was seen on this scan. Carcinoid tumors are the most common malignant neoplasm of the small bowel and are rarely diagnosed early.
890
ISSN 1072-7515/02/$21.00 PII S1072-7515(02)01300-5
Tessier et al
Vol. 195, No. 6, December 2002
Patients typically present with nonspecific symptoms. Up to 50% of patients present with a mechanical small bowel obstruction, and by taking a careful history it is usually noted that the patient had subtle symptoms for a quite a long time.1 The classic carcinoid syndrome is only seen in 5% of patients with small bowel carcinoid tumors.2 Our patient did not have symptoms of carcinoid syndrome. Nearly one-third of patients have synchronous carcinoid tumors of the small bowel. Surgical management is the mainstay of treatment for isolated carcinoid tumors. Patients with metastatic carcinoid tumor should be treated medically unless they become refractory, have intestinal obstruction or ischemia, or fail to thrive.3 Tumors less than 1 cm have an overall better prognosis, but tumors less than 0.5cm have been known to cause metastatic disease.4 Un-
Images for Surgeons
891
like patients with appendiceal carcinoids who have a better prognosis, patients with local or regional small bowel carcinoid have a 5-year survival of only 65% and with metastatic diseases have a 36% survival rate.1 REFERENCES 1. Kulke MH, Mayer RJ. Medical progress: Carcinoid tumors. New Engl J Med 1999;340:858–868. 2. Onaitis MW, Kirshborn PM, Hayward TZ, et al. Gastrointestinal carcinoids: Characterization by site of origin and hormone production. Ann Surg 2000;232:549–556. 3. Kendrick ML, van Heerden JA. Small bowel carcinoid tumors. In: Current surgical therapy. 7th ed. St Louis: Mosby Press; 2001:167–170. 4. Makridis C, Oberg K, Kuhlin C, et al. Surgical treatment of midgut carcinoid tumors. World J Surg 1990;14:377–385.
Future National Meetings Submissions The Journal of the American College of Surgeons is pleased to provide information about medical meetings. The “Future National Meetings” page is updated frequently. To submit a meeting notice, send the following information to [email protected] or fax to 312-202-5027: • • • •
Name of meeting group Dates of meeting Place of meeting Telephone number and name of person to be called for full information
Example: The Surgeons of America, January 1–4, 2000, City, State, John Surgeon, 800-111-2222. The Journal reserves the right to decline meeting announcements at discretion of editorial office.
An 84-year-old woman was an outpatient for chronic abdominal pain for 1 year at another institution. She required 5 to 10 Percocet (Endo Pharmaceuticals, Chadds Ford, PA) per day to control her symptoms. She had no earlier abdominal operations and was otherwise healthy. Colonoscopy, esophagogastroduodenoscopy, and a small bowel series were reportedly normal. Dissatisfied with her care she presented to our institution. Gastroenterology and vascular surgery evaluated the patient for food fear and postprandial pain. Duplex of the mesenteric arteries, angiography, CT scan with contrast, colonoscopy, and esophagogastroduodenoscopy were nondiagnostic. Two months into her evaluation by our institution she presented to the emergency room with increased pain and signs of a partial small bowel obstruction. A small bowel barium study showed a high-grade stenosis of the mid-small bowel (A, large arrow). Proximal to this stenosis the bowel was dilated and had numerous filling defects (A, small arrows). Given the patient’s symptoms and small bowel study, she was taken to the
© 2002 by the American College of Surgeons Published by Elsevier Science Inc.
operating room for exploratory laparotomy. There were two strictures of the mid-small bowel. On palpation there were numerous hard, freely mobile masses within the dilated, proximal segment. The small bowel and mesentery were resected and sent for pathologic inspection. The bowel had numerous pills consistent with the reported Percocet the patient had been consuming (B). Microscopic analysis of the two stricture sites found carcinoid tumors. Retrospective analysis of the CT scan performed 2 months earlier demonstrated a loop of small bowel with numerous filling defects, initially interpreted as normal sigmoid colon (C). No distinct mass lesion was seen on this scan. Carcinoid tumors are the most common malignant neoplasm of the small bowel and are rarely diagnosed early.
890
ISSN 1072-7515/02/$21.00 PII S1072-7515(02)01300-5
Tessier et al
Vol. 195, No. 6, December 2002
Patients typically present with nonspecific symptoms. Up to 50% of patients present with a mechanical small bowel obstruction, and by taking a careful history it is usually noted that the patient had subtle symptoms for a quite a long time.1 The classic carcinoid syndrome is only seen in 5% of patients with small bowel carcinoid tumors.2 Our patient did not have symptoms of carcinoid syndrome. Nearly one-third of patients have synchronous carcinoid tumors of the small bowel. Surgical management is the mainstay of treatment for isolated carcinoid tumors. Patients with metastatic carcinoid tumor should be treated medically unless they become refractory, have intestinal obstruction or ischemia, or fail to thrive.3 Tumors less than 1 cm have an overall better prognosis, but tumors less than 0.5cm have been known to cause metastatic disease.4 Un-
Images for Surgeons
891
like patients with appendiceal carcinoids who have a better prognosis, patients with local or regional small bowel carcinoid have a 5-year survival of only 65% and with metastatic diseases have a 36% survival rate.1 REFERENCES 1. Kulke MH, Mayer RJ. Medical progress: Carcinoid tumors. New Engl J Med 1999;340:858–868. 2. Onaitis MW, Kirshborn PM, Hayward TZ, et al. Gastrointestinal carcinoids: Characterization by site of origin and hormone production. Ann Surg 2000;232:549–556. 3. Kendrick ML, van Heerden JA. Small bowel carcinoid tumors. In: Current surgical therapy. 7th ed. St Louis: Mosby Press; 2001:167–170. 4. Makridis C, Oberg K, Kuhlin C, et al. Surgical treatment of midgut carcinoid tumors. World J Surg 1990;14:377–385.
Future National Meetings Submissions The Journal of the American College of Surgeons is pleased to provide information about medical meetings. The “Future National Meetings” page is updated frequently. To submit a meeting notice, send the following information to [email protected] or fax to 312-202-5027: • • • •
Name of meeting group Dates of meeting Place of meeting Telephone number and name of person to be called for full information
Example: The Surgeons of America, January 1–4, 2000, City, State, John Surgeon, 800-111-2222. The Journal reserves the right to decline meeting announcements at discretion of editorial office.