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Haupt F, Afshar-Oromieh A, Obmann VC, Huber AT, Maurer M. Cystic Hepatic Neuroendocrine Tumor: A Rare Entity. Clin Nucl Med 2021; 46:e577-e578. [PMID: 34269733 DOI: 10.1097/rlu.0000000000003803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
ABSTRACT A 70-year-old man presented with unspecific abdominal symptoms and weight loss was referred for a sonographic examination. Sonography revealed 3 cystic hepatic masses in an otherwise unremarkable liver. Contrast-enhanced MRI of the liver was performed to characterize the hepatic lesions and elucidate their etiology. The differential diagnosis was primarily parasitic disease or metastases with cystic transformations. 68Ga-DOTATOC PET/CT revealed the neuroendocrine origin of these lesions, confirmed by biopsy. However, the primary site of the neuroendocrine tumor remained unclear, leaving primary hepatic neuroendocrine tumor and neuroendocrine cancer of unknown primary as possible diagnostic options.
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Affiliation(s)
- Fabian Haupt
- From the Departments of Diagnostic, Interventional, and Pediatric Radiology
| | - Ali Afshar-Oromieh
- Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | | | - Martin Maurer
- From the Departments of Diagnostic, Interventional, and Pediatric Radiology
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2
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Hanzawa S, Sadamori H, Kagoura M, Monden K, Hioki M, Hyodo T, Omonishi K, Takakura N. Primary hepatic gastrinoma being diagnosed preoperatively: a case report and literature review. Surg Case Rep 2020; 6:290. [PMID: 33206240 PMCID: PMC7674545 DOI: 10.1186/s40792-020-01072-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 11/11/2020] [Indexed: 02/24/2023] Open
Abstract
Background A majority of gastrinomas causing Zollinger–Ellison syndrome are located in the duodenum or pancreas. Primary hepatic gastrinomas are rare and difficult to diagnose. We report a rare case of primary hepatic gastrinoma, which could be diagnosed preoperatively. Case presentation A 29-year-old man with a 55-mm tumor in segments 5 and 6 (S 5/6) of the liver was admitted to our hospital. After thorough investigations, he was treated for a suspected inflammatory pseudotumor and advised to undergo routine follow-up. Two years later, he revisited our hospital with a complaint of abdominal pain, vomiting, and diarrhea. Upper gastrointestinal endoscopy revealed multiple duodenal ulcers. His serum gastrin level was 2350 pg/mL (normal: 37–172 pg/mL), suggesting Zollinger–Ellison syndrome. Abdominal computed tomography showed a 78-mm hypervascular tumor with cystic degeneration in the S 5/6 region of the liver, with a potential to increase over time. The tumor showed hypointensity on T2-weighted and hyperintensity on diffusion-weighted abdominal contrast-enhanced magnetic resonance imaging. Somatostatin receptor scintigraphy (SRS) only detected a hepatic tumor. No tumors in the gastrinoma triangle were detected by endoscopic ultrasonography. Hence, selective arterial calcium injection (SACI) test was performed to determine the location of the gastrinoma. The serum gastrin concentration increased from 4620 pg/mL to 23,600 pg/mL at 20 s after calcium gluconate injection into the proper hepatic artery. Conversely, no effect on serum gastrin level was observed after the injection into any other arteries. Extended right hepatic lobectomy and cholecystectomy were performed after percutaneous transhepatic portal vein embolization. A histopathological examination of the liver tumor revealed a gastrinoma. The patient’s serum gastrin concentration on postoperative day 1 decreased to 65 pg/mL. Conclusion We report a surgical case of primary hepatic gastrinoma correctly diagnosed preoperatively. The patient underwent extended right hepatic lobectomy, resulting in a histological definitive diagnosis of primary hepatic gastrinoma.
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Affiliation(s)
- Shunya Hanzawa
- Department of Surgery, Fukuyama City Hospital, 5-23-1 Zao-cho, Fukuyama, Hiroshima, 721-8511, Japan.
| | - Hiroshi Sadamori
- Department of Surgery, Fukuyama City Hospital, 5-23-1 Zao-cho, Fukuyama, Hiroshima, 721-8511, Japan
| | - Masaaki Kagoura
- Department of Surgery, Fukuyama City Hospital, 5-23-1 Zao-cho, Fukuyama, Hiroshima, 721-8511, Japan
| | - Kazuteru Monden
- Department of Surgery, Fukuyama City Hospital, 5-23-1 Zao-cho, Fukuyama, Hiroshima, 721-8511, Japan
| | - Masayoshi Hioki
- Department of Surgery, Fukuyama City Hospital, 5-23-1 Zao-cho, Fukuyama, Hiroshima, 721-8511, Japan
| | - Tsuyoshi Hyodo
- Department of Radiology, Fukuyama City Hospital, 5-23-1 Zao-cho, Fukuyama, Hiroshima, 721-8511, Japan
| | - Kunihiro Omonishi
- Department of Pathology, Fukuyama City Hospital, 5-23-1 Zao-cho, Fukuyama, Hiroshima, 721-8511, Japan
| | - Norihisa Takakura
- Department of Surgery, Fukuyama City Hospital, 5-23-1 Zao-cho, Fukuyama, Hiroshima, 721-8511, Japan
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Norton JA, Foster DS, Blumgart LH, Poultsides GA, Visser BC, Fraker DL, Alexander HR, Jensen RT. Incidence and Prognosis of Primary Gastrinomas in the Hepatobiliary Tract. JAMA Surg 2019; 153:e175083. [PMID: 29365025 DOI: 10.1001/jamasurg.2017.5083] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
| | - Deshka S. Foster
- Department of Surgery, Stanford University, Stanford, California
| | - Leslie H. Blumgart
- Department of Surgery, Memorial Sloan Kettering Cancer Institute, New York, New York
| | | | | | | | | | - Robert T. Jensen
- Digestive Diseases Branch, National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases, Bethesda, Maryland
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Pirozzolo G, Cona C, Rizzo M, Shala F, Berisha S, Recordare A. Long term recurrence in primary liver neuroendocrine tumor: Report of a single case and review of literature. Ann Hepatobiliary Pancreat Surg 2018; 22:159-163. [PMID: 29896578 PMCID: PMC5981147 DOI: 10.14701/ahbps.2018.22.2.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 12/17/2017] [Accepted: 01/14/2018] [Indexed: 11/17/2022] Open
Abstract
Primary liver neuroendocrine tumors (PLNETs) are rare tumors of the liver. They share some common characteristics with neuroendocrine tumors (NETs) of the extrahepatic bile ducts, such as slow rise, hormonal, and histological features. Nevertheless, they possess some peculiarities and the major feature is the difference in the metastatic potential between PLNETs and NETs. PLNETs have less metastatic potential compared with NETs, which is the main factor based on which differential diagnosis between the two groups is achieved. There exists few reports disease's long-term outcome, especially about the recurrences management. We report the case of a 52-year-old woman admitted to hospital for jaundice and presence of liver mass. She underwent extended right hepatectomy and subsequently, PLNET was revealed. After 9 years, a new mass was discovered in the remnant liver, far from the resection line, and was surgically removed. Histological examination confirmed a PLNET recurrence. The patient is alive and doing well after a year of surgery. We conducted a review of the literature on recurrent PLNETS. Five papers followed our inclusion criteria and included 10 patients. Clinical presentation was mostly nonspecific in included cases and no carcinoid syndrome was reported. Median overall survival and median disease-free survival periods were 22 and 5 months, respectively. The primary disease was treated with surgical resection in all the included cases and recurrent diseases were mostly treated with non-surgical techniques (mainly transarterial chemoembolization). In conclusion, more studies should be conducted in order to have significant data about this uncommon neoplasm. Finally, considering the lack of data on long-term outcome, a long and accurate follow-up should be considered.
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Affiliation(s)
- Giovanni Pirozzolo
- General and Emergency Surgery Department, Angelo Hospital, Venice, Italy
| | - Camilla Cona
- General and Emergency Surgery Department, Angelo Hospital, Venice, Italy.,University of Padua, Padova, Italy
| | - Maurizio Rizzo
- General and Emergency Surgery Department, Angelo Hospital, Venice, Italy
| | - Fazli Shala
- General Surgery Department, Regional Hospital Peja, Peja, Kosovo
| | - Sadri Berisha
- General Surgery Department, Regional Hospital Peja, Peja, Kosovo
| | - Alfonso Recordare
- General and Emergency Surgery Department, Angelo Hospital, Venice, Italy
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Hindgut gastropancreatic neuroendocrine carcinoma mimicking hydatid disease. Radiol Case Rep 2017; 13:186-190. [PMID: 29487655 PMCID: PMC5826460 DOI: 10.1016/j.radcr.2017.10.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 10/25/2017] [Accepted: 10/30/2017] [Indexed: 01/06/2023] Open
Abstract
Primary neuroendocrine tumors of the colon are usually very rare and difficult to spot on a nonfunctional imaging. Metastatic lesions are mostly hypervascular, with only a small percentage appearing as cystic or hypovascular lesions. We present a case of a 34-year-old Hispanic female with a history of dull aching upper abdominal pain lasting for a few months. Initial abdominal ultrasound revealed multiple cystic lesions replacing the hepatic parenchyma concerning for a hydatid disease. Liver biopsy was obtained due to negative serology for hydatid disease, which surprisingly revealed a metastatic neuroendocrine tumor of unknown etiology. The primary disease was depicted within the sigmoid colon on a whole-body Octreotide single-photon emission computed tomography-computed tomography done following the biopsy.
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Yang K, Cheng YS, Yang JJ, Jiang X, Guo JX. Primary hepatic neuroendocrine tumors: multi-modal imaging features with pathological correlations. Cancer Imaging 2017; 17:20. [PMID: 28683830 PMCID: PMC5501439 DOI: 10.1186/s40644-017-0120-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 06/16/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Primary hepatic neuroendocrine carcinomas (PHNECs) are rare and asymptomatic, and are therefore difficult to distinguish radiologically from other liver carcinomas. In this study, we aimed to determine the computed tomography (CT), magnetic resonance imaging (MRI), and digital subtraction angiography (DSA) features of PHNECs. METHODS A retrospective analysis of 11 patients with pathologically proven PHNECs was performed from January 2009 to September 2014. The CT, MRI, and DSA image features were analysed. RESULTS Ten of the eleven patients exhibited two or more lesions, and one patient exhibited a single lesion. Abdominal CT of 8 cases revealed multiple round or oval-shaped masses with well-defined borders, which were heterogeneous and hypodense on precontrast CT images. Significant diffuse heterogeneous enhancement was observed during the arterial phase in 8 cases, and the enhancement was slightly higher than the attenuation of the surrounding normal liver parenchyma and indistinct edges of small lesions during the portal phase. Well circumscribed (11 cases), lobulated (5 cases) or multiple nodular masses (4 cases), nodule (1 case) and irregular masses (1 case) of high signal intensity were observed on T2WI and DWI of MR images. The masses were well circumscribed, heterogeneous, and hypointense on T1WI, with significant enhancement of the solid carcinoma portion in the early arterial phase and continued enhancement in the portal venous phase. Characteristic lobulated or multiple nodular masses were observed in MRI. DSA showed multiple hypervascular carcinoma-staining lesions with sharp edges in the arterial phase. CONCLUSION The CT, MRI, and DSA images of PHNECs exhibit specific characteristic features. Appropriate combinations of the available imaging modalities could therefore optimize the evaluation of patients with PHNECs.
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Affiliation(s)
- Kai Yang
- Department of Radiology and Medical Imaging, Shanghai Sixth People’s Hospital, Shanghai Jiao Tong University, 600 Yi Shan Road, Shanghai, 200233 China
| | - Ying-Sheng Cheng
- Department of Radiology and Medical Imaging, Shanghai Sixth People’s Hospital, Shanghai Jiao Tong University, 600 Yi Shan Road, Shanghai, 200233 China
| | - Ji-Jin Yang
- Department of Interventional Radiology, Affiliated Changhai Hospital of Second Military Medical University, Shanghai, 200433 China
| | - Xu Jiang
- Department of Interventional Radiology, Affiliated Changhai Hospital of Second Military Medical University, Shanghai, 200433 China
| | - Ji-Xiang Guo
- Department of Interventional Radiology, Affiliated Changhai Hospital of Second Military Medical University, Shanghai, 200433 China
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Morishita A, Yoneyama H, Nomura T, Sakamoto T, Fujita K, Tani J, Miyoshi H, Haba R, Masaki T. Primary hepatic neuroendocrine tumor: A case report. Mol Clin Oncol 2016; 4:954-956. [PMID: 27284429 DOI: 10.3892/mco.2016.822] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 11/05/2015] [Indexed: 02/06/2023] Open
Abstract
We herein present a case of an 87-year-old patient with multiple liver tumors identified on abdominal ultrasound. The assessment performed on admission included physical examination, computed tomography (CT) during hepatic angiography and CT during arterial portography. The examination revealed contrast enhancement of a proportion of the liver tumors (20 mm maximum diameter) during the arterial phase and mild contrast washout of those tumors during the delayed phase. On contrast-enhanced magnetic resonance imaging using gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid, certain liver tumors exhibited contrast enhancement during the early phase and contrast washout during the hepatocyte phase in both lobes. By contrast, no lesions were identified during positron emission tomography imaging of the liver. A liver biopsy was performed and immunohistochemical staining revealed enhanced expression of cytokeratin AE1/AE3, synaptophysin, chromogranin A and CD56 and no expression of hepatocyte antigen or CΚ7. The mindbomb E3 ubiquitin protein ligase-1 index was ~2% in most of the tumor. The liver tumors were finally diagnosed as multiple intrahepatic metastases from a primary hepatic neuroendocrine tumor (PHNET). The patient underwent transarterial chemoembolisation with a combination of miriplatin (84 mg) mixed with gelatin sponge particles and lipiodol. To the best of our knowledge, this is the first report of PHNET in an patient aged >85 years.
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Affiliation(s)
- Asahiro Morishita
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa 761-0793, Japan
| | - Hirohito Yoneyama
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa 761-0793, Japan
| | - Takako Nomura
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa 761-0793, Japan
| | - Teppei Sakamoto
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa 761-0793, Japan
| | - Koji Fujita
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa 761-0793, Japan
| | - Joji Tani
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa 761-0793, Japan
| | - Hisaaki Miyoshi
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa 761-0793, Japan
| | - Reiji Haba
- Department of Diagnostic Pathology, Faculty of Medicine, Kagawa University, Kagawa 761-0793, Japan
| | - Tsutomu Masaki
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa 761-0793, Japan
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8
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Yang K, Cheng YS, Yang JJ, Jiang X, Guo JX. Primary hepatic neuroendocrine tumor with multiple liver metastases: A case report with review of the literature. World J Gastroenterol 2015; 21:3132-3138. [PMID: 25780316 PMCID: PMC4356938 DOI: 10.3748/wjg.v21.i10.3132] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 10/26/2014] [Accepted: 11/07/2014] [Indexed: 02/06/2023] Open
Abstract
We herein present a case involving a 41-year-old woman in whom ultrasound examination revealed multiple liver hemangiomas more than 3 years ago. Follow-up ultrasound examination revealed that the masses had significantly increased; the largest was located in the right lobe (about 8.2 cm × 7.4 cm × 6.0 cm). Abdominal multidetector computed tomography revealed multiple well-circumscribed, heterogeneous, hypodense masses (largest, 6.4 cm × 6.3 cm × 5.0 cm) with significant contrast enhancement during the arterial and portal phases and with contrast wash-out and peripheral enhancement during the delayed phases. Magnetic resonance images demonstrated multiple well-circumscribed, heterogeneous, hypointense hepatic masses with significant contrast enhancement (largest, 6.4 cm × 6.5 cm × 5.1 cm); multiple enlarged porta lymph nodes; and multiple slightly enlarged retroperitoneal lymph nodes. Histological and immunohistochemical examination of the right mass biopsy specimen suggested a malignant neoplasm that had originated from a neuroendocrine cell type (grade 2 well-differentiated neuroendocrine carcinoma). After performing a systemic examination to exclude metastasis from an extrahepatic primary site, we considered that the masses had arisen from a primary hepatic neuroendocrine tumor with multiple liver metastases. The patient underwent transcatheter arterial chemoembolization using a combination of oxaliplatin (150 mg) mixed with one bottle of gelatin sponge particles (560-710 μm) and lipiodol (6 mL). Primary neuroendocrine tumors of the liver are extremely rare. This case is interesting because of the rarity of this neoplasm and previous misdiagnosis as multiple liver hemangiomas. Previously reported cases in the literature are also reviewed.
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9
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Ichiki M, Nishida N, Furukawa A, Kanasaki S, Ohta S, Miki Y. Imaging findings of primary hepatic carcinoid tumor with an emphasis on MR imaging: case study. SPRINGERPLUS 2014; 3:607. [PMID: 25392779 PMCID: PMC4210452 DOI: 10.1186/2193-1801-3-607] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 10/09/2014] [Indexed: 12/20/2022]
Abstract
Carcinoid tumors are slow-growing tumors originating in the neuroendocrine cells, and occur most frequently within the gastrointestinal tract. Although the liver is the most common site for metastatic carcinoid tumors, primary hepatic carcinoid tumors are exceedingly rare and reports of the imaging findings have been very scarce. We herein report imaging findings with an emphasis on magnetic resonance imaging in two cases of primary hepatic carcinoid tumors. In both cases, the tumors showed cystic areas with hemorrhagic components and early enhanced solid areas.
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Affiliation(s)
- Makoto Ichiki
- Department of Radiology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka, Japan
| | - Norifumi Nishida
- Department of Radiology, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, Japan
| | - Akira Furukawa
- Department of Radiological Sciences, Tokyo Metropolitan University, 1-1 Minami-Osawa, Hachioji-shi, Tokyo, Japan
| | - Shuzo Kanasaki
- Department of Radiology, Koseikai Takeda Hospital, 841-5 Higashishiokoji-cho, Shiokojidori Nishinotoin Higashi-iru, Shimogyo-ku, Kyoto, Japan
| | - Shinichi Ohta
- Department of Radiology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu, Shiga, Japan
| | - Yukio Miki
- Department of Radiology, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, Japan
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Baek SH, Yoon JH, Kim KW. Primary hepatic neuroendocrine tumor: gadoxetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging. Acta Radiol Short Rep 2013; 2:2047981613482897. [PMID: 23986857 PMCID: PMC3736966 DOI: 10.1177/2047981613482897] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 02/25/2013] [Indexed: 02/06/2023] Open
Abstract
We present a case of a 71-year-old man with prostate cancer who had no prior underlying liver disease. During metastatic evaluation, a solid mass in the liver was identified by computed tomography and ultrasound. Gadoxetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging demonstrated a well-defined, peripheral enhancing hepatic mass containing small cystic component. This lesion was diagnosed as hepatic neuroendocrine tumor. Primary neuroendocrine tumors of the liver are extremely rare. This case is interesting because of the rarity of this neoplasm and the unique radiologic findings despite its small size. Reviews of previously reported cases in the literature are also presented.
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Harvey A, Pasieka JL, Al-Bisher H, Dixon E. Primary hepatic gastrinoma causing zollinger-ellison syndrome: a rare and challenging diagnosis. Cancers (Basel) 2012; 4:130-40. [PMID: 24213231 PMCID: PMC3722648 DOI: 10.3390/cancers4010130] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Revised: 01/23/2012] [Accepted: 01/30/2012] [Indexed: 01/05/2023] Open
Abstract
The majority of gastrinomas causing Zollinger-Ellison syndrome (ZES) are located in the duodenum or the pancreas. Primary hepatic gastrinomas (PHG) are extremely rare and difficult to diagnose because the liver is the commonest site of metastatic disease and gastrinomas can be very small. Furthermore, gastrinomas are typically slow-growing thus a missed, occult primary tumour may not become evident for many years. The diagnosis of PHG is therefore dependent on a careful search for a primary and long-term biochemical follow-up following curative hepatic resection. We report a case of a 7 cm PHG in a 48 year old man with ZES. Preoperatively, both a basal and stimulated gastrin levels were elevated. Surgical exploration including intraoperative ultrasound and duodenotomy, failed to reveal a primary. Patient underwent a right hepatectomy. Yearly, gastrin and secretin stimulation tests remain normal 6 years following surgery. He remains symptom free off all medication. An additional 26 cases of PHG were found. Including this case, 21 had at least 1 year follow-up, however only eight had greater than 5 years (median 24 months). Post-op gastrin levels were reported in 25, however provocative testing was done in only 10. Persistence and recurrence occurred in one and four, respectively. PHG causing ZES is extremely rare. Although the current literature claims to include 26 additional cases of PHG, without a thorough search for the primary and long-term follow-up data including provocative testing, this diagnosis remains a challenge.
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Affiliation(s)
- Adrian Harvey
- Division of General Surgery and Surgical Oncology, Department of Surgery and Oncology, University of Calgary, Calgary, Alberta T2N 2T9, Canada.
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Abstract
Carcinoid metastases in the liver are typically solid, hypervascular lesions. We report 3 cases of cystic carcinoid tumors in the liver with radiographic findings. Two were metastatic from primary carcinoid tumors of the small intestine and one was not associated with any extra hepatic lesion at presentation or during 5 years of subsequent follow-up.
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Primary liver carcinoid tumour with a Zollinger Ellison syndrome - an unusual diagnosis: a case report. CASES JOURNAL 2009; 2:6346. [PMID: 19918579 PMCID: PMC2769289 DOI: 10.4076/1757-1626-2-6346] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2009] [Accepted: 07/03/2009] [Indexed: 12/19/2022]
Abstract
Carcinoids are neuroendocrine tumours which may secrete hormones like gastrin, insulin, ACTH, etc. Liver is a common site for metastasis of carcinoid origin and an unusual site for a primary carcinoid tumour to arise. We present the case of a 51-year-old Caucasian man with diarrhoea, weight loss, duodenum ulcers and a liver mass in ultrasonography. A primary hepatic carcinoid tumour with a Zollinger Ellison syndrome was diagnosed. Surgery resection was performed and the patient remained free of symptoms two years after, with normalisation of gastrin levels. Primary hepatic carcinoid tumour represents an uncommon diagnosis, based on radiological and pathological features. The exclusion of different primary locations is necessary. Once associated with a Zollinger Ellison syndrome, diagnose may be more complicated and challenging since only 7 cases of hepatic carcinoids with gastrin secretion were reported in medical literature. A review of medical literature is performed and diagnoses tools that should be used for an accurate diagnosis and available treatment approaches are commented here.
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14
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Balta Z, Sauerbruch T, Hirner A, Büttner R, Fischer HP. [Primary neuroendocrine carcinoma of the liver. From carcinoid tumor to small-cell hepatic carcinoma: case reports and review of the literature]. DER PATHOLOGE 2009; 29:53-60. [PMID: 18210116 DOI: 10.1007/s00292-007-0957-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Primary hepatic neuroendocrine tumors are rare neoplasms. While primary hepatic carcinoid tumors (PHCT) are well-differentiated tumors, primary hepatic small-cell carcinomas (PHSCC) represent the poorly differentiated end of the spectrum of neuroendocrine carcinomas. The first patient, suffering from PHCT, has had a follow-up for 32 years and is still alive. Within this time, the tumor relapsed 4 times with unchanged histology and immunohistochemistry features. The second patient suffered from small-cell carcinoma of the liver. There were no risk factors for a hepatocellular carcinoma. An extensive preoperative and postoperative diagnostic investigation could rule out an extrahepatic primary site. Immunohistochemically the tumor was negative for Hepar-1, AFP, TTF1 and CDX2 but reacted positively with CD56 and sporadically with the keratins 8, 18 and 20. A neuroendocrine PHSCC was diagnosed. After neoadjuvant cytostatic treatment the carcinoma was completely extirpated and 18 months after treatment the patient is healthy.PHCT and PHSCC have to be clearly separated from hepatocellular and cholangiocellular carcinomas. Exclusion of an extrahepatic primary site requires an accurate and synoptic analysis of clinical, radiologic and pathologic findings. Surgical resection is the treatment of choice.
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Affiliation(s)
- Z Balta
- Institut für Pathologie, Universitätsklinik Bonn.
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Touloumis Z, Delis SG, Triantopoulou C, Giannakou N, Avgerinos C, Dervenis C. Primary hepatic carcinoid; a diagnostic dilemma: a case report. CASES JOURNAL 2008; 1:314. [PMID: 19014620 PMCID: PMC2596793 DOI: 10.1186/1757-1626-1-314] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2008] [Accepted: 11/17/2008] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Primary hepatic carcinoid tumours (PHCTs) are extremely rare neuroendocrine neoplasms. Only 58 cases have been reported in the literature and less than 10 cases were functional. CASE PRESENTATION We present a case of a 65 years old, Caucasian female with a large unresectable primary hepatic carcinoid tumor secreting 5-hydroxyindoleacetic acid (5-HIAA), presented with flushing and diarrhoea and treated with trans-catheter arterial embolization (TACE) and subsequent administration of lanreotide (long acting somatostatin analogue). CONCLUSION The diagnosis of PHCTs is difficult due to their common radiologic characteristics with other liver lesions. Their diagnosis is based on the exclusion of other sites of disease and the histologic confirmation. Although the mainstay of treatment when is technically feasible is surgical resection with optimal 5-year survival and low recurrence rate, in cases of unresectable disease palliation with combination of TACE and administration of somatostatin analogues have good results in controlling the disease and the patients symptoms.
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Affiliation(s)
- Zisis Touloumis
- Liver Surgical Unit, First Department of Surgery, "Agia Olga" General Hospital, 3-5 Agias Olgas street, 14233 N, Ionia, Athens, Greece.
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17
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Foley DS, Sunil I, Debski R, Ignacio RC, Nagaraj HS. Primary hepatic carcinoid tumor in children. J Pediatr Surg 2008; 43:e25-8. [PMID: 18970916 DOI: 10.1016/j.jpedsurg.2008.06.045] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Revised: 06/24/2008] [Accepted: 06/24/2008] [Indexed: 11/17/2022]
Abstract
Primary carcinoid tumors of the liver are rare, with fewer than 60 cases currently reported in the English literature. We present the evaluation and management of a solid hepatic tumor in a 14-year-old boy. Intraoperative biopsy was indeterminant for malignant potential, and the patient underwent complete resection by left hepatic lobectomy. Final histopathologic evaluation of the mass revealed a carcinoid tumor. Extensive endoscopic and radiologic workup revealed no other primary source. The patient recovered well from surgery and is currently free of disease 32 months after initial resection. Review of the literature suggests that primary hepatic carcinoid tumors are particularly rare in children. As the liver is frequently a site for carcinoid metastasis from the gastrointestinal tract, any patient with a suspected primary hepatic carcinoid tumor must undergo an extensive search for an extrahepatic primary site. These tumors are typically indolent but may metastasize. In addition, medical therapy is of limited benefit in reducing tumor bulk. The mainstay for treatment of primary hepatic carcinoid tumors is surgical resection, and these tumors carry a more favorable prognosis than other primary hepatic malignancies and metastatic carcinoid. Follow-up is long-term, as these tumors can recur many years after initial resection.
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Affiliation(s)
- David S Foley
- Department of Surgery, University of Louisville School of Medicine, Louisville, KY 40202, USA.
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Zhang A, Xiang J, Zhang M, Zheng S. Primary Hepatic Carcinoid Tumours: Clinical Features with an Emphasis on Carcinoid Syndrome and Recurrence. J Int Med Res 2008; 36:848-59. [PMID: 18652782 DOI: 10.1177/147323000803600428] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
This study sought to determine the clinical profiles and optimal management of primary hepatic carcinoid tumours. The clinical features of nine Chinese patients and 64 patients reported in the English-language literature were characterized. Recurrence rate and survival analysis were performed with the Kaplan–Meier method. The impact of surgical resection and post-operative recurrence on survival was determined by means of the log-rank test. Carcinoid syndrome complicated 10 cases (14%). Sixty-two patients (85%) underwent surgical resection. Actuarial 5-and 10-year survival rates for resected patients were 80% and 75%, respectively. Twelve patients experienced recurrences: the recurrence rate at 5 years post-operatively was 26%. All patients with resectable recurrent disease achieved good long-term survival and no significant relationship was found between recurrence and survival. Owing to the high incidence of recurrence, long-term follow-up is necessary and it is recommended that recurrent cases should be managed with judicious surgical resection.
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Affiliation(s)
- A Zhang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - J Xiang
- Department of Pathology, First Hospital of Hangzhou City, Hangzhou, China
| | - M Zhang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - S Zheng
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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19
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Costin S, Dumitrascu D. The neuroendocrine tumors of the ileum. Open Med (Wars) 2008; 3:135-140. [DOI: 10.2478/s11536-008-0010-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AbstractNeuroendocrine tumors arise from the diffuse neuroendocrine system and secrete several peptides and bioactive amines (serotonin, histamine, dopamine, norepinephrine, corticotropin, calcitonin, bradykinin, kalikrein, gastrin, cholecystokinin, prostaglandins). The most common occurrence site of neuroendocrine tumors is the ileum. The symptoms of small bowel carcinoids are represented by intermittent intestinal obstruction and carcinoid syndrome. Presence of the carcinoid syndrome usually indicates hepatic or retroperitoneal metastases. The typical carcinoid syndrome is characterized by flushing, diarrhea, nonspecific abdominal pain and bronchospasm. The diagnosis of small bowel tumors is often difficult due to their rarity and the nonspecific and variable nature of the presenting signs and symptoms. The most useful initial diagnostic test for the carcinoid syndrome is to measure 24-hour urinary excretion of 5-hydroxyindolacetic acid (5 HIAA), which is the end product of serotonin metabolism. Capsule endoscopy is a more recent diagnostic tool. Surgery is the radical form of curative therapy for carcinoid tumors. Numerous therapies are available for palliation including surgery, pharmacologic therapy, interventional radiologic therapy, embolization and chemoembolization of hepatic metastases, immunotherapy (Interferon alfa) and chemotherapy. We carefully reviewed the available literature on this topic before beginning our study.
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Affiliation(s)
- Simona Costin
- 12nd Medical Department, University of Medicine and Pharmacy luliu Hatieganu, Cluj, Romania
| | - Dan Dumitrascu
- 12nd Medical Department, University of Medicine and Pharmacy luliu Hatieganu, Cluj, Romania
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Salman S. Quiz. J Taibah Univ Med Sci 2008. [DOI: 10.1016/s1658-3612(08)70046-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Berna MJ, Hoffmann KM, Serrano J, Gibril F, Jensen RT. Serum gastrin in Zollinger-Ellison syndrome: I. Prospective study of fasting serum gastrin in 309 patients from the National Institutes of Health and comparison with 2229 cases from the literature. Medicine (Baltimore) 2006; 85:295-330. [PMID: 17108778 PMCID: PMC9806863 DOI: 10.1097/01.md.0000236956.74128.76] [Citation(s) in RCA: 146] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The assessment of fasting serum gastrin (FSG) is essential for the diagnosis and management of patients with the Zollinger-Ellison syndrome (ZES). Although many studies have analyzed FSG levels in patients with gastrinoma, limited information has resulted from these studies because of their small size, different methodologies, and lack of correlations of FSG levels with clinical, laboratory, or tumor features in ZES patients. To address this issue, we report the results of a prospective National Institutes of Health (NIH) study of 309 patients with ZES and compare our results with those of 2229 ZES patients in 513 small series and case reports in the literature. In the NIH and literature ZES patients, normal FSG values were uncommon (0.3%-3%), as were very high FSG levels >100-fold normal (4.9%-9%). Two-thirds of gastrinoma patients had FSG values <10-fold normal that overlap with gastrin levels seen in more common conditions, like Helicobacter pylori infection or antral G-cell hyperplasia/hyperfunction. In these patients, FSG levels are not diagnostic of ZES, and gastrin provocative tests are needed to establish the diagnosis. Most clinical variables (multiple endocrine neoplasia type 1 status, presence or absence of the most common symptoms, prior medical treatment) are not correlated with FSG levels, while a good correlation of FSG values was found with other clinical features (prior gastric surgery, diarrhea, duration from onset to diagnosis). Increasing basal acid output, but not maximal acid output correlated closely with increasing FSG. Numerous tumoral features correlated with the magnitude of FSG in our study, including tumor location (pancreatic > duodenal), primary size (larger > smaller) and extent (liver metastases > local disease). In conclusion, this detailed analysis of FSG in a large number of patients with ZES allowed us to identify important clinical guidelines that should contribute to improved diagnosis and management of patients with ZES.
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Affiliation(s)
- Marc J Berna
- From Digestive Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
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Nishimori H, Tsuji K, Miyamoto N, Sakurai Y, Mitsui S, Kang JH, Yoshida M, Nomura M, Fuminori I, Ishiwatari H, Matsunaga T, Osanai M, Katanuma A, Takahashi K, Anbo Y, Masuda T, Kashimura N, Shinohara T, Maguchi H. Recurrence of primary hepatic carcinoid tumor in the remnant liver 13 yr after resection. ACTA ACUST UNITED AC 2005; 35:147-51. [PMID: 15879630 DOI: 10.1385/ijgc:35:2:147] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
We report here a case of primary hepatic carcinoid tumor (PHCT) recurring in the remnant liver 13 yr and 10 mo after first resection. A 70-yr-old man developed four hypervascular tumors in the liver in December 2003. He had undergone curative left-lobe hepatectomy for PHCT in February 1990. Histopathological examination of the tumor biopsy specimen showed that the tumor was composed of uniform round-to-oval cells with solid arrangement and the tumor cells stained positive for chromogranin A, synaptophysin, and neuron-specific enolase. We diagnosed this case as an intrahepatic metastasis of PHCT with a long latency period, based on the fact that no primary site of carcinoid tumor could be found despite intensive examination and the immunohistochemical findings of the resected tumors were essentially same as those of PHCT in 1990. Although PHCT is reported to have a more favorable prognosis than other hepatic cancer or metastatic carcinoid tumor in the liver, long-term observation is recommended.
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Affiliation(s)
- Hiroyuki Nishimori
- Center for Gastroenterology, Teine Keijinkai Hospital, 1-12-1-40 Maeda, Teine-ku, Sapporo, 006-8555, Japan.
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Ulusan S, Kizilkilic O, Yildirim T, Tercan F, Bolat F, Yildirim S. Primary hepatic carcinoid tumor: dynamic CT findings. ACTA ACUST UNITED AC 2005; 30:281-5. [PMID: 15785908 DOI: 10.1007/s00261-004-0241-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Most carcinoid tumors involve the gastrointestinal tract or respiratory system. Primary hepatic carcinoid tumor is a rare entity. A 46-year-old woman presented with abdominal pain, vomiting, and diarrhea. She was diagnosed with primary hepatic carcinoid tumor based on radiologic and laboratory findings, namely a mass in the fifth segment of the liver and markedly elevated levels of 5-hydroxyindole acetic acid in the urine. Histologic and immunohistochemical findings of the resected liver segment showed a malignant carcinoid tumor of the liver. This case is of interest because of the rarity of this neoplasm. This report describes the case and reviews the clinical features, radiologic findings, and treatment in previously reported cases.
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Affiliation(s)
- S Ulusan
- Department of Radiology, Baskent University Adana Teaching and Medical Research Center, 01250 Yuregir-Adana, Turkey.
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Knox CD, Anderson CD, Lamps LW, Adkins RB, Pinson CW. Long-term survival after resection for primary hepatic carcinoid tumor. Ann Surg Oncol 2004; 10:1171-5. [PMID: 14654473 DOI: 10.1245/aso.2003.04.533] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Primary hepatic carcinoid tumors (PHCTs) are extremely rare, and fewer than 50 cases have been reported in the English-language literature. We report a patient with a PHCT and review the cases in the literature. METHODS Our patient presented with symptoms and underwent liver resection for PHCT and regional lymph node metastasis. He underwent two more liver resections over the following 7 years for recurrent PHCT. Cases reported in the English-language literature were reviewed and survival analysis was performed with the Kaplan-Meier method. The survival impacts of age, gender, tumor foci, extrahepatic metastasis, unilobar versus bilobar disease, and type of preoperative treatment were determined by means of log-rank test. RESULTS Our patient has been free of symptoms for 14 years of follow-up and free of disease for 8 years of follow-up. Forty-eight cases of PHCT were found in the literature, and 92% of these patients underwent resection. Actuarial 5- and 10-year survival for all patients was 78% and 59%, respectively, whereas for resected patients, 10-year survival was 68%. The administration of preoperative chemotherapy, radiation therapy, or chemoembolization did not impact survival, nor did age, gender, presence of extrahepatic metastasis, number of tumors, or distribution of the tumor within the liver. CONCLUSIONS Resection is the treatment of choice for PHCT and has provided favorable outcomes. Resection for PHCT can be performed in most patients and offers long-term survival.
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Affiliation(s)
- Clayton D Knox
- Departments of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37232-4753, USA.
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Fenwick SW, Wyatt JI, Toogood GJ, Lodge JPA. Hepatic resection and transplantation for primary carcinoid tumors of the liver. Ann Surg 2004; 239:210-9. [PMID: 14745329 PMCID: PMC1356214 DOI: 10.1097/01.sla.0000109155.89514.42] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To discuss the diagnosis and management of primary carcinoid tumors of the liver in light of our experience and a literature review. SUMMARY BACKGROUND DATA Carcinoid tumors of the liver are rare and pose a diagnostic and management dilemma. This series is the largest reported and the only one to include liver transplantation as a treatment option. METHODS Between March 1994 and May 2002, we treated 8 patients (4 male, 4 female) with primary hepatic carcinoid tumors. Carcinoid syndrome complicated only 1 of the cases. Treatment was by liver resection in 6 patients and orthotopic liver transplantation in 2. RESULTS The diagnosis was confirmed histologically with light microscopy and immunohistochemistry in the absence of an alternative primary site. Six patients remain alive and disease free after follow-up of more than 3 years: 39, 43, 45, 50, 50, and 95 months. Two patients are recently postoperative. CONCLUSIONS Active exclusion of an extrahepatic primary site is essential for the diagnosis of primary carcinoid of the liver. The mainstay of treatment should be liver resection, although liver transplantation may be considered in patients with widespread hepatic involvement. A radical surgical approach is warranted as this disease carries a better prognosis than for other primary hepatic tumors and for secondary hepatic carcinoids.
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Affiliation(s)
- Stephen W Fenwick
- Hepatobiliary and Transplant Unit, St James's University Hospital, Leeds, UK
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Abstract
BACKGROUND Carcinoid tumours of the liver are predominantly metastases from the gastrointestinal tract. Primary hepatic carcinoids are extremely rare. DISCUSSION In contrast to metastases, primary hepatic carcinoids are usually solitary and resectable. It is important that these tumours are differentiated from metastases. Complete surgical resection should be contemplated and is generally curative.
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Affiliation(s)
- M Nikfarjam
- Department of Surgery, University of Melbourne, Austin HospitalMelbourne VictoriaAustralia
| | - V Muralidharan
- Department of Surgery, University of Melbourne, Austin HospitalMelbourne VictoriaAustralia
| | - C Christophi
- Department of Surgery, University of Melbourne, Austin HospitalMelbourne VictoriaAustralia
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Bader TR, Semelka RC, Chiu VC, Armao DM, Woosley JT. MRI of carcinoid tumors: spectrum of appearances in the gastrointestinal tract and liver. J Magn Reson Imaging 2001; 14:261-9. [PMID: 11536403 DOI: 10.1002/jmri.1182] [Citation(s) in RCA: 113] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The purpose of this study was to evaluate the spectrum of appearances of gastrointestinal carcinoid tumors at magnetic resonance imaging (MRI) and to elucidate patterns of appearances of carcinoid liver metastases on precontrast and postgadolinium images. The MR examinations of 29 patients (11 men, 18 women; age range, 33-87 years) with histologically confirmed gastrointestinal carcinoid tumors, representing our complete 9.5 years of experience with this entity, were retrospectively reviewed. Twelve patients had MR examinations prior to resection or biopsy of the primary tumor (preoperative group); 17 patients were imaged postsurgically (postoperative group). All MR studies were performed at 1.5 T and comprised T1-weighted spoiled gradient echo (SGE), T2-weighted fat-suppressed turbo spin echo, HASTE, and serial postgadolinium T1-weighted SGE sequences without and with fat suppression. Morphology, signal intensity, and contrast enhancement of primary tumors and of metastases to the mesentery, peritoneum, and liver were evaluated. Primary tumors were visualized in 8 of 12 patients and best demonstrated on postgadolinium T1-weighted fat-suppressed images. The appearance of primary tumors was a nodular mass originating from the bowel wall (4 of 12 patients) or regional uniform bowel wall thickening (4 of 12 patients) with moderate intense enhancement on postgadolinium images. In 4 of 12 patients the primary tumor was prospectively not seen. Mesenteric metastases, seen in eight patients, presented as nodular masses and were associated with mesenteric stranding in seven patients. A total of 156 liver metastases were evaluated in 16 patients. On precontrast T1- and T2-weighted images, 117 metastases (75%) were hypointense and hyperintense, respectively. A total of 146 metastases (94%) were hypervascular, showing moderate intense enhancement during the hepatic arterial phase, and 9 metastases (6%) were hypovascular. Twenty-three metastases (15%) were visible only on immediate postgadolinium images. MRI is able to demonstrate findings in carcinoid tumors, including the primary tumor, mesenteric metastases, and liver metastases. Liver metastases are commonly hypervascular and may be demonstrable only on immediate postgadolinium images.
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Affiliation(s)
- T R Bader
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7510, USA
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