Unit of Gastrenterology

Unit of Endocrinology

THEAGENIO Hospital, Thessaloniki

Metastatic neuroendocrine tumor of the jejunum-ileum

54 year old male with symptoms of weight lossabdominal pain

Past medical history: colitis? for the last 3 yearsNo family history of note

History

Biochemistry-Radiology

Mildly raised LFT’s

Abdominal computed tomography (CT)3 cm mesenteric mass and liver lesion in segment IV

Surgical treatment (1)

The patient was referred for surgical treatment

and underwent (4/2008) laparotomy in which

a 4 cm segment of small bowel was excised along with 2 para-aortic lymph nodes

Histology

Carcinoid tumor of the small bowel, diameter 1.2 cm,invasive of all intestinal wall, with +2/2 lymph nodes

(+) CgA, NSEKi-67< 2% < 2 mitoses/10HPF

G1

The patient was referred to the Gastroenterology Unit

Clinical examination-Initial assessment

Weight: 55 kg, ΒΜΙ: 17 kg/m2

BP 110/70 mm HgClinical examination: nil of noteNo symptoms of carcinoid syndrome

CgA : 230 nmol/l (<4) , 24-h urine 5 HIIA: 1 mg (<8)Heart echo- : normal Οctreoscan: normal distribution

Medical treatment

Somatostatin analogues

Chemotherapy (SZT + 5FU) from 6/2008 (5

cycles)

Reassesment

Abdominal CT (12/2008)Multiple liver metastatic lesions 1-4 cm and a4 cm mass in front of aorta

Platinum based chemotherapy started 1/2009 (6 cycles)

Somatostatin analogues continued

During 2009 the disease remained radiologically stable, although CgA rose to 900 nmol/l

Initiation of mTOR inhibitors (2010)

From January 2010 and for 16 months the patient was treated with Everolimus 10 mg daily

Abdominal CT: Improvement of the large liver lesion by 20%

CgA substantially reduced to 250 nmol/l

The patient opted to stop treatment in May 2011

Οctreoscan (5/2011)

Uptake in some liver mets and abdomen

At the beginning of 2012…

The patient was admitted at the hospital with severe epigastric pain and vomiting

Βarium follow-through

Gastroscopy

Stenosis of the 2nd part of duodenum

Abdominal CT (2/2012)

Abdominal CT (2/2012)

Surgical treatment (2)

Gastro-entero-anastomosis (3/2012)

Liver biopsy

11 months later:

The patient was admitted again with symptoms of ileus

Cachexia, anemia, low albumin, increased PT

Dysfunction of the gastro-entero-anastomosis

Surgical treatment (3)

To the operating room for the 3rd time (3/2013)

A month later the patient succumbed to his disease

In summary

This was a patient with midgut NET who developed

LN, hepatic and mesenteric metastases,

received treatment withSurgery (x 3)Somatostatin analoguesChemotherapyM-TOR inhibitors

and died 5 years after the initial diagnosis

Points for discussion

Extent of initial surgical treatment (extensive vs conservative)

Repeated surgery (palliative)

Use of chemotherapy

Alternative therapeutic approaches