JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
DISCUSSION
FIGURE 2: Intraoperative palpable small bowel mass.
A study of over 67,000 patients from the National Cancer Data Base found that carcinoid is the most common small bowel tumor (37.4%), followed by adenocarcinoma (36.9%), lymphoma (17.3), and stromal tumors (8.4%). 5 Common demographics, sign and symptoms, and locations of these four types of small bowel tumors are summarized in Table 1. Small bowel tumors that are discovered incidentally or present with symptoms should be evaluated for surgical removal, aimingat curative resection. 5-7 The diagnosisof carcinoidtumors isoftendifficultbecauseof their low incidence and vague symptomatology. Diagnosis can be made by the clinical picture and supported by imaging, endoscopy, or tumor markers such as chromogranin A and serotonin. 1,7 When abdominal carcinoid tumors are suspected, the preferred imaging technique is CT, which typically shows mucosal thickening, a submucosal mass, or luminal narrowing. 2,3 For preoperativediagnosisandplanninginapatientwithasuspected or known small bowel mass, video capsule endoscopy has shown to be more sensitive than traditional CT and fluoroscopic barium studies in identifying small bowel tumors. CT enterography and enteroclysis are two advanced cross-sectional modalities that improved the sensitivity in detected small bowel tumors. 8-11 Nuclear medicine studies, including indium-111 octreotide scan and gallium-68 PET/CT can assess for metastatic disease or in patients with suspected neuroendocrine gastrointestinal tumors that have failed to be detected using other modalities. 12 Due to the acuity of the present case, diagnostic markers for neuroendocrine tumors were not pursued preoperatively. Chromogranin A levels have been correlated with survival and prognosis in patients with metastatic gut neuroendocrine tumors. 13,14 Neurokinin A has also been correlatedwith prognosis in midgut carcinoid tumors. 15 Pancreastatin, a split product of chromogranin A, is another serum biomarker that may be elevated in up to 81% of patients with carcinoid tumors. It has
room for exploration. At laparotomy, the small bowel was run and two white, firm masses were found intraluminally at the mid and distal jejunum (Figure 2). Although both masses were intraluminal, there was extent involving mesentery, which appeared to be the transition point. A 41 cm section of jejunum that contained both masses was transected and the remaining bowel was anastomosed. Specimens were sent off for pathology, cytoanalysis, and chromogranin staining. Postoperatively, chromogranin A was drawn and elevated at 60 ng/mL (normal <36.4 ng/mL). Serum and 24 hr urine 5-hydroxyindoleacetic acid (5-HIAA) were within normal reference range. Final pathology showed carcinoid tumor with three distinct masses, the largest 3.2 cm (grade 2), negative margins, 1 of 16 lymph nodes positive for metastasis, minimal (3%) Ki-67 nuclear positivity, accounting for a staged IIIB with pathologic stage mpT2pN1pMX. The patient had an unremarkable post-operative recovery course, regaining bowel function and discharged five days following surgery without residual abdominal pain. At two month follow-up, the patient is doing well without abdominal pain and normal bowel function.
TABLE 1: Demographics, presentations, and locations of the four most common types of small bowel tumors. 5-7
Gender predominance / median age
Small bowel tumors
Common signs and symptoms
Location
Males > Females / 66 years
Most commonly asymptomatic, found incidentally If symptomatic: Abdominal pain, intestinal obstruction, palpable mass, carcinoid syndrome in ~10% Intestinal obstruction, gastrointestinal bleeding, weight loss, obstructive jaundice Abdominal pain, fatigue, weight loss, diarrhea More likely than other small bowel tumors to cause intestinal perforation Most commonly asymptomatic, found incidentally If symptomatic: Gastrointestinal bleeding > intestinal obstruction
Ileum > Duodenum > Jejunum
Carcinoid
Males > Females / 67 years Males > Females / 64 years
Duodenum > Jejunum > Ileum
Adenocarcinoma
Ileum > Duodenum > Jejunum
Lymphoma
Males > Females / 66 years
Gastrointestinal stromal tumor
Jejunum > Ileum = Duodenum
16 J La State Med Soc VOL 169 JANUARY/FEBRUARY 2017
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