JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
been shown useful in predicting response in those who undergo chemoembolization for hepatic metastases. 16,17 The National Comprehensive Cancer Network (NCCN) recommends 24 hr urine 5-HIAA and chromogranin A in the diagnostic workup of suspected midgut carcinoid tumors. Additionally, these markers can be used to follow tumor suspicion for recurrence following surgical resection along with serial cross sectional imaging. Following surgical resection of gastrointestinal carcinoid tumors, the NCCN recommends consideration of 24 hr urine 5-HIAA, chromogranin A, and multiphasic CT or magnetic resonance imaging every 3-12 months following resection. 18 Surgical resection with lymphadenectomy remains the standard treatment for gastrointestinal carcinoid tumors. Patients who undergo successful surgical resection show a favorable prognosis with an 83% 5 year survival rate. 19-21 Location of the primary tumor impacts survival of patients with gastrointestinal carcinoid tumors. Ileojejunal tumors have an increased risk of liver or lymph node metastasis and a decreased five year survival when compared to primary tumors in the appendix or colon. 19 It is important to inspect the full length of the small bowel intraoperatively because multiple tumors are seen in up to 33% of cases. 19-21 The liver is the most common site of metastasis for gastrointestinal carcinoids tumors. The size of the primary tumor has a direct impact on patient survival and rates of metastases. 2 Tumors <1cm in size less commonly metastasize to the liver and have a 10% rate of lymph node metastasis. In contrast, tumors measuring >2cm showed 28% rate of liver metastasis and a 72% rate of lymph node metastasis. 2,19 Carcinoid syndrome, present in approximately 10% of carcinoid tumors, can be seen with metastases to the liver, lung, or other sites which venous drainage bypass the portal circulation (e.g., gonads, diaphragm, osseous sites, etc.). 3,7 In the present case, we elected to perform urgent surgery, as the patient had identifiable small bowel masses and a transition point on imaging, along with no previous abdominal surgeries. Identificationof thesemassesbothonimagingandintraoperative exploration prompted the appropriate resection, which allowed for an adequate staging. In cases of small bowel obstructions in adults without previous abdominal surgeries, it is important to keep small bowel tumors such as carcinoid in the differential.
6. Bilimoria KY, Bentrem DJ, Wayne JD, Ko CY, Bennett CL, Talamonti MS. Small bowel cancer in the United States: changes in epidemiology, treatment, and survival over the last 20 years. Ann Surg 2009; 249:63–71. 7. Xynopoulos D, Mihas AA, Paraskevas E, Dimitroulopoulos D, Heuman DM. Small bowel tumors. Ann Gastroenterol 2002; 15 : 18-35. 8. Soyer P, Dohan A, Eveno C, et al. Carcinoid tumors of the small-bowel: evaluation with 64-section CT-enteroclysis. Eur J Radiol 2013; 82:943–950. 9. Paulsen SR, Huprich JE, Fletcher JG, et al. CT enterography as a diagnostic tool in evaluating small bowel disorders: review of clinical experience with over 700 cases. Radiographics 2006; 26:641–657; discussion 657–662. 10. Horton KM, Kamel I, Hofmann L, Fishman EK. Carcinoid tumors of the small bowel: a multitechnique imaging approach. AJR Am J Roentgenol 2004;182:559–567. 11. Honda W, Ohmiya N, Hirooka Y, et al. Enteroscopic and radiologic diagnoses, treatment, and prognoses of small-bowel tumors. Gastrointest Endosc 2012;76:344–354. 12. NaswaN, SharmaP, Kumar A, et al. Gallium-68-DOTA-NOCPET/CTof patients with gastroenteropancreatic neuroendocrine tumors: a prospective single- center study. AJR Am J Roentgenol 2011; 197:1221–1228. 13. Arnold R, Wilke A, Rinke A, et al. Plasma chromogranin A as marker for survival in patients with metastatic endocrine gastroenteropancreatic tumors. Clin Gastroenterol Hepatol 2008; 6:820-827. 14. Tian T, Gao J, Li N, et al. Circulating Chromogranin A as A Marker for Monitoring Clinical Response in Advanced Gastroenteropancreatic Neuroendocrine Tumors. PLoS ONE. 2016;11:e0154679. 15. Turner GB, Johnston BT, McCance DR, et al. Circulatingmarkers of prognosis and response to treatment in patients with midgut carcinoid tumours. Gut 2006;55:1586-1591. 16. Calhoun K, Toth-Fejel S, Cheek J, Pommier R. Serum peptide profiles in patients with carcinoid tumors. Am J Surg 2003;186:28-31. 17. Desai DC, O’Dorisio TM, Schirmer WJ, et al. Serum pancreastatin levels predict response to hepatic artery chemoembolization and somatostatin analogue therapy in metastatic neuroendocrine tumors. Regul Pept 2001;96:113-117. 18. National Comprehensive Cancer Network. Carcinoid Tumors (Version 2.2014). http://www.nccn.org/professionals/physician_gls/PDF neuroendocrine.pdf. Accessed September 6, 2016. 19. Pasquer A, Walter T, Hervieu V, et al. Surgical Management of Small Bowel Neuroendocrine Tumors: Specific Requirements and Their Impact on Staging and Prognosis. Ann Surg Oncol 2015;22 Suppl 3:742–749. 20. Marshall JB, Bodnarchuk G. Carcinoid tumors of the gut. Our experience over three decades and review of the literature. J Clin Gastroenterol 1993;16:123–129. 21. Hellman P, Lundström T, Ohrvall U, et al. Effect of surgery on the outcome of midgut carcinoid disease with lymph node and liver metastases. World J Surg 2002;26:991–997. Dr. Ballard is a radiology resident at the Mallinckrodt Institute of radiology; Dr. Fransman is a Halsted surgery resident at the John Hopkins Hospital; Dr. Sangster is a professor of clinical radiology and anesthesiology at LSUHSC- Shreveport; Dr Ayo is a general surgery resident at Ochsner Clinic Foundation; Dr. Samra is an assistant in the trauma and acute care surgery division at LSUHSC-Shreveport.
REFERENCES
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