Abdominal imagingCase Type
Héctor Lajusticia Andrés1, Guillermo Unzué García-Falces1, Iván Vicaría Fernández1, Paul López Sala1, Nerea Alberdi Aldasoro1, Loreto Ana de Llano Ibisate1, Tamara Laxe Vidal1Patient
74 years, male
A 74-year-old male comes to the hospital with symptoms of diarrhoea, tenesmus, faecal incontinence and weight loss of 3 kilograms. Biochemistry reveals liver function enzyme alteration. Ultrasound exam shows liver metastasis. Contrast-enhanced computed tomography (CECT) is performed to confirm the findings.
Ultrasound (US) was the first-line imaging modality used for this patient. Liver showed lobed edges, with hypertrophy of the left lobe and caudate, and atrophy of the right hepatic lobe, all related to chronic hepatic disease. Multiple hyperechogenic ill-defined lesions occupying both hepatic lobes were observed. A small quantity of free fluid in the mesenteric root was appreciated.
CECT in portal venous phase was performed to confirm the findings and depict the origin of the metastasis. Chronic liver disease imaging features were confirmed. Multiple hepatic bilateral hypodense lesions were appreciated in relation to metastasis. In addition, a mesenteric 3 cm soft tissue density mass was observed on the right flank. The lesion showed curvilinear calcifications inside and caused retraction of the adjacent mesentery, probably due to desmoplastic reaction.
Ileal carcinoid tumour was the anatomopathological definitive diagnosis.
Patient was admitted and taken to the operating room.
The ileum is the most common site of carcinoid tumours in the small bowel. The tumours arise from enterochromaffin cells of the submucosal layer and can secrete vasoactive amines. They constitute 44% of the primary malignant neoplasms in the small intestine [1,2,3,4,5].
Clinical manifestations may be local (occlusion, bleeding, invagination) or systemic (vasomotor instability, diarrhoea, bronchoconstriction), also known as carcinoid syndrome [6,7,8,9].
For anatomic imaging of carcinoids, triple-phase (arterial phase, followed by portal venous and delayed phase) multidetector CT and magnetic resonance (MR) imaging are routinely done. In our case, CECT was only performed in portal venous phase because it was executed in the emergency department. Concerning functional imaging, somatostatin receptor scintigraphy using indium111-octreotide is the most used technique [10,11].
Digestive tract findings range from small submucosal lesions to large ulcerated intraluminal masses. Calcifications are present in up to 70% of neoplasms. As the tumour grows, it spreads to the mesentery and lesion acquires ill-defined borders. Vasoactive amines cause a desmoplastic reaction with retraction of the mesentery and the intestine [10,11].
On US exam, up to 66% of patients show mesentery secondary lesions; easier to detect than the primary tumour [12,13].
On CT scan, the carcinoid tumor looks like a hypervascular intramural soft tissue mass that may show calcifications. Infiltrative extension to the mesentery is displayed as radiating linear strands and thickened adjacent bowel loops. The involvement of the mesenteric vasculature can be well depicted at CT angiography. Liver metastases are hypervascular and they are best detected in the arterial phase of the study [14,15,16].
On MR, the lesions are hypointense on T1WI and heterogeneously hyperintense on T2WI sequences and can be better identified as enhancing masses on fat-saturated contrast-enhanced T1WI sequence. Liver metastases are often hyperintense on T2WI and show nodular peripheral enhancement in the arterial phase [14,15,16].
Treatment is medical or surgical, even with metastases, since it grows slowly. It can be complemented with embolization, radiofrequency of metastases... Even in advanced stages, it can have survival rates of 70-80% at 5 years [17,18].
Carcinoid are neuroendocrine tumours that secrete vasoactive amines. Approximately 20% of patients have metastatic disease at presentation.
Even if there is metastatic disease, survival rate is high.
CT and MR are essential for detection of primary tumours and metastatic disease.
Treatment is medical or surgical, even with metastases, since it has slow growth.
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