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.
 Klimstra DS. Pathologic Classification of Neuroendocrine Neoplasms. Hematol Oncol Clin North Am. 2016;30:1-19. (PMID: 26614366)
 Vinik AI, Chaya C. Clinical Presentation and Diagnosis of Neuroendocrine Tumors. Hematol Oncol Clin North Am. 2016; 30: 21-48. (PMID: 26614367)
 Boltin D, Levi Z, Halpern M, Fraser GM. Concurrent small bowel adenocarcinoma and carcinoid tumor in Crohn’s disease-case report and literature review. J Crohns Colitis. 2011;5:461-4. (PMID: 21939921)
 Datta S, Williams N, Suortamo S, Mahmood A, Oliver C, Hedley N, et al. Carcinoid syndrome from small bowel endocrine carcinoma in the absence of hepatic metastases. Age and Ageing. 2011;40:760-2. (PMID: 21903639)
 Tsunenari T, Aosasa S, Ogata S, Hoshikawa M, Nishikawa M, Noro T, et al. Synchronous neuroendocrine tumors in both the pancreas and ileum: A case report. Int J Surg Case Rep. 2016;22:47-50. (PMID: 27046104)
 Daskalakis K, Karakatsanis A, Stålberg P, Norlén O, Hellman P. Clinical signs of fibrosis in small intestinal neuroendocrine tumours. Br J Surg. 2017;104:69-75. (PMID: 27861745)
 Buffone A, Cavallaro D, Lo Bianco S, Puzzo L, Caglià P, Cannizzaro MA. Synchronous ileal neuroendocrine tumor: diagnosis and treatment. A case report and review of the literature. Ann Ital Chir. 2016;87:92-6. (PMID: 27026360)
 Martinez-Sapiña MJ, Ríos A, Romay G, Romero JA. Severe intestinal ischemia as a presenting feature of metastatic ileal carcinoid tumor: role of MDCT with coronal reformation in the early diagnosis. Abdom Imaging. 2012;37:558-60. (PMID: 22052449)
 Juanmartiñena-Fernández JF, Fernández-Urién I, Amat-Villegas I, Prieto-Martínez C. Liver metastasis secondary to primary mesenteric carcinoid. Rev Esp Enf Digest. 2017;109:211-2. (PMID: 28256142)
 McLaughlin PD, Maher MM: Primary malignant diseases of the small intestine. AJR. 2013;201:W9-14. (PMID: 23789703)
 Winant AJ, Vora A, Ginter PS, Levine MS, Brylka DA. More than just metastases: a practical approach to solid mesenteric masses. Abdom Imaging. 2014;39:605-21. (PMID: 24509899)
 Smereczyński A, Starzyńska T, Kołaczyk K. Mesenteric changes in an ultrasound examination can facilitate the diagnosis of neuroendocrine tumors of the small intestine. J Ultrason. 2015;15:274-82. (PMDI: 26673610)
 Tsujimura K, Takushi Y, Teruya T, Iha K, Ota M, Nakachi A, et al. Neuroendocrine tumor of the small intestine diagnosed with transabdominal ultrasonographt: A case report. Int J Surg Case Rep. 2017;31:75-8. (PMID: 28122317)
 Baheti AD, Shinagare B, O´Neill AC, Krajewski KM, Hornick JL, George S, et al. MDCT and clinicopathological features of small boew gastrointestinal stromal tumours in 102 patients: a single institute experience. Br J Radiol. 2015;88:20150085. (PMID: 26111069)
 Masselli G, Colaiacomo MC, Marcelli G, Bertini L, Casciani E, Laghi F, et al. MRI of the small-bowel: how to differentiate primary neoplasms and mimickers. Br J Radiol. 2012;85:824-37. (PMID: 22422388)
 Anzidei M, Napoli A, Zini C, Kirchin MA, Catalano C, Passariello R. Malignant tumours of the small intestine: a review of histopathology, multidetector CT and MRI aspects. Br J Radiol. 2011;84:677-90. (PMID: 21586504)
 Kim JH, Moon W. Optimal diagnostic approaches for patients with suspected small bowel disease. Clin Endosc. 2016;49:364-9. (PMID: 27334413)
 Cidon E. New therapeutic approaches to metastatic gastroenteropancreatic neuroendocrine tumors: A glimpse into the future. World J Gastrointest Oncol. 2017;9: 4-20. (PMID: 28144395)