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Unit of Gastrenterology Unit of Endocrinology THEAGENIO Hospital, Thessaloniki

Metastatic neuroendocrine tumor of the jejunum-ileum. Unit of Gastrenterology Unit of Endocrinology THEAGENIO Hospital, Thessaloniki. History. 5 4 year old male with symptoms of weight loss abdominal pain Past medical history: colitis? for the last 3 years No family history of note.

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Unit of Gastrenterology Unit of Endocrinology THEAGENIO Hospital, Thessaloniki

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  1. Metastatic neuroendocrine tumor of the jejunum-ileum Unit of Gastrenterology Unit of Endocrinology THEAGENIO Hospital, Thessaloniki

  2. History 54year old male with symptoms of weight loss abdominal pain Past medical history: colitis? for the last 3 years No family history of note

  3. Biochemistry-Radiology Mildly raised LFT’s Abdominal computed tomography (CT) 3 cm mesenteric massand liver lesion in segment IV

  4. 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

  5. Histology Carcinoid tumor of the small bowel, diameter 1.2 cm, invasive of all intestinal wall, with +2/2 lymph nodes • (+) CgA, NSE • Ki-67< 2% • < 2 mitoses/10HPF G1 The patient was referred to the Gastroenterology Unit

  6. Clinical examination-Initial assessment • Weight: 55 kg, ΒΜΙ: 17 kg/m2 • BP 110/70 mm Hg • Clinical examination: nil of note • No symptoms of carcinoid syndrome • CgA : 230 nmol/l (<4), 24-h urine 5 HIIA: 1 mg (<8) • Heart echo- : normal • Οctreoscan: normal distribution

  7. Medical treatment • Somatostatin analogues • Chemotherapy (SZT + 5FU) from 6/2008 (5 cycles)

  8. Reassesment • Abdominal CT (12/2008) Multiple liver metastatic lesions 1-4 cm and a 4 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

  9. 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

  10. Οctreoscan (5/2011) Uptake in some liver mets and abdomen

  11. 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

  12. Abdominal CT (2/2012)

  13. Abdominal CT (2/2012)

  14. Surgical treatment (2) Gastro-entero-anastomosis (3/2012) Liver biopsy • (Ki-67 40% from the hepatic metastasis)

  15. 11 months later: • The patient was admitted again with symptoms of ileus • Cachexia, anemia, low albumin, increased PT • Dysfunction of the gastro-entero-anastomosis

  16. Surgical treatment (3) To the operating room for the 3rd time (3/2013) A month later the patient succumbed to his disease

  17. In summary This was a patient with midgut NET who developed LN, hepatic and mesenteric metastases, received treatment with • Surgery (x 3) • Somatostatin analogues • Chemotherapy • M-TOR inhibitors and died 5 years after the initial diagnosis

  18. Points for discussion • Extent of initial surgical treatment (extensive vs conservative) • Repeated surgery (palliative) • Use of chemotherapy • Alternative therapeutic approaches

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