IS Case 351: Primary carcinoid tumor of the small bowel

Sara Ann Majewski, MD

Imaging Sciences URMC


2009 URMC Imaging Sciences
Publication Date: 2009-11-09

History

Patient is a 63-year-old female status post right nephrectomy for renal cell carcinoma presenting with carcinoid syndrome of unknown origin.

Findings

CT demonstrates 2 submucosal lesions within the ileum compatible with primary small bowel carcinoid tumor. A spiculated mass of metastatic mesenteric lymph nodes is seen adjacent to the bowel lesions with spiculation / retraction compatible with metastasis. There are liver metastases which show arterial-phase enhancement.

Diagnosis

Primary carcinoid tumor of the small bowel

Discussion

Carcinoid is the commonest small bowel primary tumor and is typically a low-grade malignancy. It primarily occurs in the 5th to 6th decades and has a 2-to-1 male-to-female predominance. It originates from submucosal neuroendocrine cells. The tumor is usually small, not able to be seen on CT and can be associated with high serotonin levels.

One-quarter to one-third of carcinoid tumors occur in the small bowel. Of these, the majority occur in the ileum. Three-quarters of symptomatic patients have midgut carcinoid tumors. Nearly one-third of patients with small bowel carcinoid have a second primary within the gastrointestinal tract.

There may be local and lymphatic spread of tumor. Regional adenopathy occurs often. Hematogenous metastases to the liver result in carcinoid syndrome with skin flushing, headache and gastrointestinal disturbance.

CT demonstrates a vascular, submucosal lesion typically within the ileum when arising in the small bowel. A spiculated mass of metastatic mesenteric lymph nodes is seen adjacent to the bowel lesion and can exhibit calcification. There can be local stellate desmoplastic reaction with mesenteric retraction, small bowel kinking/displacement/separation and small bowel wall thickening. Lymphadenopathy can be low attenuation secondary to necrosis. Liver metastases typically show arterial-phase enhancement and become isoattenuating in the portal venous phase of CT.

Sclerosing/retractile mesenteritis, treated lymphoma and tuberculosis are included in the differential diagnosis of small bowel carcinoid.

Treatment includes surgical resection, somatostatin therapy and chemoembolization of the hepatic arteries.

For more details on carcinoid, please see IS Case 21: Carcinoid Tumor of the Small Bowel.

References

  1. Dahnert WF. Radiology Review Manual. 6th ed., Lippincott Williams & Wilkins: New York, 2007.
  2. Horton KM, Kamel I, Hofmann L, Fishman EK. Carcinoid tumors of the small bowel: a multi-technique imaging approach. AJR Am J Roentgenol. 2004 Mar;182(3):559-67. PMID: 14975946
  3. Lee JKT, Sagel SS, Stanley RJ, Heiken JP. Computed Body Tomography with MRI Correlation. 4th ed., Lippincott Williams & Wilkins: New York, 2003.

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