|Year : 2020 | Volume
| Issue : 3 | Page : 510-512
Multiple carcinoid tumor of the ileum presented as intestinal obstruction
Sunil Jagtap1, Abhijit Phalke1, RG Naniadekar2, SS Jagtap3, Amol Bhoite4
1 Department of Pathology, Krishna Institute of Medical Sciences Deemed to be University, Karad, India
2 Department of Surgery, Krishna Institute of Medical Sciences Deemed to be University, Karad, India
3 Department of Medical UG, VMC GMC, Solapur, Maharashtra, India
4 Department of Radiology, Krishna Institute of Medical Sciences Deemed to be University, Karad, India
|Date of Submission||30-Dec-2019|
|Date of Decision||15-Jul-2020|
|Date of Acceptance||30-Jul-2020|
|Date of Web Publication||1-Feb-2021|
Dr. Sunil Jagtap
Department of Pathology, Krishna Institute of Medical Sciences Deemed to be University, Karad - 415 110, Maharashtra
Source of Support: None, Conflict of Interest: None
Gastrointestinal carcinoid arises from enterochromaffin cells. These are relatively slow-growing tumors with an indolent course. We present the case of a 70-year-old male patient complaining of abdominal pain and vomiting with palpable abdominal mass clinically suspected as an intestinal obstruction. On radioimaging, computed tomography abdomen and pelvis revealed malignant stricture small bowel likely carcinoid causing mechanical small bowel obstruction. Histopathology reported multiple carcinoid tumor of the ileum with stricture and extensive spread in multiple nodules at mesentery. We present this case for its clinical, radiological, and histopathological findings.
Keywords: Carcinoid, ileum obstruction, neuroendocrine tumor
|How to cite this article:|
Jagtap S, Phalke A, Naniadekar R G, Jagtap S S, Bhoite A. Multiple carcinoid tumor of the ileum presented as intestinal obstruction. J Datta Meghe Inst Med Sci Univ 2020;15:510-2
|How to cite this URL:|
Jagtap S, Phalke A, Naniadekar R G, Jagtap S S, Bhoite A. Multiple carcinoid tumor of the ileum presented as intestinal obstruction. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Mar 4];15:510-2. Available from: http://www.journaldmims.com/text.asp?2020/15/3/510/308556
| Introduction|| |
A morphologically distinct intestinal tumor – carcinoid – was introduced by Oberndorfer. These are neuroendocrine tumors that originate in the gastrointestinal tract (GIT) and generally referred to as gastrointestinal (GI) carcinoid. Generally there are low grade malignancy arising from epithelial stem cell crypts usually occurs as small nodular lesions as a small nodular lesion in GIT and many times remains asymptomatic. The clinical manifestation of carcinoid tumor depends on its location in GIT, size, associated disorders, and evidence of its local spread and metastasis. We are presenting this case with advance manifestation with intestinal obstruction.
| Case Report|| |
A 70–year-old male patient presented with pain in the abdomen for 1 month which was insidious in onset, dull-aching type. The patient also had a complaint of vomiting for 5 days. Vomiting occurred post meal and was not projectile in nature. The patient had constipation for 4 days.
Radioimaging showed plaque-like hyper-enhancing area in the mid small bowel causing persistent narrowing of portion – malignant stricture-like small bowel carcinoid causing mechanical small bowel obstruction. Isodense lobulated mass with enhancement in the arterial phase and calcification in adjacent mesentery– metastasis [Figure 1] and [Figure 2].
|Figure 1: Radioimaging shows plaque-like hyperenhancing area in the mid small bowel causing persistent narrowing of portion – malignant stricture|
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|Figure 2: Isodense lobulated mass with enhancement in the arterial phase and calcification in the adjacent mesentery|
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The patient underwent excision of proximal ileal mass resection. On gross examination, we received specimen of the ileum along with mesenteric mass. The specimen of the ileum was measuring 20 cm in length and 4 cm in maximum diameter. The serosal surface was gray brown. The mucosal surface showed a gray–white ulceroproliferative tumor measuring 2.7 cm × 2.5 cm × 1.5 cm. The cut section of the tumor was nodular gray white and firm. The mucosa adjacent to the tumor showed loss of mucosal folds and multiple, small nodular lesions. Another ulceroinfiltrative area with stricture? measuring 1.8 cm × 0.8 cm × 0.5 cm was noted at the mid ileal segment. Rest of the mucosa appeared unremarkable grossly. The distance of the tumor from one end of the surgical margin was 6 cm. Serial sectioning of the mesocolon revealed multiple gray–white nodular lesions, cut section of which was gray white and firm [Figure 3].
|Figure 3: Submucosal tumor composed of neoplastic cells of monotonous, small, round cells arranged in solid, insular, trabecular, and glandular pattern (hematoxylin and eosin stain, ×40)|
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Microscopic examination showed a submucosal tumor composed of neoplastic cells of monotonous, small, round cells arranged in solid, insular, trabecular, and glandular pattern. Individual cells were round having mildly pleomorphic nuclei with salt pepper chromatin, small nucleoli, and moderate amount of finely granular cytoplasm. Tumor is invading all the layers and invading the mesentery as multiple nodular lesions [Figure 4],[Figure 5],[Figure 6].
|Figure 4: Submucosal tumor composed of neoplastic cells of monotonous, small, round cells arranged in solid, insular, trabecular, and glandular pattern (hematoxylin and eosin stain, ×40)|
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|Figure 5: Tumor cells are round having mildly pleomorphic nuclei with salt pepper chromatin, small nucleoli, and moderate amount of finely granular cytoplasm (hematoxylin and eosin stain, ×100)|
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|Figure 6: The tumor is invading the mesentery as multiple nodular lesions (hematoxylin and eosin stain, ×40)|
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Rest of the mucosa showed edema, hyperplasia, and mucous retention. Areas of vascular proliferation, fibrosis, and muscular hypertrophy were noted. Histological findings reported carcinoid tumor of the ileum with ulceration, stricture formation, multiple nodules, and involving the mesentery.
| Discussion|| |
Malignant tumors of the small bowel are uncommon, accounting for 2% of all GI cancers. The study by Yao et al. found a statistically significant increase in the incidence of jejunal and ileal carcinoid tumors between 1973 and 2004, reaching 0.67/100,000 between 2000 and 2004. Carcinoid tumor is the most common neuroendocrine tumor affecting GIT. Ileum is the most common site, followed by rectum, appendix, colon, and stomach. Multiple site involvement is noted in 15%–30% of cases.
On clinical findings, most of the patients remain asymptomatic. Intestinal obstruction is observed in 15%–25% of cases., Symptoms of abdominal pain, mass lesion, loose motion, bleeding, weight loss, perforation are observed., The obstruction of the intestine is related to the tumor invasion in the mesentery, which leads to a desmoplastic reaction with scarring or a mass. Age group of 50–60 years is usually most affected. The associated carcinoid syndrome is noted in 1% of cases, other condition like multiple endocrine neoplasia type 1, von-Recklinghausen disease, inflammatory polyp, celiac disease.
In our case, the patient presented with the clinical manifestation of intestinal obstruction with dull abdominal pain, post meal nonprojectile vomiting, and constipation.
On gross examination, the ileum showed a large tumor mass with ulceration and many tiny nodular submucosal lesions over the ileum. It has been reported that about 15%–35% of cases show multiple lesion.
Specific histologic patterns in well-differentiated neuroendocrine tumor observed are trabecular, insular, and glandular; on histopathology, the tumors are well to poorly differentiated. These are well-differentiated endocrine tumor with benign behavior, well-differentiated endocrine tumor with uncertain behavior, and well-differentiated endocrine carcinoma. The most specific immunohistochemical markers for neuroendocrine tumor are chromogranin A, synaptophysin, and cytokeratin 19. For small-bowel neuroendocrine tumors, multiple tumors, evidence of metastasis, tumor size >2 cm, involvement of the muscularis propria, and mitotic activity may be associated with a worse outcome. Usually, these are slow-growing tumors. The metastasis to regional lymph nodes, liver, bone, skin etc. For early detected tumor, surgical excision gives good result. More aggressive tumors, i.e., tumors' size >1 cm, having locoregional lymph node metastases, or mesenteric spread, require extensive surgical approach. The overall survival is 5 years in 50%–60% of cases if the tumor is confined to the bowel wall.
| Conclusion|| |
We present this case of multiple carcinoid tumor of the ileum with stricture and extensive spread in multiple nodules at mesentery for its clinical, radiological, and histopathological findings.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]