Primary small-cell neuroendocrine carcinoma of the duodenum - a case report and review of literature

Gastrointestinal neuroendocrine tumors in 2020

Gastrointestinal neuroendocrine tumors are rare slow-growing tumors with distinct histological, biological, and clinical characteristics that have increased in incidence and prevalence within the last few decades. They contain chromogranin A, synaptophysin and neuron-specific enolase which are necessary for making a diagnosis of neuroendocrine tumor. Ki-67 index and mitotic index correlate with cellular proliferation. Serum chromogranin A is the most commonly used biomarker to assess the bulk of disease and monitor treatment and is raised in both functioning and non-functioning neuroendocrine tumors. Most of the gastrointestinal neuroendocrine tumors are non-functional. World Health Organization updated the classification of neuroendocrine tumors in 2017 and renamed mixed adenoneuroendocrine carcinoma into mixed neuroendocrine neoplasm. Gastric neuroendocrine tumors arise from enterochromaffin like cells. They are classified into 4 types. Only type I and type II are gastrin dependent. Small intestinal neuroendocrine tumor is the most common small bowel malignancy. More than two-third of them occur in the terminal ileum within 60 cm of ileocecal valve. Patients with small intestinal neuroendrocrine tumors frequently show clinical symptoms and develop distant metastases more often than those with neuroendocrine tumors of other organs. Duodenal and jejuno-ileal neuroendocrine tumors are distinct biologically and clinically. Carcinoid syndrome generally occurs when jejuno-ileal neuroendocrine tumors metastasize to the liver. Appendiceal neuroendocrine tumors are generally detected after appendectomy. Colonic neuroendocrine tumors generally present as a large tumor with local or distant metastasis at the time of diagnosis. Rectal neuroendocrine tumors are increasingly being diagnosed since the implementation of screening colonoscopy in 2000. Gastrointestinal neuroendocrine tumors are diagnosed and staged by endoscopy with biopsy, endoscopic ultrasound, serology of biomarkers, imaging studies and functional somatostatin scans. Various treatment options are available for curative and palliative treatment of gastrointestinal neuroendocrine tumors.

A case of small cell neuroendocrine carcinoma of the ampulla of Vater

Background

Gastroenteric neuroendocrine carcinomas (NECs) account for 6.2% of gastroenteric neuroendocrine tumors (NETs), and only 1% or less of gastroenteric NETs occur in the ampulla of Vater (AoV). Clinical features of NEC of the AoV remain obscure.

Case presentation

A 65-year-old man visited a general practitioner because of jaundice, and an abdominal contrast-enhanced computed tomography scan revealed a tumor of 11 mm in diameter, which was enhanced in the arterial phase at the duodenal papilla, with dilation of the upstream bile duct. Gastrointestinal scope revealed an unexposed tumor of the AoV. Based on a biopsy of the site, a moderately differentiated tubular adenocarcinoma was suspected, and pancreatoduodenectomy was performed. Histopathological examination revealed dysplasia and highly proliferative small tumor cells, with solid and nodular formation at the AoV. Histological analysis showed a high mitotic count, and immunohistochemical staining revealed a Ki-67 index of 40–50% and cells positive for synaptophysin, chromogranin A, and p53. Small cell-type NEC was finally diagnosed. Four months post pancreatoduodenectomy, multiple liver metastases developed, and systemic chemotherapy was administered. Salvage liver resection for liver metastases was performed 14 months after the pancreatoduodenectomy. Unfortunately, multiple liver metastases developed 2 months after liver resection, and the patient died 18 months after the pancreatoduodenectomy.

Conclusions

Neuroendocrine carcinoma originating from the bile duct is very rare; therefore, in this article, we provide a review of the literature and a case report.

Neuroendocrine Carcinoma of Duodenum-an Uncommon Tumour at an Unusual Site

Neuroendocrine carcinoma rarely occurs in the duodenum, and most cases of neuroendocrine carcinoma in the duodenum show rapid progression of the disease. Such cases have poor prognosis even with radical surgery with or without chemotherapy with low 5-year survival rate. We present a case of a 52-year-old man who presented with abdominal pain of 1-month duration and one episode of vomiting. Upper gastrointestinal endoscopy revealed polypoidal lesions in the first and second part of the duodenum. Whipple's procedure was performed. Diagnosis of poorly differentiated neuroendocrine carcinoma was made with extension to pancreas with peripancreatic lymph node metastases. The patient expired on post operative day 17 following cardiac arrest.

Combined neuroendocrine carcinoma and adenocarcinoma in the stomach: A case report

Neuroendocrine carcinoma and adenocarcinoma existing in the stomach simultaneously is extremely rare. This report presents a 65-year-old male patient who was diagnosed with three types of malignant tumors in the stomach, neuroendocrine carcinoma (NEC), moderately differentiated adenocarcinoma and mucinous adenocarcinoma. In addition, the NEC and moderately differentiated adenocarcinoma existed in the same lesion and, therefore, was referred to as a mixed adenocarcinoma - NEC tumor. The patient underwent laparoscopic-assisted D2 radical total gastrectomy, Roux-en-Y esophagus-jejunum anastomosis and received FOLFOX chemotherapy for six cycles 3 weeks after surgery. Follow-up determined that the patient survived and was tumor-free 12 months after surgery. In conclusion, radical surgery combined with chemotherapy can effectively improve the prognosis of patients with these three specific tumor types simultaneously in the stomach.

Periampullary mass--a rare presentation of poorly differentiated neuroendocrine cancer of duodenum in a young adult: a case report and review of literature

Poorly differentiated neuroendocrine tumour in the periampullary region of the duodenum is a rare entity. This entity usually present in old men. Here we report a periampullary poorly differentiated neuroendocrine cancer (PDEC) of duodenum presenting in a young man with subacute history of jaundice, abdominal pain, pancreatitis and constitutional symptoms. MRI localised the tumour and endoscopy-guided biopsy of the lesion proved the diagnosis. Although palliative surgery and chemotherapy were planned, the patient opted to leave against medical advice.

Neuroendocrine tumors of the small bowels are on the rise: Early aspects and management

Neuroendocrine tumors of the small bowel are on the rise. In the US they have increased by 300%-500% in the last 35 years. At the same time their prognosis is much improved. Today, most neuroendocrine tumors (NETs) of the duodenum are detected "incidentally" and therefore recognized at an early stage. Duodenal NETs which are well differentiated, not larger than 10 mm and limited to the mucosa/submucosa can be endoscopically resected. The management of duodenal NETs ranging between 10 and 20 mm needs an interdisciplinary discussion. Endoscopic ultrasound is the method of choice to determine tumor size and depth of infiltration. Surgery is recommended for well-differentiated duodenal NET tumors greater than 20 mm, for localized sporadic gastrinomas (of any size) and for localized poorly differentiated NE cancers. Surgery is recommended for any ileal NET. Advanced ileal NETs with a carcinoid syndrome are treated with long-acting somatostatin analogs. This treatment significantly improves (progression-free) survival in patients with metastatic NETs of the ileum. For optimal NET management, tumor biology, type, localization and stage of the neoplasm, as well as the patient's individual circumstances have to be taken into account.

Primary extra-ampullary duodenal neuroendocrine carcinoma in an adult male

A primary extra-ampullary duodenal neuroendocrine carcinoma was found in a 40-year-old man who presented with upper abdominal pain and weight loss. Duodenoscopy and hypotonic duodenography revealed a protruding fungating mass with luminal occlusion at the third part of the duodenum (D3). Although the metastatic work-up was normal, the tumor was inoperable intraoperatively, hence a palliative bypass was carried out followed by chemotherapy with 5-fluorouracil and leucovorin. Examination of the biopsy by immunohistochemistry and ultrastructural study revealed it to be neuroendocrine in nature, expressing synaptophysin, chromogranin and cytokeratin and containing dense core cytoplasmic granules. However, there was no evidence of clinical endocrinopathy. The present case emphasizes the need for better detection, further analysis and evaluation of such rare cases to identify their clinical course and effective treatment modalities.

Transduodenal excision of bleeding periampullary endocrine tumor as a bridge to pancreaticoduodenectomy in a Jehovah's Witness patient

We discuss the case of a Jehovah's Witness patient who presented with a bleeding endocrine periampullary mass. Transduodenal excision of the ampullary mass was successfully performed as a bridge to pancreaticoduodenectomy in this critically ill patient. The roles of pancreaticoduodenectomy and alternatives to pancreaticoduodenectomy in the emergency setting are reviewed, in particular, for patients who decline transfusion of blood products. The surgical approach to surgery and perioperative anemia in Jehovah's Witness patients is described. Finally, we reviewed the role of transduodenal excision in the management of ampullary tumors and describe its use as a bridge to pancreaticoduodenectomy in a patient with a malignant neoplasm of the ampulla.

Duodenal neuroendocrine tumors: Classification, functional syndromes, diagnosis and medical treatment

Duodenal neuroendocrine tumors (NETs) comprise 2-3% of all GI endocrine tumors and are increasing in frequency. These include gastrinomas, somatostatinomas, nonfunctional NETs, gangliocytic paragangliomas, and poorly differentiated NE carcinomas. Although, the majority are nonfunctional, these tumors are a frequent cause of Zollinger-Ellison syndrome and can cause other clinical hormonal syndromes (carcinoid, Cushing's, etc.). In this chapter, their epidemiology, clinical aspects, localization, diagnosis and medical treatment are reviewed including the latest advances in each area.