Neoplastic diathesis of patients with carcinoid. Report of a case with four other neoplasms

Synchronous Adenocarcinoma of the Colon and Rectal Carcinoid

Primary colonic adenocarcinoma and synchronous rectal carcinoids are rare tumors. Whenever a synchronous tumor with a nonmetastatic carcinoid component is encountered, its prognosis is determined by the associate malignancy. The discovery of an asymptomatic gastrointestinal carcinoid during the operative treatment of another malignancy will usually only require resection without additional treatment and will have little effect on the prognosis of the individual. This article reports a synchronous rectal carcinoid in a patient with hepatic flexure adenocarcinoma. We present a case of a 46-year-old Hispanic woman with a history of hypothyroidism, uterine fibroids and hypercholesterolemia presenting with a 2-week history of intermittent abdominal pain, mainly in the right upper quadrant. She had no family history of cancers. Physical examination was significant for pallor. Laboratory findings showed microcytic anemia with a hemoglobin of 6.6 g/dl. CT abdomen showed circumferential wall thickening in the ascending colon near the hepatic flexure and pulmonary nodules. Colonoscopy showed hepatic flexure mass and rectal nodule which were biopsied. Pathology showed a moderately differentiated invasive adenocarcinoma of the colon (hepatic flexure mass) and a low-grade neuroendocrine neoplasm (carcinoid of rectum). The patient underwent laparoscopic right hemicolectomy and chemotherapy. In patients diagnosed with adenocarcinoma of the colon and rectum, carcinoids could be missed due to their submucosal location, multicentricity and indolent growth pattern. Studies suggest a closer surveillance of the GI tract for noncarcinoid synchronous malignancy when a carcinoid tumor is detected and vice versa.

Synchronous ileal carcinoid and primary colonic neoplasms: a case report

Primary colonic tumours with synchronous ileal carcinoid tumours are rare in occurrence and are mainly found incidentally on autopsies or pathological examination of resected surgical specimens. This article describes a case of adenomatous colonic polyps, adenocarcinoma of sigmoid colon and concurrent malignant carcinoid tumour of ileocaecal junction, detected on colonoscopic examination. The radiological staging investigations revealed no distant spread of disease. The patient was effectively treated with subtotal colectomy, resection of terminal ileum, excision of locoregional lymph nodes and the bowel continuity was restored with stapled ileo-rectal anastomosis. This article is as an example of concomitant presence of two types of malignant tumours, effectively managed surgically.

Synchronous association of rectal adenocarcinoma and three ileal carcinoids: a case report

Background

Synchronous midgut carcinoids with gastrointestinal adenocarcinoma are a rare but recognised association.

Case presentation

The patient, a 74 year old woman, underwent anterior resection for a low rectal adenocarcinoma. Intra-operatively 3 serosal deposits of tumour were noted in the distal ileum. Histology revealed these to be ileal carcinoids.

Conclusion

During resection of a gastrointestinal tumour, a thorough inspection of the abdominal cavity should be undertaken to investigate the possibility of metastatic secondaries or a synchronous tumour as is reported in this case.

Hereditary neuroendocrine tumors of the gastroenteropancreatic system

Approximately 5-10% of neuroendocrine tumors (NETs) of the gastroenteropancreatic system (GEP) have a hereditary background. The known inherited syndromes include multiple endocrine neoplasia type 1, neurofibromatosis type 1, von Hippel-Lindau disease, and the tuberous sclerosis complex. This review discusses for each of these syndromes the: (1) involved genes and specific types of mutations, (2) disease prevalence and penetrance, (3) affected neuroendocrine tissues and related clinical syndromes, (4) special morphological features of NETs and their putative precursor lesions. In addition, GEP-NETs clustering in individual families or associated with other malignancies without known genetic background are discussed.

Synchronous occurrence of carcinoid tumour of the appendix and T-cell lymphoma of the ileum. A case report with review of the literature

Carcinoid tumours of the gastrointestinal tract are often associated with other tumour types at various sites. However, only rarely has a lymphoma constituted the second tumour. In the present paper, we report the case of a 62-year-old woman who was operated on for a perforated T-cell lymphoma of the ileum and in whom an appendicular carcinoid tumour was incidentally discovered at surgery. It was possible to completely remove both tumours and postoperatively the patient underwent CHOP treatment. Ten months after surgery the patient is well, with no tumour manifestations. We also discuss problems concerning classification of the lymphoma on account of loss of the T-cell antigen CD45RO (UCHL-1).

Concurrent colonic adenocarcinoma and two ileal carcinoids in a 72-year-old male

A case of synchronous rectal cancer and two small-bowel carcinoid tumours was recently encountered in a 72-year-old man. This will be presented and discussed with a literature review. It emphasizes the importance of the concept of synchronous malignancy within the gastrointestinal tract and that patients presenting with any gastrointestinal neoplasm, especially colonic cancer and carcinoids, should undergo thorough exploration of the peritoneal cavity and its organs at initial surgery.

Carcinoid tumors in Denmark 1978-1989 and the risk of subsequent cancers. A population-based study

BACKGROUND

Previous studies have suggested an excess cancer risk in patients with carcinoid tumors. This association was reexamined using truly population-based data.

METHODS

By means of data from the Danish Cancer Registry all carcinoid tumors diagnosed in Denmark between 1978 and 1989 were identified. All patients with primary carcinoid tumors were studied for the occurrence of subsequent cancers. The numbers of subsequent cancers observed in the follow-up period were compared with the expected numbers calculated from population rates.

RESULTS

A total of 1029 patients with carcinoid tumors were identified (464 men and 565 women). The annual age-adjusted incidence rates (world standardized) for carcinoid tumors during 1978-1989 were stable at about 1.1 per 100,000 person-years for both men and women. The patients were followed for the occurrence of subsequent cancers over a period comprising 2512 person-years. Thirty subsequent cancers were identified in 29 patients. The overall relative risk of subsequent cancers was 1.1 (95% CI, 0.8-1.6). Subsequent cancers of the thyroid were in excess (RR, 21.4; 95% CI, 2.4-77.1; n = 2), as were tumors of the brain and nervous system (RR, 5.4; 95% CI, 1.1-15.9; n = 3) and non-Hodgkin's lymphomas (RR, 5.8; 95% CI, 1.2-16.9; n = 3).

CONCLUSIONS

Overall, this population-based study does not support previous studies of an excess cancer risk in patients with carcinoid tumors. Increased risks of cancers of the thyroid, tumors of the brain and nervous system, and non-Hodgkin's lymphomas were observed, but these findings were based on few cases.

Gastric polyposis caused by multiple carcinoids and early carcinoma

A case of gastric polyposis caused by multiple carcinoids with concurrent gastric carcinoma is reported in a 70 year old woman with severe atrophic gastritis and intestinal metaplasia. On microscopic examination, the carcinoids and gastric carcinoma arose separately thus representing "double primaries". Long-standing hypergastrinaemia probably plays a causative role in the development of carcinoma and carcinoids. Carcinoid tumours, although of low malignant potential, may be important as indicators of other unrelated high risk malignancies. Patients with carcinoids should be followed closely, especially as the incidence of these tumours seems to be on the increase.

Carcinoid of the small intestine

Carcinoid tumour was the most common small bowel tumour found in this series of 179 patients. It occurred in 24% of patients. Forty-six percent of patients were asymptomatic during life, the tumours being found either at autopsy or during other surgical procedures. Of those that were symptomatic, half presented with intestinal obstruction and the rest with long-standing symptoms. An abdominal mass, which occurred in 14% of cases, is an uncommon physical finding since the majority present as small submucosal tumors. Fifty-eight per cent overall and 72% of those having surgery had evidence of regional spread, either by local invasion or in the form of regional nodal involvement. Seven per cent of patients have died of their disease. Excisional surgery should be performed for all cases where feasible, and repeated for recurrent symptoms.

Mixed intestinal adenocarcinoma-argentaffin carcinoma of the vagina

A mixed intestinal adenocarcinoma-argentaffin carcinoma of the vagina in a 32-year-old woman is reported. Special stains showed the argentaffin and argyrophil reactions of the small cell population of this tumor. The small cells also contained serotonin as demonstrated by immunocytochemistry. Electron microscopy revealed characteristic cytoplasmic neurosecretory granules. The large cells were columnar and contained mucin droplets similar to those in Goblet cells in the intestines. The observations suggest that the tumor was mixed intestinal adenocarcinoma-argentaffin carcinoma (malignant carcinoid), which probably arose in aberrant intestinal epithelial cells in the vagina. The patient died with metastases of pure argentaffin carcinoma in 1 year.

Carcinoid tumors of the ileum

Thirty patients with carcinoid tumors of the ileum over a recent 10-year period have been analyzed. Seventeen patients were symptomatic and 13 others were found to have tumors incidentally at autopsy or celiotomy. Patients with symptoms almost invariably had metastatic disease, yet preoperative diagnosis was rarely achieved. Arteriography in five patients with intestinal angina demonstrated encasement, kinking, and irregularity of mesenteric branches due to nodal metastasis. In five patients, each with liver metastasis, the classic carcinoid syndrome developed. Multiple primary carcinoid tumors were found in 9 of 30 patients (30 percent); 14 had an associated second malignant neoplasm (47 percent), most frequently colorectal carcinoma. En block surgical excision was the only effective therapy. Despite a prolonged natural history, the 5-year actuarial survival rate from the date of diagnosis was only 31 percent.

Concurrent colonic carcinoma and small-bowel carcinoid tumor. Case reports and review of the literature

Recent reviews stressing the existence of synchronous and metachronous noncarcinoid neoplastic lesions in the same segment of an organ stimulated a review of experience with simultaneous small-bowel carcinoids and colonic carcinoma. Four cases of colonic malignancy associated with small-bowel carcinoid are presented. Included are cases with multiple carcinoids and concurrent multiple carcinomas; two metachronous carcinomas with subsequent ileal carcinoids, and three cases explored for colonic carcinoma with the discovery of incidental ileal carcinoids. There are few reports describing this variety of situations. The occurrence of concurrent malignant lesions, particularly more than one metachronous lesion in primary carcinoid cases, is uncommon.

The association of carcinoid tumors of the rectum with myelofibrosis: report of two cases

Two patients with myelofibrosis, a primary malignancy of the hematopoietic system, have developed carcinoid tumors of the rectum. This development is rare, as rectal carcinoids are more often associated with other carcinomas of the gastrointestinal tract. Rectal carcinoid tumors are, in general, less commonly associated with second malignancies than are carcinoid tumors of foregut and midgut origin.

Ectopic insulin and Occam's razor: reappraisal of the riddle of tumour hypoglycaemia

The concept of ectopic insulin production is challenged on the basis of a review of 120 cases from the literature on extrapancreatic tumours associated with hypoglycaemia in which insulin or insulin-like activity were measured. No case met two or more of five criteria of ectopic hormone production. The evidence indicates that hypoglycaemia of extrapancreatic tumours cannot be attributed to insulin. In those rare cases in which plasma insulin was reported as high, pancreatic beta-cells could not be excluded as the source of insulin. Interestingly, many of these dubious cases had carcinoid histology. The review also points out a close association between some spindle-cell tumours and carcinoid tumours which may be relevant to discussion on the disputed origin of some "mesothelial" tumours. Nonsuppressible insulin-like activity (NSILA) consists of a number of factors mimicking insulin activity which compete with insulin or proinsulin for membrane receptors and may crossreact in bioassays, immunoassays, and receptor assays. The question of whether one or several of these substances may be responsible for extrapancreatic hypoglycaemia remains to be elucidated.