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GASTROINTESTINAL IMAGING Table of Contents   
Year : 2004  |  Volume : 14  |  Issue : 2  |  Page : 187-188
Spiral CT diagnosis of gastrinoma : A case report


Consultant Radiologist, Imaging Point, Ramdaspeth, Nagpur-440002, India

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Keywords: Computed tomography; Islet cell tumor of pancreas; Gastrinoma

How to cite this article:
Mahajan S, Nagtode P, Khandelwal R R, Ingole S, Ingole S. Spiral CT diagnosis of gastrinoma : A case report. Indian J Radiol Imaging 2004;14:187-8

How to cite this URL:
Mahajan S, Nagtode P, Khandelwal R R, Ingole S, Ingole S. Spiral CT diagnosis of gastrinoma : A case report. Indian J Radiol Imaging [serial online] 2004 [cited 2019 Jul 23];14:187-8. Available from: http://www.ijri.org/text.asp?2004/14/2/187/28584

   Introduction Top


Endocrine tumors of pancreas are uncommon, having a prevalence of <10 per million population.

The radiological detection of endocrine tumors of the pancreas poses a difficult challenge to the radiologist because of the small size of most of these tumors and frequently requires the combined use of different imaging modalities. However, important progress in the detection of these tumors by noninvasive means has been achieved bythe introduction of spiral CT and fast MRI and with the combined use of ultrasound, CT and MRI a sensitivity of more than 90% can nowadays be achieved.

We report a relatively rare case of gastrinoma diagnosed on spiral CT and confirmed by histopathology.


   Case report Top


A middle aged female, presented with recurrent epigastric pain, vomiting, weight loss and diarrhea to a gastroenterologist. Her upper gastrointestinal endoscopy revealed multiple duodenal and gastric ulcers. With a clinical suspicion of Zollinger Ellison Syndrome her serum gastrin levels were asked for which revealed raised fasting serum gastrin levels of above 1200 pg/ml. To confirm the possibility of a gastrinoma she was referred to us for CT abdomen study.

CT study showed two well defined, intensely enhancing masses in gastrinoma triangle and medial to second part of duodenum with enhancing lesions in liver. In clinical correlation the findings were suggestive of multiple gastrinomas with hepatic metastasis.

The diagnosis was confirmed on histopathology by CT guided FNAC from hepatic lesions which revealed small round cells with bland nuclei and inconspicuous nucleoli suggestive of small round cell tumor of neural crest type.


   Discussion Top


Islet cell tumors also called APUDoma are endocrine tumor of the pancreas. The tumor arises from cells of the  Islets of Langerhans More Details and is characterized by a clinical syndrome caused by the extensive release of hormones secreted by the tumor into the circulation. The diagnosis of the secretory forms of endocrine pancreatic tumors is based on the specific clinical symptoms and the laboratory demonstration of excessive secretion of specific hormones. Radiological study is mainly useful for confirming the clinical diagnosis and for localizing the tumor.

Endocrine tumors of pancreas are rare neoplasms. Gastrinoma is the second most common pancreatic islet cell tumor, second only to insulinoma [1]. They usually present with clinical symptomatology of Zollinger Ellison syndrome, which is a syndrome characterized by marked hype rgastrinemia, gastric hypersecretion, and peptic ulceration caused by a gastrin-producing tumor of the pancreas (87%) or the duodenal wall (13%) in "gastrinoma triangle" (i.e. triangle defined by porta hepatis as apex of triangle and 2nd and 3rd parts of duodenum as the base) [2]. Sometimes the gastrinoma is in the splenic hilum, mesentery, stomach, lymph node, or ovary [2]. Most patients have multiple tumors, of which approximately 50% -60% are malignant. Usually, the tumors are small (< 1 cm in diameter) and grow and spread slowly [3]. Liver metastases represent the main criterion of malignancy, as primary tumour histology is unreliable for this purpose. Unlike most neoplasms, malignant gastrinomas may grow slowly and thus survival may be long, despite metastatic disease. They occur particularly in patients with other endocrine abnormalities, especially of the parathyroids and, less often, of the pituitary and adrenal glands (MEN-I) [4]. The main metastatic sites are regional lymph nodes, liver and bones, which are involved in 50%, 30% and 7% of gastrinomas, respectively. The lungs, mediastinum, peritoneum and, rarely, the brain and meninges may also be involved. While regional lymph node involvement has no prognostic significance, liver involvement portends shorter survival [4].

Zollinger-Ellison syndrome (Z-E) typically presents as an aggressive peptic ulcer diathesis, with ulcers occurring in atypical locations (up to 25% are located distal to the duodenal bulb) or after surgical treatment for presumed benign peptic ulceration [5]. Diarrhea is the initial symptom in 25 to 40% of patients. Complications of perforation, bleeding, and obstruction can be frequent and life threatening. In > 50% of patients, clinical, x-ray, and endoscopic findings are indistinguishable from those of ordinary peptic ulcer disease [5]. Raised gastrin level >1000 pg/ml and raised basal gastric output >15 mmollh have diagnostic value.

Until the advent of the newer cross-sectional modalities (ultrasound, CT, MRI) arteriography was, (although invasive) considered to be one of the most sensitive methods to localize pancreatic islet cell tumours. The importance of its role in this respect has now decreased considerably in view of the excellent diagnostic yield of the new noninvasive cross-sectional methods. Arteriography may occasionally still be used to clarify equivocal findings provided by other modalities and it may successfully localize tumours that were not otherwise demonstrated. It has also been used to demonstrate liver metastases particularly in combination with intra-arterial chemotherapy.

Sensitivity of preoperative localization is 25% for US, 35% for CT, 20% for MR[, 42-63% for transhepatic portal venous sampling for gastrin, 68-70% for selective angiography. 77% for arteriography combined with intra-arterial injection of secretin [6].

In our case the CT findings of intensely enhancing masses in gastrinoma triangle and medial to second part of duodenum with strongly supportive clinical presentation of Zollinger Ellison syndrome was itself diagnostic of gastrinoma, which was again confirmed on histopathology.

So we would like to conclude that spiral CT is an important non-invasive diagnostic modality for islet cell tumors of pancreas. In appropriate clinical setup CT has high sensitivity and specificity in preoperative localization and diagnosis of gastrinoma.

 
   References Top

1.Brougham TA, Leslie JD, Soto JM, Heermann RE. Pancretic islet cell tumors. Surgery-1986;99:671-678.  Back to cited text no. 1    
2.Stabile BE, Morrow DJ, Passaro E Jr. The gastrinoma triangle: Operative implications, Am. J. Surg. 1984:: 147:25-31.  Back to cited text no. 2    
3.Gunther RW, Klose KJ, Ruckert K, et al. Islet cell tumors; detection of small Lesions with computed tomography and ultrasound Radiology 1983;148: 485-488.  Back to cited text no. 3    
4.Islet Cell Tumors of the Pancreas; Clinical, Radiologic and Pathologic Correlation in Diagnosis and Localization; Radiological Society of North America-1997.   Back to cited text no. 4    
5.Zboralske FF, Amberg JR 1968 Detection of Zollinger Ellison syndrome: the radiologist's responsibility. AJR 104:529-543.  Back to cited text no. 5    
6.Sutliff VE, Doppman JL, Gibril F, et al. Growth of newly diagnosed, untreated metastatic gastrinomas and predictors of growth patterns. J Clin Oncol 1997;15:2420-31.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]

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Correspondence Address:
P Nagtode
Consultant Radiologist, Imaging Point, Ramdaspeth, Nagpur-440002
India
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Source of Support: None, Conflict of Interest: None


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    Introduction
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    References
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