Case presentationCase presentation

Done by oncology team Done by oncology team

HistoryHistory

4545 years old Yemeni male patient known x-smoker years old Yemeni male patient known x-smoker presented to the emergency department with presented to the emergency department with history of chest pain since twelve hour durationhistory of chest pain since twelve hour duration..

The pain was in retrosternal area, stabbing in The pain was in retrosternal area, stabbing in nature, radiated to the left upper arm and the nature, radiated to the left upper arm and the left jaw, it last 5- 10 min duration and relived by left jaw, it last 5- 10 min duration and relived by sublingual nitroglycerinesublingual nitroglycerine..

He had grade 1 dysponea, no orthopnia or PNDHe had grade 1 dysponea, no orthopnia or PND..

Systemic reviewSystemic review::

He has history of watery diarrhea, of small He has history of watery diarrhea, of small amount, no blood or mucous and it usually amount, no blood or mucous and it usually started 5-10 min after food intake. Since four started 5-10 min after food intake. Since four months durationmonths duration..

He has abdominal pain colicky in nature all He has abdominal pain colicky in nature all over the abdomen started 6 months ago over the abdomen started 6 months ago relived by ranitidinerelived by ranitidine..

No history of weight loss or change in appetiteNo history of weight loss or change in appetite..

Past medical history:Past medical history: unremarkable unremarkable..

Past surgical history:Past surgical history: unremarkable unremarkable..

Medication history:Medication history: unremarkable unremarkable..

Family history:Family history: no family history of IHD, no family history of IHD, BA, DM and hypertensionBA, DM and hypertension..

Social history:Social history: he was smoker for 25 he was smoker for 25 years (1pack/day) and quit one year years (1pack/day) and quit one year agoago..

ExaminationExamination

Vitally:Vitally: B/P=114/79 HR=90/ MIN RR=18/MIN B/P=114/79 HR=90/ MIN RR=18/MIN T=36,6C SPO2=100% T=36,6C SPO2=100%Generally:Generally: conscious, oriented and he is pain conscious, oriented and he is pain..CVS:CVS: normal first and second heart sounds without normal first and second heart sounds without any added sounds. Nothing was any added sounds. Nothing was positive positive..Respiratory:Respiratory: equal breathing entry bilaterally equal breathing entry bilaterally without added sounds without added sounds..GIT:GIT: the abdomen was soft and lax, no the abdomen was soft and lax, no organomegally or any tenderness organomegally or any tenderness..CNS:CNS: normal tone, power and reflexes normal tone, power and reflexes..

In the ED they did the following In the ED they did the following investigationsinvestigations::

CBC, LFT, Blood chemistry: all are normalCBC, LFT, Blood chemistry: all are normal

Cardiac enzymes: troponin ICardiac enzymes: troponin I= =

ck= LDH= ASTck= LDH= AST = =

ECG: showed T wave inversion and ST ECG: showed T wave inversion and ST depression in V2---V6depression in V2---V6..

Chest x-ray: widened mediastinum, irregular Chest x-ray: widened mediastinum, irregular cardiac borderscardiac borders..

CXRCXR

The patient was diagnosed as case The patient was diagnosed as case of acute coronary syndrome of acute coronary syndrome (ACS), and then he was shifted to (ACS), and then he was shifted to the ICU and received Heparin, the ICU and received Heparin, Tridil and the proper Tridil and the proper management theremanagement there..

ECHO was scheduled for this ECHO was scheduled for this patient and showed the patient and showed the followingfollowing::

EF=50%EF=50%

Marked concentric hypertrophyMarked concentric hypertrophy..

Grade ll diastolic dysfunctionGrade ll diastolic dysfunction..

All the valves are normalAll the valves are normal . .

Cardiac cath was scheduled and done Cardiac cath was scheduled and done for this patient and showed the for this patient and showed the followingfollowing::

Normal coronaries with dominant right Normal coronaries with dominant right coronary arterycoronary artery..

Hyper contractile left ventricle with Hyper contractile left ventricle with markedly hypertrophy papillary markedly hypertrophy papillary muscle on a massmuscle on a mass..

The patient discharged to the male The patient discharged to the male medial ward after he improves and medial ward after he improves and the plan for him to do CT scan of the the plan for him to do CT scan of the chest because they were chest because they were uncomfortable with the chest x-rayuncomfortable with the chest x-ray. .

CT chest& abdomen was done CT chest& abdomen was done and showed the followingand showed the following::

Large heterogeneous soft tissue mass in the Large heterogeneous soft tissue mass in the mediastinum and compressing both mediastinum and compressing both ventriclesventricles..

Numerous enlarged mediastinal, pre-tracheal, Numerous enlarged mediastinal, pre-tracheal, post-caval and azygoesophageal lymph post-caval and azygoesophageal lymph nodes are notednodes are noted..

There are two lesion in the liver one is two cm There are two lesion in the liver one is two cm and the other 2,5 cm consistent with metsand the other 2,5 cm consistent with mets..

CTCT

Diagnosis and Diagnosis and management?management?

Differential diagnosisDifferential diagnosis

According to this result CT-According to this result CT-guided mediastinal lymph nodeguided mediastinal lymph node

Moderately differentiated Moderately differentiated neuroendocrine tumor consistent neuroendocrine tumor consistent with atypical carcinoid most likely with atypical carcinoid most likely metastasis from the lungmetastasis from the lung..

Further investigationsFurther investigations::

2424 hour urine collection for 5-HIAAhour urine collection for 5-HIAA..

Carcinoid tumorsCarcinoid tumors

Part of neuroendocrine tumorsPart of neuroendocrine tumors

ClassificationClassification::

Foregut:esophagus,stomach, Foregut:esophagus,stomach, bronchus, thymus, bronchus, thymus,

pancreaspancreas . .

midgut:terminal ileum and midgut:terminal ileum and appendixappendix..

Hindgut: rectumHindgut: rectum..

Products released by carciniod Products released by carciniod tumorstumors::

Serotonin(5-HT)Serotonin(5-HT)..

BradykininBradykinin..

HistamineHistamine..

ProstaglandinsProstaglandins..

othersothers..

Carciniod syndromeCarciniod syndrome::

In 5% of patientsIn 5% of patients..

FlushingFlushing..

Diarrhea and abdominal painDiarrhea and abdominal pain..

BronchospasmBronchospasm..

Cardiac abnormalities: right side heart Cardiac abnormalities: right side heart involvement, tricuspid regurgitationinvolvement, tricuspid regurgitation..

DiagnosisDiagnosis::

2424 hour urine collection of 5-HIAAhour urine collection of 5-HIAA..

Somatostatin receptor scintigraphySomatostatin receptor scintigraphy..

HistopathologyHistopathology..

managementmanagement

MedicalMedical::

SomatostatinSomatostatin..

OctreotideOctreotide..

Chemotherapy: 5FU, streptozoticin, DTIC Chemotherapy: 5FU, streptozoticin, DTIC and Doxorubicin and Doxorubicin..

surgicalsurgical::

surgical resection of the tumorsurgical resection of the tumor..

Hepatic artery embolisationHepatic artery embolisation..