A Case Of A Neuroendocrine Tumor With Metastatic Liver Lesions

INTRODUCTION Neuroendocrine tumors (NETs) represent 2% of all malignancies, with approximately less than 200,000 cases reported annually in the United States. NETs have been described throughout the body, with the two most common locations being the gastrointestinal (62—67%)2 and pulmonary system (22—27%). This case represents rim—enhancing hepatic lesions that were found to be a NET. CASE REPORT A 64 year—old male initially presented with right upper quadrant (RUQ) abdominal pain, right shoulder pain, nausea, vomiting, facial flushing and three weeks of diarrhea. Over—the—counter anti—inflammatories provided no benefit to his pain. An abdomen/pelvis computerized tomography (CT) showed numerous tiny hypodense lesions throughout the liver with faint rim enhancement, gastric wall thickening, and enlarged mesenteric lymph nodes. Initially, the CT findings were concerning for microabscesses, and the patient was started on antibiotics. An esophagogastroduodenoscopy (EGD) was performed given abnormal CT findings, showing gastritis and duodenitis. A colonoscopy was also performed showing a 5 millimeter (mm) sessile, villous adenoma located in the ascending colon, and an 8 mm tubulovillous sessile polyp, located in the sigmoid colon, both removed via cold—snare polypectomy. The patient would undergo a CT—guided biopsy, which showed the presence of a metastatic carcinoid tumor (well—differentiated NET). A chromogranin A level and a 24—hour urine hydroxyindoleacetic acid was ordered, and both came back elevated. The patient was started on somatostatin subcutaneous injections. After further discussions with oncology, the patient elected to forgo chemotherapy and proceed with a naturopathic plant based diet. DISCUSSION Liver metastasis occurs in 75—80% of patients with NETs, for which the management can range from hepatic directed therapies to systemic therapies.3 The most common NET with hepatic metastasis is the carcinoid tumor, for which, if the origin is of the midgut, then the appendix is the most commonly described location. The management of liver metastases from an NET is still a matter of debate, with options ranging from surgical resection, thermal ablative techniques, embolization, to medical management. Our case represents an individual with signs and symptoms suggestive of a possible carcinoid presentation, with CT findings highly suggestive of a metastatic NET.