NHÂN MỘT TRƯỜNG HỢP
CARCINOID TÁ TRÀNG và ÐẠI TRÀNG
TRẦN KẾ HƯNG*, NGUYỄN THỊ THANH THẢO**, NGUYỄN THIỆN HÙNG***
Trung tâm Y khoa MEDIC
Thành phố Hồ Chí MinhA
Bênh nhân Võ v. M., 53 tuổi ở Châu đốc, Long xuyên đến khám tại Trung tâm Y khoa MEDIC vì đau thượng vị, có những cơn phừng mặt từ 1 tháng rưởi nay, ăn kém và sụt cân 10kg. Bệnh nhân đi cầu máu từ 1 năm nay đã chích xơ trỉ 5 lần. Siêu âm thấy có di căn gan lách với tổn thương echo kém, giới hạn rõ, có hoại tử, ít mạch máu. Kết quả nội soi cho thấy u bề mặt niêm mạc tá tràng D2 và nhiều tổn thương bề mặt niêm mạc đại tràng, vàng nhạt, có rốn ở giữa. Tiêu bản giải phẫu bệnh lý trả lời là u dạng carcinoid tá tràng D2 (PGs Nguyễn Sào Trung).
Ðây là ca thứ 2 của MEDIC trong vòng 5 năm trở lại đây.
Xem lại y văn:
1/ ÐỊNH NGHĨA (MEDICAL ENCYCLOPEDIA, MOSBY, 1995):
carcinoid /kä'sinoid/ [Gk, karkinos + eidos, form],a small yellow tumor derived from argentaffin cells in the gastrointestinal mucosa that secrete serotonin and other catecholamines. Carcinoid tumors spread slowly locally but may metastasize widely. Also called 2524argentaffinoma, Kulchitsky-cell carcinoma. See also 2523argentaffin cell, 5155carcinoid syndrome.
2/ CLINICAL GASTROENTEROLOGY, Mosby, 1995 (2).
Carcinoid Tumour
It is important to distinguish this form of metastatic liver disease from others since carcinoid tumours tend to spread slowly and have a much better prognosis than most other malignant tumours with secondary deposits. Macroscopically, carcinoid metastases have a characteristic umbilicated appearance (Fig.01). The histological appearance is of nests of small hyperchomatic cells with characteristic staining properties (Fig.02).
3/ PRACTICAL GUIDE TO DIAGNOSTIC IMAGING (pp.127)(3):
(a) Most common primary malignancy of SB but usually small and difficult to demonstrate radiographically,
(b) Desmoplastic response may cause SBO; may appear 'stellate' on CT.
(c) Usually in distal ileum.
(d) 90% tumors >2cm metastasize.
(e) Carcinoid syndrome indicates liver metastases
+ Episodic diarrhea, abdominal cramps, cutaneous flushing, and asthma caused by excess tumor-secreted serotonin, which cannot undergo normal degradation by liver.
4/ Xem thảo luận của Medscape Gastroenterology
CLINICAL DISCUSSION - CARCINOID TUMORS OF THE GUT: SURGICAL RESECTION IS THE PRIMARY TREATMENT
3/2/2000
Recently, I have been seeing a 41-year-old woman with carcinoid of the ileum and multiple metastasis of the liver. The primary tumor is more than 2 cm, very close to the ileocoecal valve, and is actually impairing the opening of the valve. The patient is in very good clinical condition, occasionally performing mild flushing, and rarely diarrhea. The diagnosis was based on CT, MRI, US, colonoscopy, double contrast small bowel Rtg, 5-HIAA in urine, heart ultrasound, liver biopsy. What would be, in your opinion, the most appropriate therapeutic approach Surgery
Martina Jakoubkova
Papanikolaou Hospital, Thessaloniki, Greece
1/11/2000
I just resected a 1.2 cm carcinoid from the second portion of the duodemum in a 20-year-old otherwise healthy male. On preop testing and intra abdominal examination there was no indication of metastatic disease. My margins were tumor free. I have been unable to find much information regarding the surgical treatment of duodenal carcinoids. I have done a local excision. Is this adequate or should he be returned to the operating room for a pancreaticoduodenectomy
R. Hussong
1/20/2000
Dear Dr. Hussong,
Midgut carcinoids which are more than 1cm in size, do carry a risk of metastases (actually more than 60% in 165 case series from Mayo Clinic). It might be reasonable to get an octreotide scan to R/O small liver mets and order 5-HIAA to make sure that there is no functional tumor anywhere (provided there was a baseline abnormal 5-HIAA levels).
Zafar Mirza M.D.
zmirza@excite.com Gastroenterology Fellow, RWJ Medical School, NJ.
5/ CD ROENTGEN (1):
a/Clinical:
+ Presentation: Early -- usually asymtomatic
Intermediate -- Diarrhea, intermittent obstruction and weight loss
Late but rare -- Carcinoid Syndrome: periodic cutaneous flushing, diarrhea, bronchospasm and right heart endocardial fibroelastosis leading to pulmonary stenosis and tricuspid regurgitation
+ Statistics: Second most common site for carcinoid (appendix is most common) and the most common site for malignant carcinoid. 91% arise within distal 2 meters of ilium.
Invasion into mesentery causes intense desmoplastic reaction.
Less than 1 cm rarely invasive. Greater than 2 cm frequently malignant.
Rule 1/3: 1/3 multiple, 1/3 metastasize, 1/3 have synchronous / metachronous malignancy.
Majority (95%) of patients with carcinoid syndrome will have liver metastasis.
+ Management:
- Should be surgically resected with clear margin and adjacent regional nodes.
- Small particle arterial embolization of liver metastasis may improve quality of life.
b/ Pathophysiology:
Slow-growing tumors which arise from enterochromaffin cells from the crypts of Lieberkuhn (Kulchitsky cells)
Secrete hormonally active substances (i.e. histamines, serotonin) which are usually inactivated by the liver.
With metastatic spread to the liver, vasoactive substances may be release directly into systemic circulation giving rise to carcinoid syndrome
c/ Radiology.
BÀN LUẬN:
Như đã trình bày bệnh nhân của chúng tôi có các triệu chứng phừng mặt của carcinoid syndrome và có tổn thương ở gan và lách. Chẩn đoán chủ yếu dựa vào kết quả sinh thiết tá tràng và hình ảnh đại thể sang thương niêm mạc khá điển hình ở tá tràng và đại tràng. Tiếc là bệnh nhân không nhập viện để mỗ theo khuyến cáo nên chúng tôi không có được kết quả sau mỗ.
TÀI LIỆU THAM KHẢO CHÍNH:
1/ McDermott MP, Krebs TL: CD Roentgen, Interactive Radiology Teaching File on CD-ROM, 1996.
2/ Misiewicz JJ, Forbes A, Price A, Shorvon P, Triger D, Tytgat G: Clinical Gastroenterology, Mosby 1995.
3/ Specht NT, Russo RD: Practical Guide to Diagnostic Imaging (pp.127), Mosby 1998.
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