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A Carcinoid Syndrome Case Study

The following case illustrates the importance of biochemical monitoring in carcinoid syndrome. Look here for:

History

46-year-old male construction worker previously in good health, except for mild chronic hypertension
Patient had self-medicated with an OTC antidiarrheal medication with mixed results

Patient presented with symptoms including occasional facial flushing, mild diarrhea (1 to 2 watery stools/day), and abdominal cramping
Biochemical workup revealed urinary 5-HIAA levels of 30 mg/24 hours (normal range: 3-15 mg/24 hours) and CgA level of 148 mcg/L (normal value: 100 mcg/L)
CT scan of the abdomen and scintigraphy revealed a tumor in the midgut
Needle biopsy was interpreted as typical carcinoid disease

Surgery was performed to remove a 2-cm tumor, which was resected with apparently clear margins

CT scan revealed two metastatic liver lesions (of approximately 1 cm and 4 cm)
Urinary 5-HIAA increased to 75 mg/24 hours
CgA level increased to 305 mcg/L
Patient claimed there was no change in mild diarrhea, abdominal cramping, and flushing

CT scan revealed two additional liver lesions and slight increase in the size of the other liver lesions
Urinary 5-HIAA levels increased to 130 mg/24 hours
CgA level increased to 520 mcg/L

This case exemplifies a situation where progressive disease is occurring biochemically and radiographically, but not necessarily clinically. Symptoms of carcinoid syndrome were present at the time of initial diagnosis and persisted over the next 18 months.
Appropriate initial intervention, in the setting of metastatic disease, includes removal of a symptomatic primary tumor,¹ as well as the consideration of a prophylactic cholecystectomy.² Surveillance documents progressive but "low-bulk" disease.²
Controlling the disease becomes the challenge of clinicians who, over the last two decades, have had an increasing number of options to consider either during or after surgical intervention.³ The potential benefits include not only suppressing symptoms but also lowering biochemical markers.¹

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