Carcinoid mesenteric tumor complicated by chylous ascites

Case contributed by Dr Karina Dorfman

Presentation

Presented to our hospital endocrinology clinic with a history of abdominal pain for two years and recent complaints about diarrhea and flushing.

Patient Data

Age: 60 years
Gender: Female

Abdominal CT at presentation

CT

Right/mid abdominal mesenteric spiculated mass adjacent to a thickened segment of small bowel loops, with retraction and stranding of the mesentery.  The mesenteric mass seems to involve the superior mesenteric vein (SMV) and distal superior mesenteric artery (SMA) branches.

Laboratory studies showed elevated 5-HIAA levels and the patient was hospitalized for surgical biopsy from the mass.

The biopsy showed neoplastic cells positive for chromogranin and synaptophysin with mitotic index 2 un 10 HPF and proliferative index (KI67) of 7%, consistent with metastatic neuroendocrine tumor.

The patient underwent Ga68 labeled somatostatin analog PETCT scan that showed mass avidity to the somatostatin analog, without evidence of distant metastases.

The patient has prescribed a somatostatin analog treatment.

One year later the patient presented with abdominal distention and was referred to CT for further evaluation.

Abdominal CT one year after the initial diagnosis

CT

Compared to the previous CT examination, the mesenteric mass appears unchanged without evidence for additional masses or liver metastases. However, large ascites and omental stranding have developed.

Ascites fluid aspiration revealed milky fluid with high triglycerides levels on laboratory exams, compatible with chylous ascites.

Case Discussion

Chylous ascites is an extremely rare complication of carcinoid tumor.

While carcinoid tumors usually have an indolent course, the development of chylous ascites harboring a poor outcome. Unfortunately, the patient described in this case died shortly after the diagnosis of the chylous ascites.

The proposed pathophysiology mechanisms for carcinoid-induced chylous ascites are
lymph nodes obstruction by a tumor or mesenteric reaction that blocks the uptake of peritoneal fluid.

Chylous ascites cannot be differentiated from water on density measurements, and therefore diagnosed clinically, based on the ascites fluid appearance and triglycerides levels measurement on laboratory studies.

Only a few case reports were described in the literature.

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