FROM PANIC DISORDER TO CARCINOID SYNDROME IN AN EXPECTING MOTHER

Abstract

INTRODUCTION/BACKGROUND

Carcinoid syndrome occurs in ~10% of neuroendocrine tumours (NET). It indicates advanced disease with liver metastasis associated with lower survival. However, it is often misdiagnosed as other gastrointestinal, respiratory or dermatologic conditions, with a median delay in diagnosis of 3.4 years because of its rarity.

CASE

We present a case of a 32-year-old female at 10 weeks gestation presenting with abdominal distension. Physical examination revealed hepatomegaly and a pansystolic murmur. Ultrasound showed an enlarged liver with multiple solid lesions. Liver biopsy confirmed a well-differentiated grade 2 NET. Further history revealed a 2-year history of progressive facial flushing and diarrhoea that had been diagnosed as panic attacks. Endoscopic ultrasound showed a 2.3 cm pancreatic mass. Echocardiography showed moderate tricuspid regurgitation with an enlarged right atrium. A provisional diagnosis of carcinoid syndrome secondary to pancreatic NET with liver metastases was made. A multidisciplinary team decision was made to terminate the pregnancy to allow further evaluation and treatment. Computed tomography of the thorax, abdomen and pelvis confirmed the pancreatic head lesion with liver metastasis. Biochemistry showed elevated 24-hour urinary 5-hydroxyindoleacetic acid and serum chromogranin A, confirming the diagnosis of carcinoid syndrome. Histopathology of the biopsied pancreatic mass was consistent with grade 2 NET with a Ki-67 of 3-4%. Gallium-68 DOTATE and fluorodeoxyglucose positron emission tomography demonstrated concordant disease involving the pancreatic head, liver, lymph nodes and bone. The tumour was deemed inoperable and the patient was commenced on somatostatin analogue, followed by peptide receptor radionuclide therapy given the predominant Gallium-68 DOTATE-avid disease.

CONCLUSION

This case highlights the delay in diagnosis of carcinoid syndrome due to the lack of awareness of NET, leading to a heavy, inoperable tumor burden with guarded prognosis. A concerted effort is required to educate all healthcare providers on NET to minimise delay in diagnosis and improve patient outcomes.