Case (32)

[Doctoor]

A 62 year-old male from Sweden underwent a cholecystectomy 7 years ago. At that time, the liver was normal but an enlarged pancreatic head was noted.

Three years ago, he was admitted for upper GI bleeding. Endoscopy revealed multiple ulcers in the duodenum and stomach. The serum gastrin level was 1000 pg/cc (nl 0-100 pg/cc).

An abdominal CT scan revealed two masses in the pancreas and multiple liver metastases. The liver biopsy confirmed the presence of non-beta islet cell, gastrin-producing, tumor tissue. LFT's were normal.

A work-up for multiple endocrine adenomatosis type I was negative with normal serum Ca., PTH, T4 and calcitonin levels. The patient was treated with Cimetidine and Probanthin and was doing relatively well for one year. Two years prior to the current admission, ascites and left pleural effusion developed and he was started on chemotherapy including Streptozocin, Adriamycin and 5FU.

The familial history revealed that the father and one brother died of prostate carcinoma. The acid phosphatase was 7.8 IU/L (nl 0-5.4 IU/L) and the prostatic fraction 0.7 (0-1.2 IU/L). The alkaline phosphatase was 561 IU/L (nl 21-130 IU/L) and the serum gastrin level greater than 1,000 pg/ml (nl 0-100 pg/ml).
Questions:
1- What is your diagnosis?
2- What support your diagnosis?
3- Why this patient developed ascites and pleural effusion?
4- what is the significance of family history with prostate carcinoma?
5- How are you going to treat him?

[Yaxya]

1- What is your diagnosis?
zollinger-ellison syndrome or gasterinoma.
2- What support your diagnosis?
1-The serum gastrin level was 1000 pg/cc (nl 0-100 pg/cc).normally fasting gastrin level is 60-150 pg/ml.
2-Endoscopy revealed multiple ulcers in the duodenum and stomach.
3-An abdominal CT scan revealed two masses in the pancreas and multiple liver metastases.
4-an enlarged pancreatic head where mostly this tumur arise.
5-The liver biopsy confirmed the presence of non-beta islet cell, gastrin-producing, tumor tissue and this most confirmitory finding.

3- Why this patient developed ascites and pleural effusion?
internal fistula may developed between pancreatitic duct with pertounioum this will cause ascites or this duct communicate with plura to cause pleural effusion.

4- what is the significance of family history with prostate carcinoma?
many studies suggest a possible prognostic significance of neuroendocrine differentiation in prostate carcinoma.

5- How are you going to treat him?
The treatment may include total gastrectomy and removal of the tumors where possible, in order to relieve the symptoms due to gastric hypersecretion. H2 receptor antagonist Cimetidin has been widely used and many patients have responded sufficiently well as to not require surgery.

[Doctoor]

Thanks Yaxya, your answers are correct.

Also metastasis to the liver and lung can cause ascites and pleural effusion respectively.

Prostate cancer can metastasize to the pancreatic lymph nodes.