Endocrine surgery

This chapter discusses the anaesthetic management of endocrine surgery. Surgical procedures covered include thyroidectomy, parathyroidectomy, phaeochromocytoma and carcinoid tumours.

Clinicopathological analysis of primary carcinoid tumour of the ovary arising in mature cystic teratomas

Objective To investigate the clinicopathological features, diagnosis and differential diagnosis of patients with primary ovarian carcinoid tumours arising in mature cystic teratomas. Methods This retrospective case series analysed the data from patients with primary ovarian carcinoid tumours arising in mature cystic teratomas. Results The study enrolled four patients. Histopathological analysis of the tumours identified the following subtypes: insular ( n = 1), trabecular ( n = 1) and strumal ( n = 2). All four primary ovarian carcinoid tumours originated from a mature teratoma. The morphology of the primary ovarian carcinoids was similar to other neuroendocrine tumours. Strumal carcinoids were composed of different proportions of thyroid tissue intimately admixed with carcinoid tumour. Tumour tissue was arranged in insular and/or trabecular patterns. The nucleus of tumour cells displayed exquisite chromatin without obvious mitotic figures. Tumour tissues were positively stained for neuroendocrine markers chromogranin A, synaptophysin and CD56 to varying degrees. Strumal carcinoid tumours were cytokeratin 19 positive and thyroid transcription factor 1 negative. No recurrence or metastasis occurred during follow-up (12–71 months). Conclusion Primary ovarian carcinoid tumours arising in mature cystic teratomas are rare. Diagnosis and differential diagnosis should be confirmed by clinical features, histopathological characteristics and specific immunophenotyping.

Pulmonary carcinoid tumours: A multi-centre analysis of survival and predictors of outcome following sublobar, lobar, and extended pulmonary resections

Background Pulmonary carcinoids are rare neoplasms, accounting for approximately 1%–2% of all lung malignancies. A retrospective analysis was undertaken of all patients who underwent surgical resection of pulmonary carcinoid tumours across multiple institutions in Melbourne, Australia. Methods From May 2000 through April 2020, 241 patients who underwent surgical resection of pulmonary carcinoid tumours were retrospectively reviewed. Patient demographics, pathologic data, and long-term outcomes were recorded. Results Median age was 57.7 years and the majority of patients were female (58.9% vs. 41.1%). Typical carcinoid was present in 77.1%. Histological subtype was associated with several factors. Atypical carcinoid was more likely to have larger tumour size and nodal involvement. Overall survival for typical carcinoid at 5, 10, and 15 years was 98%, 95%, and 84%, and for atypical carcinoid was 88%, 82%, and 62%, respectively. Histological subtype and age were found to be independent predictors of overall survival, with worse outcomes for atypical and those above 60 years of age. Disease-free survival was related to sublobar resection (p < 0.001, sub-hazard ratio (SHR): 6.89), lymph node involvement (p = 0.022, SHR: 3.18), and atypical histology (p < 0.001, SHR: 9.89). Conclusion Excellent long-term outcomes can be achieved following surgical resection of pulmonary carcinoids. Atypical histology and lymph node involvement are significant prognostic factors, and sublobar resection should not be considered in patients with either of the above features. Typical carcinoid tumour without nodal involvement may be appropriate for sublobar resection. Typical and atypical carcinoid tumours should be considered distinct disease entities, and as such treated accordingly.

Pulmonary carcinoid presenting in pregnancy with an unusual radiological feature

Pulmonary carcinoid tumours are a rare form of malignancy that often present with clinical heterogeneity and are challenging to diagnose. Diagnosis during pregnancy is further complicated by delays in imaging and procedures to minimise harm to the fetus. This case describes a primigravid healthcare worker who was diagnosed with pulmonary carcinoid in her first trimester of pregnancy, with particular focus on the unique radiological findings of subpleural blebs as a feature.

A Patient with Multiple Gastrointestinal Carcinoid Tumours Presenting with Jejunal Intussusception

Carcinoid tumours are neuroendocrine tumours which arise from the enterochromaffin cells in the gastrointestinal and bronchopulmonary systems. The presentation of multiple gastrointestinal carcinoids with jejunal intussusception is rare, and the diagnosis may be challenging. A 49-year-old patient with adult onset bronchial asthma presented with pain around the umbilical region for 1-day duration. Physical examination revealed only mild abdominal tenderness. Abdominal computed tomography revealed small bowel intussusception with two separate highly vascular tumours arising in the small bowel mesentery. Exploratory laparotomy was done, with resection of the tumours arising from the small bowel mesentery and the proximal jejunum causing the intussusception which were excised. Histopathological diagnosis confirmed the presence of a Grade 1 carcinoid tumour of classic type. After surgery, he had an uneventful recovery and was asymptomatic. Carcinoid tumours are a very rare cause of adult intussusception. So far, there have been only two reported cases of jejunal intussusception secondary to carcinoid tumours. These will require a combination of surgical intervention and systemic therapy in selective cases for complete management.

A concealed carcinoid cardiac metastasis uncovered by comprehensive cardiovascular magnetic resonance-based tissue characterization: a case report

Background Cardiac metastases of carcinoid tumours are extremely rare, and their diagnosis poses a significant challenge. A variety of techniques has been reported in the literature for this purpose, ranging from echocardiogram to the Indium-111 Octreotide, positron emission tomography using specific tracers, and biopsy. Occasionally, the diagnosis is only made post-mortem. Recently, CMR (cardiovascular magnetic resonance) has been added to the diagnostic toolkit. This case report describes the CMR sequences that can be used to characterize cardiac metastases of carcinoid tumours. Case summary A 55-year-old woman with an antecedent history of resected carcinoid tumour of the ileocecal junction underwent whole-body In-111 Octreoscan single-photon emission computed tomography in the context of her follow-up. This raised the suspicion of pericardial involvement, which prompted a CMR study. Comprehensive CMR findings were consistent with isolated carcinoid tumour metastasis embedded within the anterior papillary muscle. We describe the CMR sequences that were used to characterize the metastasis. Discussion The rarity of cardiac metastasis of carcinoid tumour makes its diagnosis challenging and warrants a high level of clinical suspicion. Cardiovascular magnetic resonance imaging proves to be an indispensable tool in the tissue characterization of such tumours.

Left bundle branch block revealing a primary small bowel carcinoid metastasizing to the interventricular septum

Carcinoid tumours of the heart occur most commonly as a result of metastatic disease and usually affect the right side of the heart. We report a case of a solitary carcinoid metastasis to the interventricular septum without hepatic involvement in a 74-year-old man.