Role of computed tomography angiography in detection and staging of small bowel carcinoid tumors

Figure 10 Metastatic terminal ileal carcinoid. Terminal ileal small bowel carcinoid tumor with liver metastases. A 57-year-old male with longstanding history of flushing, diarrhea and sweating. Three hypervascular hepatic metastases were found during a computed tomography (CT) evaluation performed after he presented with a diverticular perforation to an outside institution. A Hartmann procedure was performed. After diagnosis, he underwent an extended right hemihepatectomy. An ileal resection proved a terminal ileal 1.5 cm primary carcinoid tumor. Four years later, he presented with a recurrence at the liver resection margin. This case illustrates the imaging appearance of the primary tumor as a hypervascular mural mass and extensive locoregional nodal metastatic and liver metastatic disease despite a small (1.5 cm) primary tumor. A: Axial venous phase CECT demonstrates a small bowel loop (terminal ileum) with a small hyperenhancing mural mass (arrowhead). A detail view better demonstrates the mass (inset, arrowheads), which represents the primary tumor and was confirmed at surgery. The primary tumor is subtle and easily missed on the axial CT slices; B: Axial venous phases CECT image slightly superiorly demonstrates matted hypervascular mesenteric lymph node metastases with minimal surrounding desmoplastic reaction (arrowheads), typical for carcinoid tumor local metastases; C: Axial arterial phase images demonstrate segment VIII/V (left) and segment VII (right) hypervascular, centrally necrotic liver metastases (arrowheads). Note that this advanced disease is associated with the small (1.5 cm) primary tumor. It is not uncommon that metastatic disease is significantly larger than the primary carcinoid tumor; D, E: Follow-up exam 4 years after extended right hepatectomy shows recurrence at the resection margin (arrowheads), shown on the axial venous phase image (D) and a coronal volume rendered technique image (E). CETC: Contrast enhanced computed tomography.