Category: Pituitary Disorders/Neuroendocrinology

Monitor: 7

7 - AN UNUSUAL CASE OF DIABETES WITH CHROMOGRANIN A POSITIVE PANCREATIC NEUROENDOCRINE TUMOR

Friday, Apr 26
11:30 AM – 12:00 PM

Objective : Abdominal discomfort is a frequent complaint encountered in persons suffering from diabetes.  We present an interesting patient whose evaluation for abdominal symptoms revealed an unusual tumor.


Methods :

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Results : N/A


Discussion :

A 71 year old woman with recent onset diabetes, well controlled on oral medications presented to the clinic for evaluation for abdominal discomfort. She started noticing abdominal prominence and discomfort, not associated with food or medication intake. Patient denies abdominal pain, nausea, vomiting, diarrhea, flushing, weight loss, fever, and chills. Personal and family history were unremarkable. Physical exam was significant for a palpable epigastric mass. Initial CT was concerning for pancreatic cancer. Later patient had MRI abdomen and pelvis with and without contrast, which showed around 5x5x5 cm lobulated, predominantly solid lesion of the body of the pancreas with few satellite lesions. Findings are suspicious for islet cell tumor v/s exocrine v/s pancreatic adenocarcinoma. The patient had an endoscopic ultrasound guided biopsy, and the tumor stained positive for chromogranin A and Synaptophysin, indicative of a tumor of neuroendocrine origin.  Labs CEA and CA-19-9 were negative. The patient underwent open distal pancreatectomy and had intraoperative Ultrasound which showed three small liver nodules, which were also resected. Pathology revealed 7.5x6.4x3.3 cm well-differentiated neuroendocrine tumor, grade 1 of the pancreas with metastasis to the liver. Ki proliferative index was 2.3%, and mitotic rate was less than 2. The patient recovered well post op. Post-operative octreotide scan was negative.  Follow up surveillance with CT abdomen and pelvis with and without contrast in 3months showed three new hypoechoic lesions representing metastatic lesions. The patient was started on monthly shots of Octreotide and then switched to Lanreotide. Subsequent surveillance chromogranin levels and abdominal imaging have been unremarkable after one year. The patient is currently followed by a multidisciplinary team.


Conclusion : Pancreatic neuroendocrine tumors (PNETs) are rare neoplasms of the pancreas with a recent increase in incidence worldwide. The patient here illustrates many challenges in diagnosing and managing PNETs, one of which is relevant to endocrine practice. PNETs are often associated with alterations in glucose metabolism due to hormonal hypersecretion or tumor mass effects. Meanwhile, pre-existing diabetes can be a risk factor for the development of PNETs and treatment of diabetes can impact morbidity and mortality of these patients.

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Jahnavi Chakrala

ENDOCRINOLOGY FELLOW (PGY-5)
TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER, PERMIAN BASIN, ODESSA
Odessa, Texas

Jahnavi Chakrala, MD,
7/2017- Current- Endocrine Fellowship, TTUHSC, Permian Basin
07/2014- 2/2017- Hospitalist at Presbyterian Hospital, NM
06/2011- 06/2014 - Residency at St. John’s Episcopal Hospital, NY
09/2010-01/2011- Volunteer experience- Methodist University Hospital, Memphis, TN
06/2000-05/2006- Medical school- Narayana Medical College, India
Board Certification- Internal Medicine- 2014
Poster presentations:
Parathyroid Crisis in a Young adult- At AACE, 2017, First author,
Herpes Simplex Pneumonitis in a critically ill patient- At MSSNY, 2013, First author
Fatal Herpes Simplex Virus Hepatitis in an immunocompromised patient- At MSSNY 2013, Second author

Varuna Nargunan

Endocrinologist, Medical Center Hospital System, Odessa Tx
Texas Tech University Health Sciences, Permian Basin Region, Odessa Tx

Assistant Professor, Texas Tech University health Sciences Center, Permian Basin, Odessa Texas
Member of ACE
Member of AcP
Board certified in internal medicine.
Board Certified in Diabetes, Endocrinology and Metabolism

Ramachandra Chemitiganti

Endocrinology Faculty
Texas Tech University health Sciences Center, Permian Basin, Odessa Texas, Texas

IM/Endocrinology associate Professor