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A 67-year-old man with chronic diarrhea was referred to our institution for further investigations. Serum chromogranin A, serum serotonin, and urinary 5-hydroxyindolacetic acid were 3-fold higher than normal reference, leading to the suspicion of a neuroendocrine tumor (NET). Abdominopelvic contrast-enhanced computed tomography (CT) showed one mesenteric 6-cm lymphadenopathy but failed to detect the primary tumor. Esophagogastroduodenoscopy and total colonoscopy were normal. Video capsule endoscopy revealed a 1-cm submucosal protrusion in the distal tract of the small bowel. 6-L-18F-fluorodihydroxyphenylalanine (FDOPA) positron emission tomography (PET)/CT revealed pathological uptake in the terminal ileum and in the known mesenteric lymphadenopathy (Figure 1, A–D). Moreover, two additional foci of abnormal FDOPA uptake were shown in the middle part of the small intestine (Figure 1, E and F). Accordingly, PET/CT was consistent with a three-focal carcinoid with lymphatic involvement. During exploratory laparotomy, eight small bowel lesions were detected by visual inspection and visceral palpation (Figure 1G), requiring the resection of about 200 cm of ileum. At pathological examination, 12 ileal submucosal low-grade NETs ranging from 3 to 23 mm in diameter (Figure 1, H–K) were identified. The metastatic nature of the large mesenteric lymphadenopathy was also proved. Finally, three additional subcentimeter lymphatic metastases and a micronodule of peritoneal carcinomatosis were detected.

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Special features > Image in Endocrinology
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