A 60 year old lady presented to her GP with symptoms, she described as morning sickness.
She also reported nausea (better after eating), mild epigastric discomfort.
Examination revealed a soft non tender abdomen, with no organomegaly.
She was referred for urgent upper GI endoscopy and abdominal USS.
Initial bloods showed impaired liver function, with a ALT of 140 and a Alk Phos of 366.
USS - abdomen showed grossly abnormal large liver which contains multiple lesions. Possible 25 mm mass is seen on the body/tail of the pancreas.
OGD revealed inflammation of the stomach.
She was then referred urgently to the Gastroenterology Department.
CT scan showed multiple necrotic liver metastasis with tumour in the pancreas. Alpha-fetoprotein checked on 2 occasions showed elevation and therefore possibility of hepatocellular cancer.
Liver biopsy performed initially inconclusive but Immunohistochemistry for neuroendocrine markers shows positive staining with Synaptophysin, chromograin, CD56.
Referred on to neuroendocrine Oncology clinic.
Unfortunately she was admitted acutely after suffering a life threatening hypoglycaemic episode.
Despite uptitrating doses of Diazoxide she continued to suffer recurrent hypoglycaemia and reported feeling increasingly sickly which was impairing her ability to eat.
During the admission managing her blood sugars proved difficult and at times she was on intravenous glucose. Under advice from the Neuroendocrine Oncologists; Octreotide was commenced to try and help with blood sugar control.
There was a mild improvement with the Octreotide.
Subsequent CT scans unfortunately showed significant progression in her liver metastasis within a 10 week period but interestingly her pancreatic primary was relatively unchanged.
She was transferred to our regional tertiary centre where she was commenced on a combination of Oxaliplatin and Fluorouracil.
Conclusion: A rare neuroendocrine tumour metastatic at presentation.
This case highlights the importance of multidisciplinary team working and how to provide symptomatic relief for patients suffering life limiting hyperglycaemia secondary to insulinomas.