Primary hepatic gastrinoma: Report of a case and review of literature

Primary hepatic gastrinoma is a very rare ectopic gastrinoma with less than 20 cases reported worldwide. We report the case of a patient with hypergastrinemia who was subjected to exhaustive preoperative and intraoperative imaging and also careful surgical exploration of the duodenum and pancreas which failed initially to identify the primary tumour. Eventually the patient was subjected to left liver lobectomy,as a small palpable lesion was noted intraoperatively. The diagnosis of gastrinoma requires a high index of clinical suspicion and the flawless cooperation of many specialties.     

大剂量旋覆代赭汤治疗脾胃虚弱型糖尿病胃轻瘫临床观察

目的:观察旋覆代赭汤对糖尿病胃轻瘫(Diabetic gastroparesis,DGP)患者促胃肠动力作用量效关系研究。方法:将108例脾胃虚弱型患者随机分为治疗组:大剂量54例(一两为15.625g)和对照组54例,对照组药物口服吗丁啉,10mg,每日3次,连用4周;治疗组药物口服旋覆代赭汤,每日1剂,连用4周。免疫组化法观察治疗前后血浆中胃动素(MOT)、血管活性肠肽(VIP)、胃泌素(GAS)的分布变化。结果:治疗组血浆中MOT的含量显著升高(P<0.01)、VIP的表达明显减少(P<0.01)、显著降低血浆GAS表达(P<0.05)。结论:旋覆代赭汤的促胃肠动力作用可能与血浆中MOT的含量显著升高和VIP与GAS的表达降低有密切关系。     

Gastrinomas: A historical perspective

The journey of gastrinomas had its beginnings in 1955 when Zollinger and Ellison published their seminal paper (Zollinger and Ellison, Ann Surg 1955; 142: 709–723). The evolution of the diagnosis and management of this syndrome has paralleled many important advances in medicine, including the development of various diagnostic tools to the major impact of medical treatment on the management of an inherently surgical pathology. There are numerous excellent review articles on the most current developments and treatment options of gastrinomas available in the literature today. The purpose of this paper is to present a historical perspective on this most fascinating condition. This article will illustrate the way in which the discovery of gastrinomas evolved and how its management has developed with it. The evolution of the surgical treatment of gastrinomas has evolved over the last 50 years. J. Surg. Oncol. 2009;100:425–433. © 2009 Wiley‐Liss, Inc.     

Duodenal gastrinoma—clinical features and usefulness of selective arterial secretin injection test

Duodenal gastrinoma is recognized as a relatively common cause of Zollinger-Ellison syndrome, but its clinical and biological features are not well known. Here we report a case of duodenal gastrinoma with lymph node metastasis which was confirmed by pathology examinations. Hypergastrinemia and gastric acid hypersecretion were documented, but the secretin test showed negative results. An enlarged peripancreatic lymph node lying close to the pancreas head was the only positive finding on preoperative imaging studies. The results of the selective arterial secretin injection (SASI) test suggested that the primary tumor was located in the gastrinoma triangle. Finally, surgical exploration was carried out and a submucosal tumor, approximately 15mm in size, was detected by intraoperative palpation at the posterior wall of the proximal portion of the duodenum. Intraoperative pathology examination demonstrated metastases to regional lymph nodes. The present case calls attention to the unique features of duodenal gastrinomas, which differ from those of pancreatic origin: a highly malignant potential for its small size, and submucosal location in the proximal duodenum. The SASI test is recommended for assessing the location of a primary lesion if it cannot be identified by various conventional imaging studies. (Received Dec. 17, 1997; accepted Jan. 23, 1998)     

Multiple gastrinoma successfully resected with the aid of intraoperative arterial secretin injection test

Since gastrinoma is likely to develop in multiple sites, we should pay special attention to the removal of all daughter tumors, as well as the main tumor, during surgery for this disease. In a 24-year-old woman with pituitary prolactinoma, multiple gastrinomas were detected in a limited area of the pancreaticoduodenal region by preoperative imaging techniques, selective arterial secretin injection (SASI) test, and intraoperative inspection using ultrasonography. A pancreatoduodenectomy was performed, and it was intraoperatively confirmed that the serum gastrin concentration in the portal vein had decreased from 753 to 83 pg/ml (normal,<120pg/ml). However, intraoperative SASI test for the remnant pancreas showed a positive response, which prompted us to perform a histological examination of frozen sections obtained from the body and tail of the pancreas, despite the normal appearance. Many islet cell microtumors were discovered, and the remnant pancreas was completely removed. Postoperativelly, all of the tumors were immunohistochemically proven to be microgastrinomas. The patient is still disease-free, 2 years after the surgery, with a serum gastrin level of less than 30pg/ml. This report stresses the role of the intraoperative SASI test in preventing residual microgastrinomas before closure of the abdomen.     

Multiple gastrinoma successfully resected with the aid of intraoperative arterial secretin injection test

Since gastrinoma is likely to develop in multiple sites, we should pay special attention to the removal of all daughter tumors, as well as the main tumor, during surgery for this disease. In a 24-year-old woman with pituitary prolactinoma, multiple gastrinomas were detected in a limited area of the pancreaticoduodenal region by preoperative imaging techniques, selective arterial secretin injection (SASI) test, and intraoperative inspection using ultrasonography. A pancreatoduodenectomy was performed, and it was intraoperatively confirmed that the serum gastrin concentration in the portal vein had decreased from 753 to 83 pg/ml (normal,<120pg/ml). However, intraoperative SASI test for the remnant pancreas showed a positive response, which prompted us to perform a histological examination of frozen sections obtained from the body and tail of the pancreas, despite the normal appearance. Many islet cell microtumors were discovered, and the remnant pancreas was completely removed. Postoperativelly, all of the tumors were immunohistochemically proven to be microgastrinomas. The patient is still disease-free, 2 years after the surgery, with a serum gastrin level of less than 30pg/ml. This report stresses the role of the intraoperative SASI test in preventing residual microgastrinomas before closure of the abdomen.     

Morphology and immunohistochemically-defined endocrine function of pancreatic islet cell tumours

Thirty pancreatic islet cell tumours were histologically classified and analysed for their possible peptide hormone content using the immunohistoperoxidase method. Seven tumours contained insulin, six tumours contained gastrin and eight tumours contained glucagon. One tumour contained all three hormones. In the insulin and gastrin-containing tumours, the cells were usually arranged in solid nests of cells, with tubular and acinar formations in about half the cases. In the glucagon-containing tumours the cells were mainly arranged in anastomosing ribbons consisting of one of two layers of small cells. Most of the hormone-containing tumours were argyrophilic using Grimelius' silver reaction. All but one of the glucagon-containing tumours were incidental findings at autopsy. About half of the other tumours had metastasized. It is concluded that a relation exists between the histological pattern of growth and immunohistochemically defined endocrine function of pancreatic islet cell tumours.