case_images: PMC10589047_01
case_images: A, B, C and D are images from upper endoscopy. The yellow arrows in images A and B demonstrate a perforation in the distal esophagus with false lumen. Image C shows multiple ulcers (blue arrows) in the first part of the duodenum. Image D was taken after insertion of esophageal stent.
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case_images: PMC10589047_01_jchim-13-05-077f1.jpg
case_images: f1-jchim-13-05-077
case_images: An urgent upper gastrointestinal (GI) endoscopy was performed (Fig. 1). A perforation was noted in the distal esophagus at approximately 38 cm from the incisors (Fig. 1A and B). Multiple ulcers were visualized in the first part of the duodenum (Fig. 1C). A stent was placed across the perforation under fluoroscopic guidance (Fig. 1D).
case_images: A and B are axial and coronal images of CT abdomen and pelvis with intravenous and oral contrast showing a segment II hepatic mass measuring 3.5 x 2.6 x 3 cm (yellow arrow). There is a distal esophageal stent with adjacent pneumomediastinum with oral contrast surrounding the esophageal wall (red arrow) suggests esophageal perforation. A pleural effusion is also seen (white arrow). C, D and E are subsequently obtained abdominal MRI images. Axial (C, D) and coronal T2-weighted (E) abdominal MRI images show round enhancing masses in segment I, II, and IVA as well as additional adjacent sub centimeter satellite hypo enhancing masses (yellow arrows).
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case_images: f2-jchim-13-05-077
case_images: The abdominal CT did not demonstrate a bowel obstruction but showed an incidental liver mass concerning for a neoplasm (Fig. 2A and B). An MRI that characterized the lesion further revealed multiple enhancing masses in segments I, II, and IVA of the liver with subtle washout and associated periportal adenopathy, most compatible with a metastatic disease process (Fig. 2C, D, and 2E).
case_images: These are fused PET/CT axial images. A shows a PET-avid segment II lesion corresponding to the metastatic lesion visualized on MRI. B shows PET-avid precaval and periportal lymph nodes that correspond to enlarged lymph nodes on the MRI.
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case_images: PMC10589047_01_jchim-13-05-077f3.jpg
case_images: f3-jchim-13-05-077
case_images: Further evaluation with fluorodeoxyglucose (FDG)-positron emission tomography (PET) scan showed increased uptake by the left liver lesion and multiple porta hepatis lymphadenopathy, consistent with metastatic disease (Fig. 3A and B).
case_images: A is image of a liver core needle biopsy showing the transition from liver parenchyma (upper right) to the tumor (lower left). The nested pattern of the tumor is suggestive of possible neuroendocrine origin. B and C represent chromogranin and synaptophysin staining respectively. These stains positively highlight the tumor cells (brown) and do not stain the liver parenchyma, confirming neuroendocrine tumor. The lack of pleomorphism, mitotic figures, and low Ki-67 proliferation index (~25, not shown) identify this as a well-differentiated neuroendocrine tumor. D represents CDX-2 immunohistochemical staining that positively highlights the tumor cell nuclei (brown), whereas the liver parenchyma is negative for CDX-2 staining. This suggests the tumor is of gastrointestinal origin.
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case_images: PMC10589047_01_jchim-13-05-077f4.jpg
case_images: f4-jchim-13-05-077
case_images: A percutaneous liver biopsy revealed a metastatic, grade 1 well-differentiated neuroendocrine tumor (Fig. 4).