An incidental finding of carcinoid tumor of the cystic duct
A 58-year-old Caucasian female presented with episodic right upper quadrant pain for the past 2 weeks. The pain was associated with multiple episodes of nausea, vomiting and diarrhea. She denied any jaundice, weight loss, hematochezia or melena. Physical examination revealed a soft abdomen without a palpable mass. She had tenderness in the right upper quadrant of the abdomen and Murphy's sign was present. The white blood cell count was 18.8K/µl, hematocrit 41.0%, bilirubin 0.20 mg/dl, lipase 101 U/l, alkaline phosphatase 70 U/l, alanine aminotransferase 28 U/l and aspartate aminotransferase 30 U/l. Computed tomography of the abdomen showed an enlarged fatty liver, mildly prominent gallbladder and inflammatory changes and edema at the root of the mesentery. Abdominal ultrasound revealed gallbladder sludge and wall thickness measuring 2 mm. The patient underwent laparoscopic cholecystectomy. Pathology report revealed mild chronic cholecystitis with foci of cholesterolosis and a small 2 mm carcinoid tumor at the cystic duct margin extending into the gallbladder mucosa. Histologically, the tumor demonstrated uniform eosinophilic neoplastic cells with oval nucleus (Fig. ) and was positive for chromogranin and synaptophysin neuroendocrine markers (Figs and ).\nThe patient was returned to the operating room 15 days after her first operation for a Roux-en-Y heptaticojejunostomy and excisional biopsy of a large lymph node at the mesenteric root. Her preoperative urine 5-hydroxyindoleacetic acid (5-HIAA), chromogranin A and serotonin levels were all normal. Final pathology report showed no viable tumor identified on the common hepatic and common bile duct margins, focal residual necrotic carcinoid tumor involving the cystic duct margin and one periductal lymph node negative for carcinoid tumor. The mesenteric root lymph node was positive for follicular lymphoma. Post-operative course was unremarkable. Medical oncology was consulted and recommended no chemotherapy at this time. The patient was seen in clinic 10 months post-operatively and remains disease free with normal liver function and humoral secretion tests.