1. Case presentation
Done by oncology team

2. History
45 years old Yemeni male patient known x-smoker presented to the emergency department with history of chest pain since twelve hour duration.
The pain was in retrosternal area, stabbing in nature, radiated to the left upper arm and the left jaw, it last min duration and relived by sublingual nitroglycerine.
He had grade 1 dysponea, no orthopnia or PND.

3. Systemic review:
He has history of watery diarrhea, of small amount, no blood or mucous and it usually started 5-10 min after food intake. Since four months duration.
He has abdominal pain colicky in nature all over the abdomen started 6 months ago relived by ranitidine.
No history of weight loss or change in appetite.

4. Past medical history: unremarkable.
Past surgical history: unremarkable.
Medication history: unremarkable.
Family history: no family history of IHD, BA, DM and hypertension.
Social history: he was smoker for 25 years (1pack/day) and quit one year ago.

5. Examination Vitally: B/P=114/79 HR=90/ MIN RR=18/MIN T=36,6C SPO2=100%
Generally: conscious, oriented and he is pain.
CVS: normal first and second heart sounds without any added sounds. Nothing was positive.
Respiratory: equal breathing entry bilaterally without added sounds.
GIT: the abdomen was soft and lax, no organomegally or any tenderness.
CNS: normal tone, power and reflexes.

6. In the ED they did the following investigations:
CBC, LFT, Blood chemistry: all are normal
Cardiac enzymes: troponin I =
ck= LDH= AST=
ECG: showed T wave inversion and ST depression in V2---V6.
Chest x-ray: widened mediastinum, irregular cardiac borders.

8. CXR

9. The patient was diagnosed as case of acute coronary syndrome (ACS), and then he was shifted to the ICU and received Heparin, Tridil and the proper management there.

10. ECHO was scheduled for this patient and showed the following:
Marked concentric hypertrophy.
Grade ll diastolic dysfunction.
All the valves are normal.

11. Cardiac cath was scheduled and done for this patient and showed the following:
Normal coronaries with dominant right coronary artery.
Hyper contractile left ventricle with markedly hypertrophy papillary muscle on a mass.

12. The patient discharged to the male medial ward after he improves and the plan for him to do CT scan of the chest because they were uncomfortable with the chest x-ray .

13. CT chest& abdomen was done and showed the following:
Large heterogeneous soft tissue mass in the mediastinum and compressing both ventricles.
Numerous enlarged mediastinal, pre-tracheal, post-caval and azygoesophageal lymph nodes are noted.
There are two lesion in the liver one is two cm and the other 2,5 cm consistent with mets.

14. CT

15. Diagnosis and management?

16. Differential diagnosis

17. According to this result CT-guided mediastinal lymph node
Moderately differentiated neuroendocrine tumor consistent with atypical carcinoid most likely metastasis from the lung.

18. Further investigations:
24 hour urine collection for 5-HIAA.

19. Carcinoid tumors Part of neuroendocrine tumors Classification:
Foregut:esophagus,stomach, bronchus, thymus, pancreas.
midgut:terminal ileum and appendix.
Hindgut: rectum.

20. Products released by carciniod tumors:
Serotonin(5-HT).
Bradykinin.
Histamine.
Prostaglandins.
others.

21. Carciniod syndrome: In 5% of patients. Flushing.
Diarrhea and abdominal pain.
Bronchospasm.
Cardiac abnormalities: right side heart involvement, tricuspid regurgitation.

22. Diagnosis: 24 hour urine collection of 5-HIAA.
Somatostatin receptor scintigraphy.
Histopathology.

23. management Medical: Somatostatin. Octreotide.
Chemotherapy: 5FU, streptozoticin, DTIC and Doxorubicin.
surgical:
surgical resection of the tumor.
Hepatic artery embolisation.