Metastatic Gastrinoma Localized on Gallium-68 DOTATATE Imaging

A 63-year-old woman presents for evaluation of chronic abdominal pain and diarrhea. Earlier was negative Helicobacter pylori or nonsteroidal anti-inflammatory drug use. Multiple esophagogastroduodenoscopies revealed severe esophagitis several duodenal ulcers despite a maximum dose omeprazole 2 years before diagnosis. Computed tomography endoscopic ultrasounds only inflammation benign hepatic cyst. Magnetic resonance imaging found similar findings in addition to 10-mm pancreatic cyst with no worrisome features. Stomach pH measured at 4.0 serum gastrin levels 1967 pg/mL (reference range, <100 ng/L) while taking omeprazole, as any therapeutic cessation led intolerable patient symptoms. Zollinger-Ellison syndrome suspected. Gallium-68 (Ga-68) DOTA-TATE positron emission tomography/computed scan exhibited tracer uptake the liver (Figure 1, arrows) peripancreatic lymph nodes (Supplemental Figure arrows, available online http://www.mayoclinicproceedings.org). Core biopsies low-grade neuroendocrine tumor represented by nests cells containing nuclei salt-and-pepper chromatin pattern 2, left dashed line). The were immunoreactive CK7, chromogranin, synaptophysin, CDX2, gastrin, http://www.mayoclinicproceedings.org).Figure 2Low-grade gastrinoma histology on core biopsy.View Large Image ViewerDownload Hi-res image Download (PPT) Cytoreductive surgery metastatic 1-cm primary gastrinoma. Since surgery, patient’s symptoms have resolved, even considerable reduction omeprazole. Subsequent multiple endocrine neoplasia 1 testing normal ionized calcium, prolactin, parathyroid hormone family history. Primary gastrinomas can be missed preoperative imaging, yet early detection may prevent disease. Specialty such DOTA-TATE, which binds somatostatin receptors, substantially alter clinical management, it is most sensitive test localize tumors. If there high suspicion tumor, one should consider Ga-68 DOTATATE, especially when other modalities failed. In our patient, appropriate indications this modality included localization diagnosis, quantifying burden, surgical planning.