Dear Dr. Roach: Can you please give more insight into carcinoid syndrome? In particular, I’d like to know its symptoms and how it gets diagnosed and treated? What kind of a doctor would one see with that diagnosis?
S.B.
A carcinoid tumour is a type of neuroendocrine tumour of the digestive tract or lungs. In the gastrointestinal tract, these tumours are now referred to just as neuroendocrine tumours. They can produce substances that, in some situations, can cause carcinoid syndrome. This usually presents with flushing and diarrhea.
Symptoms are most common with carcinoid tumors of the lung or when the neuroendocrine tumour has spread. The liver normally inactivates these substances, so it is when the disease has spread to the liver that people become symptomatic. The blood from lung carcinoid tumours does not go directly to the liver, which is why lung carcinoid tumors may cause carcinoid syndrome without liver involvement. Still, more than 90% of people with carcinoid syndrome have metastatic disease — cancer that has spread to distant locations.
The diagnosis can be made by a combination of urine tests looking for the commonly produced substances, such as 5-hydroxyindoleacetic acid (5-HIAA), and by anatomic tests such as scans or endoscopy.
In the past, neuroendocrine tumours were considered benign, but a better understanding of these tumours has led them to be classified as cancers and treated aggressively. Oncologists with special expertise in gastro-intestinal cancers are the ideal specialists to see for treatment.
Treatment might be surgical — for example, to remove metastatic disease to the liver — or medical, such as octreotide, which inhibits release of the substances that cause flushing and diarrhea, and significantly improves symptoms in 80% or more of people with carcinoid syndrome.
Dear Dr. Roach: During a hospital stay in which I was admitted for a urinary tract infection and possible sepsis, a CT scan without contrast noted an abdominal nodule that the radiologist said “may represent a reactive prominent lymph node.” In numerous tests — including two upper GI series, an MRI and two additional CT scans with contrast — nothing abnormal appeared. Now my gastroenterologist wants to order an EGD/EUS, even though I am hesitant because he is not sure what we are looking for. I have no symptoms and am concerned that this is just another test to waste my money.
D.L.
Incidental findings in modern advanced scanning are routine, and enlarged lymph nodes — a place where immune and inflammatory cells gather — are among the most common of these. Many or most of these will be what the radiologist suspected. The term “reactive” is used to mean the lymph node becomes enlarged, often due to infection. Any serious infection could cause enlargement of the lymph nodes. A very few of these will turn out to be more serious, and we worry most about cancer.
The size, position and, above all, progression of the lymph node help determine whether it is benign (such as a reactive node) or malignant (due to cancer). Given that your gastroenterologist has ordered several tests to further evaluate this with no abnormal findings provides almost complete reassurance that this is nothing to worry about.
A tiny doubt could remain, but further testing might cause more harm than good. EGD, which is an upper endoscopy, has few risks but rarely can cause a perforation in the stomach or intestine. EUS is an endoscopic ultrasound, done at the same time as the EGD. I doubt he is trying to waste money, but you can certainly tell him you are willing to live with the near-certainty that the finding was benign.
Dear Dr. Roach: I am a 68-year-old female in good health taking no medications. I try to take a 40-minute walk every day. I get the high-dose flu shot each fall and have had two pneumonia shots. This year I got a sinus infection with a cough that's lasted over three weeks. The year before, I got a deep cough that lasted almost a month. I may not get the full-blown flu, but why do I suffer from things like this every winter?
D.S.
Your likelihood of getting an upper respiratory infection depends on how much exposure to germs you get.
Adults average one to two colds per year, but those with small children may get six to 10. I used to think my immune system was great: I never got colds. Then I had children. Adults over 60 get fewer than one per year, on average.
Regular colds may be complicated by sinus infections. Some viruses and bacteria predispose to a long-lasting cough, and some people are more likely to develop that complication.
Meticulous handwashing dramatically reduces colds and other respiratory infections.
