Pesquisa

US Quiz of the Month – January 2016

CASE REPORT

The present report refers to a 84-year-old man that was admitted with an history of hematemesis and lipothymia. After hemodynamic stabilization, an endoscopic examination was performed, showing in the greater curvature of the gastric body, a round sessile lesion, with approximately 4 cm, with normal overlying mucosa, except in the apical top, with an adherent clot that was removed, revealing a central erythematous depression, not considered viable for endoscopic therapy (Figures 1 and 2).

 
Figures 1 and 2: Upper endoscopy showing in the greater curvature of the gastric body a round sessile lesion, with approximately 4 cm, with normal overlying mucosa.

 

For further characterization, endoscopic ultrasound (EUS) was made within the first 24 hours, revealing a large hypoechogenic, homogeneous lesion, with distinct smooth margins, with a small hyperechoic septation, apparently located within the submucosa, without invading the muscularis propria, and with a maximum diameter of 34 mm (Figures 3 and 4).

 

Figures 3 and 4: Radial EUS showing a large hypoechogenic, homogeneous lesion, with distinct smooth margins, with a small hyperechoic septation, apparently located within the submucosa, without invading the muscularis propria, and with a maximum diameter of 34 mm.

 

No pathologic adjacent lymph nodes where detected, and after Doppler study, it presented as a low vascularized lesion. EUS fine-needle aspiration was not performed, attending to recent bleeding.

 

Thoracic and abdominal computed tomography (CT) scans were made and characterized this lesion as round, hypodense, with well distinct margins, and preservation of perigastric fat plane. No pathologic adenopathies, distant metastatic or synchronous disease were detected. No additional information was given concerning the layer of origin (Figure 5).

Figure 5: CT revealed a round, hypodense gastric mass, with well distinct margins, and preservation of perigastric fat plane.

 

On the third day, rebleeding occurred and we decided for a surgical approach and the patient undergone a partial gastrectomy. The histologic examination was compatible with a well-differentiated, low grade (G1) neuroendocrine tumor (Chromogranin A; Ki 67=1%), restricted to submucosa (Figures 6 and 7).

 

Figures 6 and 7: Histologic examination showed a well-differentiated, low grade (G1) neuroendocrine tumor (Chromogranin A; Ki 67=1%), restricted to submucosa (Figure 6: H/E stain and Figure 7: Chromogranin A antibodies).

 

The 24-hour urine measurement of 5-hydroxy-indoleacetic, and gastrin seric levels were normal. Atrophic gastritis was also excluded. Whole body scintigraphy with (99m) Tc-tektrotyd was performed, with no positive findings. We established the diagnosis of type 3 gastric carcinoid (sporadic carcinoid), with staging T2N0M0.

 

Commentary

Neuroendocrine neoplasms (NETs), are defined as epithelial neoplasms with predominant neuroendocrine differentiation and represent less than 1% of gastric neoplasms. Although carcinoids can arise in various organs, gastrointestinal tract accounts for almost two thirds of the cases, representing gastric carcinoids (GCs) less then 10% of the total gastrointestinal affection.

With this case report, we highlight the infrequent presentation of a carcinoid tumor with important gastrointestinal bleeding as well as the role of EUS on the evaluation of gastric subepithelial lesions.

 

Authors

Artur Antunes, Bruno Peixe, Horácio Guerreiro

Gastroenterology Department, Centro Hospitalar do Algarve, Faro, Portugal