Indian Journal of Radiology and Imaging Indian Journal of Radiology and Imaging

GASTROINTESTINAL
Year
: 2006  |  Volume : 16  |  Issue : 4  |  Page : 545--547

Carcinoid of the stomach -a rare tumour


S Kaur, R Goyal, H Juneja, N Sood, P Bajaj 
 Department of Radio-diagnosis, Dayanand Medical College & Hospital, Ludhiana -141001, India

Correspondence Address:
S Kaur
4-C, Udham Singh Nagar, Ludhiana -141001
India




How to cite this article:
Kaur S, Goyal R, Juneja H, Sood N, Bajaj P. Carcinoid of the stomach -a rare tumour.Indian J Radiol Imaging 2006;16:545-547


How to cite this URL:
Kaur S, Goyal R, Juneja H, Sood N, Bajaj P. Carcinoid of the stomach -a rare tumour. Indian J Radiol Imaging [serial online] 2006 [cited 2020 Aug 10 ];16:545-547
Available from: http://www.ijri.org/text.asp?2006/16/4/545/32265


Full Text

 Introduction



The original description of carcinoid tumors was made by Langhans, in 1867. Gossett and Massion in 1914 showed the affinity of certain granules in the cystoplasm of the cells for silver salts. These were designated argentaffin cells and hence the lesions were called argentaffinoma. Carcinoid is a relatively rare neoplasm occurring in the alimentary tract, lung, biliary tract and ovary. Gastric carcinoids represent only 2%-3% of the intestinal carcinoids and 0.3% of the total number of gastric neoplasm [1].

 Case report



A 50 years old man presented with history of pain in epigastrium and mild fever since 20days. Fever was intermittent, associated with chills and rigors. Pain in the epigastrium was mild continuous not associated with meals. He was known diabetic and hypertensive, taking regular treatment

Blood investigations revealed Hb-10gm. LFT and RFT s were normal.

On Sonography all the viscera were normal, no SOL was seen in the liver. There was evidence of wall thickening involving mainly fundus and greater curvature of stomach (measuring approx. 20mm) [Figure 1] and antrum [Figure 2]. The proximal part of duodenum also appeared thick walled.

CT examination was done on spiral CT AR Star Somatom with slice thickness of 10mm and table feed of 15mm, reconstruction was done at 8mm interval. Oral and I/V contrast was given to the patient. A large lobulated hypodense mass lesion was seen in relation to the fundus and greater curvature of the stomach and projecting into the gastrosplenic recess and lesser sac [Figure 3],[Figure 4]. The mass was abutting the medial border of the spleen with loss of intervening fat planes. Wall thickening was also seen in the region of body and antrum of the stomach. On endoscopy, esophagus and GE junction were normal. A large submucosal mass causing bulge on the fundus and cardia was seen, overlying mucosa was normal. In addition multiple small nodules were also seen in the body region. Biopsy was taken and sent for histopathological examination.

Gastric biopsy revealed focal intestinal metaplasia with infiltration of the lamina propria by cellular tissue arranged in sheets and nests. The cells had a relatively monomorphic round nucleus and moderate degree of cytological atypia was noted. Histology was suggestive of gastric carcinoid [Figure 5].

 Discussion



Gastrointestinal carcinoids arise from enterochromaffin cells of kulchitsky, which are considered neural crest cells situated at the base of the crypts of Lieberkuhn, from cardia to the anal sphincter [1]. These cells occur occasionally in the stomach, are moderately abundant in the jejunum and ileum, numerous in the appendix, and can be demonstrated in small numbers in the colon. The incidence of carcinoid tumor in different locations roughly parallels the frequency with which the kulchitsky cells are found [2].

Carcinoids are not peculiar to any age, but the average age varies with the location. The tumors of appendix occur at younger age. Whereas in stomach, the age ranges from twenty five to eighty-nine years with the average age being fifty-six [3]. Gastric carcinoids either develop as a result of chronic stimulation of enterochromaffin like cells by high concentrations of serum gastrin or may occur sporadically.[4]

Carcinoid tumors of the stomach exhibit unique biologic behavior that distinguishes them from their counterparts in the rest of the gastrointestinal tract;[5]

Patients with gastric carcinoid tumors have nonspecific symptoms such as pain or abdominal mass as seen in our patient [6]. These tumors are known to secrete serotonin and other histamine like substances. Carcinoid syndrome occurs when the load of secreted serotonin and histamine exceeds the metabolizing capacity of monoamine oxidase present in the liver and lung [7].

Gastric carcinoids secrete predominantly 5-hydroxytryptophan and not serotonin. Most of the gastric tumors show no evidence of endocrine function. The typical carcinoid syndrome is rarely observed. Post prandial blush seen in few patients is due to release of histamine [1].

Cinico-pathologic characterization of gastric carcinoid neoplasm is of three subtypes.[6],[5]. Type I gastric carcinoids are small benign tumors associated with chronic atrophic gastritis and chronic hypergastrinemia. Type II gastric carcinoid may be large and polypoid, associated with MEN I and Zollinger and Ellison syndrome. Lymphnode metastasis may be seen. Type III gastric carcinoids are usually large, solitary and unassociated with hypergastrinemic states.

Our case represent type III gastric carcinoid. These tumors are highly proliferative may show ulceration and are more likely to be invasive with distant metastases. These appear with striking predominance in men; carcinoid syndrome may be seen in patients with liver metastasis. In our patient there was no evidence of liver metastasis.

Pathologically carcinoids appears well circumscribed encapsulated tumors and consisting of small uniform cells which can be demonstrated microscopically. The cells occur in any combination of clusters or ribbons with varying degrees of distortion associated with desmoplasia. Mitotic activity is rare and speaks against the diagnosis of carcinoids [8]. In our case gastric biopsy revealed infiltration of the lamina propria by cellular tissue arranged in sheets and nests with relatively monomorphic round nucleus and moderate degree of cytological atypia.

The increased use of endoscopy and advances in imaging have led to a relative increase in detection of gastric carcinoid tumors [5]. Based on upper gastrointestinal studies using single contrast technique Balthazar et al had reported four different radiographic patterns of carcinoid tumors- Single intramural defect, large gastric ulcer, multiple gastric polyps and polypoidal intraluminal tumor [6].

Tumors may be located anywhere in the stomach, although, fundal locations is said to be rare. [6]

Trans abdominal sonography shows hypoechoic mass lesion arising from the wall of the stomach, Polypoidal projections can be seen on high resolution sonography [7]

On CT scan there is thickening of the stomach wall by nodular polypoid mass commonly arising from the lesser curvature of the stomach with low-density areas presumed to be necrosis [7]

Gastric carcinoids are slow growing and metastasize very late. The manner of invasion is by lymphatic and venous system. Regional metastasis are common, but distant metastasis are rare [8]. The prognosis of the gastric carcinoids is guarded but considered significantly better than that of adenocarcinoma, lesions grow slowly, and long survivals are seen even in the presence of regional or hepatic dissemination [1].

References

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2Martin JD, Atkins EC, GA Atlanta : Carcinoid of the stomach, Surgery May, 1982.
3Railford T.S; Carcinoid of the gastro-intestinal tract, Am.J, Cancer 18; 803; 1933.
4Berger MW, Stephens H.D, Gastric carcinoid tumors associated with chronic hypergastrinemia in a patient with Zollinger - Ellison syndrome. Radiology 201:371-373; 1996.
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