Sporadic gastric carcinoid tumor laparoscopically resected: a case report.

Sporadic gastric carcinoid tumors are relatively infrequent malignancies of the stomach. Tumors measuring less than 1 cm can sometimes be safely removed endoscopically; however, larger neoplasias require surgical ablation. The present case report represents a gastric carcinoid tumor laparoscopically resected in a patient with a history of hematemesis. The tumor was first marked endoscopically with India ink, which facilitated subsequent localization of the area to be resected. Laparoscopic resection of the mass was without complication, and the pathology study confirmed the preoperative diagnosis and negativity of the margins. In patients who present with masses that are not amended for endoscopic resection, sporadic gastric carcinoid tumors can be resected laparoscopically.

Although carcinoid tumors represent the most common neuroendocrine tumors in the gastrointestinal tract, gastric carcinoids are relatively infrequent and account for only 2% to 10% of all carcinoids.[1] Based on clinicopathologic features, gastric carcinoids are classified as tumors associated with atrophic autoimmune gastritis (type A), those in Zollinger-Ellison syndrome in combination with type I multiple endocrine neoplasias (MEN), and sporadic carcinoid tumors.[2] Prognosis of these neoplasias varies depending upon the subtype, with metastases rates of 7.6% for tumors underlying type A gastritis, 12% for tumors in Zollinger-Ellison syndrome, and >60% for sporadic carcinoids.[2] Due to their unfavorable biological behavior and size usually larger than 1 cm, solitary sporadic carcinoids are often an indication for surgical resection. Laparoscopic resection has been previously attempted in duodenal carcinoids,[3,4] tumors limited to the Meckel's diverticulum,[5] and appendicular carcinoids.[6] Here, we are reporting a case of a sporadic gastric carcinoid tumor laparoscopically removed.

CASE REPORT

A 31-year-old African American woman presented with a history of hypertension and hematemesis. Two years prior to this presentation, the patient was diagnosed with peptic ulcer disease requiring thermal cauterization and a blood transfusion. At that time, she was found to be Helicobacter pylori positive for which she received standard therapy. Despite the treatment initiated, the patient continued having symptoms and underwent a repeated endoscopy that showed a 13x3-mm mass near the lesser curvature anteriorly in the body of the stomach and a biopsy consistent with carcinoid tumor (. An endoscopic ultrasound later revealed the lesion extending deep into the submucosa and close to the muscularis propria; thus, endoscopic resection was not recommended. Due to the relatively small size and flat aspect of the lesion, an endoscopic India ink tattooing technique was performed to facilitate subsequent laparoscopic localization (. At this time, gastrin serum levels were found to be 28 pg/mL (normal ≤200 pg/mL, determined by Laboratory Medicine and Pathology, Mayo Clinic, Rochester).

Endoscopic localization of the tumor. Preoperative examination revealed a small, ulcerated, noncircumferential mass with no stigmata of recent bleeding in the gastric body. The lesion was located in the body on the anterior wall (arrow); asterisk denotes lesser curvature.

Intraoperative tumor localization. The tumor was endoscopically tattooed with India ink allowing posterior localization during surgery. Arrows denote the abnormality area limited to the body of the stomach.

After general anesthesia was induced and the abdomen prepped and draped in the usual fashion, the pneumoperitoneum was established via a Hasson cannula placed in the inferior aspect of the umbilicus. A second 5-mm trocar was placed in the left upper quadrant, which allowed mobilization of the left lobe of the liver. Additional ports were placed, two in the left upper quadrant and one in the right upper quadrant to allow full visualization of the area. An endoscope was then passed through the mouth and down into the stomach to visualize that the proposed area of the abnormality was in fact the carcinoid. The area of abnormality was grasped and brought up and an endo GIA stapler with a 30-3.5 load was used to sequentially pass underneath the area, leaving a careful margin around the abnormality ( Prior to the firing of the last staple, the feeding vessels from the lesser curvature were taken down using the Harmonic scalpel (. The specimen was placed in the Endocatch and brought out through the umbilical port. The mass was then sent to pathology, which confirmed the diagnosis of carcinoid tumor and negativity of the margins.

The area was grasped and wedge resection of the tumor was achieved by firing staples with an endo GIA stapler using 30-3.5 loads. A small amount of oozing from the staple line was stopped with clips.

Prior to the last firing, the feeding vessels from the lesser curvature were taken down with a Harmonic scalpel.

DISCUSSION

Sporadic carcinoid tumors typically occur in nonatrophic gastric mucosa without associated endocrine cell proliferation, which serves to distinguish them from MEN/Zollinger-Ellison tumors. They can be further categorized as having typical or atypical histology. Tumors with atypical features evidence a marked nuclear pleomorphism with irregular hyperchromatic nuclei, an increased number of mitosis, and areas of necrosis. Atypical tumors are generally larger, more invasive, and with higher metastasic rates. Regional lymph node metastases have been described in up to 60% of patients with sporadic carcinoids and liver metastases in as many as 52% of the patients.[2] Those carcinoids with typical histology measuring less than 1 cm may be removed endoscopically; however, larger tumors like the one presented here require surgical ablation.

In cases where resection is not possible endoscopically, laparoscopic approaches are an alternative therapeutic option. Preoperative assessment of patients with suspected gastric carcinoids should include determination of gastrin serum levels and endoscopic ultrasonography to evaluate invasion of the tumor into the gastric wall; intraoperative endoscopy facilitates the exact localization of the tumor and ensures complete resection with proper margins.