Carcinoid tumors of the duodenum: report of three cases treated by endoscopic resection

Clinical impact of endoscopic ultrasonography on the management of neuroendocrine tumors: lights and shadows

The incidence of gastroenteropancreatic neuroendocrine neoplasms has increased in the recent decades. An extensive bibliographical search was performed in PubMed to identify guidelines and primary literature (retrospective and prospective studies, systematic reviews, case series) published mostly between year 1997 and June 2017, using both medical subject heading (MeSH) terms and free-language keywords about the accuracy and diagnostic and therapeutic role of endoscopic ultrasound in the context of gastro-entero-pancreatic neuroendocrine neoplasms. Endoscopic ultrasound is the modality of choice for diagnosing pancreatic neuroendocrine neoplasms and for the locoregional staging of gastric, duodenal, pancreatic and rectal neuroendocrine neoplasms; in particular, in the setting of pancreatic neuroendocrine neoplasms it has demonstrated higher accuracy in tumor detection than other imaging modalities. Furthermore, the possibility of tattooing pancreatic lesions by endoscopic ultrasound fine needle aspiration may help surgeons to locate the tumor and avoid any demolition surgery. Finally, endoscopic ultrasound-guided therapies have been proposed and used in several studies for patients unsuitable for surgery, with good results on the control of symptoms and the reduction of tumor burden.

The slow progressive nature of duodenal neuroendocrine tumor: a case report of long-term observation over 14 years

The number of duodenal neuroendocrine tumors has recently increased, but their natural history has not been well characterized. Here we report the case of a 59-year-old female undergoing complete resection by endoscopic mucosal resection after monitoring endoscopic morphologic changes and the size increment of a duodenal neuroendocrine tumor over the longest follow-up duration. An elevated lesion was initially detected on the duodenal bulb. Endoscopic biopsy from this lesion was performed three times during the follow-up, but all of the specimens simply demonstrated the presence of gastric metaplasia. Thereafter, in the esophagogastroduodenoscopy performed 14 years after the initial examination, a slight depression was detected in the center of the lesion together with an incremental change of its size. The histopathologic diagnosis of neuroendocrine tumor was made by deeper tissue sampling, and the patient subsequently underwent endoscopic mucosal resection for this tumor and was finally diagnosed with a G1 duodenal neuroendocrine tumor with pT2 cN0, cM0, stage IIa in the TNM classification. This is the first case demonstrating the slowly progressive nature of such a tumor with the longest follow-up of a duodenal neuroendocrine tumor ever reported, which could provide important information regarding the natural history and management of such tumors.

Management strategy for small duodenal carcinoid tumors: does conservative management with close follow-up represent an alternative to endoscopic treatment?

BACKGROUND/AIMS

Limited data exist regarding the natural history of duodenal carcinoid tumors and the efficacy of endoscopic treatment.

METHODS

A total of 27 patients with duodenal carcinoid tumors were enrolled. All tumors were located outside the periampullary region and were ≤10 mm in size. 11 patients underwent endoscopic mucosal resection (EMR) and argon plasma coagulation (APC). 13 patients did not undergo any specific procedure for tumor removal and were followed clinically.

RESULTS

Of 13 patients not undergoing treatment, tumors disappeared in 5 cases during follow-up with diagnostic forceps biopsy. Endoscopically visible lesions remained in the last follow-up endoscopy in 8 patients (61.5%). No lymph node or distant metastases or tumor-related deaths occurred during a median follow-up of 37 months. Of 11 cases treated with EMR, tumor-free resection margins were achieved in 10 cases and no local recurrence occurred after treatment. Two perforations occurred during EMR. Of the 3 cases treated with APC, local recurrence occurred in 1 case.

CONCLUSIONS

Given the risks associated with EMR and the likely favorable natural history of small duodenal carcinoid tumors, conservative management with close follow-up may represent a viable alternative to endoscopic treatment, especially in patients with a high risk of perioperative complications.

Diagnostic and therapeutic role of endoscopy in gastroenteropancreatic neuroendocrine neoplasms

Gastroenteropancreatic neuroendocrine neoplasms have substantially increased over the last decades. Because of the indolent clinical course of the disease even in advance stages and the rise in the incidental diagnosis of small asymptomatic lesions, the prevalence of gastroenteropancreatic neuroendocrine neoplasms is higher than that of pancreatic, gastric and oesophageal adenocarcinomas, making them the second most prevalent cancer type of the gastrointestinal tract. This increase in the overall prevalence of gastroenteropancreatic neuroendocrine neoplasms has been paralleled by a growth in the importance of the endoscopist in the care of these patients, who usually require a multidisciplinary approach. In this manuscript the diagnostic and therapeutic role of endoscopic for gastroenteropancreatic neuroendocrine neoplasms will be reviewed.

Endoscopic treatment for early foregut neuroendocrine tumors

Foregut neuroendocrine tumors (NETs) include those arising in the esophagus, stomach, pancreas, and duodenum and seem to have a broad range of clinical behavior from benign to metastatic. Several factors including the advent of screening endoscopy may be related to increased incidence of gastrointestinal NETs; thus, many foregut NETs are diagnosed at an early stage. Early foregut NETs, such as those of the stomach and duodenum, can be managed with endoscopic treatment because of a low frequency of lymph node and distant metastases. However, controversy continues concerning the optimal management of early foregut NETs due to a lack of controlled prospective studies. Several issues such as indications, technical issues, and outcomes of endoscopic treatment for early foregut NETs are reviewed based on some published studies.

Endoscopic submucosal dissection for foregut neuroendocrine tumors: An initial study

AIM: To evaluate the feasibility and efficacy of endoscopic submucosal dissection (ESD) for foregut neuroendocrine tumors (NETs).

METHODS: From April 2008 to December 2010, patients with confirmed histological diagnosis of foregut NETs were included. None had regional lymph node enlargement or distant metastases to the liver or lung on preoperative computerized tomography scanning or endoscopic ultrasonography (EUS). ESD was attempted under general anesthesia. After making several marking dots around the lesion, a mixture solution was injected into the submucosa. The mucosa was incised outside the marking dots. Dissection of the submucosal layer beneath the tumor was performed under direct vision to achieve complete en bloc resection of the specimen. Tumor features, clinicopathological characteristics, complete resection rate, and complications were evaluated. Foregut NETs were graded as G1, G2, or G3 on the basis of proliferative activity by mitotic count or Ki-67 index. All patients underwent regular follow-up to evaluate for any local recurrence or distant metastasis.

RESULTS: Those treated by ESD included 24 patients with 29 foregut NETs. The locations of the 29 lesions are as follows: esophagus (n = 1), cardia (n = 1), stomach (n = 23), and duodenal bulb (n = 4). All lesions were found incidentally during routine upper gastrointestinal endoscopy for other indications, and none had symptoms of carcinoid syndrome. Preoperative EUS showed that all tumors were confined to the submucosa. Among the 24 gastric lesions, 16 lesions in 11 patients were type I gastric NETs arising in chronic atrophic gastritis with hypergastrinemia, while the other 8 solitary lesions were type III because of absence of atrophic gastritis in these cases. All of the tumors were removed in an en bloc fashion. The average maximum diameter of the lesions was 9.4 mm (range: 2-30 mm), and the procedure time was 20.3 min (range: 10-45 min). According to the World Health Organization 2010 classification, histological evaluation determined that 26 lesions were NET-G1, 2 gastric lesions were NET-G2, and 1 esophageal lesion was neuroendocrine carcinoma (NEC). Complete resection was achieved in 28 lesions (28/29, 96.6%), and all of them were confined to the submucosa in histopathologic assessment with no lymphovascular invasion. The remaining patient with NEC underwent additional surgery because the resected specimens revealed angiolymphatic and muscularis invasion, as well as incomplete resection. Delayed bleeding occurred in 1 case 3 d after ESD, which was managed by endoscopic treatment. There were no procedure-related perforations. During a mean follow-up period of 24.4 mo (range: 12-48 mo), local recurrence occurred in only 1 patient 7 mo after initial ESD. This patient successfully underwent repeat ESD. Metastasis to lymph nodes or distal organs was not observed in any patient. No patients died during the study period.

CONCLUSION: ESD appears to be a safe, feasible, and effective procedure for providing accurate histopathological evaluations and curative treatment for eligible foregut NETs.

Endoscopic resection of duodenal bulb neuroendocrine tumor larger than 10 mm in diameter

Background

Endoscopic treatment for duodenal bulb neuroendocrine tumor larger than 10 mm is still controversial. This report presents four cases successfully treated with endosonography (EUS)-assisted endoscopic mucosal resection (EMR) procedure for duodenal bulb neuroendocrine tumor larger than 10 mm in diameter.

Methods

The case series of four patients diagnosed with neuroendocrine tumor from 2003 to 2008 were reviewed. EUS demonstrated well-defined hypoechoic tumors confined to the submucosal hyperechoic layer and the underlying hypoechoic muscularis propria was intact in all four patients. EMR were planned and performed for the duodenal bulb neuroendocrine tumors larger than 10 mm.

Results

En bloc resections with tumor free lateral and basal margins were accomplished using an endoscopic diathermic snare with forward-viewing instruments without any complications. Neither residual duodenal neuroendocrine tumors nor metastatic lesions were detected during the observation period ranging 19 to 78 months

Conclusion

Duodenal bulb neuroendocrine, larger than 10 mm in diameter, can be treated by endoscopic procedure, after confirming that the tumor confined to the submucosal layer in EUS examination, and no lymph node involvement by abdominal CT and US.

Carcinoid tumors of the gastrointestinal tract

The gastrointestinal tract is the largest neuroendocrine system in the body. Carcinoid tumors are amine precursor uptake decarboxylase (APUD) omas that arise from enterochromaffin cells throughout the gut. These tumors secrete discrete bioactive substances producing characteristic immunohistochemical patterns. Most tumors are asymptomatic and detected at late stages. Hepatic metastases are commonly responsible for carcinoid syndrome. The small bowel is the most common location of carcinoids. Computed tomography scan and magnetic resonance imaging are useful in the detection of these tumors. The measurement of bioactive amines is the initial diagnostic test. Various treatment options, including somatostatin analogs, interferon, chemotherapy, surgery, hepatic artery chemoembolization, and surgery have emerged in the past two decades. However, the incidence and prevalence of carcinoid tumors has increased, while mean survival time has not changed significantly. The lack of standardized classification, federal support, and an incomplete understanding of the complications of this disease are some of the impediments to progress in treatment.

Minimally invasive surgery for resection of duodenal carcinoid tumors: endoscopic full-thickness resection under laparoscopic observation

BACKGROUND

Carcinoid tumors of the duodenum are rare, and the most effective treatment for duodenal carcinoid tumors remains debatable. Because carcinoid tumors of the gastrointestinal tract tend to spread to the submucosal layer even during the early stages of the disease, the possibility of tumor seeding in the vertical margin of the tumor cannot be eliminated by conventional endoscopic mucosal resection (EMR). In addition, because the duodenal wall is thinner than the gastric wall, EMR performed for duodenal lesions may be associated with a high risk of accidental perforation. In this article, we introduce a minimally invasive endoscopic full-thickness resection technique after laparoscopic repair for the local resection of duodenal carcinoid tumors.

METHODS

Under general anesthesia, after the duodenum was mobilized laparoscopically, the duodenal serosa at the site of the lesion was suctioned under laparoscopic observation, and full-thickness resection of the duodenum was performed using a cap-fitted endoscope, i.e., EMR-c, without injecting hypertonic saline-epinephrine. The sample was retrieved endoscopically after resection. After confirming that the full-thickness resection of the duodenal wall with enough surgical margins was achieved and that there was no active bleeding, the wound was sutured by the laparoscopic hand-suturing technique.

RESULTS

We have performed this surgical procedure in two cases of duodenal carcinoid tumor. The mean operation time was 116 +/- 14 minutes, and the estimated blood loss was 2.5 +/- 0.5 ml. The postoperative courses were uneventful in both cases.

CONCLUSIONS

The technique of endoscopic full-thickness resection of gastrointestinal tract under laparoscopic observation is a safe, simple, and can be radical surgical procedure for a small duodenal carcinoid tumor. This surgical procedure may be applicable in the case of other gastrointestinal tumors.

Current status of gastrointestinal carcinoids

Gastrointestinal (GI) carcinoids are ill-understood, enigmatic malignancies, which, although slow growing compared with adenocarcinomas, can behave aggressively. Carcinoids are classified based on organ site and cell of origin and occur most frequently in the GI (67%) where they are most common in small intestine (25%), appendix (12%), and rectum (14%). Local manifestations--mass, bleeding, obstruction, or perforation--reflect invasion or tumor-induced fibrosis and often result in incidental detection at emergency surgery. Symptoms are protean (flushing, sweating, diarrhea, bronchospasm), usually misdiagnosed, and reflect secretion of diverse amines and peptides. Biochemical diagnosis is established by elevation of plasma chromogranin A (CgA), serotonin, or urinary 5-hydroxyindoleacetic acid (5-HIAA), while topographic localization is by Octreoscan, computerized axial tomography (CAT) scan, or endoscopy/ultrasound. Histological identification is confirmed by CgA and synaptophysin immunohistochemistry. Primary therapy is surgical excision to avert local manifestations and decrease hormone secretion. Hepatic metastases may be amenable to cytoreduction, radiofrequency ablation, embolization alone, or with cytotoxics. Hepatic transplantation may rarely be beneficial. Chemotherapy and radiotherapy have minimal efficacy and substantially decrease quality of life. Intravenously administered receptor-targeted radiolabeled somatostatin analogs are of use in disseminated disease. Local endoscopic excision for gastric (type I and II) and rectal carcinoids may be adequate. Somatostatin analogues provide the most effective symptomatic therapy, although interferon has some utility. Overall 5-year survival for carcinoids of the appendix is 98%, gastric (types I/II) is 81%, rectum is 87%, small intestinal is 60%, colonic carcinoids is 62%, and gastric type III/IV is 33%.

Laparoscopic Resection of Posterior Duodenal Bulb Carcinoid Tumor

Duodenal carcinoid tumors are rare neuroendocrine foregut tumors that, in contrast to midgut carcinoid tumors, have a low metastatic potential. The majority can be resected endoscopically. This case details a 67-year old man presenting with a biopsy-proven carcinoid tumor located at the posterior superior aspect of the duodenal bulb which was not amenable to endoscopic resection. The patient underwent a laparoscopic resection of the tumor after precise localization using simultaneous laparoscopy and duodenoscopy, with reconstruction of the duodenotomy defect using intracorporeal suturing techniques. The authors present a case report and details of an operative technique that may be utilized on other operations of the duodenum.

Duodenal carcinoid tumors: how aggressive should we be?

Duodenal carcinoid tumors are uncommon. It is not known whether they behave more like carcinoid tumors in the appendix (indolent course) or those in the ileum (often virulent)-crucial information for determining the need for radical resection. A retrospective review at our tertiary referral center (from 1976 to 1999) identified 27 patients with primary duodenal carcinoid lesions, excluding functional islet cell tumors. Endoscopic biopsy provided the diagnosis in 78% of patients. Treatment was by endoscopic excision (n = 11), transduodenal excision (n = 8), pancreaticoduodenectomy (n = 3), segmental distal duodenectomy (n = 2), or palliative operation (n = 2). One patient did not undergo operation because of comorbidity. Eighteen of 19 patients with tumors smaller than 2 cm remained disease free after local (endoscopic or transduodenal) excision. The exception was a patient with a small periampullary carcinoid lesion. In contrast, all four patients with carcinoid tumors 2 cm or larger who were resected for cure developed a recurrence (2 to 9 years postoperatively). We conclude that duodenal carcinoid tumors smaller than 2 cm may be excised locally; to ensure complete resection we recommend open transduodenal excision for tumors between 1 and 2 cm. Endoscopic follow-up is indicated. It is unclear whether patients with larger tumors benefit from more aggressive locoregional resection. Ampullary/periampullary carcinoid tumors should be considered separately, as their behavior is unpredictable.

Experimental endoscopic repair of gastric perforations with an omental patch and clips

BACKGROUND

The omental patch is a standard surgical treatment of gastroduodenal ulcer perforation. This is a report of an experimental method for endoscopic repair of anterior gastric perforations with an omental patch developed by using a porcine model.

METHODS

A standardized gastric perforation was created in 10 pigs. The omentum was pulled into the gastric lumen and fixed endoscopically to the muscularis propria layer of the stomach with metallic clips.

RESULTS

The postoperative course was normal in 9 animals. An ulcer was evident at the site of repair at follow-up endoscopy. At autopsy, the omentum was adherent to the external side of gastric wall. One animal died with peritonitis, presumably because the muscularis propria layer could not be seen during the procedure, and the clips attached the omentum only to the mucosa.

CONCLUSIONS

Endoscopic repair with an omental patch appears to be an effective procedure for closure of gastric perforations.

[Laparoscopic excision of a duodenal neuroendocrine tumor]

A 75-year-old woman with melena was found to have a carcinoid tumor in the posterior wall of the duodenal bulb. The biology was normal. The tumor measured 10 mm in size, and endoscopic ultrasonography showed only submucosal involvement. There was no liver metastasis and no regional lymph nodes. Tumoral resection was performed laparoscopically with success. Postoperative course was uneventful. Laparoscopic resection could be an appropriate minimally invasive treatment for selected small size duodenal tumors.

Diagnosis of submucosal tumor of the upper GI tract by endoscopic resection

BACKGROUND

Submucosal tumors are frequent findings during endoscopy, although definitive diagnosis based on histologic confirmation presents some difficulties. The aim of this study was to evaluate the efficacy and safety of endoscopic resection based on endoscopic ultrasonography (EUS) findings to reach a definitive diagnosis of submucosal tumor.

METHODS

Fifty-four submucosal tumors of the upper gastrointestinal (GI) tract were included in this study. EUS was performed to determine the layer of origin and location of the lesion and to rule out malignancy. En bloc resection was attempted for lesions originating in the muscularis mucosa or submucosa. For tumors originating in the muscularis propria, we performed partial resection limited to the covering mucosa to expose the lesion and obtained a sample with standard biopsy forceps.

RESULTS

Sufficient samples were obtained in all 54 cases. There was no perforation. Bleeding occurred in only 5 cases (9%) and was easily managed with endoscopic hemostatic methods. EUS and pathologic findings coincided in 74.1% of cases (40 of 54). Benign lesions (leiomyoma, aberrant pancreas, and others) were predominant (52 of 54), although 2 small lesions were confirmed at pathologic study to be malignant (leiomyosarcoma and leiomyoblastoma).

CONCLUSIONS

Endoscopic resection based on EUS findings proved to be an effective and safe method to confirm the histologic diagnosis of submucosal tumor of the upper GI tract. Endoscopic resection should be considered a valuable choice for definitive management of benign submucosal tumors originating in the superficial layers.

Review article: current status of gastrointestinal carcinoids

Carcinoid tumours are enigmatic, slow growing malignancies which occur most frequently (74%) in the gastrointestinal tract. In recent years, it has become apparent that the term 'carcinoid' represents a wide spectrum of different neoplasms originating from a variety of different neuroendocrine cell types. Carcinoid lesions are usually identified histologically by their affinity for silver salts, by general neuroendocrine markers, or more specifically by immunocytochemistry using antibodies against their specific cellular products. Within the gut, the most frequent sites are the small bowel (29%), the appendix (19%) and rectum (13%). Clinical manifestations are often vague or absent. Nevertheless, in approximately 10% of patients the tumours secrete bioactive mediators which may engender various elements of characteristic carcinoid syndrome. In many instances the neoplasms are detected incidentally at the time of surgery for other gastrointestinal disorders. The tendency for metastatic spread correlates with tumour size, and is substantially higher in lesions larger than 2.0 cm. An association with noncarcinoid neoplasms is ascribed in 8-17% of lesions. Treatment consists of radical surgical excision of the tumour, although gastric (type I and II) and rectal carcinoids may be managed with local excision. Overall 5-year survival is excellent for carcinoids of the appendix (86%) and rectum (72%), whereas small intestinal (55%), gastric (49%) and colonic carcinoids (42%) exhibit a far worse prognosis.