Carcinoid of the small intestine

Upper gastrointestinal carcinoid tumors incidentally found by endoscopic examinations

AIM

This study shares Asian clinical experiences of carcinoid tumors that originated in the upper gastrointestinal tract.

METHODS

From May 1987 to June 2002, we had found only 13 cases of histologically confirmed carcinoid tumors in the upper gastrointestinal tract by endoscopic examinations. There were eight males and five females. The mean age was 53.16+/-20.51 years that ranged from 26 to 82 years. Each of their clinical presentations, locations, tumor morphology, and size and the treatment outcome were analyzed and discussed.

RESULTS

One patient had a polypoid lesion at the lower esophagus, nine were stomach lesions and three located at the duodenum. All patients with polypoid and submucosal tumor types were of small size (<1.7 cm) and all patients survived after simple excision or polypectomy. Four of the five patients in tumor mass forms died and the tumors were more than 2.0 cm in size.

CONCLUSION

Carcinoid tumors rarely originated from the upper gastrointestinal tract and are usually found accidentally after endoscopic study. Bigger size (more than 2 cm) tumor masses may indicate a more severe disease and poor prognosis.

Small bowel tumors

Primary tumors of the small bowel are rare, and their clinical presentation is nonspecific. Consequently, preoperative diagnosis remains the exception rather than the rule. Although the small intestine makes up 75% of the length and 90% of the surface area of the gastrointestinal tract, small bowel tumors make up approximately 3% of all malignant gastrointestinal neoplasms. Primary neoplasms of the small intestine are notorious for their insidious presentation and vague symptoms, including abdominal pain, anorexia, and weight loss. These nonspecific symptoms, coupled with the lack of physical findings, often cause a significant delay in reaching a diagnosis. Because the small bowel has been a relatively inaccessible area to standard endoscopic techniques, contrast radiography has been regarded historically as the gold standard diagnostic modality. The management of primary malignant small bowel tumors is invariably surgical. However, adjuvant chemotherapy and radiotherapy may be warranted, depending on the type of tumor.

Occupational risk factors for small bowel carcinoid tumor: a European population-based case-control study

Small bowel carcinoid tumor (SBC) is a rare disease of unknown etiology but with an age-, sex-, and place-specific occurrence that may indicate an occupational origin. A European multicenter population-based case-control study was conducted from 1995 through 1997. Incident SBC cases between 35 and 69 years of age (n = 101) were identified, together with 3335 controls sampled from the catchment area of the cases. Histological review performed by a reference pathologist left 99 cases for study; 84 cases and 2070 population controls were interviewed. The industries most closely associated (a twofold or more odds ratio [OR]) with SBC, taking into account a 10-year time lag after exposure were, among women, employment in wholesale industry of food and beverages (OR, 8.2; 95% confidence interval [CI], 1.9 to 34.9]) and among men, manufacture of motor vehicle bodies (OR, 5.2; 95% CI, 1.2 to 22.4), footwear (OR, 3.9; 95% CI, 0.9 to 16.1), and metal structures (OR, 3.3; 95% CI, 1.0 to 10.4). The identified high-risk occupations with an OR above 2 were shoemakers, structural metal preparers, construction painters and other construction workers, bookkeepers, machine fitters, and welders (men). The OR for regular occupational use of organic solvents for at least half a year was 2.0 (95% CI, 1.0 to 4.2). Exposure to rust-preventive paint containing lead was suggested as another potential occupational exposure (OR, 9.1; 95% CI, 0.8 to 107). This explorative study suggests an association between certain occupational exposures and SBC, but some of these associations could be attributable to chance. All findings should be regarded as tentative.

Sonographic appearance of primary small bowel carcinoid tumor

BACKGROUND

To assess the value of sonography in the diagnostic work-up of small bowel carcinoid tumors and characterize their sonographic appearance.

METHODS

We retrospectively reviewed the sonographic findings (size, shape, echogenicity, contour, location, wall thickening, serosal transgression, vascularity) of all cases of carcinoid tumors investigated between January 1988 and January 1993. Six tumors, in five patients with histologic proof, were analyzed and, when possible, correlation with pathological or surgical results was made.

RESULTS

In four out of five cases, the tumor was not suspected clinically prior to sonography; in one case, a small synchronous lesion was only found at surgery. Its sonographic appearance was a hypoechoic, homogenous, predominantly intraluminal mass with smooth intraluminal contour and attached to the wall by a broad base with interruption of the submucosa and thickening of the muscularis propria in all cases. There were signs of serosal transgression in four cases, puckering and retraction in two cases, hypervascularity in two cases, and mesenteric involvement in three cases. All lesions were located in the ileum and the mean diameter was 22 x 17 mm.

CONCLUSION

Ultrasonography was useful in the detection of primary carcinoid tumors of small bowel. Their sonographic characteristics were described and some of them were highly suggestive of the diagnosis.

Malignant tumours of the small bowel

Early diagnosis of small intestinal cancers provides the best probability of cure. The astute clinician will include these tumours in the differential diagnosis when vague or non-specific abdominal complaints occur and a more common cause is not discovered. Failure to evaluate the small bowel, which is a blind spot to routine endoscopic and radiological diagnostic tests, constitutes a common error when confronted with occult gastrointestinal blood loss and normal upper and lower gastrointestinal examination. Surgical resection remains the cornerstone of therapy for these malignancies. Advances in effective chemotherapy for large bowel carcinoma may have an impact on the management of small intestinal adenocarcinomas. Substantial palliation can be offered to the patient with metastatic carcinoid tumour, but the long-term outlook for these patients remains poor. Early stage lymphomas of the intestine are readily treated by combined modality therapy while advanced stage disease remains resistant to curative management. The patient prognosis for a small bowel sarcoma is largely dependent on the tumour grade. A high index of suspicion to improve tumour detection and better treatments of tumours with the same histology at other anatomic sites should enhance the management and outcome of patients with small intestinal malignancies.

Carcinoid tumours in Auckland, New Zealand

Carcinoid tumours in Auckland diagnosed during 1976-87 have been reviewed retrospectively. Eighty-three patients with carcinoid tumours were seen during this time (56 appendiceal, 11 small bowel, two colorectal, 10 pulmonary and four other). Three patients had carcinoid syndrome. The most common presentation for appendiceal carcinoid was acute appendicitis. The most common presentations for pulmonary lesions were incidental findings on chest X-ray, recurrent chest infection or haemoptysis, while bowel lesions presented with abdominal pain or rectal bleeding. Following resection, 53 of 56 appendiceal patients were alive and well (two died from other causes) and 10 of 10 pulmonary carcinoids were alive and well. In contrast, both patients with colorectal carcinoid died from their disease within 1 year, and, of the patients with small bowel carcinoid, one died of the disease and more than half of the remainder are alive with metastatic spread and symptoms at the time of study. The most important prognostic variables governing outcome were anatomical site of the primary lesion and the state of the histological margins following resection.

Smooth muscle tumours of the upper gastrointestinal tract

Forty-six patients with smooth muscle tumours of the stomach and small intestine were treated surgically at the Princess Alexandra Hospital between 1970 and 1986. Leiomyomas were three times more common than leiomyosarcomas, but malignant tumours occurred more frequently in the small intestine than in the stomach. Gastric tumours tended to present with gastrointestinal bleeding, in contrast to intestinal lesions which presented predominantly with abdominal pain. Although leiomyomas tend to be smaller at operation than leiomyosarcomas, the size of a smooth muscle tumour is not reliable in discriminating between benign and malignant lesions. Therefore all smooth muscle tumours of the upper gastrointestinal tract should be excised as widely as possible, including local lymphatics in the dissection where practicable, so as to maximize the likelihood of radical extirpation of malignant lesions. Approximately one-third of patients with leiomyosarcomas have metastases at the time of surgery; the 5 year survival rate after surgical treatment of leiomyosarcomas of the upper gastrointestinal tract is less than 50%.