Microcarcinoidosis of the Stomach 순천향대학교병원 진소영

Case History 65/M C.C. : Recurrent gastric polyps D : 1 year PHx ROS EMR : Gastric carcinoids, 1 month ago DM for 10 years ROS Diarrhea(-), Flushing (-)

GFS Previous EMR defects and multiple tiny polyps throughout the body

Lab. Findings Hb/Hct 13.5/39.6 WBC/Platelet 7,500/279,000 Glucose 183(70-110) SGOT/SGPT 39(0-37)/45(0-41) Amylase/lipase 133.5(0-100)/15.3 CEA/CA19-9 2.73/0.83 24hrs urine HIAA 2.7mg/day(1.6-6) Serotonin 38.2 ng/mL(1.8-7.5)

High body, LC : EMR Mid body, GC : EMR Other sites : Hot biopsy x 3 외부병원 조직검사 High body, LC : EMR Mid body, GC : EMR Other sites : Hot biopsy x 3

High Body

Mid body

Hot Biopsy

제1차 EISD Upper Body

Residual Carcinoid in M & SM

Microcarcinoid

Micronodular Hyperplasia

Histochemistry Grimelius

제2차 EISD Midbody

Residual Carcinoid in M

Residual Carcinoid in M & SM

Adenomatoid Hyperplasia

Micronodular Hyperplasia

Upper Body Midbody Residual carcinoid Micronodular hyperplasia, diffuse, intramucosal Adenomatoid Hyperplasia to Microcarcinoid, 200-1200 µm

Hyperplastic Changes of Gastric Endocrine Cells Simple or Diffuse hyperplasia > x2 of control <5 cells aggregates ZES or hypergastrinemia Linear hyperplasia Linear 5+ cells lying inside of BM of gastric gland ZES or pernicious anemia Micronodular hyperplasia Clusters of 5+ cells Mean : 50 µm in diameter, less than <150 µm One cluster/mm of mucosa Autoimmune gastritis of the corpus-fundus (type A CAG) Adenomatoid hyperplasia Collection of 5+ micronodules with intact BM

Dysplastic Growths of Gastric Endocrine Cells 150-500 µm in diameter Escape endoscopic observation Always intramucosal Histologic patterns Enlarged micronodules Adenomatous micronodules : >5 micronodules, intact BM Fused micronodules : BM loss Microinfiltrative lesions Nodules with newly formed stroma

Argyrophil ECL-Cell Carcinoids 3 Clinical Subtypes Type 1 : diffuse chronic atrophic gastritis of autoimmune or A type (A-CAG) Type 2 : hypertrophic gastropathy with MEN type 1-ZES Type 3 : Sporadic, without specific gastric pathology

Clinical Behaviors of Sporadic ECL Tumors Rarely multiple No hypergastrinemia No gastrin-dependent ECL-cell hyperplasia High risk for low grade malignancy Frequent deep wall invasion Definite metastatic potential

Criteria of Malignant Potential Tumor size > 1cm Wall invasion : beyond the SM Structural atypia : solid, central necrosis Cellular atypia >2/10HPF Ki-67 (+) cells : >50/10HPF or >2% Angioinvasion, Perineural invasion Loss of granular markers P53 overexpression

Management of Microcarcinoidosis Total gastrectomy ? Regular follow up endoscopy + Polypectomy of visible polyps ?