42 years-old female very slim ( BMI = 18 kgs-m2) patient with recurrent carcinoid gastric type 1 into fundus-body about 1,5 cm previously resected by means eco-endoscopy. She presented recurrence after 4 months after full endoscopic resection. The lesion is moderate grade lesion - expression of Ki-67 = 10 %. Octreoscan is negative to distance spreading. What is the best approach to this case? New endoscopic approach? Subtotal distal or total laparoscopic gastrectomy? If total gastrectomy is choosen , Is whorthwilhe an esophago-jejunal anastomosis with interposed jejunal-pouch to decrease lost of weight?
We should remind that level of seric gastrin is very high about 1200 ng-ml n this patient.
Dear Dr Sergio
First of all, patient should perform octrotide scan for distant metastasis
Best
According NCCN :
If scan is negative:
Annual endoscopic surveillance and endoscopic resection of prominent tumors is recommended for patients with locoregional type 1 gastric neuroendocrine tumors. Antrectomy can be considered if gastric tumors are increasing significantly in size or number. For locoregional type 2 gastric neuroendocrine tumors, the primary gastrinoma should, in general, be resected. If the primary tumor is not resected, endoscopic surveillance and endoscopic resection of prominent gastric carcinoid tumors should be considered and/or octreotide or lanreotide can be given. Patients with nonmetastatic gastric neuroendocrine tumors and normal gastrin levels (type 3) often have more aggressive tumors and are usually treated with radical resection of the tumor with regional lymphadenectomy. For early stage, smaller tumors, endoscopic or wedge resection can be considered if there is no evidence of lymphadenopathy on EUS.58 Endoscopic resection should be reserved for small (
Look there was very early recurrence. This patient is young and high levels of gastin will remain everytime. So new carcinoid tumors will always return.
There is little biologic funtional - anatomic difference between antrectomy and distal subtotal gastrectomy. It matters is remove antrum, like this i have personally prefered subtotal gastrectomy over antrectomy because i am sure that antrum is always resected. When we resected all antrum, the seric levels of gastrin decreases too much. So, we shall avoid as new carcinoid recurrences as new carcinoid lesions ("de-novo"). This patient is young, then she will present long life expectance. She may choose a more agressive treatment instead repeated endoscopic resection. New resections by means eco-endoscopy may occur many times on your life.
In my opinion: endoscopic or wedge resection if there is no evidence of lymphadenopathy on EUS.
There is no lymphonodal dissemination by EUS. Anyway, as new endoscopic resection as wedge resection will keep no modifying seric levels of gastrin which will remain high. Consequently it will stimulate neuro-endocrine cells in body+fundus with new development of neuro-endocrine tumors. I had other recurrent cases wihich they attained the cure by means total gastrectomy with inclusion of lesion. I am little afraid with antrectomy or similar approach (subtotal distal gastrectomy) mainly when the lesion will stay on gastric remanent. I know that there are some papers which advise this approach, but i havent trust well because are small series of cases. This disease is rare, but it presents good prognosis even the cure with radical resection
This patient withj high gastrin levels even without anti acid medication may have atrophic gastritis as the ethiology of gastric carcinois The treatment in this case is a partial gastrectomy with removal of gastrin producing region
We know Prof Marcel she presents pernicious anemia with atrophic gastritis. Her problem is that we will remove antrum but the recurrent lesion with 1,5 cm with moderate grade carcinoid will remain into body-fundus. Our fear (as patient as me) is that this lesion will not disappear consequently distant metastasis could arise.
Since it is a recurrent disease in a 42 yr old, following Endoscopic resection ,situated at the fundus and body without any metastatic disease,Please go ahead with Total Gastrectomy.Creating a pouch is not going to make mush difference in my experience.Nutrional plan can be done after recovery.
I think is enough and clear indication to perform a local excision of the tumor by laparoscopy
several reports established that in patient with high gastrin level due to atrophic gastric and with carcinoid tumors in the body of the organ carcinoid tumors will deasapear after antral resection These are type 1 gastric carcinoid T ype 2 is secondary to pancreatic tumor as in Zollinger Ellis syndrom if gastrin level is in normal ranges then the gastric carcinoid is type 3 is a malignant lesion can have metastasis will not deasapear and total gastrectomy is the best treatment
YES, IT IS WELL STABLISHED. HOWEVER, THIS CASE IN PARTICULAR PRESENTED A VERY EARLY RECURRENCE AND WE SEE THAT IT IS RECURRED WITH MODERATE GRADE - KI-67 = 10 %. THIS PROGNOSIS SEEMS WORSE THAN A SIMPLE CASE OF CARCINOID GASTRIC THAT WE HAVE SEEN ALMOST CASES. NOWADAYS, I ALREADY TREATED ELEVEN CASES OF GASTRIC CARCINOID TYPE 1 ALMOST RECCUR WHEN ENDOSCOPIC TREATMENT IS CHOOSEN BUT ALMOST IS VERY INDOLENT. IN FIVE CASES, THE PATIENTS CHOSE PARTIAL GASTRECTOMY, ALL OF THEM HAVE PRESENTED WITHOUT ANY RECURRENCE. IN OTHER TWO CASES THAT PRESENTED as HIGH BODY as fundus lesions lesions and comprised -very narrow MARGINS AFTER ECO-ENDOSCOPIC TREATMENT , WE PREFERRED TO COMPLET TOTAL GASTRECTOMY , ALL OF THEM ARE ALIVE. WE HAVE DONE JEJUNAL POUCH MAINLY IN VERY SLIM WOMEN WITH GOOD WEIGHT RECOVERY.
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