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CC BY-NC-ND 4.0 · Journal of Digestive Endoscopy 2016; 07(01): 024-026
DOI: 10.4103/0976-5042.180096
Case Report

Small neuroendocrine tumor of the duodenal bulb: Endoscopic submucosal dissection, laparoscopic and endoscopic cooperative surgery or surgery?

Nikolaos V. Chrysanthos
1   Department of Gastrointestinal, St. George General Hospital of Chania, Crete,
,
Evagelia Anagnostopoulou
1   Department of Gastrointestinal, St. George General Hospital of Chania, Crete,
,
Eleni Triga
2   Department of Anatomopathogical, Athens Medical School, Athens, Greece
,
Stratigoula Sakelariou
2   Department of Anatomopathogical, Athens Medical School, Athens, Greece
,
Pinelopi Korkolopoulou
2   Department of Anatomopathogical, Athens Medical School, Athens, Greece
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Abstract

Neuroendocrine neoplasms of the gastric tube are less common than adenocarcinomas. Topography includes stomach, small intestine, Vater ampulla, and gross intestine. They are graded as neuroendocrine tumors grade I and II (NETs GI and GII) and neuroendocrine carcinomas GIII based on Ki-67 index and mitotic count.[[1]] Endoscopic treatment for GI NETs ≤1 cm that does not extend beyond the submucosal layer and does not demonstrate lymph node metastasis is recommended. Tumors ≥2 cm, with lymph node metastasis, are indicated for surgical treatment. The treatment strategy for tumors between 10 and 20 mm in size remains controversial.[[2]] We present a rare case of a 60-year-old male patient with end-stage renal failure who underwent a screening pretransplantation endoscopic control. Colonoscopy had no pathological findings. Gastroscopy reveals an abnormal mucosa in the anterior upper part of the duodenal bulb that was described as a micronodular mucosa and a central nodule of 6 mm with erythematous mucosa. Histology of the micronodular mucosa reveals a heterotopic gastric mucosa and a small hyperplastic polyp. Biopsies from the nodule reveal a carcinoid tumor (NET GI). Immunohistochemistry: Positive chromogranin levels, low mitotic index (1/10 HPF), and Ki-67 index <1% [Figure 2]. Gastrin levels were normal and chromogranin levels were abnormal (314 ng/ml, ULN <120 ng/ml). Spiral tomography of the thorax and the abdomen were normal. Endoscopic submucosal dissection is indicated for small NETs (≤1 cm). Laparoscopic and endoscopic cooperative surgery is a novel method, but the experience is limited. Surgery is the best choice for large NETs (>2 cm) and those of the duodenal bulb with histological extensions and the lack of assessing depth invasion.

Key words

Endoscopic submucosal dissection - laparoscopic and endoscopic cooperative surgery - neuroendocrine tumors - surgery


Publication History

Publication Date:
26 September 2019 (online)

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  • References

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  • 2 Klöppel G, Couvelard A, Perren A, Komminoth P, McNicol AM, Nilsson O, et al. ENETS Consensus Guidelines for the Standards of Care in Neuroendocrine Tumors: Towards a standardized approach to the diagnosis of gastroenteropancreatic neuroendocrine tumors and their prognostic stratification. Neuroendocrinology 2009;90:162-6.
  • 3 Hiki N, Nunobe S, Matsuda T, Hirasawa T, Yamamoto Y, Yamaguchi T. Laparoscopic endoscopic cooperative surgery. Dig Endosc 2015;27:197-204.