A new method of endoscopic mucosal resection of neoplastic lesions in the stomach: its technical features and results

BACKGROUND/AIMS: In gastric cancer, endoscopic treatment can be expected to provide an absolute cure only if the lesion is mucosal and not accompanied by metastatic lymph nodes. To further evaluate such possibly curable lesions, we retrospectively reviewed 208 cases of early gastric cancer surgically resected over the past 20 years. METHODOLOGY: Our new method of endoscopic mucosal resection using a cap-fitted panendoscope, which is called EMRC, has been employed in the treatment of 73 gastric neoplastic lesions. RESULTS: It was found that curable lesions would, as the primary condition, be histologically well-differentiated carcinomas and measure 2 cm or less of the elevated type and less than 1 cm of the depressed type. The lesions were consequently identified as 49 early cancers (46 mucosal, 3 submucosal), 23 adenomas and 1 carcinoid. Although resection was completed in a single session of EMRC treatment in all cases, approximately 40% of them required fractionated resection, leaving an ulcer measuring 3 cm or more in approximately 30%. Bleeding or muscle resection occurred in 7 patients, in whom conservative treatment was effective. No recurrence has been found in any of the 73 lesions, demonstrating a favorable outcome. CONCLUSIONS: This method is advantageous in that it is simple and relatively easily applied at almost any location within the stomach. In addition, the size of the specimen obtained by en bloc resection is approximately 2 cm. The method is thus fairly likely to come into widespread use.     

Laparoscopic resection of gastric leiomyoblastoma

Smooth muscle gastric tumors represent 2% of resected neoplasms of the stomach. Clinically, they are often silent and incidentally found at endoscopy or radiologic examination. These tumors can be histologically classified as benign (leiomyoma) or malignant (leiomyoblastoma), but clinical behavior is not strictly related to this classification. When symptomatic, they are present with anemia in 50% of cases due to mucosal ulceration. Surgical removal of the tumor is the accepted therapy, leaving a margin of surrounding free tissue: this treatment can be performed by laparoscopy, usefully associated with gastroscopy. We present one case of a patient with severe anemia due to bleeding from an ulcerated leiomyoblastoma 5 cm in diameter that we resected with combined gastroscopic-laparoscopic technique. We isolated the portion of gastric wall where the mass was located and resected the specimen under gastroscopic control. The postoperative period was uneventful, and the patient recovered promptly with minimal pain and discomfort.     

Multimodality treatment for gastric carcinoid tumor with liver metastases

Carcinoid tumors are the most common neuroendocrine tumors in the gastrointestinal tract, and between 10% and 30% of these tumors are gastric in origin. Three types of gastric carcinoid tumors are recognized: type I, associated with chronic atrophic gastritis type A; type II, associated with multiple endocrine neoplasia; and type III, sporadic and the most malignant. We present a patient with an aggressive, sporadic-type gastric carcinoid that metastasized to the liver. Her symptomatic treatment included the somatostatin analog octreotide. Octreotide scintigraphy demonstrated that this tumor avidly bound the peptide. The patient's gastric carcinoid (assessed by endoscopy and endoscopic ultrasound) regressed and she underwent hepatic artery embolization for her liver metastases. After initial partial CT resolution the tumor grew, compressing the inferior vena cava. The patient underwent orthotopic liver transplant with excellent recovery, although she was subsequently found to have two small lung metastases. She has responded well to adjuvant Indium-111 octreotide receptor targeted therapy. This case highlights the therapeutic options for metastatic neuroendocrine tumors, including liver transplantation and adjuvant receptor targeted therapy.     

Gastrin and gastrin receptor

Gastrin is a well known endogenous stimulator of gastric acid. In addition, recent studies have revealed that gastrin has a growth promoting effect on gastric ECL cells. Indeed, development of ECL carcinoid tumor occurs almost exclusively in patients with hypergastrinemia such as autoimmune gastritis and Zollinger-Ellison syndrome with MEN type I. We have recently cloned human gastrin receptor gene, and by using it, we found that both gastric carcinoid tumor and endocrine cell carcinoma of the stomach express significant amount of gastrin receptor gene whereas none of gastric cancer tissue shows gastrin receptor gene expression. Thus, it is clear that gastrin plays important roles in the development of gastric carcinoid tumor as well as endocrine cell carcinoma of the stomach.     

Carcinoid tumor metastatic to the breast

Breast metastases from nonmammary malignant neoplasms are uncommon, accounting for approximately 2% of breast tumors. There are 13 cases reported in the literature of carcinoid tumor metastatic to the breast, and more than half of these cases were misdiagnosed pathologically and treated as primary breast carcinoma, even in cases with a medical record of carcinoid tumor. We describe a patient with a history of asthma and diarrhea who presented to the University of Arkansas for Medical Sciences, Little Rock, with an exacerbation of the asthma. The results of routine physical examination revealed a mass in the left breast. A diagnosis of carcinoid tumor metastatic to the breast was made after a partial mastectomy was performed. The differential diagnosis between primary carcinoid tumor of the breast and carcinoid tumor metastatic to the breast is often controversial in surgical pathology. Diagnoses need to be made correlating clinical and histological examination in difficult cases in which there is not a diagnosis of carcinoid tumor elsewhere. Accurate diagnosis of breast metastases is important to avoid unnecessary treatment.     

Bleeding in portal hypertensive gastropathy evaluated in terms of gastric mucosal microcirculation and coagulation-fibrinolysis system

Gastric intramucosal bleeding in portal hypertensive gastropathy was investigated in terms of gastric mucosal microcirculation, coagulation-fibrinolysis factors, and local fibrinolysis in patients with liver cirrhosis. The gastric mucosa was examined by endoscopy, and the patients were classified into two groups with or without bleeding. Gastric mucosal blood flow was measured simultaneously with coagulation-fibrinolysis factors or local fibrinolysis in both groups. As gastric mucosal blood flow, the gastric mucosal blood volume (IHb) and the oxygenated hemoglobin concentration (ISO2) were determined by the organ reflection spectrum method. Coagulation-fibrinolysis factors were measured in the blood. For evaluation of local fibrinolysis, gastric biopsy specimens were placed on a standard fibrin plate, and the fibrinolysis area was measured. Compared with the non-bleeding group, the bleeding group showed increased IHb and decreased ISO2 (p < 0.05), suggesting marked congestion of blood flow. Gastric intramucosal bleeding was frequently observed in patients with marked congestion of blood flow and markedly abnormal values of coagulation-fibrinolysis factors. Gastric local fibrinolysis was also significantly enhanced in the bleeding group (p < 0.05). In addition, local fibrinolysis was correlated positively with the gastric mucosal blood volume (r = 0.68, p < 0.05) and negatively with the oxygenated hemoglobin concentration (r = -0.58, p < 0.05). These results suggest the following mechanism of gastric mucosal bleeding in liver cirrhosis and portal hypertension. Congestion of gastric mucosal blood flow is present in liver cirrhosis and portal hypertension. An increase in the microvascular pressure and hypoxia cause release of tissue plasminogen activators from gastric mucosal cells and vascular endothelial cells. As a result, gastric local fibrinolysis is enhanced, causing gastric mucosal bleeding.     

Clinical and endoscopic evaluation of gastroduodenal haemorrhage

Endoscopic evaluation of 100 consecutive cases of haematemesis and melaena attending the emergency ward of NRS Medical College, Calcutta 700014 showed that in 2/3rd of all the patients acid peptic disease was the cause of bleeding, out of which 60% was due to duodenal ulcer and 40% was due to gastric ulcer. Five per cent of all the cases were having portal hypertension where the cause of bleeding was oesophageal varices. Gastric malignancy was responsible for bleeding in 3% cases. In about 6% cases bleeding was due to acute gastric erosion caused by NSAID, steroid and other corrosive agents. In 20% patients no apparent cause for upper gastro-intestinal haemorrhage could be detected endoscopically.     

Evaluation of treatment for the prevention of acute gastric lesions in stress, in rats

Since portal hypertension affects the gastric mucosa, leading to congestive gastropathy and thus to increased incidence of bleeding, it is one of the possible causes of increased permeability of gastric mucosal capillaries. The aim of this study was the quantitative assessment of the permeability of the gastric mucosal endothelial cells. Eight CCl4-induced cirrhotic rats and eight matched controls were subjected to i.v. injection of FITC-albumin, and a morphometric evaluation of fluorescence in serial histological sections of the gastric mucosa was performed by a video image analysis system. Fluorescence was found to be 0.351 +/- 0.01% of the area scanned in experimental animals versus 0.073 +/- 0.005% in controls, i.e. it was significantly increased by the treatment, which implies a significant endothelial leakage into the extravascular space.     

A cytogenetic deletion, del(17)(q11.22q21.1), in a patient with sporadic neurofibromatosis type 1 (NF1) associated with dysmorphism and developmental delay

Pure primary ovarian carcinoid tumors are uncommon and only 21 cases have been recorded in the literature. In the past 15 years, we have seen two cases. One was a strumal carcinoid and the other, the case presented here, was a primary ovarian carcinoid tumor arising from the left ovary of a 25-year-old woman who had no carcinoid syndrome. The tumor was made up of pure carcinoid tumor without other teratomatous elements. On light microscopy the neoplasm, composed of uniform tumor cells, was arranged in solid nests or a trabecular pattern. The differential diagnosis included granulosa cell tumor. However, the strongly argyrophilic, chromogranin staining and ultrastructural presence of neurosecretory granules confirmed the diagnosis of primary ovarian carcinoid tumor. After a careful survey of the contralateral ovary and the gastrointestinal tract, the patient underwent a left oophorectomy. Her postoperative course was uneventful. The literature and the pathologic findings are reviewed and discussed, along with the differential diagnosis and treatment of primary ovarian carcinoid tumor.     

Effects of intravenous lansoprazole on acute gastric mucosal lesions and acid secretion

The effects of lansoprazole given intravenously on gastric mucosal lesions, gastric bleeding and acid secretion were investigated in rats in comparison with those of omeprazole, famotidine and ranitidine. Lansoprazole inhibited the formation of gastric mucosal lesions in rats induced by water-immersion stress or aspirin with ID50 values of 0.26 and 0.99 mg/kg, respectively, and also inhibited gastric bleeding induced by hemorrhagic shock or water-immersion stress with ID50 values of 0.46 and 1.22 mg/kg, respectively. Lansoprazole was more potent than omeprazole, famotidine and ranitidine in inhibiting gastric mucosal lesions and hemorrhagic shock- or stress-induced bleeding. Famotidine and ranitidine showed negligible inhibition of water-immersion stress-induced gastric bleeding. Lansoprazole strongly inhibited water-immersion stress-stimulated acid secretion in rats, whereas famotidine and ranitidine did not show a potent inhibitory effect. These results indicate that lansoprazole exerts prominent inhibitory actions against the formation of gastric mucosal lesions and gastric bleeding by inhibiting acid secretion, and they show that it is superior to histamine H2-receptor antagonists in inhibiting stress-induced gastric bleeding.     

Gastric re-resection in emergency

BACKGROUND/AIMS: We reviewed a consecutive series of patients with acute complications following gastric resection, in order to evaluate the role of gastric re-resection as the operation of choice in emergency. METHODOLOGY: Records of 90 patients with acute complications following gastric resection observed from January 1991 to January 1996 were retrospectively analyzed. RESULTS: Hemorrhagic events occurred in the vast majority of cases (87), either as acute complications after a long time since surgery (78 cases) or as early postoperative complications (9). Among late acute complications, three cases were related to bleeding cancer of the gastric stump. Anastomotic obstructions presenting as acute complications occurred in 3 cases. Emergency surgery was indicated in three cases of acute obstruction, in 1 case of bleeding cancer of the gastric stump, in 9 (12%) out of the 75 remaining late acute hemorrhagic complications and in 1 (11%) out of 9 early hemorrhagic complications. Completion gastrectomy was chosen in the one case of bleeding cancer of the gastric stump with indication for emergency surgery. Gastric re-resection was performed in 11 cases: 9 for hemorrhagic complications and 2 for obstructive acute complications. In two cases, one for hemorrhage and one for occlusion, other surgical procedures were carried out. CONCLUSIONS: Gastric re-resection can represent the most suitable operation in acute complications following gastric resection.     

Subacute orbital abscess in a four-year-old girl with a new kitten

BACKGROUND: Carcinoid tumors are neoplasms of neuroendocrine origin that rarely affect the genital tract. CASE: A 75-year-old woman underwent hysterectomy and bilateral adnexectomy due to vaginal bleeding and uterine pathology (leiomyoma, cervical low grade squamous intraepithelial lesions and endometrial hyperplasia on ultrasound). Pathologic examination of the specimen disclosed a uterine corpus carcinoid tumor. The patient had been taking tamoxifen for adjuvant treatment of breast cancer diagnosed and treated seven years before. CONCLUSION: A review of the literature revealed one case of carcinoid tumor of the uterine wall. There does not appear to be any relationship between tamoxifen and the carcinoid tumors reported.     

Portal-hypertensive gastropathy

In the present article we describe updated information concerning the clinical feature of portal-hypertensive gastropathy (PHG), which is characterized by mucosal and submucosal vascular dilatation without inflammation. Although this lesion represents non-variceal bleeding, there is a wide variation of its prevalence. Portal pressure and some humoral factors may play important roles in its pathogenesis. Gastric acid secretory activity is reduced, whereas the gastric mucosal barrier is impaired. With regard to gastric mucosal haemodynamics, whether 'overflow' (i.e. active congestion) or 'stasis' (i.e. passive congestion) cause gastric mucosal hyperaemia is not known. A severe lesion is a potential source of bleeding, while mild lesions are of little clinical significance and endoscopic variceal obliteration aggravates PHG in some patients. In the treatment of PHG, pharmacological (e.g. propranolol), surgical (e.g. portosystemic shunt) and radiological (e.g. transjugular intrahepatic portosystemic shunt) procedures may be useful in preventing bleeding from PHG.     

Severe metabolic alkalosis

In the rat, hypergastrinaemia induced by drug treatment with omeprazole or potent H2-receptor antagonists leads to the development of gastric enterochromaffin-like cell carcinoids. In man, gastric carcinoids induced by hypergastrinaemia have been described only in patients with chronic atrophic gastritis type A and in patients with the multiple endocrine neoplasia syndrome type 1. This patient with Zollinger-Ellison syndrome without gastric mucosal atrophy and without evidence of the multiple endocrine neoplasia syndrome developed an argyrophil gastric carcinoid tumour. This observation indicates that hypergastrinaemia in the sporadic Zollinger-Ellison-syndrome may induce gastric carcinoids.     

Horseshoe kidney is associated with an increased relative risk of primary renal carcinoid tumor

PURPOSE: Carcinoid tumor is a rare neoplasm of the kidney with an unknown histogenesis. Of only 31 cases previously reported in the literature 4 arose within horseshoe kidneys. We report a case of primary carcinoid tumor arising within a horseshoe kidney and discuss the unique insight it provided into the pathogenesis of this tumor. MATERIALS AND METHODS: We reviewed in detail all 31 reported cases of renal carcinoid tumor and, using reported incidence rates of horseshoe kidney, we calculated the relative risk of renal carcinoid tumor arising within a horseshoe kidney. Immunohistochemical staining for neuroendocrine related markers was performed on tissue sections from the present carcinoid tumor, the adjacent kidney and 5 control samples of normal renal parenchyma. RESULTS: Of the reported tumors 15.6% occurred in horseshoe kidneys, yielding a calculated relative risk of 62. The present tumor was multifocal, arising from the wall of a cystic lesion and possibly representing a dilated calix within the isthmus. Intestinal epithelium lining the cyst cavity exhibited multifocal neuroendocrine cell hyperplasia with an immunohistochemical profile identical to that of the carcinoid tumor cells. CONCLUSIONS: The relative risk of renal carcinoid tumor developing in a horseshoe kidney is markedly greater than that for Wilms tumor or transitional cell carcinoma. The clinical course of renal carcinoid tumor arising within a horseshoe kidney appears to be more benign than that of the nonhorseshoe variant. Our observations support the hypothesis that renal carcinoid tumors may arise from neuroendocrine cells within foci of metaplastic or teratomatous epithelium within the kidney.     

Effects of ondansetron on gastrointestinal symptoms in carcinoid syndrome

The effect of short-term treatment with the highly selective serotonin receptor antagonist ondansetron on symptoms and gastric emptying in 11 carcinoid patients was studied. Diarrhoea improved in 6 of 6 patients, nausea in 3 of 4 patients. Flushing was not affected. The rate of gastric emptying increased during ondansetron treatment (P = 0.08). No changes in serotonin in platelets and urinary excretion of 5-hydroxyindoleacetic acid were found. It is concluded that ondansetron can improve gastrointestinal symptoms in carcinoid patients and possibly slows gastric emptying.     

Chronic nicotine intake causes vascular dysregulation in the rat gastric mucosa

Chronic cigarette smoking has adverse effects on peptic ulcer disease because the healing of ulcers is delayed and the incidence of relapses is enhanced. Short term intake of nicotine induces vascular damage in the rat gastric mucosa, but the pathophysiological mechanisms of nicotine's action in the stomach are largely unknown. In this study rats were treated with nicotine, added to their drinking water, for 50 days. They were then anaesthetised and their stomachs perfused with acidified acetylsalicylic acid (ASA). Chronic nicotine treatment failed to change the effects of acidified ASA to induce gastric mucosal acid back diffusion, haemorrhagic damage and bleeding. Basal blood flow in the gastric mucosa was also unchanged by chronic nicotine intake, whereas the mucosal hyperaemia evoked by ASA induced acid back diffusion was averted. The concentrations of sulfidoleukotrienes were significantly augmented in the gastric wall of nicotine treated rats. These data show that chronic nicotine intake causes dysregulation of the gastric microcirculation, an effect that is associated with biochemical changes in the stomach. This study thus substantiates the adverse effects of smoking on gastric mucosal pathophysiology. These data suggest that inappropriate regulation of gastric mucosal blood flow inhibits recovery from gastric mucosal injury in smokers.     

Carcinoid tumor of the thymus with divergent sarcomatoid differentiation: report of a case with histogenetic consideration

An anterior mediastinal tumor resected from a 54-year-old man without paraneoplastic symptoms was found to be an unusual biphasic thymic tumor composed of carcinoid tumor in sarcomatous stroma characterized by fibrosarcoma-like spindle cells with areas of chondroid and osseous differentiation. Immunohistochemical and ultrastructural studies verified that the tumor described was a carcinoid tumor with divergent sarcomatoid differentiation rather than a mixed carcinoid tumor and sarcoma. The chondroid and osseous differentiations observed were unique features. This tumor is rare and provides an opportunity for understanding tumors with divergent components. The sarcomatoid transformation of thymic carcinoid tumor might denote highly malignant clinical behavior as illustrated by this case.     

Postembolic colonic infarction

From a total of 23 cases from five hospitals, acute colonic mucosal necrosis developed in three patients following transcatheter embolotherapy for colonic hemorrhage. Although embolic therapy for lower gastrointestinal bleeding is associated with appreciable risk, these risks are less than those of emergency operation for hemorrhage. The alternative transcatheter therapeutic modality, vasopressin infusion, is often associated with continued or recurrent hemorrhage, is relatively contraindicated in patients with coronary disease, and produces numerous complications. Transcatheter embolotherapy is recommended for patients with colonic bleeding who have a contraindication to vasopressin administration, who are refractory to vasopressin, or who rebleed following treatment with vasopressin.     

Adverse reactions associated with autologous blood transfusion: evaluation and incidence at a large academic hospital

Malignant fibrous histiocytoma (MFH) in the stomach is very rare, and only four cases have been reported. As a result, there is still little understanding of its clinical and pathological features. We recently experienced two cases of gastric MFH. The first case was a 78-year-old man with epigastralgia and a loss of body weight. Endoscopy revealed an ulcerated submucosal tumor. A gastrectomy was performed and the diagnosis of MFH was made histopathologically. The second case was a 77-year-old man with pulmonary symptoms. An image diagnosis indicated a strong suspicion of lung cancer, and a right middle and lower lobectomy was thus performed. One month after the operation, a bleeding gastric tumor was found and therefore a gastrectomy was performed. Both tumors were diagnosed as MFH. From the analysis of six reported cases including ours, a preoperative correct diagnosis is found to be difficult although the lesion has grown to a considerable size at the time of operation. Since a metastatic lung lesion was first detected in two out of six cases, it is thus recommended that the stomach should be examined when lung MFH is found. Considering the high mortality and the short survival in the six cases, the prognosis for gastric MFH seems to be poorer than that in the extremities. However, lymph node metastasis is uncommon, and a curative resection is possible in some cases such as in our second case.