Letters To The Editor Open Access
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World J Gastroenterol. Sep 21, 2011; 17(35): 4052-4054
Published online Sep 21, 2011. doi: 10.3748/wjg.v17.i35.4052
Hypergastrinemia and recurrent type 1 gastric carcinoid in a young Indian male: Necessity for antrectomy?
Viplove Senadhi, Niraj Jani
Viplove Senadhi, Division of Gastroenterology and Hepatology, Indiana Institute for Personalized Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, United States
Niraj Jani, Johns Hopkins University/Sinai Hospital and the Greater Baltimore Medical Center, Chief of Division of Gastroenterology, Baltimore, MD 21204, United States
Author contributions: Senadhi V wrote, revised and gathered all the data for the manuscript; Senadhi V corresponded with the editors and incorporated the revisions; Jani N reviewed and modified the manuscript; Jani N was the mentor author on the manuscript; both authors reviewed and approved the final version of the manuscript.
Correspondence to: Dr. Senadhi V, Division of Gastroenterology and Hepatology, Indiana University, 1050 Wishard Blvd, Suite 4100, Indianapolis, IN 46202, United States. vsenadhi@hotmail.com
Telephone: + 1-317-9480414   Fax: +1-678-6235999
Received: November 15, 2010
Revised: May 21, 2011
Accepted: May 28, 2011
Published online: September 21, 2011

Abstract

Carcinoid tumors are the most common neuroendocrine tumors. Gastric carcinoids represent 2% of all carcinoids and 1% of all gastric masses. Due to the widespread use of Esophagogastroduodenoscopy for evaluating a variety of upper gastrointestinal symptoms, the detection of early gastric carcinoids has increased. We highlight an alternative management of a young patient with recurrent type 1 gastric carcinoids with greater than 5 lesions, as well as lesions intermittently greater than 1 cm. Gastric carcinoids have a variable presentation and clinical course that is highly dependent on type. Type 1 gastric carcinoids are usually indolent and have a metastasis rate of less than 2%, even with tumors larger than 2 cm. There are a number of experts as well as organizations that recommend endoscopic resection for all type 1 gastric carcinoid lesions less than 1 cm, with a follow-up every 6-12 mo. They also recommend antrectomy for type 1 gastric carcinoids with greater than 5 lesions, lesions 1 cm or greater, or refractory anemia. However, the American Society of Gastrointestinal Endoscopy guidelines state that type 1 gastric carcinoid surveillance is controversial based on the evidence and could not make an evidence-based position statement on the best treatment modality. Our report illustrates a rare cause of iron deficiency anemia in a young male (without any medical history) due to multiple recurrent gastric carcinoid type 1 lesions in the setting of atrophic gastritis causing hypergastrinemia, and in the absence of a vitamin B12 deficiency. Gastric carcinoid type 1 can present in young males without an autoimmune history, despite the known predilection for women aged 50 to 70 years. Type 1 gastric carcinoids can be managed by endoscopic resection in patients with greater than 5 lesions, even with lesions larger than 1 cm. This course of treatment enabled the avoidance of early antrectomy in our patient, who expressed a preference against more invasive measures at his young age.

Key Words: Gastric carcinoid, Antrectomy, Endoscopic resection, Hypergastrinemia, Iron deficiency anemia



TO THE EDITOR

It is with great interest that we read the experiences of Kadikoylu and colleagues in the management of a solitary gastric carcinoid[1]. Carcinoid tumors are the most common neuroendocrine tumors[2] and gastric carcinoids represent 2% of all carcinoids and 1% of all gastric masses[1]. Due to the widespread use of Esophagogastroduodenoscopy (EGD) to evaluate a variety of upper gastrointestinal symptoms, the detection of early gastric carcinoids has increased. We highlight an alternative management of a young patient with recurrent type 1 gastric carcinoids with greater than 5 lesions as well as lesions intermittently greater than 1 cm.

A 28-year-old Indian male with no significant medical history presented with fatigue. He was found to have severe iron deficiency anemia (hemoglobin of 68 gm/L) with a mean corpuscular volume of 77 fL, and an iron level of 370 mcg/L. Endoscopic evaluation for anemia revealed nine sessile polyps in the body and fundus of the stomach ranging from 5 mm to 9 mm, which were all resected. An Endoscopic Ultrasound showed the lesions to be within the mucosa and there was no evidence of gastrinoma or metastatic disease to the liver or pancreas. The serum gastrin level was 1534 ng/L and other causes of hypergastrinemia were considered (Table 1)[3-6]. Histopathological examination of the polyps confirmed carcinoid tumors with positive synaptophysin and chromogranin. The body of the stomach revealed autoimmune atrophic gastritis without oxyntic mucosa, helicobacter pylori, or evidence of parietal cell hyperplasia. Capsule endoscopy and colonoscopy did not reveal any other sources of blood loss or further carcinoid tumors. Octreotide scans, vitamin B12 levels, as well as Computed Tomography scans of the thorax, abdomen, and pelvis were normal. Surveillance EGD 6 mo later showed recurrence with 5 polyps, with the largest measuring 1.1 cm, which was resected. Since resection, the patient has experienced a resolution of his anemia along with normal gastrin levels. The patient has not had more than 5 lesions or a lesion greater than 1 cm for over two years.

Table 1 Differential diagnosis of hypergastrinemia.
Elevated antral pHGastrinoma
Chronic atrophic gastritis-type A++++ (> 1000)
Pernicious anemia++++ (> 1000)
Other immune dz (RA, vitiligo, SS, DM)+ (150-250)
Chronic atrophic gastritis-type B (H.Pylori), gastric cancer++ (250-450)
Renal insufficiency/high protein diet+ (150-250)
Massive small bowel resection+ or ++
G cell hyperplasia/pyloric outlet obstruction+ or ++
Calcium, caffeine, insulin, catecholamines+ (150-250)
H2 blocker/PPI’s+ (H2) ++ (PPI)
Truncal vagotomy/retained antrum s/p surgery+

Gastric carcinoids have a variable presentation and clinical course that is highly dependent on type (Table 2)[7]. Type 1 gastric carcinoids are usually indolent and have a metastasis rate of less than 2%, even with tumors larger than 2 cm[8]. Kadikoylu et al[1] recommend endoscopic resection for all type 1 gastric carcinoid lesions less than 1 cm with follow-up every 6-12 mo and antrectomy for type 1 gastric carcinoids with greater than 5 lesions, lesions 1 cm or greater, or refractory anemia. However, the American Society of Gastrointestinal Endoscopy guidelines state that type 1 gastric carcinoid surveillance is controversial based on the evidence and could not make an evidence-based position statement on the best treatment modality[9].

Table 2 Gastric carcinoid types and differentiating characteristics.
Type 1Type 2Type 3
% of gastric carcinoids70%-80% - most commonLess than 5%15%-20%
AssociationChronic atrophic gastritisGastrinomas (Zollinger-Ellison)Sporadic carcinoid syndrome
EpidemiologyTypically women 50-70 yrs oldFamily hx of MEN type 1 syndromeIncreased in African Americans
PresentationAsymptomatic or anemiaPeptic ulcer diseaseHepatic mets or carcinoid syndrome
Rate of metastasis over a lifetime< 2% even if larger than 2 mm2%-4%65% metastatic at presentation
TreatmentObservation vs endoscopic resection vs antrectomyEndoscopic resection vs antrectomy vs octreotide vs gastrectomyPartial or total gastrectomy with lymph node dissection vs chemotherapy

This report illustrates a rare cause of iron deficiency anemia in a young male (without any medical history) due to multiple recurrent gastric carcinoid type 1 lesions in the setting of atrophic gastritis causing hypergastrinemia and in the absence of a vitamin B12 deficiency. Gastric carcinoid type 1 can present in young males without an autoimmune history, despite the known predilection for women aged 50 to 70 years. Type 1 gastric carcinoids can be managed by endoscopic resection in patients with greater than 5 lesions, even with lesions larger than 1 cm. This course of treatment enabled the avoidance of early antrectomy in our patient, who expressed a preference against more invasive measures at his young age.

Footnotes

Peer reviewer: Dr. Edward J Ciaccio, Department of Medicine, Columbia University, 180 Fort Washington Avenue, HP804, NY, 10032, United States

S- Editor Sun H L- Editor Rutherford A E- Editor Xiong L

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