Here we report a case of a 61-year-old Italian woman of Caucasian origin who presented to our out-patient clinic with a three-month history of epigastric pain especially between meals, heartburn, early satiety and dyspepsia. The patient had a history of chronic lymphocytic thyroiditis, osteoporosis and small intestinal bacterial overgrowth. Her current medications included rifaximin, metronidazole and aluminum-magnesium hydroxide. The physical examination revealed a normal nutritional state. Laboratory tests revealed: serum gastrin 1900 pg/mL (reference range, 30–115), hemoglobin 11.6
g/dL (reference range, 12–16 in women), vitamin B12 level 139 pg/mL (reference range, 158–600) and internationalized normalized ratio 1.34 (reference range 0.8–1.2); because of this, she started phytonadione 10 mg/day. The results of other laboratory tests, including the white-cell count and the differential count, erythrocyte sedimentation rate, serum levels of electrolytes, glucose, total protein, albumin, globulin, cholesterol, lipids, folate, ferritin, amylase, lipase, renal function, liver function, thyroid function, serum neuron-specific enolase, chromogranin A, 5-hydroxy-indoloacetic acid, carcinoembryonic antigen, cancer antigen (CA) 19–9, CA 125, and gastric parietal cell and intrinsic factor antibodies, were normal. A urea breath test for Helicobacter pylori
infection was negative. An upper gastrointestinal endoscopy was performed. A two-cm single sessile protruding-type polyp was found in the greater curvature of the patient’s stomach. Microscopic examination showed clumps of small round-oval shaped cells with areas arranged in a trabecular or solid pattern in the gastric mucosa (Figure ). There were no area of necrosis and the KI-67 index was 3%. Immunohistochemical staining showed that the cancer cells were positive for neuron-specific enolase, cytokeratin and synaptophysin. The findings were those of a well-differentiated neuroendocrine carcinoma (carcinoid tumor). Mild chronic atrophic gastritis and intestinal metaplasia were present in the surrounding, non-neoplastic tissue in the corpus of her stomach. Thiazine staining for H
was negative. Total body computed tomography showed no evidence of lymph node or hepatic metastases and confirmed a hypervascular 1.7×1.3 cm polyp in the stomach (Figure ). The patient underwent a gastric tangential resection, restricted to the portion of corpus of gastric wall involved by tumor and sparing almost all of the stomach (Figure ). Microscopic examination confirmed a well-differentiated, low-grade, neuroendocrine tumor of the stomach infiltrating the submucosal layer with microvascular invasion. The margin of the resection was free of disease. Postoperative staging was pT1 according to the Union for International Cancer Control’s TNM Classification of Malignant Tumours (7th edition). The patient’s postoperative course was uneventful and she remained in a good clinical condition. Six months later, her serum gastrin was 2011 pg/mL. A total body computed tomography scan and an upper gastrointestinal endoscopy excluded recurrence of the disease. A gastric antral biopsy showed mild chronic atrophic gastritis and intestinal metaplasia. Staining for H
was negative. Immunohistochemical staining for cytokeratin and synaptophysin showed mild hyperplasia of neuroendocrine gastric cells. No tumor recurrence was revealed.
Figure 1 Hematoxylin and eosin staining (×100) of gastric biopsy showed trabecular structures of small round-oval cells (A); immunohistochemical staining (×100) showed that the cytoplasm is positive for synaptophysin, which confirms the diagnosis (more ...)
Abdomen computed tomography scan showed a gastric polyp with arterial enhancement and an apical area of necrosis.
A gross photograph of the gastrectomy specimen showed a polyp (two cm in diameter) with an apical area of necrosis and the resected mucosal ring.