Journal of Clinical Oncology, Vol 20, Issue 9
(May), 2002: 2403-2404
© 2002 American Society for Clinical Oncology
Unusual Presentations of Uncommon Tumors
Case 2. Gastric Carcinoid Metastatic to the Liver
Roderich E. Schwarz,
Rob A. Fuller,
Peiguo Chu
City of Hope National Medical Center, Duarte, CA
A 50-year-old woman with a history of lupus erythematosus presented with sharp, left-sided back pain. A chest radiograph, which demonstrated an elevated right diaphragm, was followed by computed tomography of the abdomen. A highly vascularized mass 7 cm in diameter was identified within the upper retroperitoneum, without obvious direct involvement of the stomach wall, pancreas, or liver (Fig 1, arrows). Further work-up suggested the presence of liver metastases. With the suspected diagnosis of a gastric stromal tumor, a resection was planned without a prior biopsy attempt. The intraoperative findings were consistent with a large, exophytic mass at the lesser curvature of the stomach, and three left-sided liver metastases (Fig 2). The patient underwent a central gastrectomy (without pyloroplasty), retroperitoneal lymph node dissection, cholecystectomy, and three hepatic wedge resections (Fig 3), for complete clearance of all disease visible or imaged on intraoperative ultrasonography. Histopathologic analysis revealed a carcinoid tumor of the gastric wall (Fig 4), three of 12 lymph nodes with metastatic tumor, and three liver metastases. All resection margins were negative. Tumor cells stained strongly for pancytokeratin (Fig 5) and weakly for synaptophysin. There was no chromogranin reactivity. The patient recovered uneventfully, was discharged after 8 days, and is currently symptom- and disease-free 11 months after resection.
The tumor was a type 3 enterochromaffin-like (ECL) cell carcinoid of the stomach. Unlike types 1 and 2 ECL carcinoids, which arise due to hypergastrinemia secondary to atrophic gastritis or multiple endocrine neoplasia type 1, type 3 ECL carcinoids are thought to be sporadic.1 In contradistinction to types 1 and 2 carcinoids and their favorable prognosis, type 3 tumors are frequently malignant. At presentation, 42% of gastric carcinoids have distant metastases, and the 10-year survival rate is 59%.2 Radical resection is recommended for type 3 carcinoids, whereas type 1 lesions may undergo endoscopic removal and follow-up.3 Aside from size and depth of gastric wall invasion, angioinvasion, mitotic index, and Ki-67 expression have been shown to be parameters with prognostic relevance.4
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