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Transcript of Quotation 1
Surgical Resident (R1)
Consultant General Surgeon
History & Physical Examniation
A 33 year old yemeni female patient was C/O recurrent attack of
upper abdominal pain
Her problem started during her last pregnancy when she started to have :
epigastric pain , heartburn , regurgitation , vomiting .
-All of her symptoms were
worsening by meal & relieved by over the counter antacid medication .
-No hx of melena , no hematamesis , no respiratory symptoms , no horeseness, and no dental complain.
-No fever , no wight loss , no change in her appetite
-No significant PSH
-Medication: thyroxin .
-She is a mother of 3 kids
General : looks well , normal body wt .
not pale or jaundice .
Vitally : stable .
Abdomen : soft , lax . non-tender
no palpable mass , no organomegally ,
and no ascitis
During the last 3 months , she seek medical advice at gastroenterology clinic , she was started on medication for her reflux symptoms but no improvement !
EGD was done for her :
grade II GERD
Sliding hiatus hernia
She passed a smooth post op course .
The histopathology result showed :
WHO grade 1 carcinoid tumor
4 / 25 lymph node show tumor deposite .
Mucosa was normal.
surgical margin was free.
Carcinoid tumors are relativelly rare & generally slow growing tumor.
The GIT accounts for about 2/3 of all carcinoids
The stomach is the most common location for the GIT carcinoid tumor 47%
Screening & Diagnosis :
Plasma Chromogranin A (CgA):
sensitivity and specificity 86% and 75%, respectively.
5-Hydroxyindoleacetic Acid (5-HIAA)
EGD , Colonoscopy
Endoscopic Ultrasound (EUS)
Somatostatin Receptor Scintigraphy (SRS) : sensitivity 88% & specificity 65%
Somatostatin Receptor Positron Emission Tomography (PET) :sensitivity 93% & specificity 96%
WHO grade classification :
well-differentiated, slowly proliferative neoplasms ,small (<1.5- 2.0 cm) and contained, with metastases occurring in less than 2% of cases
Neoplasms with moderate differentiation . Type III gastric carcinoids are characteristic
of grade 2 neoplasms. These NETs are larger, with rates of metastases approaching 50%
poorly differentiated neoplasms. The prognosis for this group is dismal, even with surgical intervention and/ or chemotherapy.
Type 3 (sporadic)
treated by partial or total
gastrectomy with local lymph
node resection. The risk of
nodal metastases is
dependent on tumor
site , size and depth.
Lymph Node Dissection
Post Surgery follow up:
For gastric carcinoids ≤2 cm :
history and physical examination with (EGD) every 6 to 12 months for three years and annually thereafter; imaging studies only as clinically indicated.
Peptide Receptor Radionuclide Therapy (PRRT).
Gastrin receptor inhibition.
Review: Screening, Diagnosis and Management of Gastric Carcinoid
Review Article : Current Concepts on Gastric Carcinoid Tumors.
Review article: pathogenesis and management of gastric
Guidelines for the diagnosis and management of carcinoid tumours
Shwartz's , principle of surgery
Classification of Gastric Carcinoid Tumour
Depend on the type :
Type 1 and 2 :
smaller than 1 to 2 cm endoscopic resection represents adequate therapy. Subsequent endoscopic surveillance is needed every 6 to 12 months since these patients continue to exhibit mucosal changes and hyperplasia of ECL cells due to sustained hypergastrinemia.
Antrectomy is a reasonable option for type 1 gastric carcinoids if there are numerous progressive tumors.
There is no evidence to support the routine use of D2
gastrectomy for the surgical treatment of cancer of the
stomach. Both trials failed to show any benefit but had
higher complication rates particularly related to
resection of the spleen and the tail of the pancreas
The patient was referred to UGI surgery clinic as a case of GERD for anti-reflux surgery after failure of medical treatment.
Biopsy result :
nests of cells with round regular isomorphic nuclei
positive staining of chromogranin A and synaptophysin
Gastrin : 14.2 pmol / l
Chromogranin A : 19 ng / ml
Type III gastric Carcinoid
GERD grade II
Sliding hiatus hernia