1 Microcarcinoidosis of the Stomach순천향대학교병원 진소영

2 Case History 65/M C.C. : Recurrent gastric polyps D : 1 year PHx ROSEMR : Gastric carcinoids, 1 month ago DM for 10 years ROS Diarrhea(-), Flushing (-)

3 GFS Previous EMR defects and multiple tiny polyps throughout the body

4 Lab. Findings Hb/Hct 13.5/39.6 WBC/Platelet 7,500/279,000Glucose (70-110) SGOT/SGPT (0-37)/45(0-41) Amylase/lipase (0-100)/15.3 CEA/CA /0.83 24hrs urine HIAA 2.7mg/day(1.6-6) Serotonin ng/mL( )

5 High body, LC : EMR Mid body, GC : EMR Other sites : Hot biopsy x 3외부병원 조직검사 High body, LC : EMR Mid body, GC : EMR Other sites : Hot biopsy x 3

6 High Body

7 Mid body

8 Hot Biopsy

9 제1차 EISD Upper Body

10 Residual Carcinoid in M & SM

11 Microcarcinoid

12 Micronodular Hyperplasia

13 Histochemistry Grimelius

14 제2차 EISD Midbody

15 Residual Carcinoid in M

16 Residual Carcinoid in M & SM

17 Adenomatoid Hyperplasia

18 Micronodular Hyperplasia

19 Upper Body Midbody Residual carcinoidMicronodular hyperplasia, diffuse, intramucosal Adenomatoid Hyperplasia to Microcarcinoid, µm

20 Hyperplastic Changes of Gastric Endocrine CellsSimple or Diffuse hyperplasia > x2 of control <5 cells aggregates ZES or hypergastrinemia Linear hyperplasia Linear 5+ cells lying inside of BM of gastric gland ZES or pernicious anemia Micronodular hyperplasia Clusters of 5+ cells Mean : 50 µm in diameter, less than <150 µm One cluster/mm of mucosa Autoimmune gastritis of the corpus-fundus (type A CAG) Adenomatoid hyperplasia Collection of 5+ micronodules with intact BM

21 Dysplastic Growths of Gastric Endocrine Cellsµm in diameter Escape endoscopic observation Always intramucosal Histologic patterns Enlarged micronodules Adenomatous micronodules : >5 micronodules, intact BM Fused micronodules : BM loss Microinfiltrative lesions Nodules with newly formed stroma

22 Argyrophil ECL-Cell Carcinoids3 Clinical Subtypes Type 1 : diffuse chronic atrophic gastritis of autoimmune or A type (A-CAG) Type 2 : hypertrophic gastropathy with MEN type 1-ZES Type 3 : Sporadic, without specific gastric pathology

23 Clinical Behaviors of Sporadic ECL TumorsRarely multiple No hypergastrinemia No gastrin-dependent ECL-cell hyperplasia High risk for low grade malignancy Frequent deep wall invasion Definite metastatic potential

24 Criteria of Malignant PotentialTumor size > 1cm Wall invasion : beyond the SM Structural atypia : solid, central necrosis Cellular atypia >2/10HPF Ki-67 (+) cells : >50/10HPF or >2% Angioinvasion, Perineural invasion Loss of granular markers P53 overexpression

25 Management of MicrocarcinoidosisTotal gastrectomy ? Regular follow up endoscopy + Polypectomy of visible polyps ?