Well-differentiated neuroendocrine tumors, also called carcinoid
tumors, in the duodenum are rare. The therapeutic approach is highly dependent
on both tumor size and depth of invasion; for tumors smaller than 1.0 cm
and without penetration of the muscularis propria, endoscopic resection is
considered as the method of choice [1].
A 65-year-old woman with a histologically proven neuroendocrine
tumor in the duodenal bulb was referred for further evaluation. Upper
gastrointestinal endoscopy ([Fig. 1]) revealed a
single, slightly elevated, round lesion that was covered by normal mucosa and
had a central depression. Endoscopic ultrasonography ([Fig. 2]) revealed a 10-mm lesion without penetration
into the muscularis propria. There were no signs of regional lymph node
metastasis.
Fig. 1 Upper gastrointestinal
tract endoscopy showed a round lesion covered by normal mucosa with a central
depression, located in the posterior duodenal bulb.
Fig. 2 Endoscopic ultrasound
view of the lesion, 10 × 5 mm in size, confined to
the submucosal layer of the duodenal bulb.
Somatostatin receptor scintigraphy was also negative for metastatic
spread. Therefore, endoscopic en-bloc resection of the lesion using the cap
technique ([Fig. 3]) was carried out. After the
resection, an arterial bleeding was noted, which was successfully controlled
with a hypertonic saline and epinephrine injection and placement of four metal
clips ([Fig. 4]).
Fig. 3 Endoscopic resection of
the carcinoid tumor, using the cap technique.
Fig. 4 Bleeding controlled with
an epinephrine injection and placement of four metal clips.
Macroscopically, the tumor was completely removed ([Fig. 5]), and this was confirmed histologically ([Fig. 6]). Immunohistochemical staining was strongly
positive for synaptophysin and chromogranin. Recovery was uneventful and the
patient was discharged the following day after a second-look endoscopy.
Fig. 5 Macroscopic view of the
resected carcinoid.
Fig. 6 Well-differentiated,
synaptophysin-positive neuroendocrine tumor of the duodenum with tumor-free
margins (magnification × 40).
The present case illustrates that endoscopic en-bloc resection with
the cap technique is an effective method for the curative treatment of
carcinoid tumors in the narrow area of the duodenal bulb. Laparoscopic
techniques may be considered as an alternative only in cases where endoscopy is
deemed unsuitable [2].
Endoscopy_UCTN_Code_TTT_1AO_2AG
