1.Clinical data
There were 20 cases in this group, among which 10 cases (50%) were male and 10 cases (50%) were female, age ranged from 28 to 78 years, average 50.5 years; the duration of disease ranged from 10 d to more than 10 years. Age distribution characteristics: 6 cases (30%) under 40 years old, 5 cases (25%) between 40 and 50 years old, 3 cases (15%) between 51 and 60 years old, and over 60 years old (30%), including 8 cases (40%) between 40 and 60 years old. In all cases, the lesions were found by endoscopy and confirmed by pathology and/or immunohistochemistry.
The clinical symptoms were mainly abdominal pain, abdominal distension, diarrhea, anal swelling, dysphagia, acid reflux and dizziness, depending on the lesion site. There was no carcinoid syndrome in this group of cases. Zhang Zhiwei, Department of Gastroenterology, Fenyang Hospital, Shanxi Province, China
2. Results
2.1 Site and size of endoscopic carcinoid tumors Among the 20 cases of carcinoid tumors, except for one case (5%) with multiple carcinoid tumors in the gastric sinus, all other cases were single lesions.
Among them, 10 cases (50%) were located in the rectum within 5-10 cm from the anal verge, 6 cases (30%) were less than 0.5 cm in diameter, 2 cases (10%) were 0.6-1.0 cm in diameter, and 2 cases (10%) were 1.1-2.0 cm in diameter; 2 cases (10%) were in the gastric sinus, 0.6-1.5 cm in diameter; 2 cases (10%) were in the cardia and fundus, 1.2-3.0 cm in diameter; 2 cases (10%) were in the gastric body, 0.5-2.0 cm in diameter; and 2 cases (10%) were in the duodenal bulb descending. 2 cases (10%), diameter 0.5~1.2 cm; 2 cases (10%) at the duodenal papilla, diameter about 0.5~1.0 cm.
2. 2 Endoscopic morphological manifestations of carcinoid tumors Among the 20 patients, 13 cases (65%) showed smooth surface or congested erosion, with broad-based or subtibial polyp-like hemispherical elevated lesions. The surface mucosa was yellowish or yellow-white in 6 cases (30%), red in 4 cases (20%), and the color was the same as the surrounding mucosa in 3 cases (15%), and the texture was tough or moderate. There were 4 cases (20%) with mass-like protrusions, including 1 case with smooth surface of the duodenal bulb and 3 cases with nodular uneven surface, accompanied by erosion or ulceration, with hard and brittle texture.
There were 2 cases (10%) of mucosal ulcers with uneven bottom of ulcers, irregular shape, unclear border, dirty moss, loss of local peristalsis, brittle texture, and easy bleeding. There was one case of esophageal cardia stenosis (5%) with a hard texture.
2. 3 Endoscopic diagnosis After endoscopic examination of the gastrointestinal tract, polyps were diagnosed in 5 cases (40%), gastric cancer in 3 cases (15%), duodenal papillary cancer in 1 case (5%), the nature of the mass was to be investigated in 2 cases (10%), the nature of mucosal elevation, ulcer, erosion, and white lesion was to be investigated in 9 cases (45%), and ultrasonic endoscopy was also performed in 4 cases (20%). In 3 cases, the lesions were of hypoechoic origin in the mucosa and submucosa, and in 1 case, the diagnosis of smooth muscle tumor was originally diagnosed by ultrasound endoscopy of the gastric sinus, but the diagnosis was confirmed after 2 years. All of the above cases were diagnosed as carcinoid tumor by endoscopic biopsy or electrocoagulation and electrosurgery, and the specimens were sent for histology and/or immunohistochemistry.
Among them, 5 patients underwent endoscopic electrocoagulation and electrosurgery (lesion diameter 0.5-1 cm), 3 patients underwent clamping (lesion diameter about 0.2-0.4 cm), 4 patients underwent additional surgical lesion resection and were followed up by endoscopy for 1~42 months, and 5 patients (lesion diameter >1 cm) underwent direct surgical treatment.
2.5 Depth of lesion infiltration Thirteen patients with a maximum lesion diameter <1 cm had no muscle layer or intra-mucosal lymph node involvement; 4 patients with a maximum diameter of 1-2 cm, 1 involved the muscle layer, and the rest had no muscle layer or intra-mucosal lymph node involvement; 3 patients with a maximum diameter >2 cm, 2 with lymph node or abdominal metastasis.
3.Discussion
Carcinoid tumors are usually found in the gastrointestinal tract and account for 80%~86% of all carcinoid tumors in the gastrointestinal tract, mostly in the rectum, and can occur in all parts of the gastrointestinal tract. The disease often has no typical clinical symptoms and signs, and the age of prevalence is 40-60 years old, with no significant difference between men and women. In our group, the rectum is the most frequent, and the incidence ratio of men and women is equal, which is consistent with the literature. The age of onset was seen in all ages.
The rectal carcinoid tumors in this group were all within 5-10 cm from the anal verge, and the diameter was mostly within 1.0 cm, and there was no recurrence or metastasis after treatment. The growth of rectal carcinoid tumors was slow, while colon carcinoid tumors and advanced rectal carcinoid tumors had a higher rate of liver metastasis and lymph node metastasis. This shows that biopsy should not be abandoned for small mucosal polyp-like elevations. The two cases of duodenal carcinoid tumor occurred in Vater’s jugular abdomen, but the symptoms were not obvious and obstructive jaundice was not seen.
Gastric carcinoid tumors account for 2% of gastrointestinal tract carcinoid tumors, which can be asymptomatic in the early stage and have epigastric discomfort and vague pain in the late stage, similar to ulcer disease. Gastroscopy shows submucosal nodules in the fundus of the stomach or polyp-like protrusions in the gastric sinus, and because the tumor is located in the submucosa, the biopsy material should be deeper. In our group, we saw one case of multiple polyp-like protrusions in the gastric sinus, one case of localized mucosal protrusion, and one case of swelling in the lower part of the gastric body, all of which were confirmed by deep biopsy. It has been reported that patients with carcinoid tumors have a tendency to combine with other tumors. In our group, there was one case of gastric carcinoid tumor combined with sigmoid lipoma.
Therefore, in addition to local tumors, other areas should be carefully examined. The diagnosis of this disease is often made by physical examination or surgery, and its gross morphology is often a yellowish or yellowish-white hemispherical bulge, which can be diagnosed by immunohistochemical examination of neuron-specific enolase (NSE) markers. There are very few cases with carcinoid syndrome, and there was no case of carcinoid syndrome in our group.
In recent years, the rate of early detection, early diagnosis and early treatment of GI carcinoid tract has been improved due to the continuous development in the field of gastrointestinal endoscopy technology and the improvement of people’s awareness of health examination and economic level. Gastrointestinal endoscopy combined with pathological examination can not only observe the location, size, shape, texture and activity of tumors, but also determine the nature of tumors. Endoscopically
Most carcinoid tumors are broad-based elevated lesions with a tip or subtip, with a sense of submucosal motion, smooth surface or congested erosion, and a diameter of less than or equal to 2.0 cm. Rarely, the lesion is a circumferential mass, a limited mass, or an irregular ulcer. When endoscopy shows a smooth surface elevated lesion, it should be distinguished from polyps and other types of submucosal tumors. The differentiation from polyps is mainly based on observing the opening of the glandular ducts on the surface of the lesion.
The high-frequency ultrasound endoscopic probe can distinguish the structure of each layer of the gastrointestinal tract wall, and can be distinguished from other types of submucosal tumors according to the characteristics of ultrasound endoscopy; lipomas often show high echogenicity in the submucosal layer under ultrasound endoscopy, and mesenchymal tumors are mostly hypoechoic in the intramucosal layer, while carcinoid tumors are mostly hypoechoic in the intramucosal layer or submucosal layer.
Some carcinoid tumors also infiltrate to the intrinsic muscular layer, which is not easily distinguished by ultrasound endoscopy and requires postoperative pathology to confirm the diagnosis. Preoperatively, the depth of tumor infiltration, the surrounding adjacent organs, and the presence of enlarged lymph nodes are required.