Correspondence Address:
Dr. Sharma Shruti
National Institute of Pathology, ICMR, Safdarjung Hospital Campus, New Delhi - 110 029
India

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Dear Editor,

A 69-year-old man presented with abdominal pain, nausea, and gradually worsening abdominal distention for the past 4 months. The patient had a history of peptic ulcer disease for which he had been taking medications. Upper endoscopy performed showed numerous polypoidal lesions involving the entire stomach. Biopsy taken exhibited features of neuroendocrine tumor, G1. Laboratory investigations revealed mild anemia with a hemoglobin level of 9 gm/dl, high serum gastrin levels (1200 pg/mL, normal ≤200 pg/mL), and negative antiparietal cell antibody test. There were no symptoms to suggest Zollinger–Ellison syndrome or multiple endocrine neoplasia Type 1 (MEN-1). The patient underwent a contrast-enhanced computed tomography scan which revealed multiple polyps in the entire stomach [Figure 1]. He was recommended to undergo total gastrectomy. On gross examination, multiple sessile and pedunculated polyps with size ranging from 0.5 cm to 3.0 cm were seen replacing almost the entire stomach with a thin rim of normal mucosa in the periphery [Figure 2]. Cut section of the polyps was yellow [[Figure 2], inset]. Histological examination showed a submucosal tumor infiltrating muscularis propria. It was composed of nests and trabeculae of monotonous small round cells with finely granular cytoplasm and salt and pepper chromatin. Mitotic figures were rare [Figure 3]. Surrounding gastric mucosa showed features of chronic gastritis. On immunohistochemistry, tumor cells were positive for chromogranin A [[Figure 3], inset]. Thus, a diagnosis of multiple gastric neuroendocrine tumors, G1 was rendered. Postsurgery serum gastrin levels decreased to the normal range.{Figure 1}{Figure 2}{Figure 3}

Gastric neuroendocrine tumors are rare, constituting <1% of gastric tumors.[1] They are categorized into three subtypes based on pathogenesis and histologic characteristics. Type I is the most common and is associated with enterochromaffin-like cellular hyperplasia, hypergastrinemia, and chronic atrophic gastritis, with or without pernicious anemia. They have the best prognosis but may show recurrences. Type II tumors are the least common and are associated with MEN-1 or Zollinger–Ellison syndrome. Type III is sporadic, usually solitary and is not associated with hypergastrinemia. These represent about 13% of gastric neuroendocrine tumors, G1 and are clinically the most aggressive type.[1],[2] Our patient belonged to Type I category.

This case highlights an unusual florid polypoidal presentation of gastric neuroendocrine tumor.

Although multiplicity is known in Type I, the florid polyposis in our case was unique. Owing to the extensive involvement, total gastrectomy was recommended in the present case.[3]

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