Tombazzi - Carcinoid, GIST, Lymphoma Flashcards Preview

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Flashcards in Tombazzi - Carcinoid, GIST, Lymphoma Deck (36):
1

What are the basic features of carcinoid tumors?

- Late middle-aged pts

- Most in GI tract: 40% in small intestine (also in the lungs and tracheobronchial tree)

1. Often at multiple sites in the GI tract: can be found anywhere b/t stomach and rectum 

- Make molecules w/effects in other parts of the body, most commonly: histamine or serotonin 

- CLINICAL PRESENTATION: often asymptomatic, but may present with abdominal pain if tumor is big enough (via intermittent obstruction, which can also cause bleeding and/or anemia) 

2

What are the 3 types of carcinoid found in the stomach?

- 80% type 1 or type 2: found in body of the stomach (b/c this is where NE/parietal cells are), generally multiple, very small most of the time, and grow in high levels of gastrin -> difference b/t these 2 is that gastrin is coming from different areas 

1. T1: assoc w/hyper-gastrinemia in antrum; good prognosis

2. T2: assoc w/gastrinoma outside the stomach; some w/metastasis 

- T3 (20%): not assoc w/hyper-gastrinemia, and many with mets at diagnosis -> AGGRESSIVE

- NOTE: malignant tumors that often behave in a much more benign way than adenocarcinoma 

3

What are some of the things gastric carcinoid may be associated with?

- Endocrine cell hyperplasia

- Autoimmune chronic atrophic gastritis

- MEN-I

- Zollinger-Ellison syndrome 

4

What is the most frequent cancer in the GI tract?

Adenocarcinoma

5

71-yo WM presents w/epigastric pain and anemia. Endoscopy shows >10 nodules (7-12mm) in body and fundus of stomach. Biopsy shown. What is going on?

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- Type I neuroendocrine/carcinoid tumor: biopsy shows aggregates of neuroendocrine cells 

- Multiple, benign, located in body and fundus (more parietal (NE) cells), will show improvement after reducing gastrin by antrectomy

- HISTO: islands of small, round cells with salt and pepper chromatin

- NOTE: all low-grade NE tumors look the same, no matter where they come from

6

What is the most important prognostic factor for GI carcinoid tumors?

- LOCATION

Foregut: stomach, duodenum prox to ligament of Treitz, and esophagus, rarely metastasize and are generally cured by resection

1. Particularly true for gastric carcinoid tumors that arise in association with atrophic gastritis

- Midgut: jejunum and ileum are often multiple and tend to be aggressive 

- Hindgut: appendix and colorectum are typically discovered incidentally 

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7

What are some standard txs for removal of hindgut NE/carcinoid tumors?

- Most comm neoplasm in appendix: can tx with appendectomy, unless large (>1cm) 

- Small rectal nodules (<1cm) can be removed endoscopically with the same rubber band used for esophageal banding (see attached image)

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8

What is the pathophysiology of carcinoid tumors?

Chronic gastritis OR gastric acid suppression 

leads to

Hyper-gastrinemia compensatory response 

leads to

Gastric diffuse neuroendocrine hyperplasia

leads to

Gastric carcinoid tumors

- Any clinical situation w/high gastrin puts pt at risk, i.e., chronic H. pylori infection (can develop atrophic gastropathy)

- PPI’s do NOT INC risk according to current data in humans (in animals, yes) 

9

What do you see here? Describe the disease and the histo.

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Auto-immune gastritis: Ab's to parietal cells (H/K ATPase or intrinsic factor) in body of the stomach that lead to DEC acid production and INC gastrin 

- SEQUELAE: atrophy, pernicious anemia, carcinoid tumor, adenocarcinoma

- ASSOCIATIONS: autoimmune disease -> thyroiditis, diabetes mellitus, Graves disease

- HISTO: lymphos (inflammation) + gland atrophy + intestinal metaplasia + NE hyperplasia 

1. Sometimes see little islands in background, but best to stain: synaptophysin/chromogranin show a lot more than you can see on H&E

2. Atrophic gastritis w/NE hyperplasia (in patho)

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10

71-yo WM presents w/epigastric pain and anemia. Endoscopy shows >10 nodules (7-12mm) in body and fundus of stomach. Biopsy shows carcinoid tumors. Tx?

Antrectomy: can get malabsorption of Vit. B12, iron, and Vit. C in some pts., but they can live w/o significant problems

- So many nodules in this pt, they can't be removed with scope -> have to remove gastrin, and nodules will go away

11

What is this? Utility?

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- Endoscopic ultrasound: can be used to see how deep tumors go into wall of the stomach 

12

60-yo WM presents w/new onset of iron deficiency anemia and 4-mo hx of diarrhea and abdominal pain. Frequent episodes of cutaneous flushing+ feeling that he is about to pass out. Abdominal CT and upper endoscopy of pancreas attached.

What is going on? What additional studies might you do?

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- Type 2 neuroendocrine/carcinoid tumor: primary tumor outside of the stomach + high gastrin level due to associated gastrinoma 

1. See attached image of small nodules in stomach detected via upper endoscopy

- CT: white spots = hyper-dense lesions -> NE tumors are 1 of the few cancers that are hyper-dense

- EUS: hyper-echoic, rounded lesion sitting at head of the pancreas 

- ADDITIONAL STUDIES: 5-HIAA, chromogranin, serum gastrin, Octreotide scan, biopsy of liver lesion

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13

What is this?

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Octreotide scan with SPECT (single-photon emission computed tomography): shows where tumors are 

- Located in 2 different areas here: mass near pancreatic head and multiple lesions within the liver c/w neuroendocrine tumor 

14

What do you see here? What hormone might you stain this for?

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- Neuroendocrine tumor from liver biopsy: nests, trabeculae and gland-like arrangements of mid-size cells

- Small round nuclei and moderate basophilic cytoplasm 

- No normal liver here 

- (+) immunostain for gastrin attached: hormone expression NOT sufficienctly specific to assign origin of metastasis 

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15

What immunostains would be positive in a NE tumor?

- Chromogranin 

- Synaptophysin 

- CD56

16

What are the clinical features of carcinoid syndrome? Dx? Tx?

10% of pts w/carcinoid tumors: typically ileal tumors w/liver mets -> bioactive products can be released directly into systemic circulation 

- Episodes of cutaneous flushing, sweating, diarrhea, bronchospasm, and colicky abdominal pain

1. Due to vasoactive polypeptides, SEROTONIN

- R heart endocardial/valvular fibrosis (50%): these substances disappear in lung, so no problems L heart 

- Also can be overcome with large tumor burden and hormones secreted into non-portal circulation 

- DX: high urine 5-hydroxyindole acetic acid (5-HIAA), a metabolic product of serotonin; limited sensitivity and specificity 

- TX: Octreotide injections once per week 

- NOTE: may be an exam question on this...

17

What is the clinical presentation of Z-E? Diagnosis?

- CLINICAL PRESENTATION: complicated peptic ulcer disease, diarrhea, abdominal pain, weight loss, other

1. Diarrhea b/c extra acid in small intestine from stomach, inactivating pancreatic enzymes

2. Risk for devo of T2 gastric carcinoma

- DIAGNOSIS: 

1. Fasting gastrin >1000 pg/ml + gastric pH <5

2. Secretin stimulation test: gastrin levels 0, 2, 5, 10, 15 & 20 min after IV Secretin -> INC in gastrin of >200 pg/ml (“normally" a DEC in gastrin)

a. Sensitivity 83%, specificity 100%

18

What are the treatments for Z-E syndrome?

- SURGICAL RESECTION: if solitary, non-metastatic 

- MEDICAL MGMT: all should receive high-dose PPI

1. Long-acting somatostatin analog (Sandostatin)

2. Metastatic disease: streptozocin/doxorubicin or temozolomide

a. Resection, orthotopic liver transplant (OLT) trans-arterial chemo-embolization (TACE), radiofrequency ablation (RFA)

19

What do you see here?

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Ménétrier disease: hypertrophic gastropathy

- Characterized by irregular enlargement of gastric rugae in body and fundus

1. MICRO: sheet of polypoid structures 

- Antrum generally spared

- Unknown cause: may be precipitated by infection

20

What is going on here?

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- Z-E syndrome: doubling of oxyntic mucosal thickness due to a five-fold INC in # of parietal cells

21

Based on this endoscopic presentation (submucosal lesion) what is the least likely diagnosis?

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- Adenocarcinoma

- Comes from the mucosa -> you would expect changes in the mucosa

22

What is a GIST? Clinical presentation? Prognosis?

- Most frequent sub-mucosal tumor in stomach

- Neoplasms of spindle, epithelioid, or pleomorphic mesenchymal cells, and often express KIT (CD117)

1. Neoplastic transformation of pluripotent mesenchymal cells in G.I. tract. formerly labeled leiomyomas and neurofibromas, among others

- CLINICAL PRESENTATION: from asymptomatic (benign) to very aggressive

1. More common manifestations: incidental finding, GI bleeding, abdominal mass or pain

- PROGNOSIS: behaves depending on size and histo (biopsy)

23

What are 2 causes of hypertrophic gastropathy?

- Ménétrier disease

- Zollinger-Ellison Syndrome

24

55-yo M w/heartburn for 8 yrs. Normal appetite, no weight loss. PE = normal. Upper endoscopy attached. 

What is going on? Why? What next?

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- GIST: smooth nodules covered in normal-appearing mucosa

- EUS/FNA (biopsy): tumor coming from muscularis propria (interstitial cells of Cajal) 

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25

65-yo M presents w/hx of black stools for 5d. Weak. Normal appetite, and no weight loss. PE = melena. Hb: 7g/dl, Hct: 21%. Upper endoscopy attached.

What is going on? Tx?

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GIST with active bleeding: very low hemoglobin + active bleeding from tumor on endoscopy

- Normal-appearing mucosa covering the tumor

- This is an emergency

- TX: coat tumor in epinephrine to stop bleeding, and remove (surgery)

26

69-yo presents w/DOE. PE = epigastric mass. Hct: 30.7%. Large, ulcerated gastric mass measuring 23 x 13 x 20 cm. No LAD.

What is going on? Why does he have DOE?

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- Big, aggressive GIST: unresectable (attached), and he had tumor embolism and died 

- DOE: anyone with baseline CV disease and anemia will not have enough red cells to supply body with O2

 

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27

This is a GIST. What stain is this? Characteristic histo?

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- C-kit stain: 75-80% of GIST's have oncogenic, GOF mutations in the receptor tyrosine kinase KIT (=CD117)

1. Newer/better stain = DOG-1 (more specific)

- Spindle-cell (or epithelioid) lesion of the GI tract (see image)

- Most common mesenchymal tumor of the abdomen, and >50% occur in the stomach 

- From interstitial cells of Cajal, or pacemaker cells, of the GI muscularis propria  

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28

How might you distinguish a GIST from a leiomyosarcoma?

- Leiomyosarcoma much more pleomorphic, and will NOT stain (+) for C-kit (CD117) -> see attached images

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29

What is the Carney triad?

- Non-hereditary syndrome of unknown etiology seen primarily in young females that includes:

1. Gastric GIST,

2. Paraganglioma (pheos not in the adrenal; Zellballen appearance*), and

3. Pulmonary chondroma 

- INC incidence of GIST in pts w/neurofibromatosis T1

- *Nest-like clusters of uniform, round-to-polygonal chief cells surrounded by delicate, richly vascular tissue and sustentacular cells 

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30

How are GIST's diagnosed and treated?

- DX: endoscopy shows a submucosal lesion

1. Endoscopic US-guided FNA has 82% sensitivity and 100% specificity

- TX: surgery

1. If metastatic, can usually be given tyrosine kinase inhibitor, Imatinib mesylate

31

How do GI lymphomas present? Most common?

- More frequent in stomach and small bowel, but infrequent overall 

- Almost all are Non-Hodgkin lymphoma, and most are B-cell (MALT and diffuse large B-cell most comm in the US)

1. 2o involvement common: 10% in limited and 60% in advanced NHL 

- Most PRESENT similar to adenocarcinoma: epigastric pain > anorexia > weight loss > N/V > GI bleeding > early satiety

2. 12% have Systemic B symptoms: weight loss, fever, and night sweats 

32

What are the 5 GI lymphomas we need to know (and their associations)?

- Extra-nodal marginal zone lymphoma of mucosa-associated lymphoproliferative tissue (MALT): assoc w/H. pylori (can cure with AB’s)

- Diffuse large B-cell lymphoma, NOS (not otherwise specified): aggressive

- Immunoproliferative small intestinal disease (IPSID): malabsorption & Ig (esp. IgA); weight loss + diarrhea (more common in Middle East)

- Enteropathy-associated T-cell lymphoma (EATCL) : associated to sprue (celiac pt. not responding to gluten-free diet)

- Post-transplant lymphoproliferative disorder: assoc w/Epstein-Barr -> DEC immunosuppression, and they do much better 

33

45-yo AAM w/dyspepsia. No weight loss, fever, or night sweats. Normal PE. Endoscopy and EUS attached. 

What should you do next?

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- BIOPSY -> this guy had MALT, and was treated for H. pylori 

- Doing well now, and asymptomatic off treatment 

- NOTE: no significant changes on endoscopy, but thickened gastric wall on EUS

34

65-yo w/hx of Hep C. Screening CT attached: gastric tumor w/diffuse perigastric adenopathy and extragastric extension.

What might be going on? Histo?

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- MALToma: this is a "bad" one, however, and pt. did not respond to typical tx

1. Chemo (Rituximab), but pt. ended up with sepsis and multi-organ failure 

2. Dr. T said he gave this example to show that not all MALTomas have a good course

- HISTO: atypical lymphoid infiltrate (attached)

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35

73-yo WM presenting for failure to thrive and abdominal pain. CT of abdomen: wall thickening, multiple periaortic lymph-nodes, multiple liver masses and splenomegaly.

What might this be? Tx?

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- Gastric ulcer consistent with diffuse large B-cell lymphoma (DLBCL): started on chemo (R-CHOP)

- This guy had low Plt, Hct, and WBC, so probably had BM involvement -> died 3 mos after dx 

- VERY aggressive type of tumor

36

What do you see here?

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- Diffuse large B-cell lymphoma: worse prognosis (5yr survival 46%)

- Common histo in gastric lymphoma: 68-75% of GI lymphomas

- 3% of gastric neoplasms and 10% of lymphomas

- Age 50-60 years, and male predominance