Neal Dharmadhikari, MD
Providence, Rhode Island
Neal D. Dharmadhikari, MD1, Tian Gao, MD2, Osman Yilmaz, MD3, Samir A. Shah, MD, FACG2
1Brown University, Providence, RI; 2Warren Alpert Medical School of Brown University, Providence, RI; 3Rhode Island Hospital, Cambridge, MA
Introduction: Neuroendocrine tumors (NET) are rare (0.49 % of all malignancies) and slow-growing that can arise anywhere in the body from neuroendocrine cells. They are most commonly seen in the gastrointestinal tract, but compromise < 2 % of all gastrointestinal malignancies. NETs in the duodenum are even less common as they make up 2.6 % of all NETs. This case illustrates the appropriate diagnosis and management of a rare gastrointestinal malignancy – duodenal NET. Endoscopic mucosal resection (EMR) has become more common for the management of duodenal NETs, but guidelines are still evolving.
Case Description/Methods: A 79-year-old male with a medical history of prostate cancer, stage 3 chronic kidney disease, gastroesophageal reflux disease with occasional dysphagia underwent an upper endoscopy which revealed a benign Schatzki ring that was dilated. A single 7 mm shiny nodule in the duodenal bulb was biopsied revealing a grade 1 NET. Endoscopic ultrasound (EUS) to assess showed the lesion measured 4.4 mm in thickness and 6 mm in diameter, originate within the submucosa and there was no surrounding lymphadenopathy. The lesion was raised by injecting it with a solution of epinephrine and methylene blue. A ligation-assisted endoscopic mucosal resection was completed. Pathology noted a well-differentiated grade 1 NET measuring 6 mm involving the submucosa and mucosa with no malignant cells noted in the margins. He returned home without any complications.
Discussion: The diagnosis of neuroendocrine tumors is difficult given their rarity, size, and potential asymptomatic presentation. For small, non-functional, localized duodenal NETs, resection is the goal and endoscopic therapy is becoming the preferred method of resection. Numerous surgical and endoscopic techniques have been explored; however, the optimal method has yet to be determined. This case shows the successful use of EMR after EUS evaluation in treating a duodenal NET with evidence of clean margins on pathology. We were able to describe a rarely encountered tumor and highlight the evolving use of advanced endoscopy in its management. Clinicians should be suspicious for NETs when encountering a shiny-appearing nodule in the gastrointestinal tract.
Citation: Neal D. Dharmadhikari, MD; Tian Gao, MD; Osman Yilmaz, MD; Samir A. Shah, MD, FACG. P1502 - SUCCESSFUL ENDOSCOPIC MUCOSAL RESECTION FOR DUODENAL NEUROENDOCRINE TUMOR: TO NET A NET. Program No. P1502. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.