Gastric NET Subtypes: Do We Need An Additional One?

Depending on etiology, prognosis and malignant potential, recent S2k guideline differentiates gastric neuroendocrine tumors (gNET) in 4 types with different treatment implications.We report on a 55-year-old patient with the accidental finding of a 15 mm gNET. Apart from a prolonged use of proton pump inhibitors (PPI) for 20 years as a treatment for gastroesophageal reflux disease, there were no other associations or risk factors for gNETs. Formally, this patient would have been classified as a type III gNET, implicating gastric surgery. From a pathophysiological point of view, however, the assumed prolonged gastrin hypersecretion would have justified an assignment as a type I gNET. The gNET was resected by ESD, but histology showed an R1 situation. After cessation of PPIs, there is no recurrence so far. Besides, the initially documented numerous and large gland polyps showed an impressive regression only a few weeks after cessation of PPI.This case points to a probably underestimated gap in the present gNET classification. On the basis of present literature, the therapeutic dilemma of PPI-associated gNETs is discussed. A new assignment of PPI associated gNETs as type Ib could help to overcome this dilemma.

An Unusual Case of Iron-Deficiency Anemia: The Culprit Hides in the Aorta.

In a 72-year-old patient with anemia (Hb 7 g/dl), duodenoscopy exhibited an area of polypous irregular-looking mucosa. Histology revealed duodenal infiltration by epithelioid tumor cells, immunhistochemically positive for endothelial cell markers (CD34, CD31, ERG). Ultrasonography showed thrombotic material in the otherwise unremarkable abdominal aorta with some uptake of contrast bubbles on CEUS. Histological and clinical diagnosis assumed an epithelioid angiosarcoma of the thoraco-abdominal aorta at the level of the visceral and renal arteries with duodenal metastases.To prevent further shedding of tumor cells and aortic rupture, a branched stent-graft was placed into the thoraco-abdominal aorta. Palliative chemotherapy with gemcitabine and docetaxel was started, leading to a partial remission after 6 cycles. Three months later, however, there was a progress of the duodenal masses with new pulmonal and osseous metastases. Thirteen months after the initial diagnosis, death occured due to a hemorrhagic shock caused by a hematothorax.Aortic tumors are exceedingly rare, with only slightly more than 220 cases reported so far. In most cases, diagnosis is made either at autopsy or after an emergency operation for embolic complications like embolic intestinal ischemia. With an overall median survival of 8 months, prognosis is very poor.This case sensitizes for the correct sonographic interpretation of aortic "thrombi" in an otherwise normally appearing aorta, possibly with the aid of CEUS. Besides, it demonstrates the relatively early and uncommon diagnosis of an aortic angiosarcoma by the combination of endoscopy, immunohistochemistry, and ultrasonography.

[Partynight outcome]. / Folgen einer Partynacht.

HISTORY AND CLINICAL FINDINGS: An 18 year old girl was admitted with progressive painful dysphagia and a severe hemorrhagic endoscopically impassable esophagitis. She reported to have consumed an unknown liquid from a small flask on a party three weeks ago. Later on, this liquid was identified as a party- and sex-drug known as "Poppers", designed to be consumed by sniffing. On admission she had difficulties in swallowing liquids and even saliva. She had lost 8 kg of weight during the last 3 weeks. Clinical examination revealed tachycardia, a moderate tenderness in the epigastrium and sparse bowel sounds. Investigation and treatment: On endoscopy, there was a severe corrosion injury of the esophagus with a consecutive stenosis at 40 cm ab ore. The stenosis could not be passed even with a 4.9 mm instrument. After initial placement of a feeding tube the stenosis was dilated with Savary-Bougies. In the following years, the patient suffered from recurrent stenosis due to excessive scar formation. Repeated treatment with longitudinal incisions by needle knife and steroid injections improved symptoms to a tolerable degree. 5 years after ingestion, the patient still carries a long segment esophageal scarring with mild to moderate stenosis. CONCLUSION: The party drug Poppers is an organic nitrogen compound that has increasingly come into use over the past years. It may cause severe and life threatening esophageal chemical burn injury. Symptoms of painful dysphagia after intake of an "unknown" liquid party drug should raise the suspicion of an accidental oral ingestion of Poppers.