One finding and two surprises

November 16, 2017 By: Bjorn Rembacken

One finding and two surprises

A 65-year-old man presents with a microcytic anaemia and a gastric polyp is found. What is your endoscopic diagnosis?

The gastric polyp seen in the video was discovered in a 65-year-old man who presented with a microcytic anaemia. 

 

 

 

 

 

 

 

Case question 1

WHAT IS YOUR ENDOSCOPIC DIAGNOSIS?

a)    Healing gastric ulcer

b)    Hyperplastic polyp

c)     Gastric inflammatory fibroid polyp

d)    Gastric adenoma

e)    Gastric cancer

Answer to case question 1, discussion and case question 2

Answer to case question 1

Correct answer: e.

 

Discussion

This is a somewhat peculiar looking gastric lesion that is composed of a pale part and more erythematous, indurated part. The lesion is clearly malignant and has an ominous-looking nodularity in the centre and a more infiltrative edge.

The pale part of the lesion corresponded to the poorly differentiated part of this gastric cancer, whilst the moderately differentiated part of the cancer corresponded to the more erythematous part.

The photographs below show the histological findings for the lesion and reveal something unexpected.

 

Figure 1 | H&E slide – low power to high power images of the superficial and deeper part of the lesion.

 

Case question 2

WHAT IS THE UNEXPECTED FINDING REVEALED BY THE HISTOLOGY?

a.     This cancer is limited to the mucosa

b.     There is lymphovascular infiltration

c.     This is likely to be a metastatic deposit

d.     The cancer has undergone neuroendocrine differentiation

e.     The cancer appears to have arisen from within a gastrointestinal stromal tumour (GIST)

Answer to case question 2 and discussion

Answer to case question 2

Correct answer: d.

 

Discussion

The dark purple, angular cell clusters indicate the poorly differentiated adenocarcinoma. In the bottom images several more round and purple deposits are seen that are composed of large dark cells. These cells are neuroendocrine cells. Mixed adenoneuroendocrine carcinoma (MANEC) is a rare gastrointestinal tumour that consists of both an adenocarcinomatous component and a neuroendocrine component that comprises at least 30% of the tumour.  Prior to the introduction of the term mixed adenoneuroendocrine carcinoma in 2010, these lesions were reported as a mixed or composite tumour.1

This kind of neoplasm is aggressive and usually has a poor prognosis, presumably because both components are malignant.2 Typically, the neuroendocrine portion of the neoplasm is grade 3 with >20 mitoses per 10 high-powered fields (HPF) and/or a Ki-67 proliferative index of >20%.  The only hope of cure is offered by gastrectomy. In patients who have advanced disease platinum-based chemotherapy, such as a combination of cisplatin and etoposide, has been recommended.

 

Comments

Jurij Hanzel, November 23, 2017 21:06
There's neuroendocrine differentiation - mixed adenoneuroendocrine carcinoma
Maya Risteska, November 23, 2017 20:56
Question 2:
d) - neuroendocrine differentiation
, November 20, 2017 21:57
e
Lejla Saranovic - Ceco, November 19, 2017 19:37
E
, November 19, 2017 18:20
Gastric cancer
, November 19, 2017 18:18
e
John Jacob, November 18, 2017 23:19
E
, November 17, 2017 18:47
d

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