EMR of large periampullary neuroendocrine tumor

A 74-year-old man with a history of hypertension, chronic kidney disease, and diabetes mellitus type 2 presented with a 2-day history of melena. His hemoglobin level remained unchanged during hospitalization. He underwent an upper endoscopy that showed a 2- to 3-cm periampullary mass (Fig. 1A) concerning for malignancy just distal to the ampulla (Figs. 1B and C). Examination of initial pinch biopsy specimens showed negative results. Subsequent EUS showed a 21- by 11-mm mass that was mucosal in origin without invasion through the muscularis propria. Examination of core biopsy specimens revealed a neuroendocrine (carcinoid) tumor.

Figure 1.

A, Upper endoscopic image showing a 2-cm neuroendocrine tumor. B, C, Upper endoscopic images showing the relationship of the tumor to the ampulla. D, Upper endoscopic image showing defect with clips placed. E, F, Pathology slides showing neuroendocrine tumor (H&E, orig. mag. × 100 and H&E, orig. mag. × 400, respectively). Arrows show neuroendocrine cells.

The patient was referred to surgery; however, he declined surgical intervention and requested attempts for endoscopic removal. He underwent upper endoscopy under general anesthesia with a plan for EMR (Video 1, available online at www.VideoGIE.org). Injection of 5 mL of epinephrine (1:20,000) was performed in and around the tumor, and a large hexagonal snare was used to remove the tumor in 1 piece with the use of 30 W set to pulse blend cut. The tumor was retrieved with a Roth net. A small defect in the duodenal mucosa was then clipped 3 times (Fig. 1D). Final pathologic examination revealed a well-differentiated neuroendocrine tumor, G1: low grade with clear cautery margins (Figs. 1E and F).

Disclosure

All authors disclosed no financial relationships relevant to this publication.

Supplementary data

Video 1

Demonstration of EMR of neuroendocrine tumor.