Gastric carcinoid type III—appearances can be deceptive!

Gastric neuroendocrine tumors (NETs) are rare tumors which are subdivided into three types based on the tumor characteristics, histology, association with hypergastrinemia, and biological behavior. Type I and II carcinoid tumors are indolent while type III carcinoids have far more aggressive course. Endoscopic polypectomy is performed for treatment of type I and II carcinoids while type III gastric carcinoids should be treated similar to adenocarcinoma. Type III gastric carcinoids are large invasive lesions, are seen more commonly in males, have normal gastrin levels and are generally diagnosed when they present with metastasis. In some cases, lesion may be confined to gastric mucosa with bland cytomorphological features and low mitotic count. Such cases especially pose diagnostic, prognostic and therapeutic challenge. A 68-year-old male presented with an episode of upper GI bleed. Upper GI endoscopy was suggestive of an ulcer in fundus of stomach. Endoscopic biopsy revealed small nodular aggregates of monomorphic cells adjacent to gastric glands limited to mucosa pointing towards a diagnosis of Intramucosal Carcinoid Tumor. CECT abdomen showed multiple lesions in liver, spleen, gastro-hepatic and periportal lymph nodes and PET scan showed low FDG avid disease in liver, spleen, lung and bone. Liver biopsy performed subsequently showed similar cells infiltrating liver parenchyma, and a final diagnosis of type III gastric carcinoid was rendered.