MKSAP: 68-year-old woman with dyspepsia

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 68-year-old woman undergoes upper endoscopy for evaluation of dyspepsia. She has a history of pernicious anemia. She has no other medical problems and her only medication is oral vitamin B12.

On physical examination, vital signs are normal, as is the remainder of the physical examination.

Upper endoscopy discloses a 6-mm polyp in the body of the stomach, which is removed by polypectomy. Other endoscopic findings, including biopsy of the duodenum to evaluate for celiac disease, are normal. Pathologic examination of the polyp confirms a well-differentiated neuroendocrine tumor.

The fasting serum gastrin level is 1025 pg/mL (1025 ng/L).

Which of the following is the most appropriate management?

A: CT of the abdomen and pelvis
B: Partial gastrectomy
C: Radiolabeled somatostatin receptor scintigraphy
D: Observation

MKSAP Answer and Critique

The correct answer is D: Observation.

The most appropriate management is observation. This patient has a gastric neuroendocrine tumor (NET) that has developed in the presence of chronic autoimmune gastritis, which is characterized by pernicious anemia and hypergastrinemia due to achlorhydria or hypochlorhydria. Endoscopic polypectomy is considered curative treatment for this patient’s NET. Gastric NETs are classified into three subtypes: type I, II, and III. This classification distinguishes the underlying pathogenesis and guides the appropriate management of the NET. Type I NETs account for the majority of gastric NETs, have an increased prevalence in older women, and are associated with autoimmune atrophic gastritis and hypergastrinemia. Type I gastric NETs are not associated with multiple endocrine neoplasia or Zollinger-Ellison syndrome (unlike type II gastric NETs) and rarely metastasize. Curative treatment of type I NETs is achieved with endoscopic removal of these lesions when they are small (<1 cm) and few lesions are present (<5), as is the case in this patient.

Tumor staging for type I gastric NETs (using CT of the abdomen and pelvis or radiolabeled somatostatin receptor scintigraphy) is not indicated because type I NETs rarely metastasize.

Surgical intervention is not indicated for this patient’s small, type I NET that has been completely eradicated. Partial gastrectomy would be indicated if this patient’s tumor was larger than 2 cm because of a risk of metastasis.

Key Point

  • Curative treatment of type I gastric neuroendocrine tumors is achieved with endoscopic removal of these lesions when they are small (<1 cm) and few lesions are present (<5).

This content is excerpted from MKSAP 17 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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