carcinoid tumors

1. CARCINOID TUMORS
MR.MEKKI HASSAN
POST CCT COLORECTAL FELLOW
BRADFORD TEACHING HOSPITALS FOUNDATION TRUST

2. INTRODUCTION
• Rare neuroendocrine tumors
• Incidence 1.1-2/100000
• 70 % in GIT

3. EMBRYOLOGICAL CLASSIFICATION
• Foregut Carcinoids (stomach ,duodenum , Pancrease ,lung and
thymus)
• Midgut Carcinoids (small bowel 30%- proximal 2/3 of colon)
• Hindgut Carcinoids (colon and rectum)

4. HISTOLOGICAL CLASSIFICATION
• Cells of origin (classical – originate from enterochromaffin cells
stain + with silver stain ,non classical- neuro endocrine
tumours , atypical – goblet cells ,no somatostatin receptors)
• Differentiation : depend on mitotic index and proliferative
index which assess by Ki67 stain: range from G1- well
differentiated (functioning )to G3- poorly differentiated (non
functioning )

5. WHO CLASSIFICATION
Grade Ki67 Mitotic index
G1 <2% <2
G2 2-20% 2-20
G3 >20% >20

6. CLINICAL FEATURES
• Asymptomatic
• Anemia
• Abdominal pain
• Rectal pain /bleeding
• Carcinoid syndrome (5%) – liver metastasis :
Diarrhoea – flushing- bronchospasm-tricuspid valve fibrosis –
pellagra :Diarrhoea , dermatitis , dementia)

7. DIAGNOSIS
• Histology of resected specimens
• Blood tests – used usually for follow up :24 hr urine 5HIAA , plasma
Chromogranin A level.
• Endoscopy : OGD , colonoscopy ,Capsular endoscopy)
• Imaging :
-Somatostatin receptor scintigraphy – used for lesion localisation
-Staging :
CTTAP
MRI /endoanal Us – for rectal carcinoids

8. STAGING (TNM)
tumor nodes met
T1a < 1cm N1 nodes +ve M1
T1b 1-2 cm
T2 2-4 cm
T3 >4cm
T4 breach peritoneum

9. TREATMENT (NET MDT?)
• Localised disease :
• Appendix :
<2cm – appendectomy ,>2cm , +ve L.nodes .mesoappendix invasion >3mm
,incomplete resection – Right hemicolectomy
• Small bowel : (flat lesions , large L.nodes ,mesenteric dysmoplastic reaction) –
resection of bowel with affected mesenteric segment +anastomosis
• Colon : resection +anastomosis
• Rectum:<2cm TEMS/local excision ,>2cm TME resection
• Metastatic disease: somatostatin receptor analogues,Cytotoxis therapy

10. CARCINOID CRISIS
• Tumor manipulation during surgery related serotonin surg
• C/F : hypotension , hyperthermia , bronchospasm.
• Predictors : cardiac carcinoids on echo ,elevated preop 5HIAA,CagA,
high tumor load .
• Prophylaxis :
-Preop: octreotide for 2/52
-IntraOp :octreotide infusion
-PostOp: Octreotide for 1/52

11. FOLLOW UP ( NET MDT?)
>1 year 1-10 years >10 years
3- 12 monthly
History and physical
examination +
biochemistry * + cross-
sectional imaging (CT/MRI)
Frequency: 6–12 monthly
(ENETS) / every 1–2 years
(CommNETs/NANETS/NCC
N).
Examinations: History and
physical examination +
biochemistry * + cross-
sectional imaging (CT/MRI)
ENETS guidelines suggest 2
yearly SSTR imaging if
positive at diagnosis
Individualised decision to
continue; recommended
life-long (ENETS)

12. FURTHER READING
• Consensus Guidelines for the Management and Treatment of
Neuroendocrine Tumors
• Pancreas. 2013 May; 42(4): 557–577.
• doi: 10.1097/MPA.0b013e31828e34a4