case study of a mass in stomach
DESCRIPTION
Endoscopy revealed a submucosal mass in the stomach. What are the differential diagnoses? GIST or GI stromal tumour features and further management of the caseTRANSCRIPT
PENINSULAR MALAYSIA EAST COAST GASTROENTEROLOGY AND HEPATOLOGY MEETING
Dr Yeong Yeh LeeMD MRCP (UK) MMed
Lecturer/Physician
Department of Medicine Dec 2007
History and Physical Findings
• 44 years old Chinese gentleman• Admitted 31.10.06 with melaena and symptomatic
anaemia for 1 week • Weight loss 7 kg past 10 months. Appetite good• No past medical illnesses• Social alcohol drinker. Non-smoker• Normal abdominal findings• No palpable lymph nodes• Started on pantoprazole and was given blood tranfusions
OGDS Findings
• There were 2 large extramucosal masses compressing on the lesser curvature. The surface was smooth and regular
• Melaenic stool was seen covering the surface• Mild antral gastritis• CLO negative• Multiple deep biopsies were taken from the center of the
protruding mass and sent for HPE
OGDS Findings
CT Scan Abdomen Findings
• Well defined smooth outline enhancing mass from the anterior and posterior wall of stomach extending from body to antrum
• The mass measured 8.4 x 8.5 x 6.6 cm• No calcification or necrosis seen• No clear plane of demarcation between left lobe liver,
splenic flexure and certain part of pancreas suggesting infiltration
• Well defined enhancing lobulated mass in pancreatico-duodenal group of lymph nodes closed to SMV measuring 2.8 cm and aorto-caval region measuring 0.9 cm
CT Scan Findings
Blood results
• WBC 8.19x103/mm3
• Hb 10.2 g/dl• FBP: hypochromic microcytic anaemia. WBC normal
morphology• LFT/RFT Normal• HIV EIA negative• LDH 250 iu/l• Alpha-fetoprotein negative• CEA negative
Differential?
• ? Lymphoma of Stomach• ? Leiomyosarcoma of Stomach• ? Gastrointestinal Stroma Tumour (GIST)
What to do next?
• Endoscopic ultrasound (EUS) and FNAC?• Staging laparatomy with distal gastrectomy?
Histology Findings from Distal Gastrectomy
• Gross: The 9cm tumour arises from submucosa and completely encapsulated by fibrous tissue. The parenchyma is lobulated, solid and pale in colour
• Microscopic: pleomorphic cells with round to spindle shaped nuclei with abundant eosinophilic cytoplasm. In some areas, tumour cells show infiltration into muscular wall. No vascular invasion. All surgical margin free from tumour. Mitosis 6 in 50 per Hpf
• Immunochemistry: CD117 positive
Vimentin positive
CD 34 positive
Desmin negative
S-100 negative
Histology
Epitheloid cells
Immunochemistry stain with CD 117
Diagnosis
• Gastrointestinal Stromal Tumour (GIST)
- High Risk
- Complete resection
Guidelines for predicting behaviour of tumour using size of tumour and mitotic count/ 50HPF
(Berman 2001 ; Fletcher et al 2002)
Size cm Mitotic count • Very low risk <2 <5 • Low risk 2- 5 <5• Intermediate risk < 5 6 - 10
5-10 < 5 • High risk > 5 > 5
> 10 any any > 10
Is molecular analysis necessary?
• Is c-kit analysis necessary in all cases of GIST?
Management
• PET scan did not show any relapse (high uptake) after gastrectomy
• The oncology did not start him on glivec (imatinib mesylate)
• Currently on follow-up 3/12ly with CT scan
Glivec?
• Is Glivec (imatinib mesylate) indicated in this case?