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Gastrointestinal Stromal Tumor of the Stomach Presenting as Multilobular with Diffuse Calcifications.

Kim SH, Lee MS, Cho BS, Park JS, Han HY, Kang DW - J Gastric Cancer (2016)

Bottom Line: A computed tomography (CT) scan demonstrated a 4.5 cm multifocal calcified mass at the gastric body as well as at the gastric fundus.Laparoscopic gastric wedge resection was performed according to the extent of multifocal calcifications that are shown on the CT.Intraoperative specimen mammography and intraoperative biopsy might be helpful to obtain a tumor-free margin.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Eulji University Hospital, Daejeon, Korea.

ABSTRACT
Gastrointestinal stromal tumors (GISTs) are the most common primary mesenchymal neoplasms of the gastrointestinal tract and usually appear as a well-circumscribed mass. However, it may be difficult to confirm the extent of the disease for some GISTs. A 70-year-old asymptomatic female presented for a regular physical exam. An esophagogastroduodenoscopy showed a 2.0 cm protruding mass on the gastric fundus. Endoscopic ultrasound revealed an ill-defined heterogenous hypoechoic lesion (3.0×1.5 cm). A computed tomography (CT) scan demonstrated a 4.5 cm multifocal calcified mass at the gastric body as well as at the gastric fundus. Laparoscopic gastric wedge resection was performed according to the extent of multifocal calcifications that are shown on the CT. Intraoperative specimen mammography and intraoperative biopsy might be helpful to obtain a tumor-free margin. Final pathologic diagnosis was an intermediate risk GIST in multilobular form. In patients with diffuse multifocal calcifications in the stomach, the possibility of GIST should be considered.

No MeSH data available.


Related in: MedlinePlus

Pathologic findings. (A) Gross resection of the tumor revealed a solid, whitish-yellow parenchyma with multifocal diffuse calcifications (cut section of gastrointestinal stromal tumor). (B) Microscopically, the tumor originated from the muscularis propria and extended longitudinally in a multilobular form with diffuse calcifications (H&E, ×20). (C) The sliced surface of the tumor was characterized by spindled and epithelioid mixed tumor cells (H&E, ×40). (D) Immunohistochemically, the tumor cells were positive for CD117 (c-kit [CD117] immunohistochemical stain, ×200).
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Figure 3: Pathologic findings. (A) Gross resection of the tumor revealed a solid, whitish-yellow parenchyma with multifocal diffuse calcifications (cut section of gastrointestinal stromal tumor). (B) Microscopically, the tumor originated from the muscularis propria and extended longitudinally in a multilobular form with diffuse calcifications (H&E, ×20). (C) The sliced surface of the tumor was characterized by spindled and epithelioid mixed tumor cells (H&E, ×40). (D) Immunohistochemically, the tumor cells were positive for CD117 (c-kit [CD117] immunohistochemical stain, ×200).

Mentions: A 70-year-old female without a significant medical history visited Eulji University Hospital for a regular physical exam. She had denied any symptoms such as abdominal pain, melena, anorexia, or weight loss. The physical examination was unremarkable. Laboratory examination showed no abnormalities. An esophagogastroduodenoscopy showed a 2.0×2.0 cm protruding mass with normal overlying mucosa at the fundus in the stomach (Fig. 1A). Endoscopic ultrasound (EUS) revealed an ill-defined heterogenous hypoechoic lesion (3.0×1.5 cm) with multiple hyperechoic spots, arising from the muscularis propria layer (Fig. 1B). A computed tomography (CT) scan of the abdomen demonstrated a 4.5 cm multifocal calcified mass at the gastric body as well as at the gastric fundus (Fig. 2A, B). There were no enlarged perigastric or periesophageal lymph nodes. A preoperative evaluation led to the possible diagnosis of multifocal hemangiomas with phleboliths or a calcified GIST. A laparoscopic gastric wedge resection of the gastric fundus and high body was performed using linear stapler according to the maximal extent of multifocal calcifications that was shown on CT for tumor-free margin due to indistinct boundary of the tumor and discordant finding between endoscopy and CT (Fig. 2C). In addition, intraoperative mammography and frozen biopsy of the specimen was performed to confirm the complete removal of the excised specimen including the multifocal calcifications, and the specimen was compared to the preoperative CT finding (Fig. 2D). Calcification on the intraoperative specimen mammography was measured at 5.4×1.9 cm. The resected specimen revealed a well-circumscribed elongated mass measuring 5.2×2.0 cm, showing solid, whitish-yellow parenchyma (Fig. 3A). Histologically, the tumor that originated from the muscularis propria was extended longitudinally in multilobular form with diffuse calcifications (Fig. 3B). The tumor was composed of admixed spindle and epithelioid cells displaying finely vesicular chromatin and palely staining cytoplasm arranged in short intersecting fascicles and diffuse sheets (Fig. 3C). The mitotic rate was less than 5 mitoses per 50 high power fields and no prominent sign of nuclear atypia was seen. There was mild pleomorphism without necrosis. On immunohistochemical staining, the tumor cells were strongly positive for CD117 (Fig. 3D) and CD34, and negative for S-100 protein, alpha-smooth muscle actin, and desmin, and weakly positive for the DOG1 antibody. Since the size of this tumor was 5.2 cm (5~10 cm), the GIST was deemed an intermediate risk according to risk stratification guidelines.5 The postoperative recovery was uneventful and the patient was discharged eight days later.


Gastrointestinal Stromal Tumor of the Stomach Presenting as Multilobular with Diffuse Calcifications.

Kim SH, Lee MS, Cho BS, Park JS, Han HY, Kang DW - J Gastric Cancer (2016)

Pathologic findings. (A) Gross resection of the tumor revealed a solid, whitish-yellow parenchyma with multifocal diffuse calcifications (cut section of gastrointestinal stromal tumor). (B) Microscopically, the tumor originated from the muscularis propria and extended longitudinally in a multilobular form with diffuse calcifications (H&E, ×20). (C) The sliced surface of the tumor was characterized by spindled and epithelioid mixed tumor cells (H&E, ×40). (D) Immunohistochemically, the tumor cells were positive for CD117 (c-kit [CD117] immunohistochemical stain, ×200).
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Related In: Results  -  Collection

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Show All Figures
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Figure 3: Pathologic findings. (A) Gross resection of the tumor revealed a solid, whitish-yellow parenchyma with multifocal diffuse calcifications (cut section of gastrointestinal stromal tumor). (B) Microscopically, the tumor originated from the muscularis propria and extended longitudinally in a multilobular form with diffuse calcifications (H&E, ×20). (C) The sliced surface of the tumor was characterized by spindled and epithelioid mixed tumor cells (H&E, ×40). (D) Immunohistochemically, the tumor cells were positive for CD117 (c-kit [CD117] immunohistochemical stain, ×200).
Mentions: A 70-year-old female without a significant medical history visited Eulji University Hospital for a regular physical exam. She had denied any symptoms such as abdominal pain, melena, anorexia, or weight loss. The physical examination was unremarkable. Laboratory examination showed no abnormalities. An esophagogastroduodenoscopy showed a 2.0×2.0 cm protruding mass with normal overlying mucosa at the fundus in the stomach (Fig. 1A). Endoscopic ultrasound (EUS) revealed an ill-defined heterogenous hypoechoic lesion (3.0×1.5 cm) with multiple hyperechoic spots, arising from the muscularis propria layer (Fig. 1B). A computed tomography (CT) scan of the abdomen demonstrated a 4.5 cm multifocal calcified mass at the gastric body as well as at the gastric fundus (Fig. 2A, B). There were no enlarged perigastric or periesophageal lymph nodes. A preoperative evaluation led to the possible diagnosis of multifocal hemangiomas with phleboliths or a calcified GIST. A laparoscopic gastric wedge resection of the gastric fundus and high body was performed using linear stapler according to the maximal extent of multifocal calcifications that was shown on CT for tumor-free margin due to indistinct boundary of the tumor and discordant finding between endoscopy and CT (Fig. 2C). In addition, intraoperative mammography and frozen biopsy of the specimen was performed to confirm the complete removal of the excised specimen including the multifocal calcifications, and the specimen was compared to the preoperative CT finding (Fig. 2D). Calcification on the intraoperative specimen mammography was measured at 5.4×1.9 cm. The resected specimen revealed a well-circumscribed elongated mass measuring 5.2×2.0 cm, showing solid, whitish-yellow parenchyma (Fig. 3A). Histologically, the tumor that originated from the muscularis propria was extended longitudinally in multilobular form with diffuse calcifications (Fig. 3B). The tumor was composed of admixed spindle and epithelioid cells displaying finely vesicular chromatin and palely staining cytoplasm arranged in short intersecting fascicles and diffuse sheets (Fig. 3C). The mitotic rate was less than 5 mitoses per 50 high power fields and no prominent sign of nuclear atypia was seen. There was mild pleomorphism without necrosis. On immunohistochemical staining, the tumor cells were strongly positive for CD117 (Fig. 3D) and CD34, and negative for S-100 protein, alpha-smooth muscle actin, and desmin, and weakly positive for the DOG1 antibody. Since the size of this tumor was 5.2 cm (5~10 cm), the GIST was deemed an intermediate risk according to risk stratification guidelines.5 The postoperative recovery was uneventful and the patient was discharged eight days later.

Bottom Line: A computed tomography (CT) scan demonstrated a 4.5 cm multifocal calcified mass at the gastric body as well as at the gastric fundus.Laparoscopic gastric wedge resection was performed according to the extent of multifocal calcifications that are shown on the CT.Intraoperative specimen mammography and intraoperative biopsy might be helpful to obtain a tumor-free margin.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Eulji University Hospital, Daejeon, Korea.

ABSTRACT
Gastrointestinal stromal tumors (GISTs) are the most common primary mesenchymal neoplasms of the gastrointestinal tract and usually appear as a well-circumscribed mass. However, it may be difficult to confirm the extent of the disease for some GISTs. A 70-year-old asymptomatic female presented for a regular physical exam. An esophagogastroduodenoscopy showed a 2.0 cm protruding mass on the gastric fundus. Endoscopic ultrasound revealed an ill-defined heterogenous hypoechoic lesion (3.0×1.5 cm). A computed tomography (CT) scan demonstrated a 4.5 cm multifocal calcified mass at the gastric body as well as at the gastric fundus. Laparoscopic gastric wedge resection was performed according to the extent of multifocal calcifications that are shown on the CT. Intraoperative specimen mammography and intraoperative biopsy might be helpful to obtain a tumor-free margin. Final pathologic diagnosis was an intermediate risk GIST in multilobular form. In patients with diffuse multifocal calcifications in the stomach, the possibility of GIST should be considered.

No MeSH data available.


Related in: MedlinePlus