Aleluia, C

Gomes, A

Jonet, M

Manso, RT

Nunes, V

Rocha, R

Santiago, I

Repositório do Hospital Prof. Doutor Fernando Fonseca

Case 10816 Gastric GIST mimicking adenocarcinomaAntónio Pedro Gomes , Ricardo Rocha , Rita Theias , Marta Jonet , Inês Santiago , Clara Aleluia 1 1 2 3 4, Vitor Nunes  4 1 Abdominal Imaging Section: 2013, Mar. 19 Published: 52 year(s), femalePatient:Authors' Institution Surgery (B) Department, Hospital Prof. Doutor Fernando Fonseca, EPE; Lisbon, Portugal1 Pathology Department, Hospital Prof. Doutor Fernando Fonseca, EPE, Lisbon, Portugal2 Internal Medicine (IV) Department, Hospital Prof. Doutor Fernando Fonseca, EPE, Lisbon,3Portugal Radiology Department, Hospital Prof. Doutor Fernando Fonseca, EPE, Lisbon, Portugal4Clinical HistoryA 52 yo female with no relevant medical history was admitted to the ER with upper GI bleedingand hemodynamic instability. Esophagogastroduodenoscopy(EGD) showed a polypoid lesion withan adherent clot in the body-antrum transition of the stomach(Figure 1), which was biopsed.Imaging FindingsA thoracic, abdominal and pelvic CT scan was performed. Pre-contrast images of the abdomen andpost contrast images of the thorax, abdomen and pelvis, in the portal phase of enhancement, wereobtained (Figures 2 and 3). A 3, 4 cm polypoid lesion with an irregular surface, originating from theanterior gastric incisure, was detected. The lesion was homogeneous on the pre-contrast images.After iodinated IV contrast, it showed a thick, peripheral rim of hyper-attenuation, in continuity andwith a similar enhancement compared to the surrounding normal mucosa. No signs of extramuralgrowth, invasion of adjacent structures or distant metastasis were found.DiscussionPatient presented with a relatively large, endophytic-growing tumor of the stomach with slightlylobulated margins and a thick, irregular rim of hyper-enhancing tissue mimicking a thickenedmucosal layer. It was thus considered as likely an adenocarcinoma, for which, given the locationand absence of signs of local invasion or metastatic disease on CT, a total gastrectomy would be theoncologic curative surgery of choice. In a critically ill patient thought, such as this patient, minimalresection or hemostasis alone are preferred, due to the higher morbidity and mortality of majorsurgery. Patient was stabilized with aggressive fluid resuscitation making time for histopathologicanalysis, which showed a tumor constituted by whirled bundles of fusiform cells with slightanisocariosis, expressing CD117 and CD34 intensely and diffusely, compatible with GIST. Anatypical gastric resection was then performed and the diagnosis was later confirmed byhistopathologic analysis of the (R0) surgical specimen (Figure 4).Gastrointestinal stromal tumors(GIST) arise from the interstitial cell of Cajal or its precursor in themyenteric plexus and are the most common non-epithelial tumors of the GI tract, stomach being themost frequent location. Clinical manifestations depend on location but are often nonspecific. CT is considered the imaging modality of choice for the detection, staging, surgical planning andfollow-up of patients with GIST. The majority of primary gastric GISTs appear as well-defined,extramural or intramural masses with varying attenuation. Large lesions tend to showinhomogeneous density, with combined intraluminal and extramural growth and a tendency tospread to surrounding structures. They frequently show central areas of necrosis/hemorrhage.Furthermore, the cavities that develop from central necrosis/hemorrhage may communicate with thegastric lumen. Endophytic growing GISTs represent only 18-22% of all cases and tend to be smalland hypo enhancing. The differential diagnosis between gastric submucosal lesions, such as GISTs, and mucosal lesions,such as adenocarcinoma, is very important. CT imaging features such as smooth contour, right orobtuse angles with adjacent wall, intramural or exophytic growth and an overlying normal-thicknessmucosal layer favor a submucosal origin (Figure 5). However, exceptions do occur and must beborne in mind before critical patient management decisions are made.Final Diagnosisgastric gastrointestinal stromal tumorDifferential Diagnosis Listadenocarcinoma, benign mucosal polypFiguresFigure 1 EGDA gastric polyp, originating from the gastric incisure, with an extensive overlying adherentblood clot was found on EGD. © Hospital Fernando Fonseca, EPE, Lisbon Portugal Area of Interest: Abdomen;  Imaging Technique: PACS;  Procedure: Endoscopy;  Special Focus: Neoplasia; Figure 2 PrecontrastAxial precontrast CT image of the abdomen. © Hospital Fernando Fonseca, EPE, Lisbon Portugal Area of Interest: Abdomen;  Imaging Technique: CT;  Procedure: Ablation procedures;  Special Focus: Neoplasia; Axial precontrast CT image of the abdomen. Arrow: 3,5 cm homogeneous, soft tissueattenuation, polypoid lesion with slightly lobulated margins originating from the anteriorwall of the gastric incisure. © Hospital Fernando Fonseca, EPE, Lisbon Portugal Area of Interest: Abdomen;  Imaging Technique: CT;  Procedure: Imaging sequences;  Special Focus: Neoplasia; Axial precontrast CT image of the abdomen. © Hospital Fernando Fonseca, EPE, Lisbon Portugal Area of Interest: Abdomen;  Imaging Technique: CT;  Procedure: Imaging sequences;  Special Focus: Neoplasia; Figure 3 PostcontrastAxial post-contrast CT image of the abdomen, in the portal venous phase of enhancement. © Hospital Fernando Fonseca, EPE, Lisbon Portugal Area of Interest: Abdomen;  Imaging Technique: CT;  Procedure: Imaging sequences;  Special Focus: Neoplasia; Axial post-contrast CT image of the abdomen, in the portal venous phase of enhancement.Arrow: Lesion showed a perypheral, thick rim of marked enhancement, similar and incontinuity with the normal surrounding mucosa. © Hospital Fernando Fonseca, EPE, Lisbon Portugal Area of Interest: Abdomen;  Imaging Technique: CT;  Procedure: Imaging sequences;  Special Focus: Neoplasia; Axial post-contrast CT image of the abdomen, in the portal venous phase of enhancement. © Hospital Fernando Fonseca, EPE, Lisbon Portugal Area of Interest: Abdomen;  Imaging Technique: CT;  Procedure: Imaging sequences;  Special Focus: Neoplasia; Figure 4 PathologySurgical specimen: Polypoid lesion covered by mucosa with small erosions. © Hospital Fernando Fonseca, EPE, Lisbon Portugal Area of Interest: Abdomen;  Imaging Technique: PACS;  Procedure: Removal;  Special Focus: Neoplasia; Surgical specimen - cut surface showing an intramural tumor covered by mucosa. © Hospital Fernando Fonseca, EPE, Lisbon Portugal Area of Interest: Abdomen;  Imaging Technique: Experimental;  Procedure: Removal;  Special Focus: Neoplasia; H&E 100x - tumor constituted by whirled short bundles of fusiform cells with slightanisocariosis. © Hospital Fernando Fonseca, EPE, Lisbon Portugal Area of Interest: Abdomen;  Imaging Technique: PACS;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; CD117 100x showing diffuse and intense positivity. © Hospital Fernando Fonseca, EPE, Lisbon Portugal Area of Interest: Abdomen;  Imaging Technique: PACS;  Procedure: Acceptance testing;  Special Focus: Neoplasia; CD34 100x showing diffuse and intense positivity. © Hospital Fernando Fonseca, EPE, Lisbon Portugal Area of Interest: Abdomen;  Imaging Technique: Experimental;  Procedure: Diagnostic procedure;  Special Focus: Neoplasia; Figure 5 Differential diagnosisDifferential diagnosis between submucosal and mucosal lesions as seen on CT. © Santiago, I, Department of Radiology, Hospital Prof. Doutor Fernando Fonseca, EPE, Lisbon, Portugal Area of Interest: Abdomen;  Imaging Technique: CT;  Procedure: Computer Applications-General;  Special Focus: Neoplasia; Differential diagnosis between submucosal and mucosal lesions as seen on CT. © Santiago, I, Department of Radiology, Hospital Prof. Doutor Fernando Fonseca, EPE, Lisbon, Portugal Area of Interest: Abdomen;  Imaging Technique: CT;  Procedure: Computer Applications-General;  Special Focus: Neoplasia; Differential diagnosis between submucosal and mucosal lesions as seen on CT. © Santiago, I, Department of Radiology, Hospital Prof. Doutor Fernando Fonseca, EPE, Lisbon, Portugal Area of Interest: Abdomen;  Imaging Technique: CT;  Procedure: Computer Applications-General;  Special Focus: Neoplasia; MeSH [A03.556.875.875]StomachAn organ of digestion situated in the left upper quadrant of the abdomen between the termination ofthe ESOPHAGUS and the beginning of the DUODENUM. [C06.301.371.767]Stomach NeoplasmsTumors or cancer of the STOMACH.References[1] Oh JY; Nam KJ, Choi JC et al (2008) Benign submucosal lesions of the stomach and duodenum:Imaging characteristics with endoscopic and pathologic correlation European Journal of Radiology67: 112-124[2] Hong X, Choi H, Loyer EM et al (2006) Gastrointestinal stromal tumor: Role of CT in diagnosisand in response evaluation and surveillance after treatment with imatimib Radiographics26:481-495[3] Chourmouzi D, Sinakos E, Papalavrentios L et al (2009) Gastrointestinal stromal tumors: Apictorial review 18 nº3:379-383[4] Levy AD, Remotti HE, Thompson WM et al (2003) From the archives of the AFIPGastrointestinal stromal tumors: Radiologic features with pathologic correlation Radiographics23:283-304CitationAntónio Pedro Gomes , Ricardo Rocha , Rita Theias , Marta Jonet , Inês Santiago , Clara Aleluia 1 1 2 3 4, Vitor Nunes  (2013, Mar. 19) 4 1 Gastric GIST mimicking adenocarcinoma {Online}URL: http://www.eurorad.org/case.php?id=10816

Gastric GIST mimicking adenocarcinoma

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Gastric GIST mimicking adenocarcinoma

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