Kagan, Penelope

Rowe, Michael G.

Schoerning, Laura

English

Marian University Indianapolis

MUShare 
Student Publications and Research College of Osteopathic Medicine 
3-20-2018 
Diagnosing a GIST and Deviating from Tradition: A Case Study 
Penelope Kagan 
Marian University - Indianapolis, pkagan841@marian.edu 
Laura Schoerning 
Marian University - Indianapolis, lschoerning685@marian.edu 
Michael G. Rowe 
St. Vincent Hospital 
Follow this and additional works at: https://mushare.marian.edu/mucom_spr 
 Part of the Oncology Commons, and the Surgery Commons 
Recommended Citation 
Kagan, Penelope; Schoerning, Laura; and Rowe, Michael G., "Diagnosing a GIST and Deviating from 
Tradition: A Case Study" (2018). Student Publications and Research. 7. 
https://mushare.marian.edu/mucom_spr/7 
This Poster is brought to you for free and open access by the College of Osteopathic Medicine at MUShare. It has 
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more information, please contact emandity@marian.edu. 
Open%surgical.wedge.resection.of.
stomach.(non%laparoscopic).under.
general.anesthesia
Path.showed:.Low.grade.GIST
• Epithelioid.subtype
• KIT.+.
• DOG1+.
8/28/17
Surgery
Patient.was.discharged.to.
rehab.for.10.days
8/29/17% 9/10/17
Rehab
6/6/17
Endoscopic.US.with.biopsy
Findings:.Oval.mass.in.fundus.of.
stomach.with.suggested.invasion.into.
deep.mucosa,.suspicious.of.stromal.
cell.neoplasm..Seven.FNA.and.fine.
needle.biopsies.were.taken,.but.
pathology.findings.were.inconclusive.
5/23/17
PETCT.Skull.Base.to.Mid.Thigh
Radiology.findings:.
The.3x2cm,.pedunculated,.soft.tissue.lesion.along.the.
posterior.wall.of.the.stomach.and.just.anterior.to.the.
pancreatic.tail.probably.has.origin.from.stomach.and.
may.represent.a.gastric(GIST..The.lesion.appears.
slightly.diminished.in.size.since.the.prior.study.in.2014.
and.now.demonstrates.calcification.and.diminished.
enhancement..This.may.be.related.to.twisting.of.blood.
supply.on.pedicle.
5/16/17
CT.CAP.with.IV.contrast
1/17/17
CT.Chest.w/o.contrast
1/9/17
CXR
12/30/2014
Urogram
Radiology.findings:.There.is.a.
3x2.5cm.circumscribed.lesion.
adjacent.to.the.superior.margin.
of.the.pancreatic.body/tail.of.
unknown.etiology
Radiology.findings:.There.is.a.5mm.
non%calcified.nodule.within.lingula..
Given.history.of.melanoma,.follow%
up.suggested.
New.calcified.8mm.lingual.
nodule..Follow%up.with.CT.
recommended.
On.retrospective.review,.a.3x2.8cm.soft.tissue.mass.was.
present.along.the.anterior.aspect.of.the.pancreatic.tail..
Attenuation.was.similar.to.stomach.and.no.
calcifications.were.present..The.appearance.suggests.
this.most.likely.is.a.GIST..
Left:.H&E% stained.section.of.an.epithelioid.GIST.with.
rounded.cells,.round.central.nuclei,.and.eosinophilic.or.
clear.cytoplasm..Notable.for.nested.morphology..
Left:.Spindle.type.GIST.stained.for.cytoplasmic.KIT.
expression.by.immunohistochemistry..Positive.tumor.
cells.are.brown..
How(long(had(the(GIST(been(there?(
These.side.by.side.images.demonstrate.the.stability.of.the.patient’s.
tumor.between.December.2014.and.May.2017..
Left.image:.Measurements.of.the.lesion.obtained.from.a.CT.urogram
performed.in.December.2014.were.3x2.8cm..
Right.image:.Measurements.of.the.lesion.obtained.from.a.PETCT.
performed.in.May.2017.were.3x2cm..
No.comment.was.made.on.this.lesion.in.the.original.CT.urogram
report.from.December.2014..Consequently,.neither.the.patient.nor.
PCP.had.knowledge.of.the.lesion..
Both.scans.demonstrated.low.attenuation..Notable.changes.included.
new.calcifications.and.diminished.enhancement..Calcifications.in.
GIST.tumors.are.unusual,.but.can.occur.
Clinical(case:(
• An.80.yo female.with.a.history.significant.for:
• Resected.melanoma.in.2001
• Shingles.affecting.larynx.and.esophagus.in.APR.2013.with.two.years.of.
ongoing.neuralgia
• Annual.CXRs.were.performed.for.surveillance.based.on.her.history.of.melanoma.
• Her.CXR(performed(in(Jan(2017 showed.a.new.lingual.lesion.prompting.a.follow%
up.CT.Chest.scan.to.be.done..Based.on.the.CT.chest.results,.continued.follow%up.
of.the.lingual.nodule.was.recommended..
• CT(CAP(was(done(in(May(2017..While.the.stable.lingual.nodule.was.presumed.
benign.or.postinflammatory,.a.3x2.5cm.circumscribed,.partially.calcified.mass.was.
seen.adjacent.to.greater.curvature.of.stomach,.near.the.pancreatic.tail..Although.
not.noted.in.the.previous.report,.the.lesion.was.present.on.the.prior.chest.CT.
from.Jan.2017..Comparatively,.the.stomach.lesion.was.unchanged.in.size..
Continued.follow%up.and.comparison.to.more.remote.prior.imaging.to.assess.the.
extent.of.the.stability.was.encouraged.
• Her.oncologist.ordered.a.PETCT.to.further.evaluate.the.stomach.mass..PETCT was.
done.at.an.outside.center.that.also.possessed.images.from.a.urogram done.in.
2014..Again,.although.the.report.from.2014.made.no.mention.of.the.lesion,.
review.of.the.images.showed.a.similarly.sized.lesion.adjacent.to.the.pancreatic.
tail..Based.on.the.PETCT.findings.and.comparison.to.the.2014.images,.a.diagnosis.
of.a.GIST.was.suggested..
• The.patient.was.referred.to.a.surgeon..The.surgeon.recommended.an.Upper(
Endoscopic(Ultrasound(with(Biopsy(under.general.anesthesia..The.
endosonographic appearance.was.highly.suspicious.of.a.GIST..NxMx by.
endosonographic criteria..FNA.and.fine.needle.biopsies.were.performed,.however.
pathology.results.were.inconclusive.due.to.insufficient.cellular.material.
• The.surgeon.recommended.a.laparoscopic.resection.of.the.tumor,.however,.
concerned.about.the.potential.for.malignancy,.the.patient.requested.an.open.
approach..
• OpenLsurgical(wedge(resection(of(the(stomach(tumor(under.general.anesthesia.
was.performed.in.August.2017..Final.diagnosis.was.made.of.a.low.grade,.
epithelioid.GIST.that.was.KIT+.and.DOG1+.
• Patient.was.discharged(to(rehab for.ten.days.after.her.surgery.
GIST(so(you(know…
• Gastrointestinal.stromal.tumors.(GISTs).are.the.most.common.
mesenchymal.tumor.of.the.abdomen,.most.frequently.found.in.the.
stomach.or.proximal.small.intestine
• GISTs.are.often.an.incidental.finding.during.radiology,.endoscopy,.or.
abdominal.surgery.due.to.their.inconspicuous.or.non%specific.nature.
and.low.malignant.potential..
• The.term.stromal reflects.historical.confusion.about.the.origin.of.this.
tumor,.which.is.now.recognized.to.arise.from.the.interstitial.cells.of.
Cajal,.or.pacemaker.cells,.of.the.gastrointestinal.muscularis propria.
• Approximately.75%.to.80%.of.all.GISTs.have.oncogenic,.gain%of%
function.mutations.in.the.receptor.tyrosine.kinase.KIT(CD117).
• Prognosis.correlates.with.tumor.size,.mitotic.index,.and.location.
Epidemiology
• Annual.incidence.is.between.11.and.20.cases.per.million.people.
• Occur.in.middle.age.or.older.individuals.(>40.yrs)..Mean.age.at.
diagnosis.is.64.
Diagnosis(&(Treatment
• Diagnosing.a.GIST.preoperatively.is.challenging,.as.endoscopic.
biopsies.often.do.not.obtain.sufficient.tissue.and.imaging.often.yields.
non%diagnostic.findings.
• CT.scan.with.contrast.is.the.preferred.diagnostic.imaging.study.for.
screening.and.staging.
• PET.scanning.is.not.sufficiently.specific.to.make.a.preoperative.
diagnosis.
• Preoperative.biopsy.is.not.generally.recommended.for.a.resectable
lesion.in.which.there.is.a.high.suspicion.for.GIST.and.the.patient.is.
otherwise.operable..However,.a.biopsy.is.preferred.to.confirm.the.
diagnosis.if.metastatic.disease.is.suspected.
• All.GISTs.≥2.cm.in.size.should.be.surgically.resected.
• Imatinib for.1.year.duration.is.approved.for.adjuvant.treatment.of.
GISTs.≥3.cm.in.size.
Endoscopic.view.of.an.
actively.oozing.20.by.30.
mm.submucosal.mass.in.
the.stomach.body %
Discussion/Conclusion:
1.Why.wasn’t.the.lesion.noted.on.the.Urogram.report.in.2014.or.
in.the.Chest.CT.in.Jan.2017?
2.Was.unnecessary.testing.done.in.search.of.a.preoperative.
diagnosis?
3. Should.open.surgery.have.been.performed?.While.current.
research.recommends.surgical.resection.of.GISTs.>2cm,.the.
patient’s.tumor.could.have.been.resected.laparoscopically.
(although.she.requested.open.surgery).
4.In.an.80%year%old,.widowed,.female.on.Medicare,.was.surgical.
resection.of.the.tumor.necessary.given.its.3+.year.stability?
5.Were.diagnosis.assessments.and.surgical.removal.worth.the.
risks.that.they.posed.to.the.patient,.and.the.psychological.and.
financial.burden.placed.on.the.patient?
6.What.are.potential.problems.associated.with.having.imaging.
done.at.multiple.centers.and.how.can.these.problems.be.
mitigated?
Diagnosing(a(GIST(and(Deviating(from(Tradition:(A(Case(Study
Penelope(Kagan,(BA,(OMSAII,1 Laura(Schoerning,(BA,(OMSAIII,1 Michael(G.(Rowe,(MD2
1Marian(University(College(of(Osteopathic(Medicine,(Indianapolis,(IN,(USA((2(Department(of(General(Surgery,(St.(Vincent(Hospital,(Indianapolis,(IN,(USA
References
Kumar,.V.,.Abbas,.A.K..(2015)..Robbins'and'Cotran Pathologic'Basis'of'Disease..Retrived from.
https://www.clinicalkey.com/#!/browse/book/3%s2.0%C20110055734
Up'To'Date.'(2017,.December.21)..Retrieved.March.18,.2018,.from.
https://www.uptodate.com/contents/epidemiology%classification%clinical%presentation%prognostic%features%
and%diagnostic%work%up%of%gastrointestinal%stromal%tumors%
gist?search=GIST&source=search_result&selectedTitle=1~79&usage_type=default&display_rank=1#H14828
91848
Up'To'Date.'(2017,.September.13)..Retrieved.March.18,.2018,.from.
https://www.uptodate.com/contents/local%treatment%for%gastrointestinal%stromal%tumors%leiomyomas%and%
leiomyosarcomas%of%the%gastrointestinal%
tract?search=GIST%20treatment&source=search_result&selectedTitle=1~79&usage_type=default&display_r
ank=1


Diagnosing a GIST and Deviating from Tradition: A Case Study

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