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Correspondence to: Xiao-Wu Xu, MD, Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun road, Hangzhou 310016, Zhejiang Province, China. moc.361@77uwoaixux
Telephone: +86-571-86006445 Fax: +86-571-86044817
Synchronous occurrence of epithelial neoplasia and gastrointestinal stromal tumor (GIST) in the stomach is uncommon. Only rare cases have been reported in the literature. We present here a 60-year-old female case of synchronous occurrence of gastric high-level intraepithelial neoplasia and GIST with the features of 22 similar cases and detailed information reported in the English-language literature summarized. In the present patient, epithelial neoplasia and GIST were removed en bloc by laparoscopic wedge resection. To the best of our knowledge, this is the first reported case treated by laparoscopic wedge resection.
Synchronous occurrence of epithelial neoplasia and gastrointestinal stromal tumor (GIST) in the stomach is uncommon. Only few case reports can be found in the literature[1-16]. We present here a case of synchronous occurrence of gastric high-level intraepithelial neoplasia and GIST in the body of stomach, close to the cardia. Epithelial neoplasia and GIST were removed en bloc by laparoscopic wedge resection. To the best of our knowledge, this is the first reported case treated by laparoscopic wedge resection. In addition, we also summarized the features of 22 similar cases with detailed information reported in the English-language literature.
A 60-year-old woman was admitted to our department in June 2009 because of epigastric pain for three months. She had no fever, nausea or vomiting, hematemesis or melena, and weight loss. Physical examination showed no abnormalities. Blood biochemistry was within the normal range. Computed tomography (CT) of the abdomen with intravenous contrast demonstrated a soft tissue mass measuring 5 cm × 5 cm in size with a clear borderline near the lesser curvature of the gastric body, which was consistent with a GIST (Figure (Figure1).1). Gastroscopy revealed a mucosal ulcer about 1 cm in diameter located in the lesser curvature of the stomach, 3 cm away from the cardia (Figure (Figure2).2). Histological examination of the specimen from the ulcer showed high-level intraepithelial neoplasia with positive Helicobacter pylori.
During laparoscopic exploration, an extramural pedunculated mass, approximately 5 cm in diameter, was located in the lesser curvature of the gastric body. By intraoperative gastroscopic injection of methylene blue, the mucosal ulcer was localized proximate to the extramural tumor, with 2 cm in between. Laparoscopic wedge resection of the two lesions was performed with triple endoscopic linear staplers (Endocutter 60 staple, green cartridge; Ethicon, Endo-Surgery, Cincinnati, OH, USA) (Figure (Figure3).3). Intraoperative frozen section of the resected margins was free of tumor. The operation time was 150 min and intraoperative bleeding was 50 mL. The postoperative course was uneventful, and the patient was discharged 4 days later. She was followed up and abdominal CT and upper gastrointestinal imaging 6 mo after operation showed no signs of recurrence.
Histopathological examination of the mucosal ulcer revealed high-grade intraepithelial neoplasia (Figure (Figure4A)4A) without lymph node metastasis (0/8), while the extramural mass was verified as a stromal tumor consisted of spindle to ovoid-shaped mesenchymal cells arranged in interlacing bundles or sheets (Figure (Figure4B).4B). The cells demonstrated eosinophilic cytoplasm and single elongated nuclei with a moderate level of mitotic activity (3 mitoses per 50 HPF, H&E stain). Immunohistochemical staining was positive for CD117 (Figure (Figure5A)5A) and CD34 (Figure (Figure5B)5B) but negative for SMA, S-100 and Desmin.
The term of GIST was introduced by Mazur et al in 1983 in order to indicate a distinct heterogeneous group of mesenchymal neoplasms of spindle or epithelioid cells with varying differentiation. GIST occurs from the lower esophagus to the anus, with its most common site in the stomach. However, simultaneous occurrence of GIST and epithelial tumor in the stomach is uncommon. To the best of our knowledge, 44 cases have been reported in the English-language literature[1-16]. The largest published study consisted of 22 cases, but without detail information. The remaining 22 cases (12 males and 10 females) at the age of 64-82 years (mean 74.6 years) are listed in Table Table1.1. Of the 22 cases, 20 had adenocarcinoma and 2 had carcinoid.
The simultaneous development of gastric epithelial and stromal tumors, especially two cases of collision tumor composed of gastric adenocarcinoma intermingled with primary GIST[4,14], indicating that such an occurrence is intrinsically connected. An interesting hypothesis is that a single carcinogenic agent can interact with 2 neighboring tissues, inducing the development of tumors of different histotypes in the same organ, and experimental evidence for this possibility has been provided[18,19]. Oral administration of N-methyl-N9-nitro-N-nitrosoguanidine induces the development of gastric adenocarcinomas in rats. When it is used in combination with other agents that alter the gastric mucosal barrier, such as aspirin or stress, leiomyosarcoma develops in conjunction with epithelial tumor.
Although many surgeons have realized the possibility of simultaneous development of gastric epithelial and stromal tumors, it is still difficult to diagnose it before operation. In our reviewed cases, simultaneous gastric adenocarcinoma and GIST were confirmed only in 1 case by histological examination before operation. To increase the preoperative diagnostic rate of synchronous tumors, enhanced abdominal CT scan, gastroscopy and endoscopic ultrasonography have been recommended. Careful exploration of residual stomach intraoperatively is also important to avoid missing GIST when it is too small to be found by image examination.
It has been reported that laparoscopic surgery for early gastric cancer and GIST is safe, valid, and minimally invasive[20,21]. However, rare reports are available on laparoscopic resection of synchronous gastric epithelial tumor and GIST. In our reviewed cases, only 1 case was treated by laparoscopic procedure (laparoscopy-assisted distal gastrectomy + laparoscopic wedge resection). In our case, complicated lymphadenectomy was not needed for either gastric high-level intraepithelial neoplasia or GIST located in the same region with only 2 cm in distance, that makes laparoscopic wedge resection a optimal choice for the patient. Because of the close location of the lesions to the cardia, care should be taken not to injure the esophagocardial junction while firing the stapler. Intraoperative gastroscopy is a simple and effective procedure for the complete excision of tumors and intactness of esophagocardial junction.
The authors thank Zhi-Nong Jiang for proofreading the pathological materials.
Peer reviewer: Stephen M Kavic, MD, FACS, Assistant Professor of Surgery, Department of Surgery, University of Maryland School of Medicine, 22 South Greene Street, Room S4B09, Baltimore, MD 21201, United States
S- Editor Sun H L- Editor Wang XL E- Editor Zheng XM