PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of wjgLink to Publisher's site
 
World J Gastroenterol. 2010 October 21; 16(39): 5005–5008.
Published online 2010 October 21. doi:  10.3748/wjg.v16.i39.5005
PMCID: PMC2957612

Laparoscopic wedge resection of synchronous gastric intraepithelial neoplasia and stromal tumor: A case report

Abstract

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.

Keywords: Laparoscopy, Stomach neoplasm, Gastrointestinal stromal tumor, Gastrectomy, Synchronous neoplasm

INTRODUCTION

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.

CASE REPORT

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.

Figure 1
Computed tomography scan demonstrating a soft tissue mass (arrow) near the lesser curvature of the gastric body.
Figure 2
Gastroscopy revealing a mucosal ulcer (arrow) located in the lesser curvature.

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.

Figure 3
Resected specimens of mucosal ulcer (arrow) and GIST (arrowhead).

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.

Figure 4
Histological features of high-level intraepithelial neoplasia (A) (HE stain, 200 ×) and gastrointestinal stromal tumor (B) (HE stain, 100 ×). Scale bar = 100 μm.
Figure 5
Over-expression of CD117 (A) and CD34 (B) (200 ×). Scale bar = 100 μm.

DISCUSSION

The term of GIST was introduced by Mazur et al[17] 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[16], 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.

Table 1
Summary of previous synchronous gastric epithelial tumors and gastrointestinal stromal tumors in the stomach

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[18]. 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[19].

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[7]. 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)[8]. 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.

Acknowledgments

The authors thank Zhi-Nong Jiang for proofreading the pathological materials.

Footnotes

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

References

1. Maiorana A, Fante R, Maria Cesinaro A, Adriana Fano R. Synchronous occurrence of epithelial and stromal tumors in the stomach: a report of 6 cases. Arch Pathol Lab Med. 2000;124:682–686. [PubMed]
2. Andea AA, Lucas C, Cheng JD, Adsay NV. Synchronous occurrence of epithelial and stromal tumors in the stomach. Arch Pathol Lab Med. 2001;125:318–319. [PubMed]
3. Kaffes A, Hughes L, Hollinshead J, Katelaris P. Synchronous primary adenocarcinoma, mucosa-associated lymphoid tissue lymphoma and a stromal tumor in a Helicobacter pylori-infected stomach. J Gastroenterol Hepatol. 2002;17:1033–1036. [PubMed]
4. Liu SW, Chen GH, Hsieh PP. Collision tumor of the stomach: a case report of mixed gastrointestinal stromal tumor and adenocarcinoma. J Clin Gastroenterol. 2002;35:332–334. [PubMed]
5. Bircan S, Candir O, Aydin S, Başpinar S, Bülbül M, Kapucuoğlu N, Karahan N, Ciriş M. Synchronous primary adenocarcinoma and gastrointestinal stromal tumor in the stomach: a report of two cases. Turk J Gastroenterol. 2004;15:187–191. [PubMed]
6. Wronski M, Ziarkiewicz-Wroblewska B, Gornicka B, Cebulski W, Slodkowski M, Wasiutynski A, Krasnodebski IW. Synchronous occurrence of gastrointestinal stromal tumors and other primary gastrointestinal neoplasms. World J Gastroenterol. 2006;12:5360–5362. [PubMed]
7. Lin YL, Tzeng JE, Wei CK, Lin CW. Small gastrointestinal stromal tumor concomitant with early gastric cancer: a case report. World J Gastroenterol. 2006;12:815–817. [PubMed]
8. Uchiyama S, Nagano M, Takahashi N, Hidaka H, Matsuda H, Nagaike K, Maehara N, Hotokezaka M, Chijiiwa K. Synchronous adenocarcinoma and gastrointestinal stromal tumors of the stomach treated laparoscopically. Int J Clin Oncol. 2007;12:478–481. [PubMed]
9. Lee FY, Jan YJ, Wang J, Yu CC, Wu CC. Synchronous gastric gastrointestinal stromal tumor and signet-ring cell adenocarcinoma: a case report. Int J Surg Pathol. 2007;15:397–400. [PubMed]
10. Salemis NS, Gourgiotis S, Tsiambas E, Karameris A, Tsohataridis E. Synchronous occurrence of advanced adenocarcinoma with a stromal tumor in the stomach: a case report. J Gastrointestin Liver Dis. 2008;17:213–215. [PubMed]
11. Villias C, Gourgiotis S, Veloudis G, Sampaziotis D, Moreas H. Synchronous early gastric cancer and gastrointestinal stromal tumor in the stomach of a patient with idiopathic thrombocytopenic purpura. J Dig Dis. 2008;9:104–107. [PubMed]
12. Kountourakis P, Arnogiannaki N, Stavrinides I, Apostolikas N, Rigatos G. Concomitant gastric adenocarcinoma and stromal tumor in a woman with polymyalgia rheumatica. World J Gastroenterol. 2008;14:6750–6752. [PMC free article] [PubMed]
13. Hsiao HH, Yang SF, Liu YC, Yang MJ, Lin SF. Synchronous gastrointestinal stromal tumor and adenocarcinoma at the gastroesophageal junction. Kaohsiung J Med Sci. 2009;25:338–341. [PubMed]
14. Bi R, Sheng W, Wang J. Collision tumor of the stomach: gastric adenocarcinoma intermixed with gastrointestinal stromal tumor. Pathol Int. 2009;59:880–883. [PubMed]
15. Ozgun YM, Ergul E, Sisman IC, Kusdemir A. Gastric adenocarcinoma and GIST (collision tumors) of the stomach presenting with perforation; first report. Bratisl Lek Listy. 2009;110:504–505. [PubMed]
16. Liu YJ, Yang Z, Hao LS, Xia L, Jia QB, Wu XT. Synchronous incidental gastrointestinal stromal and epithelial malignant tumors. World J Gastroenterol. 2009;15:2027–2031. [PMC free article] [PubMed]
17. Mazur MT, Clark HB. Gastric stromal tumors. Reappraisal of histogenesis. Am J Surg Pathol. 1983;7:507–519. [PubMed]
18. Sugimura T, Fujimura S, Baba T. Tumor production in the glandular stomach and alimentary tract of the rat by N-methyl-N'-nitro-N-nitrosoguanidine. Cancer Res. 1970;30:455–465. [PubMed]
19. Cohen A, Geller SA, Horowitz I, Toth LS, Werther JL. Experimental models for gastric leiomyosarcoma. The effects of N-methyl-N'-nitro-N-nitrosoguanidine in combination with stress, aspirin, or sodium taurocholate. Cancer. 1984;53:1088–1092. [PubMed]
20. Basu S, Balaji S, Bennett DH, Davies N. Gastrointestinal stromal tumors (GIST) and laparoscopic resection. Surg Endosc. 2007;21:1685–1689. [PubMed]
21. Strong VE, Devaud N, Allen PJ, Gonen M, Brennan MF, Coit D. Laparoscopic versus open subtotal gastrectomy for adenocarcinoma: a case-control study. Ann Surg Oncol. 2009;16:1507–1513. [PubMed]

Articles from World Journal of Gastroenterology are provided here courtesy of Baishideng Publishing Group Inc