Selected Articles from the
Journal Abdominal Surgery

This article originally appeared in the Spring, 2007 issue of the Journal.

Malignant Gastrointestinal stromal tumor of stomach masquerading as a mesenteric cyst.

Dr. RCM Kaza, MS
Professor

Dr. Shailesh C. Sahay, MBBS
Resident

Dr. Abhishek Maru, MBBS
Resident

Dr. Jasvinder Singh, MBBS
Resident

Correspondence to:
Department of Surgery,
Maulana Azad Medical College & Associated
Lok Nayak Hospital, New Delhi, India

Communication Address
Dr. S.K. Jain,
171, Bank Enclave,
Laxmi Nagar,
Delhi-110092, India
Email: sudhirkumar11@gmail.com

ABSTRACT
Gastrointestinal stromal tumor (GIST) of stomach presenting as palpable, large mobile lump is very unusual. Most of the malignant GIST occurs in the stomach usually as submucosal small tumor that is slow growing and usually found incidentally. Giant GIST of stomach presenting as palpable mass is extremely rare and so far only three cases have been reported in indexed publications. A 45 year old female presented with progressively increasing, mobile lump in the right upper abdomen. Clinical examination and Computed Tomographic Scan (CT scan) findings suggested possibility of mesenteric cyst. Exploratory laparotomy was performed which showed a cystic lesion arising from greater curvature of stomach. On histopathology of the resected specimen it was found to be malignant GIST of stomach.

INTRODUCTION
Gastrointestinal stromal tumor (GIST) of stomach usually presents as an asymptomatic small submucosal lesion detected incidentally at endoscopy or rarely as upper GI bleed. Here we report a GIST of stomach presenting as freely mobile large intra abdominal lump masquerading as a mesenteric cyst without any upper GI symptoms.

CASE REPORT
A 45 year old female presented with history of progressively increasing lump in the right upper abdomen for the last 3 years associated with pain and constipation for last 6 months without any history of vomiting, malena, hematemesis, loss of appetite or weight loss. On examination there was a 15x10 cm lump in the umbilical region extending into epigastrium and the right lumbar region. The lump was freely mobile in horizontal direction with reduced mobility in the vertical direction (fig 1). Rest of the physical examination was unremarkable.

Figure 1 Computed tomographic (CT) scan of abdomen suggested the possibility of a cystic lesion arising from the mesentery of small bowel (fig 2).

An exploratory laparotomy was performed which showed a cystic lesion arising from distal half of greater curvature of stomach with few enlarged surrounding lymph nodes (fig 3). A distal gastrectomy with Billroth II Hoffmeister type Gastrojejunostomy was performed. Post operative period was unremarkable and patient was discharged after 7 days. Histopathology of the resected specimen was suggestive of malignant GIST with clear resected margins and negative lymph nodes. Patient remain well on 1 year of follow up.

DISCUSSION
Two third of all gut malignant GIST occur in the stomach. These are submucosal small tumors that are slow growing and usually found incidentally, though they occasionally may ulcerate and cause impressive bleeding¹. Larger lesions generally produce symptoms of weight loss, abdominal pain, fullness, early satiety and bleeding. GIST of stomach presenting as palpable, large mobile lump is very unusual². In this case the tumor was subserosal in location presenting as mobile intra abdominal lump without any mucosal ulceration or upper GI bleed. Three cases of giant GIST of stomach presenting as a palpable abdominal mass has been reported in indexed publications. Okuda et al reported a case of giant GIST of stomach presenting as an abdominal lump, dizziness, malaise, and fever³.A pedunculated giant GIST of the stomach with extra gastric growth was reported by Kimura et al⁴. Giant GIST of stomach rupturing into gastric lumen has also been reported⁵.

Figure 1

Figure 2

Figure 3

REFERENCES

1. Burkill GJ, Badran M, Al muderis O, et al. Malignant Gastrointestinal Stromal tumor; Distribution, Imaging features, and pattern of metastatic spread. Radiology 226:527, 2003.

2. Miettian M, El Rifai W, HL Sobin L, Lasota J: evaluation of malignancy and prognosis of GI stromal tumors: A review. Hum Pathol 33: 478, 2002.

3. Okuda H, Tanaka H, Ueno M et al. A case of giant GIST of the stomach successfully treated with Imatinib Mesylate Neoadjuvant therapy and followed post operatively. Gan T Kagaku Ryoho.32(12):1941-4,2005.

4. Kimura H, Yoshida T, Kinoshita S, Takahashi I . Pedunculated giant gastrointestinal tumor of the stomach showing extragastric growth: report of a case. Surg Today, 34(2):159-62,2004.

5. Mehta RM, Sudheer V O, John AK et al. Spontaneous rupture of giant gastric stromal tumor into gastric lumen. World J Surg Oncol, 3(1):11,2005.