PENINSULAR MALAYSIA EAST COAST GASTROENTEROLOGY AND HEPATOLOGY MEETING

Dr Yeong Yeh LeeMD MRCP (UK) MMed

Lecturer/Physician

Department of Medicine Dec 2007

History and Physical Findings

• 44 years old Chinese gentleman• Admitted 31.10.06 with melaena and symptomatic

anaemia for 1 week • Weight loss 7 kg past 10 months. Appetite good• No past medical illnesses• Social alcohol drinker. Non-smoker• Normal abdominal findings• No palpable lymph nodes• Started on pantoprazole and was given blood tranfusions

OGDS Findings

• There were 2 large extramucosal masses compressing on the lesser curvature. The surface was smooth and regular

• Melaenic stool was seen covering the surface• Mild antral gastritis• CLO negative• Multiple deep biopsies were taken from the center of the

protruding mass and sent for HPE

OGDS Findings

CT Scan Abdomen Findings

• Well defined smooth outline enhancing mass from the anterior and posterior wall of stomach extending from body to antrum

• The mass measured 8.4 x 8.5 x 6.6 cm• No calcification or necrosis seen• No clear plane of demarcation between left lobe liver,

splenic flexure and certain part of pancreas suggesting infiltration

• Well defined enhancing lobulated mass in pancreatico-duodenal group of lymph nodes closed to SMV measuring 2.8 cm and aorto-caval region measuring 0.9 cm

CT Scan Findings

Blood results

• WBC 8.19x103/mm3

• Hb 10.2 g/dl• FBP: hypochromic microcytic anaemia. WBC normal

morphology• LFT/RFT Normal• HIV EIA negative• LDH 250 iu/l• Alpha-fetoprotein negative• CEA negative

Differential?

• ? Lymphoma of Stomach• ? Leiomyosarcoma of Stomach• ? Gastrointestinal Stroma Tumour (GIST)

What to do next?

• Endoscopic ultrasound (EUS) and FNAC?• Staging laparatomy with distal gastrectomy?

Histology Findings from Distal Gastrectomy

• Gross: The 9cm tumour arises from submucosa and completely encapsulated by fibrous tissue. The parenchyma is lobulated, solid and pale in colour

• Microscopic: pleomorphic cells with round to spindle shaped nuclei with abundant eosinophilic cytoplasm. In some areas, tumour cells show infiltration into muscular wall. No vascular invasion. All surgical margin free from tumour. Mitosis 6 in 50 per Hpf

• Immunochemistry: CD117 positive

Vimentin positive

CD 34 positive

Desmin negative

S-100 negative

Histology

Epitheloid cells

Immunochemistry stain with CD 117

Diagnosis

• Gastrointestinal Stromal Tumour (GIST)

- High Risk

- Complete resection

Guidelines for predicting behaviour of tumour using size of  tumour and mitotic count/ 50HPF 

(Berman  2001 ; Fletcher et al 2002)

                 Size cm   Mitotic count   • Very low risk    <2         <5     • Low risk            2- 5         <5• Intermediate risk  < 5      6 - 10

                        5-10        < 5 • High risk         >  5         > 5

                       > 10        any                       any        > 10

Is molecular analysis necessary?

• Is c-kit analysis necessary in all cases of GIST?

Management

• PET scan did not show any relapse (high uptake) after gastrectomy

• The oncology did not start him on glivec (imatinib mesylate)

• Currently on follow-up 3/12ly with CT scan

Glivec?

• Is Glivec (imatinib mesylate) indicated in this case?