SYNCHRONOUS ADENOCARCINOMA AND STROMAL SYNCHRONOUS ADENOCARCINOMA AND STROMAL TUMOR OF THE STOMACHTUMOR OF THE STOMACH : A CASE REPORT. : A CASE REPORT.

SYNCHRONOUS ADENOCARCINOMA AND STROMAL SYNCHRONOUS ADENOCARCINOMA AND STROMAL TUMOR OF THE STOMACHTUMOR OF THE STOMACH : A CASE REPORT. : A CASE REPORT.

NUNZIA SCIBETTA - LORENZO MARASA’NUNZIA SCIBETTA - LORENZO MARASA’

Department of Pathology, A.R.N.A.S. Civico, PalermoDepartment of Pathology, A.R.N.A.S. Civico, Palermo

NUNZIA SCIBETTA - LORENZO MARASA’NUNZIA SCIBETTA - LORENZO MARASA’

Department of Pathology, A.R.N.A.S. Civico, PalermoDepartment of Pathology, A.R.N.A.S. Civico, Palermo

INTRODUCTIONINTRODUCTIONINTRODUCTIONINTRODUCTION

The simultaneous development of gastric mesen-The simultaneous development of gastric mesen-chymal tumor and adenocarcinoma has been rarely chymal tumor and adenocarcinoma has been rarely documented in the literature. documented in the literature.

The majority were reported in the Japanese literature The majority were reported in the Japanese literature and regard coexistent adenocarcinoma and leiomyo-and regard coexistent adenocarcinoma and leiomyo-ma or leiomyosarcoma of the stomach. ma or leiomyosarcoma of the stomach.

Recently, Maiorana et al [2000] report 6 cases with syn-Recently, Maiorana et al [2000] report 6 cases with syn-chronous occurrence of epithelial and stromal tumors chronous occurrence of epithelial and stromal tumors in the stomach. in the stomach.

We report a case of synchronous occurrence of ga-We report a case of synchronous occurrence of ga-strointestinal stromal tumor (GIST) and adenocarcino-strointestinal stromal tumor (GIST) and adenocarcino-ma located in different regions of the stomach.ma located in different regions of the stomach.

The simultaneous development of gastric mesen-The simultaneous development of gastric mesen-chymal tumor and adenocarcinoma has been rarely chymal tumor and adenocarcinoma has been rarely documented in the literature. documented in the literature.

The majority were reported in the Japanese literature The majority were reported in the Japanese literature and regard coexistent adenocarcinoma and leiomyo-and regard coexistent adenocarcinoma and leiomyo-ma or leiomyosarcoma of the stomach. ma or leiomyosarcoma of the stomach.

Recently, Maiorana et al [2000] report 6 cases with syn-Recently, Maiorana et al [2000] report 6 cases with syn-chronous occurrence of epithelial and stromal tumors chronous occurrence of epithelial and stromal tumors in the stomach. in the stomach.

We report a case of synchronous occurrence of ga-We report a case of synchronous occurrence of ga-strointestinal stromal tumor (GIST) and adenocarcino-strointestinal stromal tumor (GIST) and adenocarcino-ma located in different regions of the stomach.ma located in different regions of the stomach.

METHODSMETHODSMETHODSMETHODS

A 88-year-old woman , with nausea and abdominal di-A 88-year-old woman , with nausea and abdominal di-scomfort was subjected to esophago-gastro-duodeno-scopy, scomfort was subjected to esophago-gastro-duodeno-scopy, that showed a polypoid mass located on the an-trum. On that showed a polypoid mass located on the an-trum. On small biopsy fragments, a pathologic diagno-sis of small biopsy fragments, a pathologic diagno-sis of adenocarcinoma was rendered. She no showed family adenocarcinoma was rendered. She no showed family history of cancer. Abdominal computed tomogra-phic scans history of cancer. Abdominal computed tomogra-phic scans and thoracic radiographs performed had di-sclosed no and thoracic radiographs performed had di-sclosed no metastatic deposits.metastatic deposits.

Partial gastrectomy was performed. Specimens had been Partial gastrectomy was performed. Specimens had been fixed in 4% formaldehyde and embedded in para-plast. fixed in 4% formaldehyde and embedded in para-plast. Sections were stained with H&E.Sections were stained with H&E.

Immunohistochemistry was performed using a panel of Immunohistochemistry was performed using a panel of antibodies directed against the following antigens:EMA, antibodies directed against the following antigens:EMA, vimentin, desmin, muscle-specific actin, S100 protein, CD34, vimentin, desmin, muscle-specific actin, S100 protein, CD34, CD117, KI 67.CD117, KI 67.

A 88-year-old woman , with nausea and abdominal di-A 88-year-old woman , with nausea and abdominal di-scomfort was subjected to esophago-gastro-duodeno-scopy, scomfort was subjected to esophago-gastro-duodeno-scopy, that showed a polypoid mass located on the an-trum. On that showed a polypoid mass located on the an-trum. On small biopsy fragments, a pathologic diagno-sis of small biopsy fragments, a pathologic diagno-sis of adenocarcinoma was rendered. She no showed family adenocarcinoma was rendered. She no showed family history of cancer. Abdominal computed tomogra-phic scans history of cancer. Abdominal computed tomogra-phic scans and thoracic radiographs performed had di-sclosed no and thoracic radiographs performed had di-sclosed no metastatic deposits.metastatic deposits.

Partial gastrectomy was performed. Specimens had been Partial gastrectomy was performed. Specimens had been fixed in 4% formaldehyde and embedded in para-plast. fixed in 4% formaldehyde and embedded in para-plast. Sections were stained with H&E.Sections were stained with H&E.

Immunohistochemistry was performed using a panel of Immunohistochemistry was performed using a panel of antibodies directed against the following antigens:EMA, antibodies directed against the following antigens:EMA, vimentin, desmin, muscle-specific actin, S100 protein, CD34, vimentin, desmin, muscle-specific actin, S100 protein, CD34, CD117, KI 67.CD117, KI 67.

RESULTSRESULTSRESULTSRESULTS

Grossly the stomach showed a polypoid, ulcerated Grossly the stomach showed a polypoid, ulcerated mass of 5 cm of largest diameter located in the antrum, mass of 5 cm of largest diameter located in the antrum, and a 0,5 cm, subserosal nodule, on section well-and a 0,5 cm, subserosal nodule, on section well-circumscribed, with smooth appearance, located in the circumscribed, with smooth appearance, located in the lesser curvature.lesser curvature.

Microscopic examination revealed that the exophytic Microscopic examination revealed that the exophytic mass was an intestinal-type adenocarcinoma infiltrating mass was an intestinal-type adenocarcinoma infiltrating the submucosa, and the subserosal nodule was a GIST the submucosa, and the subserosal nodule was a GIST with epithelioid cells, with clear cytoplasm and well-with epithelioid cells, with clear cytoplasm and well-defined cell membranes.The non neoplastic gastric defined cell membranes.The non neoplastic gastric mucosa showed chronic gastritis.mucosa showed chronic gastritis.

Grossly the stomach showed a polypoid, ulcerated Grossly the stomach showed a polypoid, ulcerated mass of 5 cm of largest diameter located in the antrum, mass of 5 cm of largest diameter located in the antrum, and a 0,5 cm, subserosal nodule, on section well-and a 0,5 cm, subserosal nodule, on section well-circumscribed, with smooth appearance, located in the circumscribed, with smooth appearance, located in the lesser curvature.lesser curvature.

Microscopic examination revealed that the exophytic Microscopic examination revealed that the exophytic mass was an intestinal-type adenocarcinoma infiltrating mass was an intestinal-type adenocarcinoma infiltrating the submucosa, and the subserosal nodule was a GIST the submucosa, and the subserosal nodule was a GIST with epithelioid cells, with clear cytoplasm and well-with epithelioid cells, with clear cytoplasm and well-defined cell membranes.The non neoplastic gastric defined cell membranes.The non neoplastic gastric mucosa showed chronic gastritis.mucosa showed chronic gastritis.

2 . Intestinal–type, gastric adenocar-cinoma: immunoreactivity for CKAE1

1

2

2

3

1

23

2

3

1 . Intestinal-type, gastric adenocar- cinoma

3 . Intramuscolar- subserosal gastric nodule

1

2

2

3

1

23

2

3

4 . The tumor is composed of epithe-lioid cells with clear cytoplasm

3 4

IMMUNOHISTOCHEMICAL EXAMINATION IMMUNOHISTOCHEMICAL EXAMINATION IMMUNOHISTOCHEMICAL EXAMINATION IMMUNOHISTOCHEMICAL EXAMINATION

Immunohistochemical reactions in the GIST were diffusely Immunohistochemical reactions in the GIST were diffusely positive for CD34 and vimentin, focally positive for CD117, positive for CD34 and vimentin, focally positive for CD117, negative for EMA, S100 protein, desmin, muscle-specific negative for EMA, S100 protein, desmin, muscle-specific actin. The mitoses were <5 mitoses/50HPF.actin. The mitoses were <5 mitoses/50HPF.

Immunohistochemical reactions in the GIST were diffusely Immunohistochemical reactions in the GIST were diffusely positive for CD34 and vimentin, focally positive for CD117, positive for CD34 and vimentin, focally positive for CD117, negative for EMA, S100 protein, desmin, muscle-specific negative for EMA, S100 protein, desmin, muscle-specific actin. The mitoses were <5 mitoses/50HPF.actin. The mitoses were <5 mitoses/50HPF.

VimentinVimentin CD117CD117 CD34CD34

CONCLUSIONSCONCLUSIONSCONCLUSIONSCONCLUSIONS This coexistence of epithelial and stromal gastric tumor raises This coexistence of epithelial and stromal gastric tumor raises

the question of whether such an occurrence is a simple the question of whether such an occurrence is a simple incidental association, or the 2 lesions are connected by a causal incidental association, or the 2 lesions are connected by a causal relationship. Gene mutations might underlie tumor predisposition relationship. Gene mutations might underlie tumor predisposition in patients harbouring a double gastric neoplasia, at present, in patients harbouring a double gastric neoplasia, at present, however, no data are available to support this hypothesis.however, no data are available to support this hypothesis.

A tumorigenic agent interacting with 2 neighboring tissues could A tumorigenic agent interacting with 2 neighboring tissues could produce development of tumors of different histotypes in the produce development of tumors of different histotypes in the same organ and experimental evidence for this possibility has same organ and experimental evidence for this possibility has been provided.been provided.

Investigating the molecular alterations in cases such as this one Investigating the molecular alterations in cases such as this one will possibly shed interesting light on the mechanism of will possibly shed interesting light on the mechanism of tumorigenesis.tumorigenesis.

MAIN REFERENCEMAIN REFERENCE Maiorana A. et al.- Maiorana A. et al.- Arch Pathol Lab MedArch Pathol Lab Med 124 : 682 – 686 ; 124 : 682 – 686 ; 2000.2000.

This coexistence of epithelial and stromal gastric tumor raises This coexistence of epithelial and stromal gastric tumor raises the question of whether such an occurrence is a simple the question of whether such an occurrence is a simple incidental association, or the 2 lesions are connected by a causal incidental association, or the 2 lesions are connected by a causal relationship. Gene mutations might underlie tumor predisposition relationship. Gene mutations might underlie tumor predisposition in patients harbouring a double gastric neoplasia, at present, in patients harbouring a double gastric neoplasia, at present, however, no data are available to support this hypothesis.however, no data are available to support this hypothesis.

A tumorigenic agent interacting with 2 neighboring tissues could A tumorigenic agent interacting with 2 neighboring tissues could produce development of tumors of different histotypes in the produce development of tumors of different histotypes in the same organ and experimental evidence for this possibility has same organ and experimental evidence for this possibility has been provided.been provided.

Investigating the molecular alterations in cases such as this one Investigating the molecular alterations in cases such as this one will possibly shed interesting light on the mechanism of will possibly shed interesting light on the mechanism of tumorigenesis.tumorigenesis.

MAIN REFERENCEMAIN REFERENCE Maiorana A. et al.- Maiorana A. et al.- Arch Pathol Lab MedArch Pathol Lab Med 124 : 682 – 686 ; 124 : 682 – 686 ; 2000.2000.