© Borgis - New Medicine 3/2013, s. 84-87
*Wiesława B. Duda-Król1, Małgorzata Kołodziejczak2, Iwona Sudoł-Szopińska2,3,4, Marlena Woch1, Michał Adamczyk5, Artur Mamcarz1
Atypical location of a stromal cell carcinoma in the rectal wall – a case report
1Third Clinic of Internal Medicine and Cardiology of the Medical University of Warsaw, Solec Hospital, Warsaw
Head of Clinic: Artur Mamcarz, MD, PhD
2General Surgery Department with Proctology Subdivision, Solec Hospital, Warsaw
Head of Department: Jacek Bierca, MD, PhD
Head of Proctology Subdivison: Małgorzata Kołodziejczak, MD, PhD
3Radiology Department, Institute of Rheumatology, Warsaw
Head of Department: prof. Sudoł-Szopińska, MD, PhD
4Department of Diagnostic Imaging, Warsaw Medical University
Head of Department: prof. Wiesław Jakubowski, MD, PhD
5Diagnostic Imaging Department, Central Clinical Hospital of the Ministry of Internal Affairs & Administration, Warsaw
Head of Department: prof. Jerzy Walecki, MD, PhD
Gastrointestinal stromal tumours (GIST) are rare proliferative lesions arising from the mesenchyme. In the United States, there are approximately 5000 cases diagnosed per year. The incidence of GISTs in males and females is equal. Only in about 5% of the cases, these lesions occur in the large intestine – whether in the submucosal, intramural or subserosal location. Approximately 10-30% of the GISTs have an asymptomatic course, and are incidentally diagnosed during imaging or surgical procedures performed for other indications. This article presents the case of a 74-year old female, who was found to have a stromal tumor in the wall of the rectum. The initial diagnosis was based on a proctological examination, anorectal endosonography and computed tomography. The final diagnosis was established based on histological analysis of material obtained via core-needle biopsy. The patient was referred to the Institute of Oncology, where she was qualified for neoadjuvant therapy, and later underwent surgery. A two-year observation period did not reveal any local recurrence or distant metastases.
GISTs occur very rarely in the rectum and thus pose a diagnostic challenge. Endosonography and computed tomography are useful in determining the location of the tumor with respect to the pelvic structures. The final diagnosis rests upon histopathological and immunohistochemical analysis of material obtained via core-needle biopsy.
Abbreviations: GIST = Gastrointestinal stromal tumors, BMI = body mass index, CT = computed tomography, MRI = magnetic resonance imaging
Gastrointestinal stromal tumors (GISTs) are rare proliferative lesions arising from the mesenchyme, which constitute only 1-3% of primary malignant gastrointestinal tumors (1, 2). In the United States, there are approximately 5000 cases diagnosed per year, with an equal incidence among males and females (3-5). The peak in their incidence usually occurs in the 5th-7th decade of life, but the tumors can sporadically occur in younger patients (3, 6, 7). GISTs are most often located in the stomach (60-70%), small intestine (25-35%), rarely in the large intestine (5%), esophagus (2-3%), and sporadically in the omentum, mesentery, or in the retroperitoneal space (7-12). GISTs in the rectum have thus far been described in only a few articles (13-16).
GIST location may be submucosal, intramural or subserosal. In approximately 10-30% of cases the tumors are asymptomatic. They are characterized by local proliferation, which could lead to compression of the mucous membrane and trophic disturbances with possible necrosis and subsequent ulceration (3). GISTs most commonly metastasize to the liver, peritoneum; sporadically to the lungs, pleura, bones; and there are rare reports of brain metastases. The prognosis depends on the size of the tumor, its mitotic index (the ratio of the number of cells undergoing mitosis to the total number of cells), and the depth of its infiltration into the mucous membrane (3, 8-10).
A 74-year old female was admitted electively to the Third Clinic of Internal Medicine and Cardiology of the Medical University of Warsaw for diagnosis of a lesion detected in the rectal wall on rectal examination. The patient’s medical history revealed pain in the perineal and coccygeal area, unrelated to defecation, that had lasted for about 6 months prior to admission. Initially, this pain responded to oral nonsteroidal anti-inflammatory drugs (NSAIDs), but in the month prior to admission it increased in severity, and was accompanied by tenesmus. The patient denied weight loss and increased temperature; her stools were normal. The patient’s past medical history included peptic ulcer disease (for which she periodically took proton pump inhibitors (PPIs]), arterial hypertension (effectively controlled with an angiotensin receptor blocker (ARB) and a calcium channel blocker (CCB)), spondyloarthrosis, and smoking for many years.
On examination the patient was in overall good condition, BMI 25 kg/m2. The physical examination did not reveal any abnormalities. Laboratory tests, aside from leukocyturia with a negative urine culture, did not show any abnormalities. Tumor marker levels (CEA, AFP, and CA 125) were within normal limits. Gastroscopy showed gastritis with erosions and a focus of angiodysplasia in the duodenal bulb (ablated with Argon plasma coagulation). A rectal examination revealed a hard submucosal tumor, with a diameter of approximately 5 cm, on the left wall of the rectum, whose distal end reached approximately 2 cm from the anal margin. On anoscopy, stage I/II hemorrhoids were seen. Colonoscopy did not show any lesions in the colon, but the tumor which had been palpated on examination, measuring approximately 4 x 3 cm, was seen 2 cm above the anal sphincters, located on the left and partially also on the posterior walls of the rectum.
Initial diagnosis: a tumor of the rectal wall. Samples were taken for histopathology. The samples showed preserved glandular structure with a single lymph follicle and evidence of hyperemia and thickening of the muscularis mucosa. Immunohistochemical stains for CD 117 were negative.
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