© 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
Summary
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
INTRODUCTION
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).
CASE REPORT
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.
Powyżej zamieściliśmy fragment artykułu, do którego możesz uzyskać pełny dostęp.
Mam kod dostępu
- Aby uzyskać płatny dostęp do pełnej treści powyższego artykułu albo wszystkich artykułów (w zależności od wybranej opcji), należy wprowadzić kod.
- Wprowadzając kod, akceptują Państwo treść Regulaminu oraz potwierdzają zapoznanie się z nim.
- Aby kupić kod proszę skorzystać z jednej z poniższych opcji.
Opcja #1
19 zł
Wybieram
- dostęp do tego artykułu
- dostęp na 7 dni
uzyskany kod musi być wprowadzony na stronie artykułu, do którego został wykupiony
Opcja #2
49 zł
Wybieram
- dostęp do tego i pozostałych ponad 7000 artykułów
- dostęp na 30 dni
- najpopularniejsza opcja
Opcja #3
119 zł
Wybieram
- dostęp do tego i pozostałych ponad 7000 artykułów
- dostęp na 90 dni
- oszczędzasz 28 zł
Piśmiennictwo
1. Berton F, Gola G, Wilson SR: Perspective on the Role of Transrectal and Transvaginal Sonography of Tumors of the Rectum and Anal Canal. Am J Rad 2008; 190: 1495-1504. 2. Zawisza A, Milewski J, Rydzewska G: Nowotwory stromalne przewodu pokarmowego. [W:] Wybrane zagadnienia gastroenterologii praktycznej. Małecka-Panas E, Rydzewska G (red.). Termedia Wydawnictwa Medyczne; Poznań 2007, 103-113. 3. Cichoż-Lach H, Kasztelan-Szczerbińska B, Słomka M: Stromalne guzy przewodu pokarmowego – epidemiologia, obraz kliniczny, diagnostyka, rokowanie oraz zasady leczenia. Pol Arch Med Wewn 2008; 118(4): 216-221. 4. Pietruszka M, Toczko Z: Olbrzymi guz podścieliskowy przewodu pokarmowego (GIST) – opis przypadku. Pol Przegl Chir 2006; 78: 51-58. 5. Prywiński S, Szopiński J, Wierzchowski P, Dąbrowicki S: Guz jelita cienkiego typu GIST jako przyczyna masywnego krwawienia do przewodu pokarmowego – opis przypadku. Chir Pol 2008; 10(2): 107-112. 6. Jaworski R, Zieliński J, Gross M, Kopacz A: Enormous gastrointestinal stromal tumor – a case report. J Onkol 2008; 58(1): 55-57. 7. Milnerowicz S, Strutyńska-Karpińska M, Markowska-Woyciechowska A, Rabczyński J. Guz stromalny przestrzeni zaotrzewnowej wywodzący się z dwunastnicy – przedstawienie przypadku. Adv Clin Exp Med 2005; 14(1): 175-178. 8. Miettinen M, Lasota J: Gastrointestinal Stromal Tumors (GISTs): Definition, Occurrence, Pathology, Differential Diagnosis and Molecular Genetics. Pol J Pathol 2003; 54(1): 3-24. 9. Miettinen M, Lasota J: Gastrointestinal Stromal Tumors: Review on Morphology, Molecular Pathology, Prognosis, and Differential Diagnosis. Arch Path Lab Med 2006; 130(10): 1466-1478. 10. Miettinen M, El-Rifai WE, Sobin LH, Lasota J: Evaluation of malignancy and prognosis of gastrointestinal stromal tumors: a review. Hum Pathol 2002; 33: 478-483. 11. Todoroki T, Sano T, Samurai S et al.: Primary omental Gastrointestinal stromal tumor (GIST). World J Surg Oncol 2007; 5: 66. 12. Zaręba K, Kamocki Z, Hołody-Zaręba J et al.: Rzadki przypadek współistnienia gruczolakoraka, raka endokrynnego i guza stromalnego żołądka; Przegl Gastro 2010; 5(5): 297-300. 13. Lau S, Lui CY, Yeung YP et al.: Gastrointestinal stromal tumor of rectum: a report of 2 cases. J Comput Assist Tomogr 2004; 27: 609 -615 14. Nasu K, Ueda T, Kai S et al. Gastrointestinal stromal tumor arising in the rectovaginal septum. Int J Gynecol Cancer 2004; 14: 373-377. 15. Tan GY, Chong CK, Eu KW, Tan PH: Gastrointestinal stromal tumor of the anus. Tech Coloproctol 2003, 7: 169-172. 16. Nigri GR, Dente M, Valabrega S et al.: Gastrointestinal stromal tumor of the anal canal: an unusual presentation. World J Surgl Oncol 2007; 5: 20. 17. Fletcher CD, Berman JJ, Corless C et al.: Diagnosis of gastrointestinal stromal tumors: a consensus approach. Int J Surg Pathol 2002; 10: 81-89. 18. Wroński M, Cebulski W, Pawłowski W, Krasnodębski IW: Trudności diagnostyczne u chorych z guzem stromalnym przewodu pokarmowego. Przegl Gastr 2006; 1(3): 115-120. 19. Panzironi G, Manganaro L, Ricci F et al.: A case of rectal GIST: findings of MR-spiral CT imaging and transrectal ultrasound guided biopsy. Eur J Rad Extra 2003; 47(2): 66-69. 20. Yeun Jung Lim, Hee Jung Son, Jong-Soo Lee et al.: Clinical course of subepithelial lesions detected on upper gastrointestinal endoscopy. World J Gastroenterol 2010; 16(4): 439-444. 21. Aydin A, Tekin F, Günşar F et al.: Value of endoscopic ultrasonography for upper gastrointestinal stromal tumors: a single center experience 2004; 15(4): 233-237. 22. Lau S, Tam KF, Kam CK et al.: Imaging of gastrointestinal stromal tumor (GIST). Clin Radiol 2004; 59: 487-498. 23. Chak A: EUS in submucosal tumors. Gastro Endosc 2002; 56 (Suppl. 4): S43-49. 24. Velasco S, Milin S, Maurel C et al.: Scanographic features of gastrointestinal stromal tumors. Gastro Clin Biol 2008; 32(12): 1001-1013. 25. Santos Fernandes G, Cutait de Castro Cotti G, Freitas D et al.: Downstaging of a rectal gastrointestinal stromal tumor by neoadjuvant imatinib therapy allowing for a conservative surgical approach. CLINICS 2009; 64(8): 819-821. 26. McAuliffe JC, Hunt KK, Lazar AJF et al.: A Randomized, Phase II Study of Preoperative plus Postoperative Imatinib in GIST: Evidence of Rapid Radiographic Response and Temporal Induction of Tumor Cell Apoptosis. Ann Surg Onkol 2009; 16: 910-919. 27. Nakamura T, Ihara A, Mitomi H et al.: Gastrointestinal Stromal Tumor of the Rectum Resected by Laparoscopic Surgery: Report of a Case. Surg Today 2007; 37: 1004-1008. 28. Ebihara Y, Okushiba S, Kawarada Y et al.: Neoadjuvant imatinib in a gastrointestinal stromal tumor of the rectum: Report of a case. Surg Today 2008; 38: 174-177. 29. DeMatteo RP, Lewis JJ, Leung D et al.: Two hundred gastrointestinal stromal tumors: recurrence patterns and prognostic factors for survival. Ann Surg 2002; 31: 51-58.
