Presentation
Abdominal discomfort, dyspepsia
Patient Data
A large lobulated heterogeneously enhancing mass with a necrotic component at the left hypochondriac region, measuring approximately 13 x 9 x 11cm (AP x W x CC). Medially, no clear fat plane with the stomach wall. The stomach appears to be compressed by the mass. Posteriorly, the mass is displacing and abutting the spleen. No clear demarcation between the mass and part of the left liver lobe. Laterally, the mass is abutting the left lateral abdominal wall. No internal calcification.
No bowel-related mass or abnormal bowel dilatation.
Reverse attenuation of the liver-spleen in keeping with fatty liver. Few well-defined hypodense lesions in segments II, III, VI and VII of the liver. These may represent liver cysts. However, cystic metastasis cannot be excluded.
Absence of gallbladder in keeping with previous cholecystectomy. Prominent common bile duct.
Pancreas is atrophic. No focal pancreatic parenchymal lesion.
Bilateral small renal cysts with no complex features.
No enlarged abdominal lymphadenopathy.
Case Discussion
Findings are suggestive of gastrointestinal stromal tumor with mass effect without evidence of local infiltration on imaging.
The patient underwent trucut biopsy of the left hypochondrial mass for further operative planning.
Histopathological examination:
Levels show cores of cellular tumor tissue formed by interlacing fascicles of spindle cells. The cells are fairly uniform. They possess pale fibrillary eosinophilic cytoplasm, elongated nuclei with fine chromatin and inconspicuous nucleoli. Paranuclear vacuoles are easily seen. Rare mitotic figures are found (<5 mitoses per 5 mm2). No tumor necrosis is identified.
Immunohistochemistry: The spindle cells are diffusely and strongly positive for c-kit (CD117) and CD34.
Focal and weak smooth muscle actin (SMA) expression is also seen. They are negative for cytokeratin (AE1/3), desmin and S-100.
Interpretation:
Gastrointestinal stromal tumor (GIST)
GIST can occur from any part of gastrointestinal tract, the commonest is stomach, followed up small bowel, large bowel and esophagus 1,2.
Abdominal lymphadenopathy is the typical feature of GIST.
Differential diagnosis could be gastric lymphoma with presence of multiple lymphadenopathy.
GIST can metastasize to liver, mesentery, omentum, bone and lung 2.
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