Gastrointestinal stromal tumor with ulceration - stomach

Case contributed by Jose Antonio Habana
Diagnosis certain

Presentation

Epigastric pain and melena

Patient Data

Age: 65 years
Gender: Female

Large (11.2 x 5.7 x 5.3 cm) peripherally enhancing endoluminal mass arising from the lesser curvature of the stomach.

Ulceration is noted in its lateral aspect, with air bubbles in the ulcer cavity. Few bubbles of air are seen streaming from the ulcer orifice, in keeping with Torricelli-Bernouli sign.

Case Discussion

Torricelli-Bernoulli sign refers to air bubbles within and sometimes streaming from an ulcer cavity of a gastrointestinal tumor on cross-sectional imaging. In the upright position, the mass is located superior to the air-fluid level of the stomach. As the patient moves to a supine position for imaging, the ulcer orifice falls below the air-fluid level, which causes fluid to enter the ulcer lumen, displacing the air previously within the ulcer cavity. A stream of air bubbles coming out of the ulcer cavity may sometimes be identified.

The patient underwent gastrectomy.

Pathology report:

11.5 x 6.5 x 5.5 cm ovoid to slightly nodular submucosal mass which invades the lamina propria and muscularis propria but not beyond the serosa. It exhibits an ulcerated area measuring 1.5 cm. Serial sections of the mass revealed a solid, homogeneous tan surface. Histologic sections disclose a tumor composed of neoplastic spindle cells having ovoid to elongated nuclei with blunt ends, inconspicuous nucleoli, fine to slightly coarse chromatin, and ample eosinophilic cytoplasm with occasional paranuclear vacuoles. Mitosis is noted at 3 to 4 per 50 high power fields. Tumor necrosis is not identified. All regional lymph nodes are uninvolved by tumor.

Immunohistochemistry results are positive for CD117, DOG1, and SMA (weak).

Diagnosis: Gastrointestinal stromal tumor (GIST) with moderate risk

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