Presentation
Severe gastrointestinal blood loss.
Patient Data
Lobulated soft tissue with peripheral enhancement, central low attenuation, and a few coarse calcifications centered in the mid left abdominal small bowel (jejunum). No surrounding desmoplastic reaction. No adenopathy or metastases.
Arrows indicate the location of the jejunal soft tissue mass.
MICROSCOPIC DESCRIPTION: Gastrointestinal Stromal Tumor (GIST)
Procedure: Partial small bowel resection.
Tumor Site: Proximal jejunum.
Tumor Size: 3.5 X 3.0 X 2.5 cm.
Tumor Focality: Unifocal.
GIST Subtype: Spindle cell.
Mitotic Rate: 0/50 HPF.
Necrosis: Present; <5%
Histologic Grade: Low grade.
Risk Assessment: Low.
Margins: Free of tumor.
Pathologic Staging: pT2.
Ancillary Studies: KIT (CD117) and CD34 positive; s100, desmin, cytokeratin negative.
Preresection Treatment: None.
FINAL DIAGNOSIS:
Proximal jejunum, partial resection - Gastrointestinal stromal tumor (GIST).
Case Discussion
The most alarming thing about this case is just how subtle the mass is: the use of oral contrast in this case was nearly counter-productive, as the density of the small bowel contrast makes it easy to overlook the coarse calcifications within the mass. This case also is a great reminder to very carefully run the small bowel, particularly when there is a high clinical suspicion.
GISTs are the most common mesenchymal neoplasm of the gastrointestinal tract. They can occur in the stomach, bowel, omentum, retroperitoneum, or mesentery. They are characterized by the expression of KIT, a tyrosine kinase growth factor receptor, which is the basis for targeted drug therapy with imatinib (Gleevac), a tyrosine kinase inhibitor. About 20-30% of GISTs are malignant. The clinical presentation can range from asymptomatic to local invasion with bleeding and ulceration (as in this case).
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