DOI: 10.5958/j.2319-5886.2.2.

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International Journal of Medical Research & Health Sciences

www.ijmrhs.com
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Volume 2 Issue 2 April-June

Coden: IJMRHS
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Copyright @2013

ISSN: 2319-5886

Received: 7 Mar 2013 Case Report

Revised: 28 Mar 2013

Accepted: 31st Mar 2013

A RARE CASE OF GIST PRESENTED AS LEIOMYOMA *Hiremath PB1, Nidhi Bansal2 , Meenal C3 , Thulasiraman VN 4, Arun Kumar SP5, Reshma Hiremath6
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Associate Professor, 2 Assistant Professor, 3 Professor & Head, Dept. of Obstetrics & Gynaecology, SVMCH & RC, Ariyur, Puducherry 4 Professor, Dept. of General Surgery, SVMCH & RC, Ariyur, Puducherry 5 Professor & Head , Dept. of Pathology, SVMCH & RC, Ariyur, Puducherry 6 IMO Mapusa, Goa.
*Corresponding author email: hiremath0312@gmail.com ABSTRACT

Gastrointestinal stromal tumour (GIST) is the most commonly identified mesenchymal tumour of the gastrointestinal tract. There is a great deal of dilemma in diagnosing GIST . Confirmation is possible only by histopathological examination and by immunohistochemistry. Complete surgical removal followed by long term postoperative chemotherapy is essential for the optimal cure.

Keywords: GIST, Ileum, cellular leiomyoma, Imatinib

INTRODUCTION

Gastrointestinal stromal tumor (GIST) is a most common mesenchymal tumor of gastrointestinal tract (G.I)tract (80%)1. The incidence of GIST is 1020 million people per year with a malignant potential of 20-30%1,2. Presentations include abdominal mass (5-50%), obstruction (5%), haemorrhage and rarely perforation (0.8%)4,5.
CASE REPORT

A 50year old, post menopausal, an asymptomatic woman came with an ultrasound report showing uterus measuring 9x4.6x4.9cm with heterogenous echotexture, evidence of 6x4.2cm isoechoeic lesion seen antero-superior to uterus with internal vascularity and attached to the

uterus. Both ovaries not clearly seen. Impression Pedunculated fibroid Right ovarian mass Endometriotic deposit. P4L4A2. All FTND and a known case of hypertension on regular treatment. On examination general condition was fair, pulse rate of 82/min, BP of 130/90mmHg. Abdominal examination was normal, no mass palpable. On bimanual examination, uterus was irregularly enlarged to 14-16 weeks size, both the fornices free, no mass palpable. Investigations: Hb11gms%, Blood group O+ve, RBS-142mgs%, Blood urea - 28mg%, Serum Creatinine0.8mg%, HIV- negative, HbsAg- negative , chest x ray - normal, ECG- normal. USG as mentioned above. Patient was taken for Laparoscopy. Intraoperative findings uterus not visualized,
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omentum completely adherent and covering the uterus and pulling the bladder up. Bladder separated from the anterior anterior abdominal wall. The decision to convert laparoscopy to laparotomy was taken. At laparotomy, 8 x 8 cm omental mass completely adherent to the small intestine intestine and the uterus was visualized. visualized. Omental adhesions freed from the uterus. Uterus showed multiple multiple small fibroids, Right side ovary was normal, left ovary was cystic. Total abdominal hysterectomy with left salphingo-ovariotomy salphingo ovariotomy (TAH, LSO) was done. Right ovary could not be removed due to the adhesions. The mass was infiltrating the small intestine (ileum) (ileum) covered by omentum, ileal lumen was intact and was difficult to enucleate. Hence the decision to do partial resection and end to end anastomosis was taken,

haemostasis achieved, saline irrigation done. Romovac drain was inserted and the abdomen closed in layers. Post operatively patient recovered well, discharged on 10th post-operative operative day. Histopathology report revealed Gastrointestinal stromal tumor (GIST) with 3 3-4 4 mitotic figures /10 HPF . No evidence evidence of necrosis. Impression GIST / Cellular leiomyoma. Pathologists advised CD117 to confirm the diagnosis. On Immunohistochemistry, the tumor was found to be positive for CD117, CD34, negative for SMA. Thus a final diagnosis of gastrointestinal stromal tumor was established on histopathology histopathology and immunohistochemistry. Subsequently, the patient was referred to the on oncologist cologist for further management and was started on Imatinib therapy for three years.

Fig .1 : USG showing abdomino pelvic mass

Fig.2 : Intraoperative finding of ileal mass

Fig.3: Gross specimen of uterus showing Multiple fibroids

Fig.4: Histopathology (40X) ( ) showing tumor with Giant cells suggesting acute inflammatory cellular infiltration

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DISCUSSION Gastrointestinal stromal tumour (GIST) is most common mesenchymal tumour of gastrointestinal tract (GI)tract (80%)1. The incidence of GIST is 1020 million people per year with a malignant potential of 20-30%.Presentations include abdominal mass (5-50%), obstruction (5%), haemorrhage and rarely perforation (0.8%)1,2. GIST tumors arise either from stem cells that differentiate towards Interstitial Cells of Cajal or directly from Interstitial Cells of Cajal (ICCs)..GIST are most often characterized by strong immunoreactivity to the KIT protein, the CD117 antigen3. On the other hand, leiomyoma, leiomyosarcoma , schwannoma , lipoma, , hemangioma, are negative for CD1174. Risk criteria were first published in 2001 and were amended as more was learned about the importance of mitotic rate, anatomic primary site, and size, in large part due to large case series developed by Miettinen, Lasota and colleagues5,6. GISTs are chemotherapy and radiotherapy resistant and there remains high risk of 7-10 recurrence after tumor resection . All GISTs have a potential for malignancy and the standard therapy is complete surgical removal with negative tumor margins 11 . 50% of patients with GIST will have a relapse after surgery, necessitating the need for adjuvant 9 chemotherapy . The culprit for the pathogenesis of this tumour is the mutations of the KIT proto-oncogene and the tumors show a immunoreactivity to the KIT protein, the CD117 antigen 12,13. KIT tyrosine kinase inhibitor has showed a hope of improved outcome in advanced GIST. Imatinib mesylate is one such tyrosine kinase blocker being considered as the drug of choice for advanced tumour14-16. Imatinib is also being used for palliative therapy or in patients with recurrent disease. CONSENT

Consent for publication of this case report was taken from the patient, copy of which is available with the corresponding author.
ACKNOWLEDGEMENT

We would like to extend our heartfelt gratitude to the head of dept, Obstetrics & Gynecology and Professor, Dept of General surgery and Dept of Pathology.
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