Published online: 2020-12-22

Valiyaveettil, et al.: Outcomes in anaplastic gliomas

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Letter to the Editor contents on aspiration. Fluid analysis revealed normal levels A large cystic gastrointestinal stromal tumor of amylase, lipase, carcinoembryonic antigen and carbohydrate antigen (CA) 19.9 and normal cytology. Differential diagnoses within lesser sac: A diagnostic dilemma were bowel duplication , pancreatic cystic , DOI: 10.4103/sajc.sajc_10_18 , and cystic GIST. Exploratory laparotomy Dear Editor, was planned by the multidisciplinary team consisting of Gastrointestinal stromal tumors (GIST) are smooth muscle oncosurgeon, endoscopist, and radiologist. Exploration showed tumors arising from GI tract. Expression of c‑kit, CD 117, etc. cystic lesion in lesser sac adherent to surrounding viscera separate them from remaining smooth muscle tumors.[1] along with amber colored ascites. Ascitic fluid analysis showed normal amylase, lipase, and cytology. Cyst wall biopsy showed Although commonly solid, they may present as cystic lesions high‑grade tumor with mitoses suggestive of GIST on frozen at critical locations and impose diagnostic dilemma in their section (FS). It was dissected off surrounding viscera and was management. We report such a case to make medical fraternity found to be arising from greater curvature of the . En aware of them. bloc wedge resection of greater curvature along with the mass A 56‑year‑old male presented with 6 months’ history of epigastric was performed. Final histology showed high‑grade GIST with pain and fullness. There was no history suggestive of . 5–6 mitoses/50high power field [Figure 2]. Tumor was positive Serum levels of amylase and lipase were normal. Magnetic for c‑kit [Figure 3], CD 117, CD 34, and SMA with MiB1 index resonance imaging (MRI) [Figure 1] showed noncommunicating, of 35%–40%. The patient was administered adjuvant imatinib. thick‑walled cystic lesion with hemorrhagic contents in lesser Now, he is disease free at the end of 6‑month follow‑up. sac 22 cm × 20 cm × 12 cm in size pushing adjacent viscera GISTs originate from the pacemaker cells of muscularis propria, with pancreatic atrophy with intact and preserved most commonly in the sixth decade. They can be low‑to‑high fat planes with . (EUS) showed grade lesions, depending on the anatomic site, tumor size, and extramucosal bulge on the posterior gastric wall with brownish mitotic frequency.[1,2] (Continue on page 10...) 4 South Asian Journal of Cancer ♦ Volume 7 ♦ Issue 1 ♦ January-March 2018 Kumar, et al.: ER, PR, and HER2 status in breast cancer in South India

23. Patnayak R, Jena A, Rukmangadha N, Chowhan AK, Sambasivaiah K, 2017;338:22-7. Phaneendra BV, et al. Hormone receptor status (estrogen receptor, 25. Gupta A, Jain J, Kumar A, Kumar S, Wadhwa N. Triple negative breast progesterone receptor), human epidermal growth factor‑2 and p53 in cancer – An overview and review of literature. Asian J Med Sci South Indian breast cancer patients: A tertiary care center experience. 2012;3:16-20. Indian J Med Paediatr Oncol 2015;36:117‑22. 26. Kakarala M, Rozek L, Cote M, Liyanage S, Brenner DE. Breast cancer 24. Adusumilli P, Konatam ML, Gundeti S, Bala S, Maddali L. Treatment histology and receptor status characterization in Asian Indian and challenges of Her2-positive breast cancer. Indian J Med Paediatr Oncol Pakistani women in the U.S. – A SEER analysis. BMC Cancer 2010;10:191.

(Letter to the editor continue from page 4...) Cystic GISTs are rare and impose diagnostic challenge. The possibility of GIST should be considered when investigating large, cystic lesions in association with GI tract. Judicious use of radiological imaging, multidisciplinary team discussions, intraoperative FS, and optimum patient counseling are imperative while managing such tricky cases to achieve most optimal results. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Figure 1: Lesser sac cystic lesion with thick walls and hemorrhagic contents Acknowledgment pushing stomach, pancreas with intact fat planes We would like to thank Dr. Sonali Deshmukh, MD. Department of Radiology, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India. Dr. Sheetal Biradar, MD. Department of Pathology, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India Novo Life Cancer Clinic, Pune, Maharashtra, India. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Anup Sunil Tamhankar, Tanuja Anup Tamhankar1 Department of Surgical , Deenanath Mangeshkar Hospital, 1Department of Surgical Oncology, Novo Life Cancer Clinic, Pune, Maharashtra, India Correspondence to: Dr. Anup Sunil Tamhankar, E‑mail: [email protected] References 1. Burkill GJ, Badran M, Al‑Muderis O, Meirion Thomas J, Judson IR, Fisher C, Figure 2: High‑grade Figure 3: Strong c‑kit expression et al. Malignant gastrointestinal stromal tumor: Distribution, imaging gastrointestinal stromal tumors by the tumor features, and pattern of metastatic spread. Radiology 2003;226:527‑32. with high mitotic rate 2. Miettinen M, Lasota J. Gastrointestinal stromal tumors – Definition, clinical, histological, immunohistochemical, and molecular genetic Cystic GIST lesions are rare and invariably impose diagnostic features and differential diagnosis. Virchows Arch 2001;438:1‑2. dilemma. Metastases of GIST are often cystic. Furthermore, 3. Hansen Cde A, José FF, Caluz NP. Gastrointestinal stromal tumor (GIST) Neoadjuvant treatment by imatinib also causes central cystic mistaken for pancreatic pseudocyst – Case report and literature review. Clin Case Rep 2014;2:197‑200. degeneration within tumor. Due to the diagnostic dilemma, in 4. Hamza AM, Ayyash EH, Alzafiri R, Francis I, Asfar S. Gastrointestinal [3,4] the past, they have been treated as pseudocyst of pancreas, stromal tumour masquerading as a cyst in the lesser sac. BMJ Case Rep undergone radical resections thinking of aggressive cystic 2016;2016:pii: bcr2016215479. [doi: 10.1136/bcr‑2016‑215479]. malignant tumors of pancreas.[5] 5. Zhu CC, Liu Y, Zhao G. Exophytic gastrointestinal stromal tumor with cystic changes: A case report. Oncol Lett 2014;7:1427‑9. Our patient was diagnosed by a family physician as pseudocyst This is an open access article distributed under the terms of the Creative Commons of the pancreas. Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited It was important to differentiate a neoplasm from the and the new creations are licensed under the identical terms. pseudocyst preoperatively as the surgical approach needed for both are drastically different (cystogastrostomy for pseudocyst How to cite this article: Tamhankar AS, Tamhankar TA. A large cystic and excision for a neoplasm). Judicious use of MRI, EUS, FS, gastrointestinal stromal tumor within lesser sac: A diagnostic dilemma. South Asian J Cancer 2018;7:4-10. and multidisciplinary team discussion helped us to manage the © 2018 The South Asian Journal of Cancer | Published by Wolters Kluwer - Medknow case optimally. 10 South Asian Journal of Cancer ♦ Volume 7 ♦ Issue 1 ♦ January-March 2018