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Comorbidity of Gastrointestinal Stromal Tumor and Adenocarcinoma in Stomach: a Report of Three Cases and Review of Literature

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Comorbidity of Gastrointestinal Stromal Tumor and Adenocarcinoma in Stomach: a Report of Three Cases and Review of Literature Int J Clin Exp Med 2016;9(10):19491-19501 www.ijcem.com /ISSN:1940-5901/IJCEM0031009 Original Article Comorbidity of gastrointestinal stromal tumor and adenocarcinoma in stomach: a report of three cases and review of literature Lei Li1, Shanshan Wan3, Yang Zhang2, Kaixiong Tao1, Guobin Wang1, Ende Zhao1 Departments of 1Gastrointestinal Surgery, 2Clinical Laboratory Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China; 3Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA Received April 21, 2016; Accepted September 7, 2016; Epub October 15, 2016; Published October 30, 2016 Abstract: Gastrointestinal stromal tumor (GIST) is the most common tumor with mesenchymal origin in the gastro- intestinal tract with stomach as the preferred site. Gastric adenocarcinoma is the most common primary tumor in the stomach. The comorbidity of tumors with different tissue origins in the same patient was thought to be rare. However, more and more cases were reported in the wake of advancement of diagnostic technology and increased awareness of physicians. Here, we report three comorbidity cases of GIST and gastric adenocarcinoma and review the literatures. We suggest that for patients with gastric adenocarcinoma, physicians should carefully perform pre- operative, intra-operative and post-operative examinations to avoid missed diagnosis of GIST and prolong the sur- vival of patients. Keywords: Gastrointestinal stromal tumor, adenocarcinoma, comorbidity Introduction Computed tomography (CT) scan showed a small mass in the muscular layer in the gastric Gastrointestinal stromal tumor (GIST) is the fundus (Figure 1A) and asymmetrical thickness most common tumor with mesenchymal origin of gastric wall with uneven surface in the body in the gastrointestinal tract. GIST may occur in and antrum, ranging about 5-6 cm (Figure 1B). any part of the GI tract from lower esophagus to Gastroscopy indicated ulcer in gastric antrum anus. However, 50%-62% of GIST was found in with bleeding. Biopsy indicated adenocarcino- the stomach. Gastric adenocarcinoma is the ma of gastric angulus and antrum (Figure 1C most common primary tumor in the stomach. and 1D). The comorbidity of tumors with different tissue origins in the same patient was thought to be The patient received subtotal gastrectomy and rare. Recently the morbidity increased due to resection of mass in gastric fundus. A crater- the advancement of pre-operative examina- like ulcer with the diameter of 4 cm was found tions and awareness of surgeons. In this report, in the gastric antrum in the greater curvature. we report three comorbidity cases of GIST and And a mass in the muscular layer with the diam- gastric adenocarcinoma in our institute and eter of 1 cm was found in the gastric fundus. review the literatures. The post-operative pathological examination showed adenocarcinoma with poor differentia- Case description tion (Figure 1E) and Her-2 (G) score (1+) (Figure Case 1 1F), and GIST with extremely low recurrence risk and less than 5/50 HPF nucleus mitotic A 60-year-old male patient was admitted with count (Figure 1G). The immunohistochemical intermittent hematemesis and melena for 3 (IHC) staining indicated CD117 (+) (Figure 1H), days. He also suffered from abdominal disten- CD34 (+), DOG-1 (+), SMA (partly +), S-100 (-) tion, acid reflux and numbness of left arm. and Ki67 (LI: 1%). GIST and gastric adenocarcinoma Figure 1. (A, B) CT scan showed a small mass in the muscular layer in the gastric fundus (A) and asymmetrical thick- ness of gastric wall with uneven surface in the body and antrum (B). (C, D) Gastroscopy indicated ulcer in gastric antrum. (E-H) Post-operative pathological examination showed adenocarcinoma with poor differentiation (E) and positive Her-2 staining (F), and GIST with extremely low recurrence risk (G) and positive CD117 staining (H). CT scan indicated the thick- ness of the gastric antrum. Gastroscopy showed ulcer- ation of gastric antrum and pyloric obstruction. Preopera- tive pathology indicated the high grade intraepithelial neo- plasia of gastric antrum; how- ever, gastric adenocarcinoma couldn’t be excluded. The patient received surgical treatment with radical total gastrectomy. Two masses were palpated during opera- tion, one located in the lesser curvature of gastric antrum with the size of 5×5 cm and the other in the fundus of Figure 2. (A, B) Post-operative pathological examination of the mass from stomach with the size of 4×4 distal stomach indicated moderately differentiated tubular adenocarcinoma cm. (A) with negative Her-2 staining (B). (C, D) Pathological examination of the mass from the proximal stomach showed GIST with low recurrence risk (C) Post-operative pathological and positive CD117 staining (D). examination of the mass from distal stomach indicated mo- Case 2 derately differentiated tubular adenocarcino- ma (partially showed as papillary adenocarci- A 70-year-old male patient with emaciation was noma) with lymph nodes metastasis, which admitted with the complaint for abdominal pain invaded the whole layers of gastric wall and the and distention for 4 months, which would be external fat tissues (Figure 2A). The IHC stain- aggravated after food intake. He had frequent ing showed Her-2 (-) (Figure 2B). And pathologi- defecation without change of the stool charac- cal examination of the mass from the proximal ter. The patient had the sign of abdominal ten- stomach showed GIST with <5/50 HPF nucleus derness in the epigastrium without rebound mitotic count and low recurrence risk (Figure tenderness. 2C). The IHC staining of GIST showed CD117 (+) 19492 Int J Clin Exp Med 2016;9(10):19491-19501 GIST and gastric adenocarcinoma ly low recurrence risk and <5/50 HPF nucleus mitotic count (Figure 3C). The IHC staining showed CD117 (+) (Figure 3D), CD34 (+), DOG-1 (+), SMA (-), S-100 (rarely pos- itive) and Ki67 (LI: about 2%). Discussion GIST was firstly described by Mazur et al in 1983 as mes- enchyme-derived tumor com- posed with heterogenic fusi- form or epithelioid cells with different differentiation gra- des [1]. GIST derives from Cajal cells and may occur in the whole digestive tract from esophagus to anus with Figure 3. (A-D) The post-operative pathological examination indicated car- dial adenocarcinoma with poor differentiation (A) and positive Her2 staining stomach and small intestine (B), and esophageal GIST with extremely low recurrence risk (C) and positive as the preferred sites [2]. CD117 staining (D). Comorbidity of GIST with other epithelium-derived tu- mors was considered rare. Table 1. Location of gastric adenocarcinoma and GIST in three However, recently research- cases ers found more and more Adenocarcinoma GIST comorbidity cases of tumors Case 1 Gastric antrum (lesser curvature) Gastric fundus (greater curvature) originated from different tis- Case 2 Gastric antrum (lesser curvature) Gastric fundus (greater curvature) sues with the advancement Case 3 Gastric cardia (lesser curvature) Esophagus of diagnostic technology and increased awareness of sur- geons. The comorbidity of (Figure 2D), CD34 (+), DOG-1 (+), SMA (-), S-100 GIST with other tumors was usually reported in (-) and Ki67 (LI: <5%). case reports and case analysis from single institution with the rate of 3-33% [2] or 2.25- Case 3 41% [3] for lacking of large sample statistics. The most common comorbidity with GIST is A 62-year-old male patient was admitted for gastrointestinal cancer, followed by lymphoma, epigastric distention for half a month. The prostate cancer, breast cancer, kidney cancer, patient lost body weight for 3 kg and had a his- lung cancer, female genital cancer, soft tissue tory of cholecystectomy about 2 months ago. and bone sarcoma, malignant melanoma and No other positive signs or symptoms were seminoma [2]. We reported three comorbidity complained. cases of GIST and gastric adenocarcinoma in this study. The location of the tumor mass in The pre-operative gastroscopy and biopsy indi- the three cases was summarized in Table 1. cated gastric adenocarcinoma with poor differ- And we further reviewed the literatures regard- entiation level in the gastric cardia. The patient ing comorbidity of GIST and other tumors with received radical total gastrectomy with the tho- epithelial origin in stomach in Table 2. raco-abdominal incision. A cardial ulcer with the size of 3 cm was found during operation. The mechanism remains unclear regarding the The post-operative pathological examination comorbidity of two different types of tumors in indicated cardial adenocarcinoma with poor one patient. Some reporters considered it as differentiation (Figure 3A) and Her2 score (1+) coincidence, however, in the other hand, some (Figure 3B), and esophageal GIST with extreme- researchers thought it may be due to the carci- 19493 Int J Clin Exp Med 2016;9(10):19491-19501 GIST and gastric adenocarcinoma Table 2. Clinical characteristics of GIST and gastric epithelial tumor of 135 cases from literature GIST Epithelial tumor Hp No. Source Sex Age Surgical pattern Location Size (cm) Pathological features Location Size (cm) Histology infection 1 Maiorana et al [14] F 81 Fundus 5 Epithelioid borderline Cardia 4 Adenocarcinoma Unknown Partial gastrectomy 2 Maiorana et al [14] F 79 Pylorus 6 Spindle cell malignant Antrum 2 Adenocarcinoma Unknown Partial gastrectomy 3 Maiorana et al [14] M 75 Antrum 5 Spindle cell borderline Antrum 4 Adenocarcinoma Unknown Total gastrectomy 4 Maiorana et al [14] F 79 Corpus 5 Spindle
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