J Gastric Cancer.  2015 Mar;15(1):68-73. 10.5230/jgc.2015.15.1.68.

Two Cases of Advanced Gastric Carcinoma Mimicking a Malignant Gastrointestinal Stromal Tumor

• Shin HS
• Oh SJ
• Suh BJ

• KMID: 2372374
• DOI: http://doi.org/10.5230/jgc.2015.15.1.68

Abstract

Gastric cancer that mimics a submucosal tumor is rare. This rarity and the normal mucosa covering the protuberant tumor make it difficult to diagnosis with endoscopy. We report two cases of advanced gastric cancer that mimicked malignant gastrointestinal stromal tumors preoperatively. In both cases, the possibility of cancer was not completely ruled out. In the first case, a large tumor was suspected to be cancerous during surgery. Therefore, total gastrectomy with lymph node dissection was performed. In the second case, the first gross endoscopic finding was of a Borrmann type II advanced gastric cancer-like protruding mass with two ulcerous lesions invading the anterior wall of the body. Therefore, subtotal gastrectomy with lymph node dissection was performed. Consequently, delayed treatment of cancer was avoided in both cases. If differential diagnosis between malignant gastrointestinal stromal tumor and cancer is uncertain, a surgical approach should be carefully considered due to the possible risk of adenocarcinoma.

Keyword

Stomach neoplasms; Gastrointestinal stromal tumors

MeSH Terms

Adenocarcinoma
Diagnosis
Diagnosis, Differential
Endoscopy
Gastrectomy
Gastrointestinal Stromal Tumors*
Lymph Node Excision
Mucous Membrane
Stomach Neoplasms
Ulcer

Figure

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  Fig. 1 (A) Gastroscopic findings revealed a protuberant tumor on the posterior wall of the upper body and lesser curvature of the stomach. The tumor was covered by mucosa that appeared normal except for slight ulceration. (B) Computed tomography findings revealed a lobulated soft tissue mass in the hepatogastric ligament, and encasement of the left gastric artery abutting the gastric wall, with thickening in the cardia and the upper body of the stomach.

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  Fig. 2 (A) The serosal surface is grayish white and a protruding lesion measuring 7.0×5.5×2.5 cm was noted. The mucosa revealed a diffusely infiltrating lesion measuring 6.0×3.0 cm on the lesser curvature of the upper body of the stomach. (B) Staining method: H&E. Magnification: ×10 (left), ×200 (right).

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  Fig. 3 (A) A large protruding ulcerative mass originating from the submucosa at the anterior wall of the lower body of the stomach and a single small raised erosion at the cardia. (B) Submucosal gastric mass at the lesser curvature of the gastric lower body (4.8 cm in segment and 1.7 cm in depth) with central ulceration.

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  Fig. 4 (A) Multiple cut sections revealed a yellowish gray and myxoid mass measuring 5.8 × 3.0×1.4 cm, with infiltration of the serosal layer. The tumor was mostly located within the submucosa and the muscle layer, with a very focal mucosal lesion. A deep infiltrating gland showed intraluminal mucin and an extracellular mucin pool in the subserosal layer. (B) Staining method: H&E. Magnification: ×20 (left), ×100 (right).

Reference

1. Umehara Y, Kimura T, Okubo T, Sano Y, Nakai K, Oi S, et al. Gastric carcinoma resembling submucosal tumor. Gastric Cancer. 1999; 2:191–193.

2. Burkill GJ, Badran M, Al-Muderis O, Meirion Thomas J, Judson IR, Fisher C, et al. Malignant gastrointestinal stromal tumor: distribution, imaging features, and pattern of metastatic spread. Radiology. 2003; 226:527–532.

3. Hasegawa T, Matsuno Y, Shimoda T, Hirohashi S. Gastrointestinal stromal tumor: consistent CD117 immunostaining for diagnosis, and prognostic classification based on tumor size and MIB-1 grade. Hum Pathol. 2002; 33:669–676.

4. Heinrich MC, Griffith DJ, Druker BJ, Wait CL, Ott KA, Zigler AJ. Inhibition of c-kit receptor tyrosine kinase activity by STI 571, a selective tyrosine kinase inhibitor. Blood. 2000; 96:925–932.

5. Schwameis K, Fochtmann A, Schwameis M, Asari R, Schur S, Köstler W, et al. Surgical treatment of GIST: an institutional experience of a high-volume center. Int J Surg. 2013; 11:801–806.

6. Morinaga N, Sano A, Katayama K, Suzuki K, Kamisaka K, Asao T, et al. Laparoscopic transgastric tumor-everting resection of the gastric submucosal tumor located near the esophagogastric junction. Surg Laparosc Endosc Percutan Tech. 2004; 14:344–348.

7. Orditura M, Galizia G, Sforza V, Gambardella V, Fabozzi A, Laterza MM, et al. Treatment of gastric cancer. World J Gastroenterol. 2014; 20:1635–1649.

8. Ng EH, Pollock RE, Munsell MF, Atkinson EN, Romsdahl MM. Prognostic factors influencing survival in gastrointestinal leiomyosarcomas. Implications for surgical management and staging. Ann Surg. 1992; 215:68–77.

9. Hohenberger P, Ronellenfitsch U, Oladeji O, Pink D, Ströbel P, Wardelmann E, et al. Pattern of recurrence in patients with ruptured primary gastrointestinal stromal tumour. Br J Surg. 2010; 97:1854–1859.

10. Eisenberg BL, Harris J, Blanke CD, Demetri GD, Heinrich MC, Watson JC, et al. Phase II trial of neoadjuvant/adjuvant imatinib mesylate (IM) for advanced primary and metastatic/ recurrent operable gastrointestinal stromal tumor (GIST): early results of RTOG 0132/ACRIN 6665. J Surg Oncol. 2009; 99:42–47.