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Departement of Internal Medicine
Airlangga School of Medicine-dr.Soetomo Teaching HospitalSurabaya
2009
CASE PRESENTATION
Dian Fajarwati
Pangestu Adi
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INTRODUCTION
GIST
Immunohistochemically KIT
+, mesenchymal neoplasmof the GI tract and abdomen
Term GIST:
Mazur and Clark (1983)
rare tumors ; incidence of 10-
20/ 1 million /year ;
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CASEChief complaint :
Vomitus of coffee ground
material
Black stool
Early satiety, nausea, abdominal
discomfort
Decreased appetite
Fatigue, pale
History of past illness:
Hospitalized three times , same
complaint
No traditional medicine and NSAID
consumption
No icteric
No cancer in family
Mrs. F, 48 years old
Javanesse
Stay in Surabaya
Housewife
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Physical Examination
H/L: unpalpable, mass in epigastrium
to left hypocondrium region 8x8 cm,
fixed, not well defined
Edema -/- , eritema palm -/-
Alert, weak, GCS 456,
BP 110/70 mmHg, pulse 92 x/m,RR 20x/m, axillary temp. 36.8C
Anemia (+)
Heart & Lung : no abnormality,
spider nevi - /-
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Laboratory studies
Hb 5.1 g/dl
WBC 9,800/mm3
Plt 820,000/mm3
LED 20/60Coagulation test noabnormality
Urinalysis no abnormality
Blood sugar 128 mg/dl
Creatinine serum 0.7 mg/dlBUN 10 mg/dl
AST 62 IU/L
ALT 35 IU/L
total protein 4.8 g/dLalbumin 2.42 g/dL
globulin 2.4 g/dL
potassium 3.47 mmol/L
sodium 132 mmol/L
chlorida 99.3 mmol/L
ECG : sinus rhytm 90 x/ minutes
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Imaging studies
Abdominal USG :
mass 4x 10 cm trace from gaster, liverwas normal ( no nodul/ cyst/abses)
Chest X-ray :No abnormality
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1st Endoscopy (Sept,17,
2008): tumor at the corpus
that covered posterior wall,minor and major curvatura.
Conclusion suspect gaster
carcinoma.
1st Biopsy : erosive gastritis
2nd Endoscopy (Nov,3,
2008): no erosion and
esophagus varices.
Conclusion : mass in the
corpus gaster that
caused obstruction
(suspected as
malignancy)
2nd biopsy : chronicgastritis
Upper endoscopy
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Imaging studiesSolid mass in the gaster wall 12.2 x
9.4 cm , unclear border,inhomogen contrast enhancement.
No liver enlargement. No
nodul/mass/cyst.
Spleen/ Pancreas/Ren D/S were
normal. No bone destruction.Conclusion : mass in the gaster
wall.
FNAB,CT Scan guiding (Nov, 27,
2008) : hypercellular consist ofgroup and spreading of spindle cell
nucleus partly plump and lobulated,
pleiomorfik , coarse chromatin, and
matrix myxoid. Conclusion spindle
mesenchymal tumor
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Initial assessment :
Obs.Hematemesis
melena
Anemia Hypoalbumin
S. Gastric tumor
Planning Dx :
Upper GI X-Ray
CEA; Ca 19-9
Planning Tx :
infus PZ
Blood tranfusion Gastric lavage/ 6 hours
Lavement/12 hours
Inj. Octreotid iv.
Inj.proton pump inhibitor iv. albumin infusion
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Imaging studies
Upper GI X-Ray( Des, 5, 2008)
: ground glass appearance at
the upper left , minimal gas in
the gaster.Filling defect with fungating
type and ulcerative type,
destroyed mucosal pattern in
the corpus until anthrum gaster
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Dec, 2,2008
No hematemesis melena. Consultation to
digestive surgery : Gastric malignancy andpost HM. Planning Dx. Upper GI X-Ray , CEA,Ca19-9
Dec, 5,
2008
Upper GI : filling defect , fungating & ulcerative type, destroyedmucosal pattern in the corpus until anthrum gaster .
CEA 0.8 ng/ml ( < 5 ) ; Ca 19-9 1.2 U/ml ( < 37)
Dec,22,2008
The patient underwent operation. Tumor was unresectablebecause the tumor adhered at the porta vein and multiplenodul in liver. Jejunostomy was done for enteral feeding
Jan,16,2009
No complaint
The patient discharged from the hospital and refused to betreated with chemotheraphy
Advice : controlled to gastrohepatology ,hematology-oncology & surgery clinic
Progress Note
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Hystopatology
Malignant tissue tumor:
anaplastic cell proliferation,
pleiomorphic round nucleus,hyperchromatic, mitosis >20/10
HPF, trabecular formed,
Conclusion: high grade
malignancy dd.
adenocarcinoma poorlydifferentiated ; stromal tumor.
Imunohistochemistry :CD 117 positive .
Conclusion :
Gastrointestinal Stromal
Tumor (c.KIT positive).
Imunohistochemistry
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DISCUSSION
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This patient : hematemesis-melena, weight
loss, anemia, palpable mass in the abdomen
Sign and Symptom non-specific : early satiety, bloating, non
specific abdominal pain, gastrointestinal
bleeding , fatigue from anemia, or obstruction.
Abdominal pain, melena and weight loss
most common symptoms
Rarely, an abdominal mass is palpable
Gastrointestinal Stromal Tumor
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Laboratory examination
No laboratory test specifically confirm GIST.
This patient : anemia and hypoalbumin. The
tumor markers (CEA and Ca 19-9) were negative
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Imaging studies
no standard imaging protocol, all imaging techniques
may be used.
preoperative diagnosis based on clinical and radiologic
data is difficult
nonspecific presentation typically grow as bulky, well-defined, endo- or exophytic
masses parallel to the bowel lumenstromal origin
normally present with the typical signs ofsubmucosal or
extrinsic GI lesions on imaging studies
overlyingmucosa can be normal or show signs of necrosis or
ulceration.
i di
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Imaging studies Endoscopic examination :smooth protrusion of the bowel
wall, lined with mucosa, some cases show signs of bleeding
and ulceration
Full layer biopsy true histopathologic Dx. GIST: 27-50% by endoscopic biopsy
The results : gastric tumor and the biopsy revealed erosive
and chronic gastritis
Barium series detect GIST sufficient size filling defect : sharply demarcated and is elevated compared
with surrounding mucosa
overlying mucosa is smooth unless ulceration
the information is limited because of striking image
Upper GI : mass in the corpus to anthrum gaster , fungating
& ulcerative type with destroyed mucosal pattern
d
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Imaging studies USG studies : well-defined or polylobulated solid
masses. Cystic changes,necrosis, or calcifications.
image quality is often degraded by intervening bowel
gas
USG studies : mass 4x10 cm and no abnormality in the
other structures
CT Scan : important in the diagnosis and staging of GIST
Detect multiple tumors and provide evidence of metastatic spread
less aggressive GIST : < 5 cm, well-defined, round or oval, exophytic
masses and homogeneous enhancement
Aggressive GIST : irregular and lobulated margins, >10 cm, centralnecrosis, ulceration, and heterogeneous contrast enhancement
CT Scan : solid mass 12.2 x 9.4 cm in the gastric wall , irregular,
heterogenous contrast enhancement , no metastatic to adjacent
organs.
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Biopsy
GIST tend to fall into
three categories of
morphology
epitheloid, spindlecell, or mixed
The diagnosis of
GIST relies on
histopatology andimunohistochemistry
CD 117 is generally
positive
FNAB with CT scan
guiding: spindle
mesenchymal tumor
Biopsy durante op :
adenocarcinoma dd.
Stromal tumor
Imunohistochemistry:CD 117 positive
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Risk Classification in GIST
Mass 12.2x 9.4 cm , mitosis > 20/10 HPF high risk
Kim, 2005
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Therapy Surgical : definitive therapy
1. Complete resection : recurrent 36 months Recurrence Rate 40-52%
This patient was classified in to high risk
GIST, metastatic disease and unresectable
tumor. The prognosis was poor.
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Summary
We have reported a patient withGastrointestinal stromal tumor with liver
metastases
The diagnosis of GIST based onhistopathology and imunohistochemistry
examination
The patient underwent operation but the tumor
was unresectable. Jejunostomy was done forenteral feeding
The patient was classified in to high risk GIST
the prognosis was poor
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THANK YOU
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Kim,2005
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Kim,2005
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Rubin,2007
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Rubin,2007
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Rubin,2007
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Rubin,2007
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Chemical structure of Imatinib mesylate
Rubin,2007
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Rubin,2007
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Rubin,2007
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Rubin,2007
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Rubin,2007
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Rubin,2007
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Miettinen,2006
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Miettinen, 2006
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Immunohistochemical differential diagnosis of themost important mesenchymal tumor of the GI tract
Miettinen, 2003
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Miettinen, 2003
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Demetri, 2004
N l d M t t d KIT d th A ti f I ti ib
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Normal and Mutated KIT and the Action of Imatinib
Demetri, 2004
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