Answer for BIR CoW 03 Nov 2024
Gastrointestinal stromal tumour
Findings
CECT - evidence of relatively well-defined heterogeneously enhancing submucosal endophytic mass lesion with internal necrosis causing luminal narrowing noted involving distal body, antropyloric region along lesser curvature extending to di segment of duodenum. on oral contrast administration, free flow of contrast noted distally. PET- Well-defined rounded polypoidal mildly metabolically active intraluminal growth arising from the lesser curvature of the stomach. No extraserosal spread. Surrounding fat planes are all preserved. No significant metabolically active perigastric / celiac axis lymphnodes. IMPRESSION : Possibility of GIST with no lymphnode /Extraserosal spread.
Discussion
Gastrointestinal stromal tumor (GIST) Middle-aged and elderly populations GISTs can arise from any part of the gastrointestinal tract, including Meckel’s diverticulum. Most common in stomach > Small intestine >Duodenum > Esophagus. Interstitial cells of cajal, which are involved in enteric neurotransmission in the gastrointestinal tract. Ki-67 is used to estimate biological aggressiveness. Three subtypes 1. Spindle cell type 2. Epithelioid type 3.Mixed type Growth pattern 1. Endophytic 2. Exophytic 3. Intramural Small <5cm - Round and homogeneous tumors. Large >5cm - Lobulated and heterogeneous SIGNS Early venous return, defined as the return of contrast media in the arterial phase, is common in small bowel GISTs but not in gastric GISTs. The tumor vessel sign indicates the presence of conspicuous vessels that can be traced from the tumor margin to named vessels. Early development of a draining vein is frequently observed in small bowel GISTs on digital subtraction angiography. The diameter of the draining vein correlates positively with tumor size. Deep crescent-shaped ulceration demonstrating an internal air-fluid level may be referred to as the Torricelli-Bernoulli sign Calcification is rare in gist Intratumoral hemorrhage is seen. HIGH RISK FEATURES Malignant GISTs Size >5 cm Irregular or indistinct margins Heterogeneous contrast enhancement Local invasion Hematogenous liver or peritoneal metastasis. Tumor size and number of mitotic figures per HPFs Tumors larger than 5 cm with more than 5 mitotic counts per 50 HPF Tumors larger than 10 cm, regardless of the mitotic count, have a high risk of malignancy. DIFFERENTIAL DIAGNOSIS Gastric GISTs Leiomyomas, leiomyosarcomas, schwannomas, neurofibromas and neuroendocrine tumors. Exophytic with gh, gs ligament or lesser sac extension. Histopathology and immunohistochemistry Small and large bowel GISTs Adenocarcinoma and lymphoma. Adenocarcinomas and lymphomas - regional lymphadenopathy. Adenocarcinoma - Concentrically; Lymphoma, GISTs - aneurysmal dilatation of the bowel. Primary or metastatic peritoneal GISTs - peritoneal tuberculosis and peritoneal carcinomatosis. The mesenteric and omental masses - smooth surfaces and do not show spiculation or indrawing of themesentery. The rarity of ascites and dilated feeding arteries or draining veins on CT further favors GISTs over tubercular peritonitis or peritoneal carcinomatosis
REFERENCES
1. Levy A, Remotti H, Thompson W, Sobin L, Miettinen M. Gastrointestinal Stromal Tumors: Radiologic Features with Pathologic Correlation. Radiographics. 2003;23(2):283-304, 456; quiz 532. doi:10.1148/rg.232025146 - Pubmed 2. Vinay Kumar, Abul K. Abbas, Nelson Fausto. Robbins and Cotran Pathologic Basis of Disease. (2005) ISBN: 9780721601878 - Google Books 3. King D. The Radiology of Gastrointestinal Stromal Tumours (GIST). Cancer Imaging. 2005;5(1):150-6. doi:10.1102/1470-7330.2005.0109\ - Pubmed
Findings
CECT - evidence of relatively well-defined heterogeneously enhancing submucosal endophytic mass lesion with internal necrosis causing luminal narrowing noted involving distal body, antropyloric region along lesser curvature extending to di segment of duodenum. on oral contrast administration, free flow of contrast noted distally. PET- Well-defined rounded polypoidal mildly metabolically active intraluminal growth arising from the lesser curvature of the stomach. No extraserosal spread. Surrounding fat planes are all preserved. No significant metabolically active perigastric / celiac axis lymphnodes. IMPRESSION : Possibility of GIST with no lymphnode /Extraserosal spread.
Discussion
Gastrointestinal stromal tumor (GIST) Middle-aged and elderly populations GISTs can arise from any part of the gastrointestinal tract, including Meckel’s diverticulum. Most common in stomach > Small intestine >Duodenum > Esophagus. Interstitial cells of cajal, which are involved in enteric neurotransmission in the gastrointestinal tract. Ki-67 is used to estimate biological aggressiveness. Three subtypes 1. Spindle cell type 2. Epithelioid type 3.Mixed type Growth pattern 1. Endophytic 2. Exophytic 3. Intramural Small <5cm - Round and homogeneous tumors. Large >5cm - Lobulated and heterogeneous SIGNS Early venous return, defined as the return of contrast media in the arterial phase, is common in small bowel GISTs but not in gastric GISTs. The tumor vessel sign indicates the presence of conspicuous vessels that can be traced from the tumor margin to named vessels. Early development of a draining vein is frequently observed in small bowel GISTs on digital subtraction angiography. The diameter of the draining vein correlates positively with tumor size. Deep crescent-shaped ulceration demonstrating an internal air-fluid level may be referred to as the Torricelli-Bernoulli sign Calcification is rare in gist Intratumoral hemorrhage is seen. HIGH RISK FEATURES Malignant GISTs Size >5 cm Irregular or indistinct margins Heterogeneous contrast enhancement Local invasion Hematogenous liver or peritoneal metastasis. Tumor size and number of mitotic figures per HPFs Tumors larger than 5 cm with more than 5 mitotic counts per 50 HPF Tumors larger than 10 cm, regardless of the mitotic count, have a high risk of malignancy. DIFFERENTIAL DIAGNOSIS Gastric GISTs Leiomyomas, leiomyosarcomas, schwannomas, neurofibromas and neuroendocrine tumors. Exophytic with gh, gs ligament or lesser sac extension. Histopathology and immunohistochemistry Small and large bowel GISTs Adenocarcinoma and lymphoma. Adenocarcinomas and lymphomas - regional lymphadenopathy. Adenocarcinoma - Concentrically; Lymphoma, GISTs - aneurysmal dilatation of the bowel. Primary or metastatic peritoneal GISTs - peritoneal tuberculosis and peritoneal carcinomatosis. The mesenteric and omental masses - smooth surfaces and do not show spiculation or indrawing of themesentery. The rarity of ascites and dilated feeding arteries or draining veins on CT further favors GISTs over tubercular peritonitis or peritoneal carcinomatosis
REFERENCES
1. Levy A, Remotti H, Thompson W, Sobin L, Miettinen M. Gastrointestinal Stromal Tumors: Radiologic Features with Pathologic Correlation. Radiographics. 2003;23(2):283-304, 456; quiz 532. doi:10.1148/rg.232025146 - Pubmed 2. Vinay Kumar, Abul K. Abbas, Nelson Fausto. Robbins and Cotran Pathologic Basis of Disease. (2005) ISBN: 9780721601878 - Google Books 3. King D. The Radiology of Gastrointestinal Stromal Tumours (GIST). Cancer Imaging. 2005;5(1):150-6. doi:10.1102/1470-7330.2005.0109\ - Pubmed
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!