Extragastrointestinal stromal tumors of the pelvic cavity and the vagina: Two case reports and review of the literature

KIT/PDGFRA inhibitors for the treatment of gastrointestinal stromal tumors: getting to the gist of the problem

INTRODUCTION

Approximately 90% of gastrointestinal stromal tumors (GISTs) are driven by activating mutations in receptor tyrosine-kinases KIT or PDGFRA. Despite the outstanding results of first-line imatinib in advanced GIST, resistance ultimately occurs mainly through secondary mutations in KIT/PDGFRA. Other tyrosine-kinase inhibitors (TKIs) with a broader spectrum of activity against these mutations are approved after imatinib failure. However, response rates and progression-free survival are drastically lower compared to imatinib. Notably, imatinib also triggers early tolerance adaptation mechanisms, which precede the occurrence of secondary mutations.

AREAS COVERED

In this review, we outline the current landscape of KIT inhibitors, discuss the novel agents, and present additional biological pathways that may be therapeutically exploitable.

EXPERT OPINION

The development of broad-spectrum and highly selective TKIs able to induce a sustained KIT/PDGFRA inhibition is the pillar of preclinical and clinical investigation in GIST. However, it is now recognized that the situation is more intricate, with various factors interacting with KIT and PDGFRA, playing a crucial role in the response and resistance to treatments. Future strategies in the management of advanced GIST should integrate driver inhibition with the blockade of other molecules to enhance cell death and establish enduring responses in patients.

Gastrointestinal stromal tumour: presenting as an ovarian cystadenoma

A gastrointestinal stromal tumortumour (GIST) is an uncommon gastrointestinal neoplasm that can arise from any part of the gastrointestinal tract. They can rarely present as a pelvic mass, which might result in a gynaecological condition being misdiagnosed in a female patient. A woman in her early 70s presented with a huge pelvic mass. Abdomen-pelvis CT scan showed a significant cystic mass in the left-sided pelvis with a mass effect on adjacent structures, which suggested a possibility of an ovarian cystadenoma. Her CA-125 was normal. She underwent an exploratory laparotomy with pelvic mass excision. A diagnosis of a gastrointestinal stromal tumour (GIST) arising from the ileum was made on a histopathology study.

Primary vulvar extragastrointestinal stromal tumor in a 77-year-old woman

Extragastrointestinal stromal tumors (EGISTs) carry the same morphological, immunohistochemical and molecular features as gastrointestinal stromal tumors (GISTs) and involve extragastrointestinal tract soft tissue. The majority of reported EGIST cases arise from intraabdominal, retroperitoneal, or pelvic soft tissue. A significant subset of such tumors originates from the gastrointestinal muscle layer, grows in an exophytic manner, then loses attachment to the gastrointestinal tract. Consequently, true EGISTs are exceedingly rare. Herein, we are reporting a case of a vulvar EGIST. A 77-year-old woman presented with a painless subcutaneous nodule on the right perineum. An excisional biopsy showed a fairly circumscribed bland spindle cell lesion in the dermis. The tumor cells were positive for CD117 and ANO1/DOG-1 and negative for smooth muscle myosin, smooth muscle actin, STAT6, low- and high-molecular-weight cytokeratins, SOX10, MART-1, CD10, S-100 protein, and estrogen and progesterone receptors. A diagnosis of EGIST was made and complete excision was recommended. Superficial/subcutaneous EGISTs are extremely rare, and it is important for dermatopathologists to be aware of this entity as it can be misdiagnosed as more common spindle cell neoplasms, both benign and malignant, including but not limited to smooth muscle neoplasms (leiomyoma/leiomyosarcoma), spindle cell melanoma, and sarcomatoid squamous cell carcinoma.

Analysis of Effect on Infection Factors and Nursing Care of Postoperative Incision in Gynecological Cancer Patients

Purpose

To study the effect on infection factors and nursing care of postoperative incision in gynecological cancer patients.

Method

72 patients with gynecological malignant tumors who came to the hospital from January 2019 to December 2019 were selected as the research objects. They were divided into the study group and control group by cluster random sampling. The control group was given routine nursing mode, including matters needing attention in surgery, health education, prevention of complications, and dietary guidance. The study group implemented the high-quality nursing mode on the basis of the control group. Postoperative situation, incision infection rate, and quality of life were observed and compared between the two groups.

Results

The control group's time to get out of bed, postoperative eating time, postoperative exhaust time, and hospital stay were longer than those of the study group. The comparison of the postoperative related conditions of the two groups showed that P < 0.05, which indicated that the difference was statistically significant. The postoperative incision infection rate in the study group was 2.78%, and in the control group, the postoperative incision infection rate was 19.44%; the postoperative incision infection rate in the study group was significantly lower than that in the control group. The difference was statistically significant, P < 0.05. The factors affecting the quality of life of patients in the study group were lower than that of the control group, and the difference was statistically significant, P < 0.05. Time to get out of bed, postoperative eating time, postoperative exhaust time, hospital stay, and quality of life were the main influencing factors of postoperative incision infection in gynecological tumors.

Conclusion

Time to get out of bed, postoperative eating time, postoperative exhaust time, hospital stay, and quality of life were the main influencing factors of postoperative incision infection in gynecological tumors. High-quality nursing intervention had better clinical nursing effect in preventing postoperative incision infection. It should be widely used in clinical nursing.

Primary Extragastrointestinal Stromal Tumor of Greater Omentum with Intraperitoneal Bleeding

Gastrointestinal stromal tumors (GISTs) develop in the digestive tract, mainly in the stomach, small intestine, colon, or esophagus. However, primary tumors with the same pathologic features as GISTs have been reported to occur outside of the digestive tract and are called extragastrointestinal stromal tumor (EGIST). We herein report a rare case of EGIST arising from the greater omentum in a patient with abdominal pain caused by intraperitoneal bleeding from the tumor.

Extragastrointestinal Stromal Tumor Presenting as a Recurrent Vaginal Mass: Case Report

Gastrointestinal stromal tumors (GISTs) are the dominant mesenchymal tumors of the digestive tract. Extragastrointestinal stromal tumors (EGISTs) usually originate outside the gastrointestinal tract without connection to the gastric or intestinal wall. However, EGISTs arising from the vaginal wall are very rare. Here, we report a case of EGIST that occurred in the vagina of a 60-year-old woman. The tumor was present in the posterior vaginal wall. It was surgically excised, and histological examination revealed spindle cell morphology with up to 14 mitoses per 50 high power field (HPF) and necrosis with the tumor-negative margins. Immunohistochemical analyses showed strongly positive CD34, CD117, and DOG-1 expression, but negative SMA, S-100, CD10, desmin, and actin expression. The patient underwent surgery and is currently being followed up. A literature review of EGSTs and treatments is also discussed in this report.

Metachronous extragastrointestinal stromal tumor (EGIST) in utero: Report of an unusual case

INTRODUCTION

The gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor in the digestive tract. Currently, GIST is the name given to CD117 positive mesenchymal tumors, primary of the digestive tract, mesentery, and retroperitoneum. Nevertheless, they have been reported in the mesentery, omentum, gallbladder, bladder wall, and few cases in the uterus; known as extragastrointestinal stromal tumors (EGIST).

PRESENTATION OF CASE

Seventy-six-year-old woman with a history of the third recurrence of pelvic tumor located in the uterus initially diagnosed as uterine leiomyosarcoma. CT and MRI showed a tumor in the uterine corpus of approximately 10 cm. It was decided to perform the surgical rescue. The immunohistochemistry and anatomic pathology report revealed a tumor compatible with a uterine EGIST. It was decided to perform adjuvant treatment with imatinib. Currently, the patient continues to be disease-free 20 months after the surgery.

DISCUSSION

For years, GIST has often been confused with leiomyosarcoma, given that they are histologically almost indistinguishable. The IHC analysis for KIT (CD117) has become essential in the GIST diagnosis. On the other hand, stromal tumors arising outside the gastrointestinal tract are rare (5%), which have a histological and biological behavior similar to that of GISTs.

CONCLUSION

EGISTs are extremely rare and often incidentally detected. Currently, evidence about this location is scarce. According to the literature, this is the first case of uterine EGIST with a metachronous presentation.

Primary extra-gastrointestinal stromal tumor (EGIST) of the mesentery: Case report and review of literature

Introduction

Gastrointestinal stromal tumors (GISTs) represent <1% of all gastrointestinal (GI) tumors. Extra-gastrointestinal stromal tumors (EGISTs) are mesenchymal tissue neoplasm arising outside the GI tract. This rare group comprises only 5% of all GISTs. This case demonstrates a rare entity in a patient with non-specific symptoms, a large tumor size and unremarkable past personal and family history.

Presentation of case

We present a 45-year old man with non-specific symptoms who was diagnosed with a primary EGIST arising in the small bowel mesentery after surgery. The tumor was not compromising the GI tract and it was completely resected. The tumor was sent for pathological examination that confirmed the diagnosis. Histological examination revealed a 15 cm in diameter mass, comprised of spindle cells and high mitotic activity. Treatment with imatinib mesylate was initiated.

Discussion

There have been only a few previous reports of EGISTs arising from the small bowel mesentery. It is believed that EGISTs originate from cells with similar pathological characteristics and biological behaviour as the intestinal cells of Cajal. Such tumors are associated with poorer prognosis, lager tumor size and younger presentation than their GI counterparts. The preferred treatment is complete surgical resection. The addition of specific tyrosine kinase inhibitors such as imatinib mesylate is recommended for high risk patients. Even though morphological and immunohistochemical similarities between GISTs and EGISTs are described, their pathogenesis, incidence, genetic background, complications and prognosis are not completely known because they are extremely rare.

Conclusion

EGISTs are very rare tumors which originate from cells outside the GI tract and are associated with a more aggressive biological behavior than their GI counterparts. These tumors may grow without any clinical implications and should be kept in mind in the differential diagnosis for patients presenting with an abdominal mass. Further studies are needed due to lack of large patient cohort studies and long-term follow-up regarding the prognosis and management of this rare pathology.

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EGISTs are extremely rare. They represent only 5% of all GISTs, which comprises only <0.05% of all GI tumors.

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High index of suspicion in patients with nonspecific symptoms and the presence of an abdominal mass is necessary.

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The preferred treatment is a complete surgical resection in low-risk patients.

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Clinicopathologic parameters and clinical implications are not yet described in literature.

Imaging in gynecological disease (19): clinical and ultrasound features of extragastrointestinal stromal tumors (eGIST)

OBJECTIVE

To describe the clinical and sonographic characteristics of extragastrointestinal stromal tumors (eGISTs).

METHODS

This was a retrospective multicenter study. The data of patients with a histological diagnosis of eGIST who had undergone preoperative ultrasound examination were retrieved from the databases of nine large European gynecologic oncology centers. One investigator from each center reviewed stored images and ultrasound reports, and described the lesions using the terminology of the International Ovarian Tumor Analysis and Morphological Uterus Sonographic Assessment groups, following a predefined ultrasound evaluation form. Clinical, surgical and pathological information was also recorded.

RESULTS

Thirty-five women with an eGIST were identified; in 17 cases, the findings were incidental, and 18 cases were symptomatic. Median age was 57 years (range, 21-85 years). Tumor marker CA 125 was available in 23 (65.7%) patients, with a median level of 23 U/mL (range, 7-403 U/mL). The vast majority of eGISTs were intraperitoneal lesions (n = 32 (91.4%)); the remaining lesions were retroperitoneal (n = 2 (5.7%)) or preperitoneal (n = 1 (2.9%)). The most common site of the tumor was the abdomen (n = 23 (65.7%)), and less frequently the pelvis (n = 12 (34.3%)). eGISTs were typically large (median largest diameter, 79 mm) solid (n = 31 (88.6%)) tumors, and were less frequently multilocular-solid tumors (n = 4 (11.4%)). The echogenicity of solid tumors was uniform in 8/31 (25.8%) cases, which were all hypoechogenic. Twenty-three solid eGISTs were non-uniform, either with mixed echogenicity (9/23 (39.1%)) or with cystic areas (14/23 (60.9%)). The tumor shape was mainly lobular (n = 19 (54.3%)) or irregular (n = 10 (28.6%)). Tumors were typically richly vascularized (color score of 3 or 4, n = 31 (88.6%)) with no shadowing (n = 31 (88.6%)). Based on pattern recognition, eGISTs were usually correctly classified as a malignant lesion in the ultrasound reports (n = 32 (91.4%)), and the specific diagnosis of eGIST was the most frequent differential diagnosis (n = 16 (45.7%)), followed by primary ovarian cancer (n = 5 (14.3%)), lymphoma (n = 2 (5.7%)) and pedunculated uterine fibroid (n = 2 (5.7%)).

CONCLUSIONS

On ultrasound, eGISTs were usually solid, non-uniform pelvic or abdominal lobular tumors of mixed echogenicity, with or without cystic areas, with rich vascularization and no shadowing. The presence of a tumor with these features, without connection to the bowel wall, and not originating from the uterus or adnexa, is highly suspicious for eGIST. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Extragastrointestinal stromal tumor in the rectovaginal septum associated with acute arterial occlusion

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EGIST in rectovaginal septum with unusual presentation (excessive vaginal bleeding).

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EGIST was misdiagnosed by MRI as vaginal leiomyoma.

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The first report of untreated EGIST associated with acute arterial occlusion.

Extragastrointestinal stromal tumors (EGISTs) arise from atypical sites, such as the omentum, mesentery, retroperitoneal space, urinary bladder, or rectovaginal septum, and account for fewer than 10% of gastrointestinal stromal tumors (GISTs). Most EGISTs are asymptomatic at the time of diagnosis, due to the fact that they rarely cause symptoms until they grow to greater than 10 cm in diameter. Common presenting symptoms are a feeling of vaginal fullness and increased urinary frequency. Cases described in previous reports have been treated with surgery with or without targeted therapy. Here we report an unusual case of an EGIST at the rectovaginal septum presenting with excessive vaginal bleeding and acute arterial occlusion. This rectovaginal mass was successfully removed using the abdominoperineal approach and did not require targeted therapy.

Primary Gastrointestinal Stromal Tumor Presenting as an Isolated Lung Mass

Gastrointestinal stromal tumors (GISTs) are rare gastrointestinal (GI) tumors, representing a small portion of soft tissue tumors of the abdominal cavity. Extraintestinal gastrointestinal stromal tumors (EGISTs) are uncommon forms of GISTs that present outside the GI tract. There have only been a rare number of reported cases of EGIST presenting above the diaphragm. We present the case of a 50-year-old female with shortness of breath, and found to have bilateral pleural effusions and left-sided lung mass. The initial lung mass aspiration was negative for malignancy; yet, pleural fluid was suggestive of malignancy, and repeat biopsy and immunohistochemical stain were diagnostic for GIST. Ultimately, the patient underwent video-assisted thoracoscopic surgery, pleurodesis with doxycycline, and adjuvant therapy with imatinib. This is a report of primary EGIST presenting as an isolated lung lesion with no involvement of the GI tract. In patients with suspected malignancy, it is of paramount importance to obtain a detailed history, including remote signs and symptoms, while performing a thorough work-up. Especially in the lung where initial biopsies can be skewed due to inflammation and atelectasis, repeat biopsies may be necessary to obtain an accurate diagnosis.

Pelvic angiomyofibroblastoma: an unusual case report

Angiomyofibroblastoma is a rare mesenchymal benign tumor that frequently occurs in young- to middle-aged women, arising from the genital tract. There are many overlapping radiological and immunohistochemical features with other stromal cell lesions, making the diagnosis difficult. We report here a case of a 29-year-old woman admitted for a pelvic mass, in whom, the histopathological and immunohistochemical studies led to the diagnosis of angiomyofibroblastoma.

Gastrointestinal stromal tumor presenting as a rectovaginal septal mass: A case report and review of literature

INTRODUCTION

Gastrointestinal stromal tumors (GISTs) arising from the gynecological tract are extremely rare. A case of GIST with an unusual presentation as a vaginal mass is presented with comprehensive literature review, aiming to gain a better understanding of the diagnostic and treatment strategy of the disease.

PATIENT CONCERNS

A 78-year-old woman presented with persistent vaginal bleeding and difficulty in micturition. Although the tumor mass was diagnosed, the results of preoperative evaluations are uncertain.

DIAGNOSIS

Preoperative evaluation included the computed tomography examination (a 6.3×5.3 cm cervical mass lesion with rectal and vaginal invasion), colonoscopy (an external compression with an intact mucosa), tumor markers, and biopsy (spindle cell tumor). Postoperative histopathology confirmed the diagnosis of GIST.

INTERVENTIONS

Posterior exenteration with complete resection was performed. The patient received postoperative adjuvant imatinib therapy.

OUTCOMES

The patient has survived without the disease for more than 3 years.

CONCLUSION

It is still a challenge to diagnose GISTs in women with rectovaginal mass preoperatively. Efforts should be made, including a high suspicion and an assistance of immunohistochemistry. A precise diagnosis may offer a better surgical and treatment plan, especially on the preservation of reproductive organs and accessibility of targeted therapy.