Primary gastrointestinal stromal tumor of the esophagus in an HIV-positive patient

Perforated small bowel GIST in an immunocompromised male

Gastrointestinal (GI) stromal tumor is a relatively rare tumor of the GI tract, with estimated prevalence of 2%, which arises from the interstitial cells of Cajal. Common presentations range from asymptomatic to abdominal pain, bloating, GI bleeding, and anemia. Less-common signs include obstruction and peritonitis. In this case, a young immunocompromised patient experienced a changing symptomatic spectrum with an enlarging abdominal mass, which ultimately perforated, leading to acute peritonitis.

Rapid emergence of cryptococcal fungemia, Mycobacterium chelonae vertebral osteomyelitis and gastro intestinal stromal tumor in a young HIV late presenter: a case report

Background

Highly active antiretroviral therapy has significantly changed the natural history of HIV infection, leading to a dramatic reduction of HIV-related morbidity and mortality. Late Presenters, Very Late Presenters and AIDS presenters still represent, also in Europe, including Italy, a huge challenge in terms of diagnostic and therapeutic management.

Case presentation

A 35-year-old male with a history of fever and back pain. HIV test resulted positive with a high HIV Viral Load and a very low T-CD4 number of cells (5 cells/mm³). Imaging investigations revealed multiple vertebral and pulmonary lesions together with abdominal and thoracic lymphadenopathy. Blood cultures were positive for Cryptococcus neoformans and for Staphylococcus haemolyticus.

Lymphnode biopsy resulted positive in PCR for Non-Tuberculosis Mycobacteria (Mycobacterium chelonae). A gastric biopsy also revealed a GIST. The patient also had CMV DNA positive. Although we performed antiretroviral therapy and specific-therapies for each disease, he was transferred to intensive care unit where he died due to an Acute Respiratory Distress Syndrome.

Conclusion

The reported case is unusual due to the relevant number of opportunistic diseases (both infectious and tumoral) emerging not long after the HIV infection had been diagnosed.

Late presenters HIV patients and AIDS presenters still represent a challenge, which is often too complex for clinicians to deal with. In spite of proper management, the risk of suboptimal results cannot be excluded.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3573-z) contains supplementary material, which is available to authorized users.

Clinicopathologic Features and Clinical Outcomes of Esophageal Gastrointestinal Stromal Tumor: Evaluation of a Pooled Case Series

Clinicopathologic features and clinical outcomes of gastrointestinal stromal tumors (GISTs) in esophagus are limited, because of the relatively rare incidence of esophageal GISTs. Therefore, the aim of the current study was to investigate the clinicopathologic features and clinical outcomes of esophageal GISTs, and to investigate the potential factors that may predict prognosis.Esophageal GIST cases were obtained from our center and from case reports and clinical studies extracted from MEDLINE. Clinicopathologic features and survivals were analyzed and compared with gastric GISTs from our center.The most common location was lower esophagus (86.84%), followed by middle and upper esophagus (11.40% and 1.76%). The majority of esophageal GISTs were classified as high-risk category (70.83%). Mitotic index was correlated with histologic type, mutational status, and tumor size. The 5-year disease-free survival and disease-specific survival were 65.1% and 65.9%, respectively. Tumor size, mitotic index, and National Institutes of Health risk classification were associated with prognosis of esophageal GISTs. Only tumor size, however, was the independent risk factor for the prognosis of esophageal GISTs. In comparison to gastric GISTs, the distribution of tumor size, histologic type, and National Institutes of Health risk classification were significantly different between esophageal GISTs and gastric GISTs. The disease-free survival and disease-specific survival of esophageal GISTs were significantly lower than that of gastric GISTs.The most common location for esophageal GISTs was lower esophagus, and most of the esophageal GISTs are high-risk category. Tumor size was the independent risk factor for the prognosis of esophageal GISTs. Esophageal GISTs differ significantly from gastric GISTs in respect to clinicopathologic features. The prognosis of esophageal GISTs was worse than that of gastric GISTs.

Sarcomas other than Kaposi sarcoma occurring in immunodeficiency: interpretations from a systematic literature review

PURPOSE OF REVIEW

In immunodeficiency, an increased sarcoma risk is confirmed for Kaposi's sarcoma. Whether rates of other sarcoma subtypes are elevated in the setting of immunodeficiency is not known. We therefore reviewed published case reports on HIV and AIDS patients and organ transplant recipients with sarcomas. For comparison, we assessed sarcomas in the U.S. general population using Surveillance Epidemiology End Results (SEER) data.

RECENT FINDINGS

A total of 176 non-Kaposi sarcoma were identified, 75 in people with HIV and AIDS and 101 in transplant recipients. Leiomyosarcomas (n = 101) were the most frequently reported sarcomas, followed by angiosarcomas (n = 23) and fibrohistiocytic tumors (n = 17). Leiomyosarcomas were reported with two age peaks, in children and young adults. Epstein-Barr virus (EBV) was detected in the tumor cells in 85 and 88% of leiomyosarcomas in HIV-infected people and transplant recipients, respectively. Angiosarcomas and fibrohistiocytic tumors were most frequently reported in men. Among kidney transplant recipients, 20% of sarcomas arose at the site of an arteriovenous fistula. In comparison, leiomyoscarcomas, angiosarcomas, and fibrohistiocytic tumors comprised 16.9, 3.8, and 18.7% of sarcomas in the U.S. general population.

SUMMARY

Leiomyosarcoma and angiosarcoma may occur disproportionately in immunodeficiency. Leiomyosarcomas appear causatively linked to EBV, whereas angiosarcomas might be correlated with an arteriovenous fistula. Additional studies are necessary to understand the contribution of immunodeficiency to the cause of these sarcomas.

Extragastrointestinal stromal tumor in a kidney transplant recipient

The occurrence of de novo malignant neoplasms has been shown in post-transplant recipients receiving immunosuppressive treatment. We present a case of a rare extragastrointestinal stromal tumor (EGIST) located in the pelvic cavity of a kidney transplant patient. A 57-year-old female patient was admitted to our department because of non-specific lower abdominal pain 6 months after renal transplantation. An abdominal computed tomography scan showed a 4.5 cm diameter pelvic tumor mass. The tumor was resected en bloc and confirmed as not being connected to the gastrointestinal wall. Microscopically, the tumor consisted of typical spindle cells with 2-3 mitotic figures per 50 high-power fields. Immunohistochemically, the tumor cells were strongly positive for CD117 (c-kit), and negative for CD34, SMA, s-100 protein, and desmin. Genetically, the tumor showed a silent mutation in exon 18 of the PDGFRA gene at codon 824 GTC > GTT (V824V) [rs2228230]. No recurrence was noted 24 months after the operation. This case draws our attention to the importance of considering EGISTs (including GISTs), even though they are extremely uncommon, in the differential diagnosis of mesenchymal neoplasms, especially in transplant patients.

Synchronous incidental gastrointestinal stromal and epithelial malignant tumors

AIM: To investigate the incidence of incidental gastrointestinal stromal tumor (GIST) and its etiopathogenesis.

METHODS: From January 1, 2000 to December 31, 2007, 13 804 cases of gastrointestinal epithelial malignant tumor (EMT) and 521 cases of pancreatic adenocarcinoma (PAC) were successfully treated with surgery at the Department of General Surgery and the Department of Thoracic Surgery, West China Hospital, Sichuan University, China. The clinical and pathologic data of 311 cases of primary GIST, including 257 cases with clinical GIST and 54 cases of incidental GIST were analyzed.

RESULTS: Of the 311 patients, 54 had incidental GIST, accounting for 17.4%. Of these tumors, 27 were found in 1.13% patients with esophageal squamous cell carcinoma (ESCC), 22 in 0.53% patients with gastric adenocarcinoma (GAC), 2 in 0.38% patients with PAC, 2 in 0.03% patients with colorectal adenocarcinoma, and 1 in one patient with GAC accompanying ESCC, respectively. Patients with incidental GIST presented symptoms indistinguishable from those with EMT. All incidental GIST lesions were small in size, and the majority had a low mitotic activity while only 1.9% (5/257) of clinical GIST lesions had a high risk.

CONCLUSION: Incidental GIST may occur synchronously with other tumors and has a high prevalence in males. Surgery is its best treatment modality.

Surgical considerations for the management and resection of esophageal gastrointestinal stromal tumors

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are the most common sarcoma of the gastrointestinal tract, but occur rarely in the esophagus. Use of tyrosine kinase inhibitors has revolutionized therapy for GISTs but complete resection remains the treatment of choice. Esophageal GISTs require special consideration regarding perioperative treatment, evaluation, and conduct of operation.

METHODS

We report our experience (from 2000 to 2003) with four patients who underwent resection of esophageal GIST, reviewed consensus management guidelines, and performed a literature review for reported cases. Query of the National Cancer Database was made to assess national experience with esophageal GISTs.

RESULTS

All four patients had esophageal GISTs successfully differentiated from leiomyomata by immunohistochemistry on fine needle aspirates obtained during endoscopic ultrasound. At the time of resection all tumors were noted to be adherent to tissues other than submucosa that required resection of esophageal muscularis, periesophageal tissue, or mucosa. All patients were thought to have complete resection and were alive at last contact (median, 33 months). Two of four patients recurred, one of whom underwent esophagectomy; the other patient is alive on imatinib. Seven case reports with median follow-up of three years reported no recurrence with either enucleation or esophagectomy. The National Cancer Database contains 33 cases of esophageal GIST reported since 1999. Nine of 24 patients died within six months of diagnosis.

CONCLUSIONS

Esophagectomy is the treatment of choice for esophageal GISTs but requires attention to operative details that emphasize complete en bloc excision of surrounding tissue. Preoperative imatinib may improve resectability.

The growing problem of non-AIDS-defining malignancies in HIV

PURPOSE OF REVIEW

The incidence and spectrum of non-AIDS-defining cancers has continued to grow. As HIV-infected individuals live longer due to highly active antiretroviral therapy, their risk of dying from one of these cancers is increased. The recent literature pertaining to non-AIDS-defining cancers is reviewed.

RECENT FINDINGS

Recent epidemiological studies have identified higher rates of carcinoma of the anus, lung, breast, skin, conjunctiva, liver and prostate; hematopoietic malignancies such as Hodgkin's lymphoma, plasma-cell neoplasia and leukemia; and other neoplasms like melanoma and leiomyosarcoma in HIV-positive patients. The role of HIV-induced immunosuppression in the development of these non-AIDS-defining cancers appears less important than lifestyle habits like smoking and sun exposure, as well as coinfection with human papilloma, hepatitis B, hepatitis C and Epstein-Barr viruses.

SUMMARY

It is unclear whether the growing number of reports on non-AIDS-defining cancers reflects a true increased incidence or merely the product of increased surveillance, detection and reporting. Highly active antiretroviral therapy not only promotes longevity in the HIV-positive population, but may increase their risk of developing cancer like Hodgkin's lymphoma. Assertive prevention strategies are needed to adequately deal with non-AIDS-defining cancers in an aging and growing HIV-positive population.

Sporadic Cajal cell hyperplasia is common in resection specimens for distal oesophageal carcinoma. A retrospective review of 77 consecutive surgical resection specimens

Interstitial cell of Cajal (ICC) hyperplasia has been documented in conditions associated with multiple gastrointestinal stromal tumours (GISTs) (familial GIST syndromes, Carney's triad and von Recklinghausen's disease) and rarely in the vicinity of sporadic GISTs. The incidence of sporadic ICC hyperplasia and the so-called seedling leiomyoma (SLM) of the lower oesophagus has not been studied in the KIT era. In a retrospective review of 77 consecutive, routinely processed oesophagogastric resection specimens for distal oesophageal carcinoma, we found foci of ICC hyperplasia in 7 of 77 (9.1%) cases and foci of SLM in 17 of 77 (22%) cases. Two types of ICC hyperplasia were recognized: a non-circumscribed type and a nodular expansile type with peripherally compressed myenteric neural tissues. All cases of ICC hyperplasia were vimentin+/CD34+/CD117+. SLMs were desmin+/vimentin(-)/CD34(-)/CD117(-), similar to smooth muscles of the gut wall. In a prospective study of 32 non-carcinomatous specimens from age-matched patients (mostly autopsy cases), we found SLMs in only one case, but we were unable to detect ICC hyperplasia in any of the cases. We concluded that sporadic KIT-positive spindle-cell hyperplasia and SLMs were unexpectedly common in distal oesophageal specimens harbouring carcinomas. The possible mechanisms leading to the development of these putative precursor lesions will be discussed.