Typical and atypical Carney's triad presenting with malignant hypertension and papilledema

Unique case of sporadic multiple gastro intestinal stromal tumour

INTRODUCTION

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract and they derived from transformed neoplastic precursors of Cajal's interstitial cell (ICC).

PRESENTATION OF THE CASE

We are presenting a sporadic and exemplary case of 42 multiple GISTs in a young female patient. Our patient showed anemia for the gastric GIST bleeding and only after other tumors were instrumentally and intra-surgery discovered. The patient showed genetic mutation V559A/1676 T>C of the juxtamembrane domain of the exon 11 causing the replacement of Valine with Alanine in the 559 codon.

DISCUSSION

GISTS estimated annual incidence is 12-14 per million. Multiple GISTs associated with familiarity or hereditary syndromes are described only in few case reports and sporadic mGISTs have not been studied yet. Literature review has been done.

CONCLUSION

We are presenting a sporadic and exemplary case of 42 multiple GISTs in a young female patient localized trough out all the gastrointestinal tract. This is the only case of sporadic multiple GISTs reported in literature.

Chondroma: an uncommon case of bronchial tumor

We report the case of a patient with an endobronchial chondroma, a rare benign endobronchial tumor. A 37-year-old woman was evaluated for suspicion of asthma. Computed tomography of the chest and flexible bronchoscopy showed an endoluminal tumor occluding the culmen (B3 left). The tumor was extirpated almost completely by bronchoscopy. Histologically, the biopsy specimens were composed of chondromatous tissue located under the normal bronchial mucosa, according to the diagnosis of chondroma. The symptoms disappeared immediately after the procedure and did not reappear after 1 year. Chondromas are usually located on the skeleton. Endobronchial presentation is rare. We know of only 41 cases reported in the literature. Hamartoma or chondrosarcoma constitutes the main histologic differential diagnosis. The treatment consists of complete resection to avoid any risk of recurrence or sarcomatous transformation. There is no consensus regarding the method of treatment, but endoscopic resection seems to be the first choice.

Carney triad: a clinicopathological analysis of one case and review of the literature

AIM: To investigate the clinical and pathological features, biological behavior and prognosis of Carney triad

METHODS: The clinical data for a patient with Carney triad was analyzed retrospectively and reviewed histologically and immunohistochemically. A literature review was performed to give a detailed description of the disease.

RESULTS: The patient was a young woman who presented with multifocal pulmonary chondroma and gastric stromal sarcoma subsequently. Microscopically, pulmonary chondroma was composed of well-circumscribed cartilage lobules that were separated by fibrovascular stroma. The gastric stromal sarcoma presented as submucosal nodes. Tumor cells were arranged in sheets or clusters and infiltrated into the stomach wall. The eosinophilic tumor cells were moderately heterogeneous and variable, polygonal or round in shape. Mitotic figures were visible. The tumor cells were immunohistochemically positive for CD34, CD117, vimentin and PDGFRA.

CONCLUSION: Carney triad is a rare syndrome which affects mostly young women and is characterized by having at least two out of three following neoplasms: pulmonary chondroma, gastrointestinal stromal tumor and extra-adrenal paraganglioma.

Gastric stromal tumors in Carney triad are different clinically, pathologically, and behaviorally from sporadic gastric gastrointestinal stromal tumors: findings in 104 cases

Carney triad, as originally described in 1977, was the association of 3 tumors: gastric epithelioid leiomyosarcoma [later renamed gastrointestinal stromal tumor (GIST)], extra-adrenal paraganglioma, and pulmonary chondroma. The disorder affected mostly young women and was not familial. We studied the clinical and pathologic features of the gastric neoplasm in 104 patients with the syndrome. Most (88%) were young women (mean age, 22 y), and the usual presentation was gastric bleeding. The tumors, commonly antral-based (61%), were multifocal, and ranged from 0.2 to 18.0 cm in dimension. Most (86%) featured round and polygonal (epithelioid) cells. Metastasis occurred in 49 patients (47%): to gastric lymph nodes (29%), liver (25%), and peritoneum (13%). Immunopositivity was detected in the tumors tested as follows: KIT, 100%; CD34, 75%; PKCtheta, 21%; PDGFRA, 90%; and smooth muscle actin, 6%. Fourteen patients (13%) died of metastatic GIST at a mean age of 45 years (range, 30 to 69 y). Estimated 10 and 40-year survivals were 100% and 73%, respectively. Median survival time was 26.5 years (range, 16 to 60 y). There was no correlation between the National Institutes of Health tumor risk classification and the tumor behavior. Compared with sporadic gastric GISTs, the gastric stromal tumor in Carney triad showed distinctive features: female predilection, young patient age, epithelioid cell predominance, multifocality, frequent lymph node metastasis, serial tumor occurrence, and unpredictable behavior. Thus, the Carney triad gastric stromal tumor is different clinically, pathologically, and behaviorally from sporadic gastric GIST.

Carney's triad: case report and review

INTRODUCTION

Carney's triad is a rare pathogenic entity which consists of the association in young women of multiple condromatosis in the lung, gastric leiomyosarcoma, and extradrenal paraganglioma; although the presence of three at the same time is not required for its diagnosis.

CASE REPORT

We present the case of a 27-year-old woman who was diagnosed of pulmonary multiple hamartomatosis and gastric stromal tumor.

DISCUSSION

A review of the literature shows the most important prognosis factors and therapeutic options. Surgery for gastrointestinal stromal tumors and extradrenal paraganglioma seems to be the best treatment up to date.

The Gist of literature on pediatric GIST: review of clinical presentation

AIM/BACKGROUND

To provide a review of existing literature on pediatric GIST with focus on clinical presentation.

METHODS

A MEDLINE search was conducted in July 2007 to give an overview on literature concerning pediatric gastrointestinal stromal tumors (GISTs) with a focus on clinical presentation, using keywords "gastrointestinal stromal tumor" and one of the following "young/boy/girl/child/children/pediatric." Two of the authors sorted the resulting abstracts by relevance for a review on clinical aspects of pediatric GIST if they were in English language, not explicitly only reporting of adults and describing clinical features of patients.

RESULTS

One hundred and six articles were found, 43 of which were excluded because they did not match the criteria mentioned above. We found 97 patients in the articles meeting our criteria, of which 38 cases had to be excluded, because of lacking clinical data, negative staining for CD117 or syndromal occurrence. This left 59 patients for analysis of clinical symptoms in the presentation of nonsyndromal CD117-positive GIST in children.

DISCUSSION

Clinical feature most frequent was anemia in 86.4% (n=51) symptomatic either through acute or subacute bleeding. There was no palpable tumor in 88.1% (n=52), no abdominal pain in 84.7% (n=50), and no vomiting in 88.1% (n=52). Girls tend to show more high-grade tumors and existing case reports show a 2.7-fold higher incidence in females. Altogether epithelioid cell tumors are most frequent, although in boys spindle-cell tumors are reported more often. On the basis of National Institute of Health criteria (6) tumors were low grade in 22% (n=13), medium grade in 37.3% (n=22), and high grade in 35.6% (n=21). There were more high-grade tumors in girls than in boys (40.5% vs. 28.6%). Local excision was the operation most often performed, but details of surgery were missing in most cases.

CONCLUSIONS

Pediatric GIST is a rare but considerable diagnosis in chronic anemia, which is the most frequent clinical finding with this tumor entity. Recent review articles focus on histopathologic criteria but omit clinical features and course of disease. In nonsyndromal CD117-positive GIST, girls tend to show more high-grade tumors and existing literature on pediatric GIST shows a 2.7-fold higher incidence in females. Altogether epithelioid cell tumors are most frequent, although in boys spindle-cell tumors are reported more often. Together with known differences in molecular changes and local as well as systemic tumor behavior this strongly suggests that pediatric GIST represents a different entity than adult GIST. After establishment of clear-cut pathologic features in the past, reports on preoperative diagnostic findings, long-term follow-up, and therapy have to be emphasized to clarify the relationship of these entities.

Multiple gastric stromal tumors in a child without syndromic association lacks common KIT or PDGFRalpha mutations

A diagnosis of multiple gastric stromal tumors that were nonmetastatic at presentation was made in an 11-year-old girl who presented with hematemesis. Gastrointestinal stromal tumor (GIST) is a rare diagnosis in childhood and reported multiple lesions are generally seen in the context of familial disease, occasionally with syndromic associations. Although there are no reports of genetic mutation in cases of pediatric GIST, very many cases of multiple GISTs investigated on a molecular level have shown germline KIT or platelet-derived growth factor receptor-alpha mutation; these were familial cases. Despite the negative family history in our patient, the multiplicity of lesions in such a young patient raised concern for a genetic predisposition and prompted extensive molecular workup. Repeat evaluation of distinct aliquots of tumor tissue by polymerase chain amplification followed by sequence analysis of selected coding sequences of KIT and platelet-derived growth factor receptor-alpha previously shown to harbor mutations in GIST, yielded no evidence of even a somatic mutation. This clinically unique case is discussed in the context of a literature review.

Endosonographic diagnosis of recurrent gastrointestinal stromal tumors associated with Carney's syndrome

This is a report of a patient who manifests all of the features of Carney's syndrome, including gastrointestinal stromal tumors (GISTs), extra-adrenal paragangliomas, and pulmonary chondromas. The patient underwent surgical resection of a gastric GIST; a retroperitoneal, nonfunctional paraganglioma; and a mediastinal, catecholamine-secreting paraganglioma (pheochromocytoma). Recently, new gastric GISTs were diagnosed by endoscopic, ultrasound-guided, fine-needle aspiration (EUS-FNA) biopsy and were resected. Recurrence of stromal tumors following complete resection is common in Carney's syndrome and presents considerable management challenges. This case illustrates several important points: (1) Carney's syndrome, although rare, should be considered in patients with foregut GISTs; (2) GISTs associated with Carney's syndrome, like sporadic gastric GISTs, may have a more indolent clinical course; and (3) EUS-FNA may be useful for the diagnosis and management of GISTs in this syndrome.