Gastrointestinal stromal tumor arising in the rectovaginal septum

Gastrointestinal stromal tumors arising in the perianal and perineal region: Two case reports and literature review

INTRODUCTION AND IMPORTANCE

Gastrointestinal stromal tumor (GIST) is rare because of its variable clinical incidence reported (from 0.4 to 2/100,000 per year) in the literature, mainly occurs primarily in the stomach and small intestine. GISTs in the perianal and perineal regions have been reported in a few pieces of literature. GIST located in the perianal and perineal regions may be misdiagnosed and missed due to atypical symptoms. We report two cases of GIST in rare sites and hope to reduce the occurrence of such events through a review of the relevant literature.

CASE DESCRIPTION

We reported two cases of GIST located in the perianal and perineal regions with different symptoms. One case underwent an emergency procedure to stop bleeding and resect the mass, and the other case was discovered during the physical examination and slowly grew in the follow-up. Following the completion of the relevant examination, the patient underwent surgical resection. Both cases were finally diagnosed as GIST by immunohistochemistry.

CLINICAL DISCUSSION AND CONCLUSION

Due to atypical clinical symptoms of perianal and perineal GIST, definitive diagnosis depends on pathology and immunohistochemistry, which can lead to misdiagnosis and missed diagnosis. Surgical resection is the preferred option for localized masses. Surgical resection of GIST located in the perianal and perineal regions requires an appropriate surgical approach based on the patients' actual condition, taking into account the protection of anal function and complete resection of the mass. Masses located in perianal and perineal region should be taken seriously by clinicians.

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.

Rectovaginal extragastrointestinal stromal tumour (EGIST): an additional entity to be considered in the differential diagnosis of tumours of the rectovaginal septum

Gastrointestinal stromal tumours (GISTs) are rare - and rectovaginal extragastrointestinal stromal tumours (RV-EGISTs) even rarer. We share a case of RV-EGIST, complemented by high-quality radiological and surgical images. A review of current literature pertaining to RV-EGIST is also included. Our case report highlights the diagnostic challenge presented by extragastrointestinal stromal tumours. Differentiated from overlapping pathologies only by targeted application of immunohistopathology and cytogenetics, the inclusion of RV-EGIST in the differential diagnosis of a rectovaginal tumour is essential to making this correct diagnosis. Primary surgery is the treatment of choice for RV-EGIST if complete cytoreduction can be achieved, combined with adjuvant tyrosine kinase inhibitor (TKI) therapy for those with high-risk features to further reduce rates of future recurrence.

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.

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.

Surgically Enucleated Gastrointestinal Tumor of the Rectovaginal Septum

The rectovaginal septum is a rare location for gastrointestinal stromal tumors (GIST) to occur. When such is the case, the question arises as to whether the lesion, which is morphologically and immunophenotypically identical to its gastrointestinal counterpart, should be referred to as an extragastrointestinal stromal tumor (EGIST). A 77-year-old, gravida 4, para 4004 post-menopausal female with an unremarkable gynecologic history presented with brown vaginal discharge. On examination, a 4 to 5-cm nodule was palpated along the rectovaginal septum. Ultrasound revealed a 4.8-cm circumscribed, solid mass with internal blood flow located posterior and inferior to the cervix. At laparoscopy, the uterus and adnexae were deemed to be normal for age, without gross pathologic abnormalities. The nodule was resected in an enucleation procedure; subsequent histopathologic examination revealed a low-grade, spindled cell neoplasm with diffuse immunoreactivity for CD117 (cKit) and DOG1, diagnostic of GIST. Further molecular testing elucidated a mutation in exon 9 of the Kit gene. A decision was made by the patient for close observation; there is no clinical or radiographic evidence of recurrence one year after initial diagnosis.

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.

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

Gastrointestinal stromal tumors (GISTs) are rare tumors of gastrointestinal (GI) tract with mesenchymal cell origin. Extragastrointestinal stromal tumors (EGISTs) are unusual tumors that exhibit the same immunohistochemical and genetic abnormalities as GISTs and most commonly affect the omentum and mesentery. EGISTs of the pelvis and the female reproductive system are exceedingly rare and a frequent diagnostic pitfall. In this report, we present two cases of EGISTs along with a review of the literature.

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All pelvic and vaginal EGISTs summarized

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Presentation of pelvic EGISTs is nonspecific leading to delay in diagnosis.

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Surgery +/− imatinib potentially curative for vaginal and pelvic EGISTs.

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C-kit testing is essential to differentiate EGISTs from other gynecological tumors.

Carcinoma of the recto-vaginal septum. Comprehensive literature review

Carcinoma of the recto-vaginal septum is an extremely rare entity. We performed a MEDLINE-based search on recto-vaginal septum carcinoma, focussing on its management, in order to clarify which are the best treatment options for this disease. In addition an unpublished case report has been added to the review. 34 case reports were included in our review. Surgery and adjuvant chemoradiation therapy seem to be the most common treatment option. However, since primary surgical treatment leads to mutilation by removing a large portion of the vagina and the anal sphincter with a permanent terminal colostomy, primary platinum-based chemoradiation therapy could be considered. In case of extragastrointestinal stromal tumours primary surgical treatment seems to be the best option. Due to the rarity of this entity only limited data is available. Therefore further investigation is necessary.

Misdiagnosis of an extragastrointestinal stromal tumor in the rectovaginal septum

INTRODUCTION

Gastrointestinal stromal tumors are very rare, representing 0.1% to 1% of gastrointestinal malignancies. Gastrointestinal stromal tumors outside the digestive tract comprise a very small fraction of all gastrointestinal stromal tumors, and their most common locations are the omentum, the mesentery, and, in few cases, the rectovaginal septum. Despite their low incidence, extragastrointestinal stromal tumors are potentially malignant tumors and they present a high rate of recurrences. This, added to the fact that they are often asymptomatic until advanced stages, determines an unfavorable prognosis.

CASE REPORT

We report a case of gastrointestinal stromal tumor located in the rectovaginal septum, which recurred after local excision; hence, a reintervention was needed.

CONCLUSIONS

A correct differential diagnosis between extragastrointestinal stromal tumors and other similar pathologies such as leiomyomas or schwannomas is imperative based on their histology and immunohistochemistry. The correct diagnosis of extragastrointestinal stromal tumors allows to start adequate treatment and follow-up, preventing recurrence that determines their poor prognosis.