Plexosarcoma: endoscopic ultrasound and electron-microscopic characteristics of a stromal tumor

Gastrointestinal autonomic nerve tumors: a clinical review

PURPOSE

Gastrointestinal autonomic nerve tumors (GANTs) are believed to be rare accounting for 1 % of all malignant gastrointestinal tumors. Many gastrointestinal surgeons and gastroenterologists are unaware of this entity. This review aims to highlight the salient clinical features and prognosis of GANTs.

METHODS

Using the common search engines and manual cross-referencing, a search of the English literature was conducted for "gastrointestinal autonomic nerve tumor."

RESULTS

All of the published literature on GANTs is either case reports or small case series. From 49 retrieved articles, a total of 107 GANT cases were collected with a mean age of 54 years and equal male to female preponderance. The most commonly affected site was small bowel followed by stomach. Esophageal and colorectal GANTs were less frequent. Clinical presentation was variable ranging from non-specific symptoms, abdominal pain, weight loss, iron-deficiency anemia, to obstruction and gastrointestinal bleeding. Acute presentation due to free rupture or perforation with subsequent peritonitis was extremely rare. Endoscopic and radiological investigations were valuable in tumor localization and determination of distant spread. Thirteen patients were lost to or had no follow-up, leaving 94 patients for long-term outcome analysis. All patients were treated by radical surgical resection of the involved organ as this offered the only hope of cure. Local recurrence, metastases, or both developed in 40 % of cases despite radical surgical resection. Resection for local recurrences and hepatic metastases was feasible in some selected cases. Response to adjuvant chemoradiation was poor and imatinib mesilate was effective in cases of metastatic or inoperable CD117-positive GANTs.

CONCLUSION

Radical surgical resection of GANTs is the mainstay of treatment. The aggressive behavior after radical resection coined with the poor response to adjuvant chemotherapy call for the urgent need to develop new adjuvant therapies.

Gastrointestinal autonomic nerve tumor of the stomach

Patient: Female, 32

Final Diagnosis: Gastrintestinal Autonomic Nerve Tumor (GANT)

Symptoms: anemia • anorexia • fatigue • fever • hearburn • nausea • weight loss

Medication: —

Clinical Procedure: —

Specialty: Gastroenterology and Hepatology

[Stromal tumour of duodenal autonomous nerves (plexosarcoma)]

Gastrointestinal tumours arising from autonomous nerves of Meisner's or Auerbach's plexus (plexomas and plexosarcomas) are rare tumours in only 87 cases described in the literature up to 2001. We present a very rare case of gastrointestinal stromal tumour (plexosarcoma) of the third and fourth portion of the duodenum, 130 x 98 x 87 mm in diameter, arising from its back wall, with central necrosis of the well circumscribed tumour, which communicated with the duodenum through an ulceration of 15 x 7mm in diameter, spreading towards the great vessels of the retroperitoneum. It was gradually and carefully removed, together with 17 cm of the duodenum and few centimetres of the jejunum with end-to-end duodenojejunostomy below the Vater's papilla. During the removal of the tumour, the superior mesenteric artery, being within the tumour's capsule, was accidentally ligated but not transsected. In spite of the removal of the ligature, the artery became thrombosed due to damage of the intima by ligature so that it had to be resected and reanastomosed. After otherwise uneventful recovery, except for a mild pus discharge through the drain, not far from the arterial anastomosis, the patient suddenly started bleeding on the 13th day after surgery. At emergency reoperation, a rupture of the mesenteric artery above the thrombosed anastomosis was found. In spite of absence of the arterial pulsation within the mesentery, the bowel looked vital and the back flow from the artery was satisfactory. The arterial rereconstruction was not possible, so the artery was ligated. The postoperative recovery was surprisingly uneventful. The patient was discharged ten days after surgery and has stayed symptom-free so far.