Gastric Lipomas: A Case Series and Review of the Literature

Introduction

The purpose of this case series was to review a rare subset of tumors known as gastric lipomas, which are typically found incidentally. The motivation for this study arose from the identification of 2 cases within our institution in a short period.

Case Presentation

The study involved a review of the diagnosis and management of 2 patients presenting with gastric lipomas at our institution after symptoms of gastrointestinal bleeding. With the advent of new radiologic investigations such as computed tomography and magnetic resonance imaging and advances in endoscopy, there are new approaches to identifying and managing these tumors. On further evaluation of the literature, we found that despite the availability of minimally invasive endoscopic techniques such as mucosal resection and submucosal dissection in the setting of large tumors, most patients tend to have to resort to surgical management.

Conclusion

This case series underscores the rarity of gastric lipomas and their often-incidental discovery. Further investigation into endoscopic approaches for managing these tumors is needed, and additionally, there is a need to explore a potential association between gastric lipomas and malignancy, as chronic inflammation of the overlying mucosa may play a significant role.

Gastric lymphoepithelial-like carcinoma presenting as a sub-mucosal mass: a case report and literature review

BACKGROUND

Lymphoepithelioma-like carcinoma of the stomach (LELC), also known as carcinoma with lymphoid stroma of the stomach, is a rare type of gastric cancer, accounting for approximately 1-4% of all gastric cancers. It is mainly associated with Epstein-Barr virus (EBV) infection. Here, we report a case of gastric lymphoepithelial-like carcinoma presenting as a submucosal mass that tested negative for EBV.

CASE DESCRIPTION

a 70-year-old patient was diagnosed with a gastric mass through routine endoscopy. There was no abdominal pain, fever, hematemesis, chills, or other discomfort, and the patient had a history of hypertension. The complete blood count, blood chemistry, and tumor indices were normal, and the results for EBV infection were also negative. According to EUS, it was diagnosed as a gastric stromal tumor. The patient underwent endoscopic submucosal dissection (ESD). Pathological exams suggested that it was a low-differentiated carcinoma, and surgical dissection was performed.

CONCLUSION

Cases of gastric LELC are rare, and clinicians need to improve their understanding of the disease to avoid misdiagnosis. The etiology and pathogenesis of this disease need further investigation.

Loss of the PTCH1 tumor suppressor defines a new subset of plexiform fibromyxoma

BACKGROUND

Plexiform fibromyxoma (PF) is a rare gastric tumor often confused with gastrointestinal stromal tumor. These so-called "benign" tumors often present with upper GI bleeding and gastric outlet obstruction. It was recently demonstrated that approximately one-third of PF have activation of the GLI1 oncogene, a transcription factor in the hedgehog (Hh) pathway, via a MALAT1-GLI1 fusion protein or GLI1 up-regulation. Despite this discovery, the biology of most PFs remains unknown.

METHODS

Next generation sequencing (NGS) was performed on formalin-fixed paraffin-embedded (FFPE) samples of PF specimens collected from three institutions (UCSD, NCI and OHSU). Fresh frozen tissue from one tumor was utilized for in vitro assays, including quantitative RT-PCR and cell viability assays following drug treatment.

RESULTS

Eight patients with PF were identified and 5 patients' tumors were analyzed by NGS. An index case had a mono-allelic PTCH1 deletion of exons 15-24 and a second case, identified in a validation cohort, also had a PTCH1 gene loss associated with a suspected long-range chromosome 9 deletion. Building on the role of Hh signaling in PF, PTCH1, a tumor suppressor protein, functions upstream of GLI1. Loss of PTCH1 induces GLI1 activation and downstream gene transcription. Utilizing fresh tissue from the index PF case, RT-qPCR analysis demonstrated expression of Hh pathway components, SMO and GLI1, as well as GLI1 transcriptional targets, CCND1 and HHIP. In turn, short-term in vitro treatment with a Hh pathway inhibitor, sonidegib, resulted in dose-dependent cell killing.

CONCLUSIONS

For the first time, we report a novel association between PTCH1 inactivation and the development of plexiform fibromyxoma. Hh pathway inhibition with SMO antagonists may represent a target to study for treating a subset of plexiform fibromyxomas.

Management of Gastrointestinal Stromal Tumors

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasm of the gastrointestinal tract. The stomach is the most common site of origin. Management of GISTs changed after the introduction of molecularly targeted therapies. Although the only potentially curative treatment of resectable primary GISTs is surgery, recurrence is common. Patients with primary GISTs at intermediate or high risk of recurrence should receive imatinib postoperatively. Imatinib is also first-line therapy for advanced disease. Cytoreductive surgery might be considered in advanced GIST for patients with stable/responding disease or limited focal progression on tyrosine kinase inhibitor therapy. GIST requires multidisciplinary management.

Trichobezoar presenting as a gastric outlet obstruction: A case report

INTRODUCTION

Rapunzel syndrome is a rare intestinal condition that starts with the ingestion of a trichobezoar. The condition is predominately found in females and can be associated with trichotillomania, or the compulsive urge to pull one's own hair out. There are less than 40 cases described in the literature with the prevention of recurrence aimed at psychological treatment.

PRESENTATION OF CASE

The patient is a 7 year-old girl with a history of trichotillomania with trichophagia as a young child who presented with abdominal pain, nausea, and vomiting, consistent with a gastric outlet obstruction. She had an exploratory laparotomy with gastrostomy performed revealing a 18cm by 18cm trichobezoar with extension into the small bowel.

DISCUSSION

Bezoars, an already rare entity, can occasionally lead to gastric and small bowel obstructions. Small collections of ingested hair build up in the intestinal tract causing significant symptoms. These obstructions can sometimes be treated through minimally invasive techniques but, in our case described, it is unlikely to have been treated any other way due to the substantial size of the trichobezoar.

CONCLUSION

Early consideration of Rapunzel syndrome is important in young females presenting with a gastric outlet obstruction.

A rare clinic entity: Huge trichobezoar

INTRODUCTION

Trichobezoar is a rare clinical entity in which a ball of hair amasses within the alimentary tract. It can either be found as isolated mass in the stomach or may extend into the intestine. Trichobezoars mostly occur in young females with psychiatric disorders such as trichophagia and trichotillomania.

CASE REPORT

Authors present a giant trichobezoar in an 18year old female presented with complaints of upper abdominal mass, epigastric area pain, anorexia and weight loss. The patient underwent trans-abdominal ultrasonography (USG), Computed tomography (CT), upper gastrointestinal endoscopy and subsequently laparotomy. USG was inconclusive due to non-specific findings. It revealed a thick echogenic layer with posterior dirty shadowing extending from the left sub-diaphragmatic area to the right sub hepatic region obscuring the adjacent structures. Abdominal CT images revealed a huge, well defined, multi-layered, heterogeneous, solid appearing, non-enhancing mass lesion in the gastric lumen extending from the gastric fundus to the pyloric canal. An endoscopic attempt was performed for removal of this intraluminal mass, but due to its large size, and hard nature, the endoscopic removal was unsuccessful. Finally the large trichobezoar was removed with open laparotomy.

CONCLUSION

Trichobezoars should be suspected in young females with long standing upper abdominal masses; as the possibility of malignancy is not very common in this age group. While USG is inconclusive, trichobezoar can be accurately diagnosed with CT. In patient with huge trichobezoar, laparotomy can be performed firstly because of big size and location of mass, and psychiatric recommendation should be made to prevent relapse of this entity.