Unusual Case of Multiple Synchronous Gastrointestinal Stromal Tumors of the Jejunum Presenting as an Arteriovenous Malformation

Introduction/Objective

Gastrointestinal stromal tumor (GIST) arises from the interstitial cell of Cajal. 30% of GISTs arise in the jejunum. GISTS are generally solitary although multiple GISTs may be synchronous or metachronous. There are a few reports of a GIST of the jejunum mimicking a vascular malformation/arteriovenous malformation (AVM) prior to surgical excision.

Methods

Herein, we report a case of four synchronous GISTs of jejunum. One GIST, highly vascularized, presented with lower gastrointestinal bleeding. The patient was a 40-year-old female presenting with epigastric pain and melena.

Results

She was found to have an ulcerated lesion in the distal jejunum by capsule enteroscopy and double balloon enteroscopy, interpreted as an arteriovenous malformation and tattooed. Several other non-ulcerated “polyps” were described. Gross examination of the ensuing segmental resection of jejunum demonstrated four bosselated tumors ranging from 3.1 cm to 6.5 cm. Microscopically, three tumors did not extend to the surface of the jejunum and were predominantly composed of spindle cells. One tumor (identified by tattoo) extended to the surface with ulceration. This tumor was dominated by wide vascular channels with a spindle cell component between the channels. The four tumors were each positive for CD117, DOG1, and Succinate dehydrogenase B (SDH), identifying the four tumors as non-SDH-deficient GISTs. Ki-67 proliferation index was less than 5% in all four masses.

Conclusion

Multiple GISTs are rare, classified as either sporadic or familial. Familial GEISTs are described in neurofibromatosis type 1, Carney’s triad and Carney-Stratakis syndrome. Pediatric GISTs, with clinical and genetic features often differing from typical adult tumors may also be multiple. Our patient’s four GISTs are considered multiple synchronous sporadic neoplasms. This case serves as an important reminder for pathologists consider GIST in the evaluation of a highly vascular gastrointestinal proliferation and keep in mind the possibility of multiplicity.

Massive hemorrhage in an ileal duplication cyst

We have described massive intermittent intestinal hemorrhage due to a vascular anomaly in an ileal duplication cyst in a 30-year-old man. This unusual case illustrates that these lesions disguise themselves symptomatically and must be considered in the differential diagnosis of gastrointestinal bleeding.

Migration of silicone gel to axillary lymph nodes after prosthetic mammoplasty

Foreign-body reaction to material optically resembling silicone gel was evident in an axillary lymph node of a patient eight years after subcutaneous mastectomy for fibrocystic disease and breast reconstruction with a silicone gel-filled prosthesis. The lymph nodes. was removed as a component of a radical mastectomy for adenocarcinoma and Paget's disease of the nipple that had developed in the residual breast tissue and preserved nipple. Silicone gel may "bleed" through a structurally intact prosthetic envelope and subsequently migrate to regional lymph nodes

Alpha-1-antitrypsin globules in hepatocytes of elderly persons with liver disease

Percutaneous needle biopsy specimens of the liver from three elderly persons (aged 77, 71, and 66) demonstrated eosinophilic intracytoplasmic globules within hepatocytes, particularly in the periportal and periseptal areas. These globules were periodic acid-Schiff positive and diastase resistant, and were identified as alpha-1-antitrypsin by immunofluorescence technics. Two of the patients had cirrhosis, and identification of protease inhibitor (Pi) type by acid starch electrophoresis and crossed immunoelectrophoresis demonstrated SZ and MZ genotypes. The patient with SZ genotype also had a long history of chronic obstructive pulmonary disease. Pi-typing was not performed for the third patient, who did not have cirrhosis. The morphologic identification of alpha-1-antitrypsin disease in liver biopsies of persons of any age is important because of (1) possible multisystem involvement (hepatic and pulmonary), (2) increased frequency of hepatocellular carcinoma, and (3) implications for genetic counseling for other family members.

Porcine heterograft valve replacement in carcinoid heart disease

A 53-year-old man with a pancreatic carcinoid tumor and liver metastases had the carcinoid syndrome with involvement of the tricuspid valve by carcinoid plaque. The mitral valve was involved by unrelated myxomatous degeneration (floppy valve). Each valve was replaced by a Hancock glutaraldehyde-prepared porcine heterograft prosthesis. When the patient died of complications of the tumor 8 months postoperatively, both valves had clinically normal function. Nevertheless, the carcinoid plaque, which was present in all four cardiac chambers and almost completely covered the endocardial surfaces of both atria, extended onto both prostheses. This eventually might have interfered with prosthetic valve function.

Paget's disease of the breast after subcutaneous mastectomy and reconstruction with a silicone prosthesis

Eight years after subcutaneous mastectomy for extensive fibrocystic disease, a patient developed Paget's disease of the breast associated with an underlying infiltrating duct cell adenocarcinoma. We emphasize the need for meticulous examination of the subcutaneous mastectomy specimen and long-term follow-up examination of the breasts in patients treated with subcutaneous mastectomy.

Hodgkin's disease, stages I and II: relationship of recurrence to size of disease, radiation dose, and number of sites involved

A total of 57 patients with Hodgkin's disease limited to above the diaphragm (Stages I and II, A and B) were treated with radiation therapy alone at the University of Florida between 1964 and 1974. Staging laparotomy was done on 24 patients (42%). A total of 16 patients have relapsed, 4 within the treatment fields, 3 marginally, and 9 as extensions. Analysis of dose vs. size showed no in-field failure with disease less than 6 cm in size, with a range of doses. Massive disease continued to recur occasionally, even with higher doses. Most of the massive disease was mediastinal or hilar; the risk of lung or pleural involvement as determined by x-ray and/or biopsy showed a dramatic increase with size of mediastinal/hilar disease. Only 2 (5%) of 43 patients with mediastinal disease less than 6 cm in size had lung or pleural involvement, compared with 10 (71%) of 14 patients with disease greater than 6 cm in size. Both in-field recurrence and generalized relapse were closely related to the number of anatomical sites involved. Treatment programs need to consider tumor size, particularly in the mediastinum, and the number of sites involved.

Foreign-body reaction to silicone gel in axillary lymph nodes after an augmentation mammaplasty

A radical mastectomy was performed for a breast adenocarcinoma occurring 10 years after a subpectoral augmentation mammaplasty with silicone gel-filled prostheses. A foreign-body reaction to silicone was seen in two of the axillary lymph nodes resected.

Localized congenital hepatic fibrosis presenting as an abdominal mass

A six month old male with a liver mass localized to the right lobe that had the histological features of congenital hepatic fibrosis is presented. The mass was resected and the patient was asymptomatic 10 months after surgery. This case serves to further broaden the range of lesions with the histological features of congenital hepatic fibrosis; only one other example of localized congenital hepatic fibrosis has been previously reported.

Dermatofibrosarcoma protuberans with lymph node involvement. A case report of simultaneous occurrence with an atypical fibroxanthoma of the skin

A 40-year-old man had dermatofibrosarcoma protuberans of the neck with rapid local recurrence, satellite nodules, and a cervical lymph node metastasis, occurring simultaneously with an atypical fibroxanthoma of the scrotum. These two tumors, with distinct clinical and pathologic features, are classified as histogenetically related lesions within the spectrum of the fibrous histiocytomas. The place for the dermatofibrosarcoma protuberans at the malignant end of this spectrum is clinically and ultrastructurally documented further in our patient.