Laparoscopic wedge resection of the stomach for gastrointestinal stromal tumor (GIST): non-touch lesion lifting method

Background

Laparoscopic surgery for GIST carries a risk of intraoperative tumor dissemination. To avoid tumor dissemination, we have utilized a “non-touch” method for surgical resection of GIST since 2000.

Methods

Forty-two patients with gastric GIST were treated at our institution between 2000 and 2012. Laparoscopic wedge resection of the stomach was used as the standard procedure for tumors that were 2–5 cm in size. Tumors larger than 5 cm were treated with open surgery. Our non-touch procedure included a lesion-lifting method using traction sutures at the normal stomach wall around the tumor. Intraoperative gastroscopy was utilized to confirm the location of the tumor with laparoscopy. After lifting of the tumor, tumors with a clear operative margin were resected using a linear stapler. Tumors located at the posterior wall of the stomach or located near the esophagogastric junction were resected using traction sutures.

Results

Median operative time was 140 min and median blood loss was 0 ml. Postoperative course was uneventful excepting one patient who experienced postoperative bleeding. The median postoperative stay was 7 days. One patient developed liver metastasis after surgery. None of the patients had local recurrence or peritoneal recurrence case.

Conclusion

This non-touch lesion-lifting method was useful for the surgical management of gastric GIST.     

Intragastric single-port surgery (IGS) for gastric endophytic gastrointestinal stromal tumor (GIST): A novel surgical treatment

BackgroundIntragastric surgery with a single incision has been performed for several diseases, such as gastric tumors[1] and pancreatic pseudocyst[2], safety, feasibility and potential benefits of which have been reported in previous relevant studies[3].MethodsThe video shows a 65-year-old man with upper gastrointestinal hemorrhage, preoperative abdominal CT scan and endoscopy suggested an endophytic tumor located in gastric corpus, suggesting gastrointestinal stromal tumor (GIST). Intragastric single-port surgery (IGS) was indicated.ResultsUnder general anesthesia, patient was placed in supine position. Surgeons stood on the right side of the patient. After a 2.5cm transverse incision was made on left upper abdominal wall, gastric anterior wall was exteriorized and fixed to the skin incision. Single-port device was inserted inside the stomach after anterior gastric wall was opened. Next, laparoscope was introduced into gastric cavity and identified the location of tumor. Full thickness resection of the tumor was performed by using linear stapler, then stapler line was embedded with continuous sutures. Finally, after specimen and single-port device removal, the stomach incision was closed extracorporeally. The operation time was 112 minutes. Final pathology confirmed GIST (4.5cm) with negative margins and patient discharged after 4 days, without postoperative complications. In 1-year follow-up time, without recurrence or death.ConclusionIGS is safe and effective for gastric endophytic GIST resection, which not only preserves all advantages of conventional laparoscopic operation, but also includes other benefits like obviating the need of abdominal cavity exploration, potential reduction of risk of neoplasm seeding, and offering good postoperative cosmetic result.     

胃肠道淋巴瘤64排螺旋CT与MRI影像学特点分析

目的 探讨原发性胃肠道淋巴瘤(PGIL)64排螺旋CT和磁共振成像(MRI)的影像学特点.方法 选取41例原发性胃肠道淋巴瘤患者,包括23例胃淋巴瘤和18例肠道淋巴瘤;同时选取32例胃间质瘤患者和40例结肠癌患者作为对照.比较胃淋巴瘤与胃间质瘤、肠道淋巴瘤与结肠癌的CT、MRI影像学特点.结果 CT扫描显示,大部分浸润型胃淋巴瘤患者的胃黏膜完整,胃壁不规则增厚且多呈稍低密度或等密度影;常规增强扫描后,胃黏膜明显强化.MRI检查显示,肿瘤组织在T1WI上多呈稍低或等信号,在T2WI上多呈稍高或等信号.胃淋巴瘤门静脉期平均CT值和平均表观弥散系数(ADC)值分别为(65.02±21.15)Hu和(0.81±0.10)×10-3cm2/s,均低于胃间质瘤,差异均有统计学意义(P﹤0.05);胃淋巴瘤和胃间质瘤的发病部位(胃窦、胃体、胃底)比较,差异均有统计学意义(P﹤0.05).肠道淋巴瘤CT扫描显示,肠道管腔狭窄或扩张,肠道管壁增厚且多呈等密度影;常规增强扫描后,增厚肠道管壁均匀强化,在T1WI上呈稍低或等信号,在T2WI上呈稍高信号.肠道淋巴瘤平均ADC值为(0.89±0.17)×10-3cm2/s,低于结肠癌的(1.27±0.32)×10-3cm2/s,差异有统计学意义(P﹤0.05).结论 胃肠道淋巴瘤CT及MRI表现有一定的特征,其CT值及ADC值具有一定的诊断价值.     

Synchronous adenocarcinoma and gastrointestinal stromal tumors of the stomach treated laparoscopically

Gastric adenocarcinomas account for approximately 95% of primary gastric tumors, and gastrointestinal stromal tumor (GIST) is the most common gastrointestinal mesenchymal tumor, accounting for 1%–3% of primary gastric tumors. However, the synchronous occurrence of GIST and gastric epithelial tumor is rare. We herein report a case of synchronous occurrence of gastric adenocarcinoma and two GISTs of the stomach. All lesions were resected laparoscopically. We discuss this case and review the literature.     

A case of primary lymphoma of the stomach, diffuse lymphoplasmacytic type, with massive hematemesis

A case of primary lymphoma of the stomach with massive hematemesis and melena who underwent emergency gastrectomy is reported. The patient was a 72-year-old woman. The tumor was 3.5 X 3.0 cm in size and occupied the posterior wall of the upper part of the gastric body. The surface of the tumor was covered with hematoma, and was there was a lack of gastric mucosa. Histological diagnosis of the tumor was primary gastric lymphoma, diffuse lymphoplasmacytic B-cell type, and monoclonal kappa-light chain was demonstrated by the immunohistochemical method. The bleeding source of the tumor tissues was a ruptured artery invading the tumor tissue in the submucosal layer of the stomach.     

Primary gastric Hodgkin lymphoma and metachronous early gastric carcinoma: a case report

Primary Gastric Hodgkin lymphoma is seen very rarely. Primary gastric Hodgkin lymphoma and gastric carcinoma in same patient is very very rare entity. Almost all of the primary gastric lymphoma cases are non-Hodgkin lymphoma type. We report the case of 45-year-old man with 3-month history of abdominal pain and weight loss. Upper gastrointestinal endoscopic examination revealed an ulcerated polypoid mass on greater curve of stomach and histopathological examination of biopsy showed adenocarcinoma. After near total gastrectomy, gastric Hodgkin lymphoma diagnosis was made, and postoperative 4 courses of doxorubicin, bleomycin, vinblastine, dacarbazine (ABVD) regimen were administered, and then total 3,600 cGy radiotherapy was delivered. After 7 years, during control examination, early gastric carcinoma was diagnosed. Our case is very rare entity of gastric Hodgkin lymphoma and metachronous gastric carcinoma. This case also shows the importance of follow-up of patients not only for the relapse of primary disease but also for the development of secondary malignancy which can be diagnosed at early curable stage.

     

进展期胃癌和胃淋巴瘤的MSCT影像学鉴别

目的：分析探讨多层螺旋CT（MSCT）在进展期胃癌和胃淋巴瘤鉴别诊断中的价值。方法对46例进展期胃癌和34例胃淋巴瘤患者的MSCT平扫和增强扫描影像学资料进行分析,比较两种肿瘤在胃侵犯部位、胃壁胃黏膜及胃腔改变、周围组织及器官的浸润或转移、中上腹部淋巴结转移等方面的差异。结果进展期胃癌组多部位侵犯14例,增强扫描不均匀强化28例,胃黏膜中断、破坏24例,胃腔狭窄、近侧胃腔扩张14例,腹主动脉周围下部淋巴结转移18例;胃淋巴瘤组多部位侵犯24例,增强扫描不均匀强化7例,胃黏膜中断、破坏5例,胃腔狭窄、近侧胃腔扩张3例,腹主动脉周围下部淋巴结转移23例;两组上述指标差异均有统计学意义（P＜0.05或P＜0.01）。进展期胃癌组和胃淋巴瘤组在胃壁厚度、肿瘤外侵和器官转移、平均淋巴结转移的部位数等差异无统计学意义（P＞0.05）。结论 MSCT可清晰显示进展期胃癌和胃淋巴瘤的侵犯部位、侵犯程度的不同,对于二者的鉴别具有重要价值。     

CD117弱表达及阴性表达的胃肠道间质瘤13例分析

  目的 分析 CD117弱表达及阴性表达的胃肠道间质瘤的特点。方法 回顾性分析 13 例经手术病理证实的 CD117弱表达及阴性表达胃肠道间质瘤的特点。结果　肿瘤位于胃部 6 例，小肠 4 例，结直肠 2 例，大网膜 1 例。腹部疼痛不适 6 例，呕血或黑便 3 例。病理学检查肿瘤为良性者 5 例，恶性者8 例。CT 检查表现为软组织密度，5例病变含有囊变及出血，所有病变均未见钙化。良性肿瘤大小（最长径×最短径）平均为3.4 cm×2.8 cm；恶性肿瘤大小平均为7.5 cm×6.2 cm。13 例患者均经手术治疗，手术切除率100 ％。10 例术后获随访6个月~ 4 年，有1 例死于肿瘤复发转移，其余至今仍生存。结论　CD117弱表达及阴性表达的胃肠道间质瘤的好发部位为胃体。CT 扫描有助于 CD117弱表达及阴性表达胃肠道间质瘤的定位和良恶性的判断。手术是其治疗的主要方法。     

Comparative endoscopic study of primary gastric lymphoma vs. gastric carcinoma

The endoscopic records of 56 patients with primary gastric lymphoma and 120 patients with gastric adenocarcinoma (matched for age and sex) were compared with respect to site, extent, and type of tumor by endoscopy and biopsy results. Diagnosis of lymphoma was suspected on the basis of gross endoscopic appearance in 30 patients with 96% sensitivity. The endoscopic findings that achieved statistical significance in favor of lymphoma were extensive disease involving whole stomach, proximal stomach involvement, extension of tumor into duodenum, and the presence of volcano crater-like ulcers on polypoid lesions. Endoscopic biopsies were positive for lymphoma in 92% patients. Immunoperoxidase staining for leucocyte common antigen was positive in all the 24 patients with lymphoma where it was performed. We conclude that lymphoid origin of the stomach tumor may be suspected in one-half of the cases of primary gastric lymphoma by gross endoscopic findings. Multiple endoscopic biopsies are safe and highly sensitive and specific in the diagnosis of primary gastric lymphoma. © 1994 Wiley-Liss, Inc.     

A case of bleeding giant gastrointestinal stromal tumor of the stomach who achieved partial response by chemotherapy

A 80-year-old female was referred to our hospital for hematomesis. An abdominal CT revealed a heterogeneous giant tumor of about 11 cm, rich in vascularity, extending from the gastric fundus, beyond the upper side of the spleen, to the left thoracic diaphragm. Gastroscopy showed a 5 cm submucosal tumor with a visible vessel at the gastric fundus. After biopsy was performed, she was diagnosed with a c-kit-positive gastrointestinal stromal tumor (GIST)of the stomach. Following endoscopic hemostasis for gastric bleeding, imatinib mesilate was administered. The tumor reduced markedly, and vascularity in the tumor was diminished, the visible vessels of the tumor disappeared. For curative resection, total gastrectomy with a distal pancreato -splenectomy and a left diaphgram resection is necessary, but surgery was high-risk for this patient because she was advanced in age. She is now achieving a good partial response without surgery.     

Primary non-Hodgkin's lymphoma in the dorsolumbar muscles

We report a case of primary soft tissue lymphoma with pulmonary involvement in a 57-year-old man, successfully treated with surgery and chemotherapy. The patient presented with a giant mass (16 × 20 cm) in the left dorsolumbar region. Computed tomography (CT) demonstrated a right-sided pulmonary tumor, in addition to the giant tumor in the left dorsolumbar muscles. On an incisonal biopsy, the left dorsolumbar muscle tumor was suspected to be a sarcoma, and en-bloc resection was therefore performed. During surgery, four left pulmonary tumors that had not been observed on CT were found and surgically resected. The patient was finally diagnosed with soft tissue non-Hodgkin's B cell lymphoma with pulmonary involvement. After postoperative chemotherapy, the right pulmonary nodule disappeared. The patient was well and had no evidence of disease 22 months after surgery. To the best of our knowledge, primary soft tissue lymphoma is extremely rare. Received: August 14, 1997 / Accepted: May 8, 1998     

Primary gastric mantle cell lymphoma in a patient with long standing history of Crohn's disease

The stomach is the most common site of primary extranodal lymphoma. Virtually all cases are of B-cell lineage, including extranodal marginal zone B-cell lymphomas of mucosa-associated lymphoid tissue (MALT lymphoma) and diffuse large B-cell lymphomas. While secondary gastric involvement from nodal mantle cell lymphoma (MCL) or in the course of primary intestinal MCL (lymphomatous polyposis) have been described, primary gastric MCL has not been reported so far. A 74-year-old man with a 14 year-history of Crohn's disease was admitted at a general hospital due to epigastric pain refractory to therapy with proton-pump inhibitors. Endoscopy disclosed a large polypoid tumor with an ulcerated surface at the greater curvature of the gastric antrum. Endosonography demonstrated the tumor to be limited to the stomach with only local lymph node involvement. Histology of gastric biopsies revealed a dense atypical lymphoid infiltrate composed of small to medium sized cells with slightly irregular nuclear contours. Immunohistochemichally, the cells were positive for CD20, CD79a, CD43 and cyclin D1, but negative for CD3, CD5 and bcl-6. They stained for IgM and showed lambda-light chain restriction. Fluorescent in situ hybridisation studies showed the presence of the t(11;14) characteristic for MCL. No further evidence of lymphoma was found on extensive clinical staging. Following chemotherapy the patient is disease free at 24 months after diagnosis. This is the first case of a primary localized gastric MCL. The lack of CD5 expression underscores the importance of performing thorough immunohistochemical studies, particularly to exclude MALT lymphoma.     

Surgery in primary gastric lymphoma: impact on clinical staging and long-term survival

This study analyzes the value of surgery in the treatment, staging and long-term survival of 17 patients affected with primary gastric lymphoma. In 7 patients the neoplasm was localized to the lower third of the stomach, in three to the middle third, in two to the upper third, while in 5 patients there was involvement of the entire stomach. Patients were classified according to the Ann-Arbor classification. Nine patients were stage Ie, five stage Ile, and three stage IVe. A partial gastrectomy was carried out in ten patients and total gastrectomy in 7. In all cases surgical excision of the gastric lymphoma was performed together with intraoperative staging including bilateral hepatic biopsies, and exploration of all abdominal lymph nodes. Two postoperative deaths occurred among the 7 patients who underwent total gastrectomy but no major complications were observed in the remaining 5 patients. No deaths occurred among the 10 patients who underwent partial gastrectomy, but in one case an acute complication developed. Staging laparotomy permitted the correction of clinical staging, and showed that three cases were understaged and one overstaged. All patients received adjuvant chemio-radiotherapy. All but one patient are currently alive, well and free of disease. Survival was correlated significantly with the stage of the disease and extent of gastric involvement, but there was no correlation between survival, histological grade, and the type of gastrectomy performed.     

A case of coexistent multiple malignant lymphomas and early carcinoma of the stomach

A 68-year-old man with multiple malignant lymphomas and early gastric carcinoma in the stomach is described. In the resected stomach, six lesions of malignant lymphoma, large cell type (LSG classification) or histiocytic type (Rappaport classification) were observed at the posterior wall of the gastric body. Well differentiated tubular adenocarcinoma as an early carcinoma of type IIc was also found on the lesser curvature of the gastric body. In addition, multiple early follicular proliferation of malignant lymphoma was microscopically revealed centering around the gastric body. This rare case of coexistent multiple malignant lymphomas and early carcinoma of the stomach is reported and discussed.     

胃癌和胃淋巴瘤的CT表现对比分析

背景与目的:进展期胃癌与胃淋巴瘤的CT表现在鉴别诊断上较困难,均可表现为胃壁增厚、腔内肿块、胃腔狭窄、淋巴结肿大、远处脏器转移等。本研究通过对比胃癌与胃淋巴瘤的CT表现差异,以提高对胃肿瘤,特别是胃淋巴瘤的CT诊断水平。方法:回顾性分析27例进展期胃癌和25例胃淋巴瘤患者的CT表现,观察病变部位、病变大体形态、胃周径侵犯范围、病灶的最大厚度、粘膜是否光整、粘膜皱襞是否增厚、浆膜受侵情况、有无坏死、病变强化程度、强化是否均匀、其他器官受累情况、腹部淋巴结情况。结果:23例(85.2%)胃癌近胃腔表面见"白线"征,门静脉期"白线"区范围较动脉期大;所有胃淋巴瘤患者均未见"白线"征。13例(48.1%)胃癌非"白线"区门静脉期强化程度高于动脉期。所有胃癌患者胃壁侵犯范围均<50%,23例(85.2%)胃淋巴瘤患者胃壁侵犯范围>75%。所有27例(100%)胃癌患者均见胃粘膜溃疡,1例(4%)胃淋巴瘤见胃粘膜溃疡。11例(44.0%)胃淋巴瘤有2个区或以上的胃周淋巴结肿大,8例(32.0%)胃淋巴瘤患者有肾门下腹膜后淋巴结肿大;所有胃癌患者均未见2个区或以上胃周肿大淋巴结,亦未见肾门下腹膜后淋巴结肿大。结论:胃癌与胃淋巴瘤的CT表现各有其特点,包括有无胃粘膜"白线"征、粘膜溃疡、胃壁侵犯范围、胃周肿大淋巴结分布、有无肾门下腹膜后肿大淋巴结等,这些特点对于二者的鉴别诊断具有一定的参考价值。     

胃体不典型血管球瘤1例报告及文献复习

Objective

The aim of this study was to analyze the clinical pathological features of the atypical glomus tumor of the stomach, and explore its biological behavior and clinical significance.

Methods

a 43-year-old female was admitted due to passing black stool for 5 months. The melena of the patient occurred after eating the crabs. The endoscopic ultrasonography (EUS) was performed, showing a hypoecho nodule found at the body of the stomach, suggesting the diagnosis of gastric stromal tumor. After onset of disease, no specific clinical symptoms were observed except for the slight feeling discomfort in upper abdominal region. The gastroscopy was performed under the general anesthesia: there was a spheroidal nodule measuring 2.5 cm × 3.0 cm at the anterior wall of the body of stomach near the side of lesser curvature with the focal erosion of gastric mucosa. The DualknifeTM and the snare were used to excise the tumor in full thickness. Grossly, the tumor nodule measured 2.5 cm in diameter. The cut surface was solid, showing moderate consistency and grey red in colour. Microscopically, this tumor presented a well circumscribed nodule. It composed of the rounded neoplastic cells which were mainly arranged in solid pattern. The tumor cells had well-defined cell membranes, centrally placed, round nuclei and amphophilic cytoplasm. Immunohistochemical staining showed the positive expression of smooth muscle actin (SMA), caldesmon and vimentin; meanwhile detecting the negative expression of desmin, pan-cytokeratin, CD34, CD117 and S-100 in tumor cells. The Ki-67 labelling index of tumor was 8%.

Results

Combined with the histopathological features, immunophenotype of the tumor, deep location in abdominal cavity and with greater diameter larger than 2 cm, and the diagnosis of atypical glomus tumor of the body of the stomach in this case was established.

Conclusion

The atypical glomus tumor of the body of the stomach is a rare mesenchymal tumor. The following differential diagnosis should be included as following: gastrointestinal stromal tumor (GIST), paraganglioma, myopericytoma and the angioleiomyoma. The immunohistochemistry exerts an essential role during the diagnosis of this tumor. The deeper location and larger size implicate its undetermined biological behavior.     

Rare synchronous primary large B-cell gastric lymphoma and huge retroperitoneal liposarcoma with inguinal hernia in chronic hepatitis B patient

Multiple primary neoplasms with synchronous or metachronous presentation are rare, although the incidence has recently increased because of several factors. We present the case of a 53-year-old patient with chronic hepatitis B who presented with abdominal mass, mild abdominal pain, and inguinal hernia. Computed tomography imaging demonstrated diffuse thickening of the gastric antral wall, together with a huge heterogeneous abdominal mass with predominant fat attenuation with septa that showed mild enhancement on contrast-enhanced scans. Distal gastrectomy and wide resection of the retroperitoneal mass was performed. Pathology exam led to a diagnosis of diffuse large B-cell gastric lymphoma with retroperitoneal liposarcoma. This is a rare case of a primary gastric lymphoma with another primary (sarcomatous) malignancy occurring synchronously in same patient.     

Pointers to the diagnosis of gastric lymphoma on computed tomography

The computed tomographic features of 12 patients with primary gastric non-Hodgkin's lymphoma and a further seven patients with gastric involvement by disseminated non-Hodgkin's lymphoma have been reviewed. In eight of these 19 patients there were clefts within the area of gastric wall involved by lymphoma where oral contrast medium passed to within 2 mm of the serosal surface in and amongst areas of gastric wall thickening (maximal thickness ranging from 18 to 40 mm). In three of these patients some clefts extended beyond the expected margin of the stomach to enter into, and be contained by, a composite soft tissue mass of stomach, spleen and splenic hilar nodes. Awareness of these features, which are in keeping with the known range of macroscopic pathological appearances in non-Hodkin's lymphoma, may help the radiologist to recognize this potentially curable disease.     

Primary gastric Hodgkin lymphoma and metachronous early gastric carcinoma: a case report

Primary Gastric Hodgkin lymphoma is seen very rarely. Primary gastric Hodgkin lymphoma and gastric carcinoma in same patient is very very rare entity. Almost all of the primary gastric lymphoma cases are non-Hodgkin lymphoma type. We report the case of 45-year-old man with 3-month history of abdominal pain and weight loss. Upper gastrointestinal endoscopic examination revealed an ulcerated polypoid mass on greater curve of stomach and histopathological examination of biopsy showed adenocarcinoma. After near total gastrectomy, gastric Hodgkin lymphoma diagnosis was made, and postoperative 4 courses of doxorubicin, bleomycin, vinblastine, dacarbazine (ABVD) regimen were administered, and then total 3,600 cGy radiotherapy was delivered. After 7 years, during control examination, early gastric carcinoma was diagnosed. Our case is very rare entity of gastric Hodgkin lymphoma and metachronous gastric carcinoma. This case also shows the importance of follow-up of patients not only for the relapse of primary disease but also for the development of secondary malignancy which can be diagnosed at early curable stage.     

Gastric MALT lymphoma presenting as Waldenström's macroglobulinemia without bone marrow involvement

We report a case of gastric mucosa-associated lymphoid tissue (MALT) lymphoma with macroglobulinemia in a 59-year-old man who presented with melena. A computed tomography scan of the abdomen showed irregular thickening of the wall of the stomach, and endoscopic examination disclosed enlarged and inflammatory folds of the fundus. Histopathologic examination of gastric samples showed mucosal infiltration by small lymphocytes, which were positive for CD20 and negative for CD10 and CD23, confirming the diagnosis of gastric MALT lymphoma. Serum electrophoresis detected a monoclonal peak and immunoelectrophoresis revealed an immunoglobulin M kappa component. Bone marrow aspirate and biopsy results were normal. The patient received chemotherapy. After treatment, he was in complete remission, and the serum monoclonal component had disappeared. Our observation is uncommon because of important macroglobulinemia occurring in gastric MALT lymphoma without bone marrow involvement.