submucosal tumor(smt) of stomach

March 2011Gateorn

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, Year VIGillian Lieberman, MD

Leiomyoma

and spectrum of submucosal

tumors of the GI tract

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Chulalongkorn

University ,Year VI

Gillian Lieberman ,MD

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Overview

•Patient presentation•Radiologic findings•Differential diagnosis•Spectrum of submucosal

tumors

•Endoscopic ultrasonography•Hospital course summary

•Take home messages

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Patient Presentation

•A 20‐year‐old healthy woman desired to attend the beauty contest.

•Screening chest X‐ray was abnormal.

•No past history of medical illness

•Physical examination and laboratory results are within normal limits.

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Our patient : chest X‐ray

Source : PACS,KCMH

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Time is up !!!

…….

Could you pick up anything abnormal ?

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6Source : PACS,KCMH

•Soft tissue density with the crescent of adjacent air in the left upper

abdomen(stomach)•Otherwise are

unremarkable

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Our patient : chest X‐ray

source : PACS,KCMH

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Our patient : mass on CT

Axial abdominal CT+oral contrast

How do you describe the findings of this CT image ?


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Axial abdominal CT+oral

contrast

• Homogeneous low attenuation polypoid

intraluminal

mass

• well‐defined margin

• smooth surface

• without evidence of invasion or obstruction

• located at the cardia

of stomach

Source : PACS,KCMH

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Our patient : differential diagnosis• Our patient was asymptomatic and young.

• Nothing found remarkably on her physical examination.

• Malignancy is less likely

• So what kind of benign gastric tumor can present with this features ?

Let’s see the classification of benign gastric mass

…...

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Mucosal mass Submucosal mass

Non-neoplastic polyp Neoplastic polyp mesenchymal Non-mesenchymal

Harmatomatous polypJuvenile polypHyperplastic polyp

Adenomatous polypFundic gland polyp

Benign gastric mass : Classification

Heterotopic pancreasBrunner’s gland harmatomaDuplication cystGastric cystic profundaIntramural pseudocyst

GISTs ( may not be benign )LeiomyomaSchwannomaLipomaVascular tumors

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Some types of gastric mass can be differentiated by CT scan

………

Here are examples of CT scan of common benign gastric tumors

Our patient : differential diagnosis

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Companion pt#1 : Inflammatory fibroid polyp

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source : Oh JY, et al. Eur Radiol 2008;67:112-24

Axial C+ abdominal CT shows an intraluminal pedunculated mass in the antrum of the stomach.

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Companion pt#2 : small GIST

Axial C+ abdominal CT shows a homogeneous low-density mass located in the fundus of the stomach with the intact overlying mucosa enhancing to a greater degree than the mass


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Companion pt#3 : large GIST

Axial C+abdominal CT shows a heterogeneous low-attenuation mass with the focal areas of necrosis arising from the stomach ( high risk of malignancy )

Source :Hong X, et al. Radiographics 2006;26:481-495

Companion pt#4 : Leiomyoma

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Axial C+ abdominal CT shows a homogeneous low- attenuation mass with central ulceration in case of large size

Companion pt#5 : Schwannoma

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Axial C+ abdominal CT obtained with water as an oral contrast agent shows the well-circumscribed mass with homogeneous enhancement.

Source : Park SH, et al. Radiographics 1999;19:1435-1446

Companion pt#6 : Ectopic pancreas

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Source : Kim JY, et al. Radiology 2009;252:92-100

Axial C+ abdominal CT shows an ill-defined ovoid endoluminal submucosal mass in the gastric antrum. The lesion shows homogeneous enhancement and higher attenuation than the pancreas

Companion pt#7 : Lipoma

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Axial C+ abdominal CT shows a well-circumscribed submucosal mass with uniform fat attenuation .Lipoma can be definitely diagnosed by CT scan .

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Source : Park SH, et al. Radiographics 1999;19:1435-1446

CT scan could be used to narrow down the differential

diagnoses

………

Now let’s go back to our patient’s abdominal CT

image……what is the most likely diagnosis ?

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Axial abdominal CT+oral

contrast

• Homogeneous low attenuation polypoid

intraluminal

mass

• well‐defined margin

• smooth surface

• without evidence of invasion or obstruction

• located at the cardia

of stomach

Source : PACS,KCMH

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No definite diagnosis could be made by only CT scan, except for Lipoma

………

The next appropriate investigation for intraluminal mass of the stomach should be gastroscopy

………

Let’s see the companion patient’s image of gastroscopy

Our patient : further investigation

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Companion pt#8 : Endoscopic findings of submucosal

tumor

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Source : Jeong ID , et al. Surg Endosc 2011;25:468-74

• An elevated submucosal

mass at the upper part of the

stomach

• The overlying mucosa is intact

• Suggesting a submucosal

lesion

It’s not mucosal lesion because the overlying mucosa was intact

And not extraluminal

compression indicated by CT scan

……………..

Now

, the diagnosis is focused on submucosal

lesion

Let’s go through a bit more about submucosal

lesion of the upper GI

tract ..….

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Submucosal

lesions : definition

Definition : A variety of neoplastic

and non‐ neoplastic

condition arising from deeper

layers of the wall of the GI tract , the overlying mucosa is not involved.

Polkowski M,et al. Gastrointest Endoscopy Clin N Am 2005;15:33– 54

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Submucosal

lesion : GI tract wall

Source : Valaamo M, http://ethesis.helsinki.fi/julkaisut/laa/kliin/vk/vaalamo/review.html

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Submucosal

lesions : overview•Incidence : 0.4% of diagnostic scope•Usually asymptomatic•Discovered as accidental findings•Symptoms : abdominal pain, bleeding, obstruction

and intussusception•CT scan and Endoscopic ultrasonography

( EUS )

are used to narrow down the differential diagnoses and to assess the risk of malignancy

Ponsaing LG , et al. World J Gastroenterol 2007;13:3301-10

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Endoscopic ultrasonography

(EUS)• The first choice for examining submucosal

lesions

in the upper GI tract.

• Important application of EUS is to stage GI malignancy , also to differentiate the types of

submucosal

tumors by their original layers.

• The sensitivity of cytological samples achieved through EUS‐FNA

has been reported to be 88%‐

91% and the specificity was 100% for the diagnosis of malignant lesions

Ponsaing LG , et al. World J Gastroenterol 2007;13:3301-10.

EUS images of stomach wallAlternating echogenicity

of layers of the GI tract wall

source : Kang J-H, et al. Eur Radiol 2009;19: 924–34

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Companion pt#9 : EUS images of tumor origins


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MM=Muscularis mucosaeSM=Submucosal layerPM=Muscularis propia

Submucosal

tumors : Origins


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Gastric submucosal

tumors : classification

Mesenchymal

tumors

Myogenic

Neurogenic

GISTs

Leiomyoma

Schwannoma

Non‐mesenchymal

tumors

Heterotopic

pancreas

Brunner’s gland harmatoma

Duplication cyst

Gastric cystic profunda

Intramural pseudocyst

32Fleury A, et al. http://emedicine.medscape.com/article/189303-overview

> 50 % of submucosal tumors

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Mesenchymal

tumors : DDx

by EUS• Differentiation among leiomyoma

, schwannoma

and GIST is

extremely difficult by imaging modalities.

• 50% of GIST and schwannoma

: complete or incomplete

marginal hypoechoic

halo from EUS findings. ( distinct

marginal halo is not seen in leiomyoma).

• Echogenicity

of tumor comparing to the surrounding proper

muscle from EUS findings.

Sakamoto H , et al. World J Radiol 2010 ;2:289-97

GIST slightly higher

Leiomyoma nearly equal

Schwannoma extremely low

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In the past , we thought GISTs

= Leiomyoma

but not any more

…….

Let’s go through more details about GISTs

and leiomyoma

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Submucosal

tumors : GISTs• GIST occurs more in stomach and small bowel than

esophagus .

• 10‐30% of GIST are eventually malignant.

• GIST expressed KIT ( CD 117) and/or CD34 antigen.• Follow up is needed after surgical resection• Imatinib

mesylate

is used to shrink large GISTs

before surgery and it is the first line treatment for recurrent or metastatic GISTs.

Kim GH , et al. World J Gastroenterol 2009;15: 3376-81 Sakamoto H , et al. World J Radiol 2010 ;2:289-97.

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Submucosal

tumors : Leiomyoma• Leiomyomas

are benign tumors without malignant

potential.

• Most common are found at esophagus but are rare in the stomach and duodenum.

• Leiomyoma

: non‐expression of KIT ( CD 117) but express desmin

and/or actin.

• Most tumors are asymptomatic.

• No recurrence after surgical resection

Oh JY, et al. Eur Radiol 2008;67:112-24Ponsaing LG , et al. World J Gastroenterol 2007;13:3301-10Sakamoto H , et al. World J Radiol 2010 ;2:289-97.

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EUS findings : Gastric GISTs

VS Leiomyoma

• Inhomogenicity

, hyperechogenic

spots , a marginal halo and higher echogenicity

as compared with the

surrounding muscle layer from EUS findings appeared more frequently in GIST than in

leiomyoma.

• GIST size > 3.5 cm : increase risk of malignancy

Kim GH , et al. World J Gastroenterol 2009;15: 3376-81

Now , let’s go to the patient’s hospital course summary and definite diagnosis

……….

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Our patient : Hospital course• Surgery was designed after CT scan and gastroscopy

suspecting GISTs

or gastric leiomyoma

,EUS was not done.

• Proximal esophagogastrectomy

was performed.

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39Courtesy of Dr.Sirichindakul , KCMH

Our patient : Surgical specimens

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40Courtesy of Dr.Sirichindakul , KCMH

The surgical specimens were sent to the pathologist

………

Let’s see the results ….

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Our patient : Histology result• Well demarcated border spindle cell tumor,

lack of pleomorphism

and scant mitotic count

Benign spindle cell tumors‐GISTs

‐Leiomyoma‐Schwannoma

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Histological result helps focus on benign spindle cell tumors of the stomach

…….. To confirm definite diagnosis ,

immunostaining

is needed.

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Hayat MA , http://books.google.com/books?id=141gKRRJegsC&Ipg=PA138&dq =immunohistochemistry schwannoma s100 SMA&pg=PA138#v=onepage&q&f=false

Spindle cell tumor:Immunostaining

Our patient : Immunostaining

CD‐117

CD‐34 SMA

S‐100

‐ ‐ +

‐

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Leiomyoma

GISTs GISTs Leiomyoma Schwannoma

• Certain abdominal pathologies can be detected by a the routine screening chest X‐ray.

• Current modalities to assess the submucosal

tumors of stomach are combination of CT scan and

endoscopic ultrasonography( EUS )

.

• Diagnostic approach of gastric submucosal

tumors is to differentiate GISTs

from the others which are

usually benign but GISTs

are by far the top candidate for malignancy .

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Take home messages

References •1.Ponsaing LG,Kiss

K, Loft A, Jensen LI, Hansen MB .Diagnostic procedures for submucosal

tumors in the GI tract .World J Gastroenterol

2007 June 28; 13(24): 3301‐3310

•2.Polkowski M, Butruk

E. Submucosal

lesions. Gastrointest

Endoscopy Clin

N Am 2005;15:33‐

54.

•3.Kang J‐H , Lim JS, Kim J‐H, Hyung

WJ , Chung YE , Choi

J‐Y, et al. Role of EUS and MDCT in the

diagnosis of gastric submucosal

tumors according to the revised pathologic concept of

gastrointestinal stromal

tumors. Eur

Radiol

2009;19:924‐34.

•4.Oh JY , Nam KJ , Choi

JC , Cho JH , Yoon SK , Choi

SS , et al. Benign submucosal

lesions of the

stomach and duodenum : imaging characteristics with endoscopic and pathologic correlation.

Eur

Radiol

2008;67:112‐24

•5. Park SH , Han JK , Kim TK , Lee JW , Kim SH , Kim YI , et al.

Unusual gastric tumors: radiologic‐

pathologic correlation. Radiographics

1999; 19: 1435‐46.

•6.Kim JY , Lee JM , Kim KW , Park HS , Choi

JY , Kim SH , et al. Ectopic pancreas : CT findings

with emphasis on differentiation from small gastrointestinal stromal

tumor and leiomyoma.

Radiology 2009;252:92‐100.

•7.Hong X , Choi

H , Loyer

EM , Benjamin RS , Trent JC , Charnsangavej

C . Gastrointestinal

stromal

tumor : role of CT in diagnosis and in response evaluation and surveillance after

treatment with imatinib. Radiographics

2006;26:481‐95.

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References• 8.Kim HJ , Kim AY , Oh ST , Kim JS , Kim KW , Kim PN , et al. Gastric cancer staging at multi‐

detector row CT gastrography

: comparison of transverse and volumetric CT scanning.

Radiographics

2005; 236:879‐85.

• 9.Park YS , Park WS , Kim TI , Song SY , Choi

EH , Chung JB , et al. Endoscopic enucleation

of

upper GI submucosal

tumor by using an insulated‐tip electrosurgical knife. Gastrointest

Endosc

2004;59:409‐15.

• 10. Fleury

A, et al.

http://emedicine.medscape.com/article/189303‐overview

• 11. Valaamo

M, http://ethesis.helsinki.fi/julkaisut/laa/kliin/vk/vaalamo/review.html

• 12.Kim GH , Park DY , Kim S , Kim DH , Kim DH , Choi

CW , et al. Is it possible to differentiate

gastric GISTA from gastric leiomyoma

by EUS? World J Gastroenterol

2009;15: 3376‐81.

• 13. Sakamoto H , Kitano M , Kudo

M. Diagnosis of subepithelial

tumors I the upper

gastrointestinal tract by endoscopic ultrasonography. World J Radiol

2010 ;2:289‐97.

Acknowledgement• Dr. Boonchoo

Sirichindakul

, MD

• Dr. Rungsan

Rerknimitr

,MD

• Dr. Jeremy Schiller , MD

• Dr. Gillian Lieberman, MD

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submucosal tumor(smt) of stomach

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