Yavuz Emre ŞÜKÜR, Güler İSRAFİLOVA, Can KONCA, Şahin Kaan BAYDEMİR, Cem Somer ATABEKOĞLU

Premenapozal Dönemde Leiomyomu Taklit Eden Jejunal Gastrointestinal Stromal Tümör

Giriş: Adneksiyel kitlelerin %90’ı benign karakterli olup, jinekolojik nedenli hastane başvuruları arasında üst sırada yer almaktadır. Gastrointestinal sistemden kaynaklanan adneksiyel kitleler jinekolojik nedenlerle kıyaslandığında daha az görülür. Gastrointestinal stromal tümörler GİST tüm gastrointestinal tümörlerin %1’ inden azından sorumludurlar. Klinik semptomlar tümör boyutuna ve lokalizasyonuna bağlı olarak kanama, ağrı, iştahsızlık, yutma güçlüğü, sarılık ve akut batına kadar değişmektedir.Olgu: 48 yaşında, G3 P3, kadın hasta menstrüel düzensizlik ve sol kasık ağrısı şikâyeti ile kliniğimize başvurdu. Jinekolojik muayenesinde sol adneksiyel alanda hareketli ve sert bir kitle palpe edildi. USGdeuterus ve mesane üst-ön komşuluğunda 7×6 cm’lik solid, heterojen kitle izlendi. Subseröz saplı myom olarak değerlendirildi. Tomografi raporunda da adneksiyel kitle ve myom ayrıcı tanısı yapılamadı. Pfannensteil kesi ile batına girildi. Gözlemde jejunumdan kaynaklanan 6×6.5 cm çapında düzgün kenarlı kitle izlendi. Kitle segmenter rezeksiyon ile çıkarıldı ve uç-uca anastomoz yapıldı. Kesin sonuç paraffin incelemeye bırakıldı. Patoloji raporu GİST olarak raporlandı. Postoperatif üçüncü günde hasta komplikasyonsuz olarak taburcu edildi.Tartışma: Adneksiyel kitle ayırıcı tanısında, özellikle hareketli kitlelerde, ince bağırsak kaynaklı kitleler de göz önünde bulundurulmalıdır. Gastrointestinal stromal tümörler çoğunlukla benign karakterli olduğundan esas tedavi cerrahi rezeksiyondur, ancak prognostik faktörlerin tümü birlikte değerlendirilerek tıbbi tedaviye karar verilmelidir.

Anahtar Kelimeler:

Adneksiyel kitle, cerrahi, gastrointestinal stromal tümör, imatinib

Jejunal Gastrointestinal Stromal Tumor Mimicking Leiomyoma in Premenopausal Period

Aim: Approximately 90% of adnexal masses are benign and located in the upper ranks among gynecologic hospitalizations. Gastrointestinal system adnexal masses are less common when compared with gynecological causes. Gastrointestinal stromal tumors GIST are responsible for less than 1% of all gastrointestinal tumors. Clinical symptoms may include bleeding, pain, anorexia, swallowing difficulty, jaundice due to tumor size and localization.Case: 48 years old, G3 P3, female patient presented to our clinic with complaints of menstrual irregularity and left groin pain. On the gynecologic examination on the left adnexal area moving and rigid mass was palpable. 7×6 cm solid, heterogeneous mass in the upper-anterior region of the uterus and bladder was observed. The mass was evaluated as subserous pedunculated fibroid. In the tomography report adnexial mass and myom couldn’t be distinguished. Abdominal exploration was through a Pfannensteil incision. A 6x6.5 cm well-circumscribed mass in jejunum was identifed on observation. The mass was excised with segmental resection and the bowel was repaired by end to end anastomosis. The specimen was sent to paraffin evaluation. Pathology result was reported as GIST. On the postoperative third day, the patient was discharged without complications.Discussion: In case of differential diagnosis of adnexal masses, especially which are mobile, small intestinal masses should also be considered. While gastrointestinal stromal tumors are usually benign, the exact treatment is surgical resection. However, it’s necessary to evalaute all prognostic factors to consider medical treatment.

Keywords:

Adnexal mass, surgery, gastrointestinal stromal tumor, imatinib,

PDF

___

Grimes DA,Hughes JM. Use of multiphasic oral contraceptives and hos- pitalizations of women with functional ovarian cysts in the United States. ObstetGynecol 1989;73:1037-42.
Cancer incidence in Sweden. Annualreport 1996. Stockholm: Swedis- hCancerRegistry, Centre for Epidemiology, National Board of Healthan- dWelfare; 1996
Hall DJ, Hurt WG. The adnexal mass. J FamPract, 1982;14:135
ACOG Practice Bulletin. Management of adnexal masses. Obstet Gyne- col. 2007;110:201–214.
Givens V, Mitchell GE, Harraway-Smith C, et al. Diagnosis and manage- ment of adnexal masses. Am Fam Physician. 2009;80:815–820.
Mazur MT, Clark HB. Gastric stromal tumors. Reappraisal of histogene- sis. Am J SurgPathol. 1983 Sep;7(6):507-19.
Sturgeon C, Cheifec G, Espat NJ. Gastrointestinal stromal tumors: a spe- ctrum of disease. Surgical Oncology 2003; 12: 21-26
Connolly EM, Gaffney E, Reynolds JV. Gastrointestinal stromal tumors. British Journal of Surgery 2003; 90: 1178-1186
Miettinen M, Sarlomo-Rikala M, Lasota J. Gastrointestinal stromal tu- mors. Annales Chirurgiae et Gynaecologiae 1998; 87: 278-281.
Tracilyn R. Hall, Thomas C. Randall, Adnexal Masses in the Premenopa- usal Patient CLINICAL OBSTETRICS AND GYNECOLOGY 2015, Volume 58, Number 1, 47–52
Terlikowska K.M, Dobrzycka B, Witkowska A.M., Mackowiak - Ma- tejczyk B, Sledziewski T.K., Kinalski M, Terlikowski S.J. Preoperati- ve HE4, CA125 and ROMA in the differential diagnosis of benign and malignant adnexal masses. J Ovarian Res. 2016 Jul 19;9(1):43. doi: 10.1186/s13048-016-0254-7.
Savage P. Tumour markers in cancers of unknown primary: a clinical perspective. (editorial) Ann Clin Biochem 2006;43:ı-2
Perkins G, Slater E, Sanders G, Prischard J. Serum tumour markers. American Family Physician. 2003;68(6): 1075-82
Drapkin R, von Horsten HH,LinY,et al. Human epididymis protein 4 (HE4) is a secreted glycoprotein that is overexpressed by serous and endomet- rioid ovarian carcinomas. Cancer Res 2005;65:2162-2169
Jacobs IJ, Oram D, Fairbanks J, Turner J, Frost C, Grudzinskas JG. A risk of malignancy index incorporating CA125, ultrasound and menopa- usal status for the accurate preoperative diagnosis of ovarian cancer. Br J Obstet Gynaecol 1990;97:922–9
Khawla Al Musalhi,, Manal Al Kindi, Faiza Al Aisary, Fatma Ramad- han, Thuraya Al Rawahi, Khalsa Al Hatali,and Waad-Allah Mula-Abed Evaluation of HE4, CA-125, Risk of Ovarian Malignancy Algorithm (ROMA) and Risk of Malignancy Index (RMI) in the Preoperative Assessment of Patients with Adnexal Mass. Oman Med J. 2016 Sep; 31(5): 336–344
Miettinen M, Makhlouf H, Sobin LH, Lasota J. Gastrointestinal stromal tumors of the jejunum and ileum: a clinicopathologic, immunohistoche- mical, and molecular genetic study of 906 cases before imatinib with long-termfollow-up. Am J SurgPathol2006;30:477-89
Tran T, Davila JA, El-Serag HB: The epidemiology of malignant gast- rointestinal stromal tumors: an analysis of 1458 casesfrom 1992 to 2000. Am J Gastroenterol. 2005, 100: 162-168. 10.1111/j.1572- 0241.2005.40709.
Deitos AP. The reapraisal of gastrointestinal stromal tumors: fromstout- tothe KIT revolution. VirchowsArch 2003; 442: 421-428.
Fletcher CD, Berman JJ, Corless C, Gorstein F, Lasota J, Longley BJ, Miettinen M, O’Leary TJ, Remotti H, Rubin BP, Shmookler B, Sobin LH, Weiss SW. Diagnosis of gastrointestinal stromal tumors: A consensus approach. Hum Pathol2002;33:459-65.
Heinrich MC, Corless CL, Duensing A, McGreevey L, Chen CJ, Joseph N, Singer S, Griffith DJ, Haley A, Town A, Demetri GD, Fletcher CD, Fletc- her JA: PDGFRA activating mutations in gastrointestinal stromal tumors. Science. 2003, 299: 708-710. 10.1126/science.1079666.
Kim KM, Kang DW, Moon WS, Park JB, Park CK, Sohn JH, Jeong JS, Cho MY, Jin SY, Choi JS, Kang DY: Gastrointestinal Stromal Tumor Committee;TheKorean Gastrointestinal Pathology Study Group. Gastro- intestinal Stromal Tumors in Koreans: Incidence and the Clinical, Pat- hologicandImmunohistochemicalFindings. J KoreanMedSci. 2005, 20: 977-984. 10.3346/jkms.2005.20.6.977
Tryggvason G, Gislason HG, Magnusson MK, Jónasson JG: Gastroin- testinalstromaltumors in Iceland, 1990-2003: TheIcelandic GIST study, a population-basedincidenceandpathologic risk stratificationstudy. Int J Cancer. 2005, 117: 289-293. 10.1002/ijc.21167.
Goettsch WG, Bos SD, Breekveldt-Postma N, Casparie M, Herings RM, Hogendoorn PC: Incidence of gastrointestinal stromal tumours is un- derestimated: Results of a nation-widestudy. Eur J Cancer. 2005, 41: 2868-2872. 10.1016/j.ejca.2005.09.009
Duensing A, Medeiros F, McConarty B, Joseph NE, Panigrahy D, Sin- ger S, Fletcher CDM, Demetri GD, Fletcher JA. Mechanisms of oncoge- nic KIT signal transduction in primary gastrointestinal stromal tumors (GISTs). Oncogene 2004; 23: 3999-4006.
Kindblom LG, Remotti HE, Aldenborg F, Meis-Kindblom JM. Gastroin- testinal pacemaker cell tumor (GIPACT): gastrointestinal stromal tumors Show phenotypic characteristics of the interstitial cells of Cajal. Am J Pathol1998;152:1259-69
Gupta P, Tewari M, Shukla HS. Gastrointestinal stromal tumor. SurgOn- col2008;17:129-38.
Greenson JK. Gastrointestinal stromal tumor sandother mesenchymal lesions of the gut. ModPathol 2003; 16: 366-375.