Clinical Challenges and Images in GI:
David A. Katzka and David L. Jaffe, Section Editors
Article Outline
- Question
- Answer to the Clinical Challenges and Images in GI Question: Image 2 (page 1380): A Gastric Glomus Tumor
- References
- Copyright
Question
A 65-year-old man was admitted to the hospital because of a syncope associated with dizziness when standing. He vomited during the preceding night and complained of a light epigastric pain. He was taking acetyl salicylic acid for a broken foot. His previous medical history was unremarkable.
On physical examination, he was pale; blood pressure and heart frequency were normal. Abdominal palpation was slightly painful in the epigastric area. Abdominal sounds and rectal examination were normal. Neither cervical, axillar, nor inguinal lymph nodes were palpable and the patient had no ascites. Laboratory tests showed a severe microcytic anemia (hemoglobin 7.8 g/dL) with a high reticulocytic count. International normalized ratio coagulation tests, C-reactive protein, and white blood cell count, as well as liver and pancreatic enzyme values were within normal ranges. Upper gastrointestinal endoscopy revealed an ulcerated tumor in the gastric antrum covered with a clot (Figure A). What further diagnostic imaging do you recommend? What is the differential diagnosis?
Look on page 1660 for the answer and the Gastroenterology website (http://www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Answer to the Clinical Challenges and Images in GI Question: Image 2 (page 1380): A Gastric Glomus Tumor
Endoscopic ultrasonography was performed; it disclosed a 25-mm in diameter, well-circumscribed, heterogeneous mass extending from the second echo-poor to the fourth sonographic layers of the gastric wall, with hyperechoic spots (Figure B). No lymph node was detected. Computed tomography (before and after IV contrast injection; Figures C and D) showed a polypoid mass in the gastric antrum with homogenous contrast uptake. No lesion was detected in the liver. The differential diagnosis mainly involved gastrointestinal stromal tumors (GISTs) and leiomyomas, but also carcinoid tumors and lymphomas.
The patient underwent antrectomy. Gross examination (Figure E) disclosed a well-circumscribed 2-cm in diameter, multinodular, hemorrhagic cystic lesion. Histopathologic examination (Figure F) disclosed moderately sized cells with a central, round, regular nucleus, and a clear cytoplasm (eosinophilic on some occasions). Mitoses were very rare (1/50 per high-power field) and were found around large vascular spaces. On immunohistochemistry, tumor cells were negative for KIT (CD 117) but positive for smooth muscle actin and CD 34 (focally). These findings led to the diagnosis of gastric glomus tumor.
Glomus tumors or glomangiomas are most common in the skin and subcutaneous tissues, but also occur in the viscera. In the gut, they predominate in the stomach (particularly in the antrum)1, 2; patients typically present with a gastrointestinal bleeding or ulcer-like symptoms and, rarely, gastric outlet obstruction. This tumor derives from glomus bodies, which are vascular structures that mediate blood flow through arteriovenous shunts in response to vasoactive factors. Because endoscopic and radiographic findings are nonspecific, the diagnosis is usually made after surgical excision. This tumor presents distinct histologic features, although some overlap with more common gastric tumors such as carcinoid tumors, gastrointestinal stromal tumors, paragangliomas, and lymphomas. This type of tumor is generally benign, but presents a small, unpredictable, potential for malignant behavior. Therefore, long-term follow-up is recommended.
References
For submission instructions, please see the Gastroenterology website (http://www.gastrojournal.org).
PII: S0016-5085(06)02199-8
doi:10.1053/j.gastro.2006.09.031
© 2006 AGA Institute. Published by Elsevier Inc. All rights reserved.
