An Unusual Cause of Upper Gastrointestinal Bleeding
Article Outline
- Answer to the Clinical Challenges and Images in GI Question: Image 2 (page 1098): Gastric Yolk Sac Tumor With a Large Retroperitoneal Metastasis
- References
- Copyright
Question: A 71-year-old woman suffered from tarry stool episodes for 1 month. Upper endoscopy showed an ulcerative tumor over the low body posterior wall of the stomach (Figure A). An endoscopic biopsy showed a poorly differentiated adenocarcinoma. Abdominal computed tomography (CT) revealed a heterogeneous enhanced tumor from the stomach with compression to the pancreas and duodenum (Figure B). The serum CEA and CA199 were within the normal limits.
What is the diagnosis?
Look on page 1427 for the answer and see the Gastroenterology web site (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 1098): Gastric Yolk Sac Tumor With a Large Retroperitoneal Metastasis
Under the preoperative diagnosis of advanced gastric cancer, the patient underwent surgical intervention. Pathologic examination disclosed a 3-cm gastric tumor and another, separate 7-cm retroperitoneal tumor just attached to the gastric serosa (Figure C). Microscopically, the primary gastric tumor was made up of the intimate mixture of yolk sac tumor and poorly differentiated adenocarcinoma components. The yolk sac components characterized by reticular, microcystic, glandular, and solid growth patterns and Schiller-Duval bodies were noted (Figure D). Adenocarcinoma components were also present. The primary tumor invaded to the submucosa. The retroperitoneal tumor showed similar features with lymphovascular tumor emboli. Based on these findings, a primary early gastric yolk sac tumor with adenocarcinoma components and retroperitoneal metastasis was diagnosed. After the operation, the patient refused any adjuvant therapy. No recurrent tumor has been noted for 1 year. Extragonadal germ cell tumors are rare and comprise 1%–5% of all germ cell tumors. The most common anatomic location for adult patients is the anterior mediastinum, followed by the sacrococcygeal region. Other locations include cervical and abdominal/retroperitoneal regions.1 Gastric yolk sac tumors, either pure or mixed, are extremely rare in cases of extragonadal germ cell tumors. The presenting symptoms include epigastric pain, abdominal fullness, hematemesis, anorexia, and weight loss. Most cases occur in elderly patients, with a mean age of 65.7 years. Men are more frequently affected. The antrum is the most common location affected by the tumor. Most reported cases had tumors of combined yolk sac and adenocarcinoma components, and only four cases had pure yolk sac tumors.2 The overall clinical outcome for extragonadal germ cell tumors is worse than gonadal germ cell tumors. They seem to have poor responses to chemotherapy and radiotherapy, despite the presence of germ cell components.3
Such a tumor is likely to be diagnosed as poorly differentiated adenocarcinoma on endoscopic biopsy. Only 1 case was diagnosed after mucosectomy for presumed early gastric cancer.2 Therefore, the clinician should be aware of this rare entity because misdiagnosis is easy to occur based on endoscopic biopsy for such tumor.
References
- . Extragonadal germ cell tumors: a review with emphasis on pathologic features, clinical prognostic variables, and differential diagnostic considerations. Adv Anat Pathol. 2007;14:69–92
- Gastric yolk sac tumor: a case report and review of the literature. Korean J Intern Med. 2009;24:143–146
- Gastric adenocarcinoma with a yolk sac component: a case report and review of the literature. J Clin Gastroenterol. 2000;31:85–88
For submission instructions, please see the Gastroenterology web site (www.gastrojournal.org).
Conflicts of interest The authors disclose no conflicts.
PII: S0016-5085(09)02197-0
doi:10.1053/j.gastro.2009.10.060
© 2010 AGA Institute. Published by Elsevier Inc. All rights reserved.
