Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 2003  |  Volume : 9  |  Issue : 2  |  Page : 79-81
Multicentric leiomyosarcoma of the stomach


1 Department of Medicine, King Fahad Central Hospital, Gizan, Saudi Arabia
2 Department of Pathology, King Fahad Central Hospital, Gizan, Saudi Arabia

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Date of Submission23-Jan-2002
Date of Acceptance21-Dec-2002
 

How to cite this article:
Ayoola EA, Arab MM, Tadros NM, Ahmed MA, Banzal SS, Abbo HM, Singal AK, El Amin AK, Gadour MO. Multicentric leiomyosarcoma of the stomach. Saudi J Gastroenterol 2003;9:79-81

How to cite this URL:
Ayoola EA, Arab MM, Tadros NM, Ahmed MA, Banzal SS, Abbo HM, Singal AK, El Amin AK, Gadour MO. Multicentric leiomyosarcoma of the stomach. Saudi J Gastroenterol [serial online] 2003 [cited 2019 Jul 23];9:79-81. Available from: http://www.saudijgastro.com/text.asp?2003/9/2/79/33368


Gastric leiomyosarcoma (GLS) is an uncommon tumor accounting for less than 1 % of the primary neoplasms of the stomach [1],[2],[3],[4],[5] . GLS occurs most frequently as a single lesion and rarely as multiple gastric lesions [3] . We report the occurrence of a multi-centric leiomyosarcoma in a Saudi male and the literature is reviewed briefly.


   Case Report Top


A 68-year old Saudi male was admitted with two months' history of anorexia, weight loss, intermittent fever, and sweats. Two weeks prior to admission, he had three episodes of hematemesis and melena accompanied by epigastric pain. He developed swelling of the abdomen and lower limbs a few days later. Review of systems revealed no additional symptoms. He smoked 'shesha', a local form of tobacco. Past medical, social and family histories were unremarkable. He had not taken any drugs prior to the illness. Physical examination revealed a thin, pale man in no acute distress. There was no jaundice, cyanosis, peripheral lymphadenopathy or spider naevi. His temperature was normal and, there was pitting edema of the lower extremities. Apart from moderate ascites, abdominal examination was normal. Liver and spleen were not palpable. Other systems including the central nervous and cardiorespiratory systems were normal on examination.

Investigations revealed the following: Hemoglobin 8.8g/dl, MCV 78, MCHC 31, WBC 3500 /cmm, platelet count 243000/cmm; prothrombin time (PT) 16.3sec (control 11.7sec), PTT 42.2 (control 35.2sec). serum potassium 4.6mmol/l. sodium 130mmol/l, calcium 2.2, urea 6.6mmol/l, creatinine 143umol/l, LDH 182u/1, ALT 32u/1, uric acid 0.2mmol/l, phosphate 1.2mmol/l, albumin 12g/1 (normal above 30g/1). Hepatitis B surface antigen (HBsAg) was positive and antibody to hepatitis C virus (anti-HCV) was negative.

Ascitic fluid obtained by paracentesis, was reddish yellow in color, with total protein of 89g/l, cholesterol 0.33u/1 and, LDH 78u/1. No malignant cells were present. Upper gastrointestinal endoscopy (UGIE) showed a friable, nodular lesion (about 3cm in size), on the lesser curvature of the cardia and another in the antrum.

The overlying mucosa was ulcerated. Mild mucosal redness was noted in the remaining segment of the stomach. Biopsy was obtained and showed a tissue composed of bundles of spindle cells with acidophilic fibrillar cytoplasm. The cells had bizarre large hyperchromatic and pleomorphic nuclei. Few mitotic cells, (3/50hpf) areas of necrosis and hemorrhage were present. The findings were consistent with leiomyosarcoma [Figure - 1].

CT of the abdomen showed moderate ascites enlarged stomach with thick irregular wall and multiple exophytic mass lesions especially on the greater gastric curvature. There were at least 2 lesions in the right lobe of the liver [Figure - 2].

Kidneys, gallbladder and pancreas were normal. Fine needle aspiration biopsy of the hepatic lesions showed sheets of hepatocytes with granular vacuolated cytoplasm and rounded or oval nuclei; foci of spindle cells and connective tissue elements. The nuclei of the spindle cells were hyperchromatic, pleomorphic and multinucleated [Figure - 3].

The patient's neoplasm was considered to be inoperable and he was discharged from the hospital on a supportive therapy. He was still alive three months thereafter.


   Discussion Top


Smooth muscle tumors including leiomyomas and leiomyosarcomas (LMS) are relatively uncommon. These may be intraluminal, extraluminal or both combined [3] . In a collective review of stromal tumors of the stomach in the literature from 1762 to 1996 by Davis et al, 2189 and 1594 had leiomyoma and LMS respectively [4] . The peak age incidence was in the seventh decade and males predominated.

There are very scant reports of stromal tumors of the stomach particularly LMS in Saudi Arabs. Among 2370 cases of primary malignant tumors confirmed histologically in KFCH over a 10-year period (1982-1992) there were 47 patients with gastric neoplasm, 20 with esophageal cancer and none with LMS [5] other report from a University hospital in Riyadh found 10 of 18 cases of smooth muscle tumors of the GIT that were located in the stomach and 5 of them were confirmed to be gastric LMS [6]

Patients with this tumor may be asymptomatic or may present with UGI bleeding and abdominal pain, which are the most common presenting symptoms [3],[7] features include a palpable mass, weight loss and symptoms of gastric outlet obstruction among patients with antral lesions (4) . Rarely, hypoglycemia may be the presenting manifestation.

The stomach is the most common site of LMS [3],[7] . The main endoscopic feature of ulcerated or raised mucosa overlying a mass lesion allows for biopsy and preoperative diagnosis. However, exogastric location of the tumor may present some difficulties in the preoperative confirmation of the nature of the lesions.

Ultrasonography and computerized axial tomography (CT) are very useful in the diagnosis of LMS. They provide information on the origin of the mass and the pattern of spread, where it maybe present. Characteristically, the lesions are irregular masses within or involving the wall of the stomach as was found in the patient reported here [9] . Confirmation of LMS is by histological examination. The presence of high count of mitosis (>5 per 10 HPF), distant metastasis and direct invasion of adjacent structures are features that readily confirm the malignant nature [7] . Although tumor size or location does not correlate with the rate of metastasis, lesions with intraluminal and extraluminal components (the so-called dumb- bell pattern) as was present in the patient reported here, have higher frequencies of metastasis [4] .

Surgical excision, including inoculation, partial gastrectomy, or extensive resection of localized masses is curative [4],[7]. However, local recurrence is high in cases of resected leiomyosarcomas [10] As was found in the patient reported here, large tumors especially dumb-bell shaped leiomyosarcomas are often inoperable at the time of diagnosis [10] . Leiomyosarcomas are resistant to chemotherapy or radiotherapy [4] . Several chemotherapeutic agents, singly and in combination, have been used with little efficacy. Our patient received none of these treatment modalities.

The rarity of LMS is worldwide and the etiology of these tumors is unknown. Predisposing factors to its development are not well understood. Therefore, its prevention is a major challenge to researchers.

 
   References Top

1.Remine WH. Gastric sarcomas Am J Surg 1970; 120: 320-3 .  Back to cited text no. 1    
2.Colovic RB, Colovic M, Ciganovic D, Matic S. Colovic N Multiple leiomyosarcoma of the stomach Hepatogastroenterology 1997; 44: 610-2.  Back to cited text no. 2    
3.­Stavorsky M, Morag B, Stavrosky LT, Papo J. Smooth muscle tumors of the alimentary tract. J Surg Oncol 19830 - 22: 109-14.  Back to cited text no. 3    
4.Davis GB, Blanchard DK. Hatch GF, Wertheimer­Hatch , L, Hatch KF, Foster RS, Skandalakis JE Tumors of the stomach World J. Surg 2000; 24: 412­20.  Back to cited text no. 4    
5.Tandon P, Pathak VP, Zaheer A, Chatterjee A, Walford N Cancer in the Gizan province of Saudi Arabia: an eleven year study Ann Saudi Med 1995; 15: 14-20.  Back to cited text no. 5    
6.AI-Salamah SM, EI-Kayali AY. Management of gastrointestinal smooth muscle tumours: Seven years experience of a teaching hospital in Saudi Arabia. Saudi J Gastroenterol. 2000; 6: 153-6.  Back to cited text no. 6    
7.Koga H. Ochlai A, Nakanishi Y. Sasako M, Mizuno S, Kinoshidta T, Maruyama K, Hirohashi S: Evaluation of prognostic factors in gastric leiomyosarcoma. Am J Gastroentrol 1995; 90: 1307­12.  Back to cited text no. 7    
8.Megibow AJ, Baltharar E.1, Hulinck DH et al. CT evaluation of gastrointestinal leiomyomas and Ieiomyosarcomas. AJR 1985; 144: 727-31.  Back to cited text no. 8    
9.Evans HL. Smooth muscle tumor of the gastrointestinal tract. A study of 56 cases followed for a minimum of 10 years. Cancer 1985; 56: 2242-50  Back to cited text no. 9    
10.Grant CS. Kim CH, Farrugia G et al. Gastric leiomyosarcoma: prognostic factors and surgical management Arch Surg 1991: 126: 985-90.  Back to cited text no. 10    

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Correspondence Address:
Ephraim Ayobanji Ayoola
P.O. Box 235, Abu Arish
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 19861811

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  [Figure - 1], [Figure - 2], [Figure - 3]



 

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