A Bleeding Gastric Tumor With Concurrent Hypervascular Hepatic Nodules

Abstract

Question: A 61-year-old man was admitted for dizziness and tarry stool for 5 days. Vital signs and laboratory results were within normal limits except for a decreased hemoglobin level of 6.6 g/dL (normal, 13.0–17.0). During an evaluation for suspected gastrointestinal bleeding using an endoscopic gastroduodenoscopy, a polypoid mass with central ulceration was detected in the antrum along the greater curvature of the stomach (FigureA). The results of contrast-enhanced computed tomography (CT; FigureB) revealed a 4-cm, well-circumscribed, homogeneously enhancing tumor (arrow) along the greater curvature side of the gastric antrum. Concurrently, multiple, small-sized, nodular lesions were suspected in the liver. Magnetic resonance imaging (MRI) of the liver was performed to obtain a differential diagnosis of the hepatic lesions. In the MRI (FigureC), multiple, small, nodular lesions (arrows) were seen in the liver, which showed a strong enhancement, similar to that of the gastric lesion depicted in the CT. The hepatic lesions were considered multiple metastases from the gastric tumor. What is the diagnosis for this patient? Look on pagepage 1798for the answer and see the Gastroenterologyweb site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Palliative wedge resection of the stomach and concurrent liver biopsy were performed. The surgical specimens from the stomach and liver showed identical histologic features of prominent vasculature and uniform tumor cells with nuclear atypia and high mitotic activity (FigureD). The results of immunohistochemical study revealed positive reactions to smooth muscle actin, vimentin, and synaptophysin. The pathologic diagnosis of malignant glomus tumor with hepatic metastases was made. Glomus tumors arise from modified smooth muscle cells of the glomus body, a specialized arteriovenous anastomosis that involves in thermoregulation. They are composed of epithelioid smooth muscle cells identical to those in the glomus body.1Tsuneyoshi M. Enjoji M. Glomus tumor: a clinicopathologic and electron microscopic study.Cancer. 1982; 50: 1601-1607Crossref PubMed Scopus (183) Google Scholar The majority of glomus tumors are benign, small, and solitary, and classically subungual in location. Glomus tumors of the stomach are rare and typically reported as well-circumscribed submucosal masses in the antrum. Most gastric glomus tumors are histologically and biologically benign.2Miettinen M. Paal E. Lasota J. et al.Gastrointestinal glomus tumors: a clinicopathologic, immunohistochemical, and molecular genetic study of 32 cases.Am J Surg Pathol. 2002; 26: 301-311Crossref PubMed Scopus (243) Google Scholar Most affected patients are asymptomatic or present with nonspecific symptoms, including epigastric discomfort or pain. However, larger lesions are prone to ulcerate and may cause gastrointestinal bleeding. On CT and MRI, these tumors show strong enhancement in the early phase of contrast material-enhanced images, reflecting their abundant vascularity, which persisted to the late phase.3Park S.H. Han J.K. Kim T.K. et al.Unusual gastric tumors: radiologic-pathologic correlation.RadioGraphics. 1999; 19: 1435-1446Crossref PubMed Scopus (83) Google Scholar The imaging findings of malignant glomus tumor of the stomach have not yet been reported. As shown in our case, malignant glomus tumor of the stomach demonstrated imaging findings similar to those of typically benign tumors. Although the majority of gastric glomus tumors can be considered benign, a small number of them may have a malignant behavior. An awareness of malignant potential of gastric glomus tumors correlated with their characteristic imaging can facilitate preoperative diagnosis.