A Case of Rapidly Recurring GIST

Abstract

Introduction: GIST (Gastrointestinal stromal tumor), a mesenchymal tumor originated from interstitial cells of cajal, a complex network of muscle layer of GI tract is largely treated with surgical resection and medically in current era of medicine. Recurrence is also reported in such tumors. We present a case of small intestinal GIST, treated with surgical resection followed by chemotherapy, found to have recurrence after 10 years even after stringent follow up. Case: A 79-year-old female presented with complaints of dyspnea and rectal bleeding. She had multiple episodes of watery diarrhea 2 days before admission, which subsided at the time of admission. She had history of small intestinal GIST, which was resected 10 years ago and was closely followed with yearly CT scan of abdomen for 8 years. Latest abdominal imaging (CT scan), 2 years ago was negative for recurrence. Since there was no recurrence for 8 years, plan was to do follow up imaging every 2 years. Two years after last CT, patient was admitted with rectal bleeding. CT abdomen revealed an18 cm heterogeneous abdominal mass involving the mesentery, parenchyma and surrounding tissue. At surgery, found to have 16cm intraabdominal tumor with necrosis involving the last 3 feet of an ileum, extensive adhesions and a tumor implant in transverse colon. The patient underwent exploratory laparotomy with resection of tumor, 3 feet of terminal ileum, transverse colon tumor resection and adhesiolysis. Tumor was confirmed as recurrent GIST with C-kit mutation and CD34 positive of spindle cell type. Tumor was graded as T4 N0 M0. Discussion: About 25 to 30% of GISTs originate from Jejunum and Ileum. Contrast enhanced CT abdomen & pelvis, every 3-6 months is imaging of choice post-treatment surveillance. It is unclear, for how long follow up imaging should be continued in chronic stable surgically treated patients. In this patient, increasing follow-up imaging interval resulted in a large recurrent GIST, even after 10 years of close follow up. Recurrence of GIST is not clear in sporadic or familial cases and further research is needed for long term follow up of treated GIST patients. Prognostic determinants include tumor size, location and mitotic rate. Tumor rupture (during surgery or spontaneously), though not included in TNM stating, is an independent risk factor that negatively impacts disease-free survival.Figure 1