A gastric glomus tumor resected using non-exposed endoscopic wall-inversion surgery

Gastric glomus tumor diagnosed by fine needle aspiration of the stomach: A report of two cases and review of the literature

Glomus tumors make up 1% of stromal tumors of the stomach. Radiologic diagnosis of glomus tumors can be challenging as they share imaging characteristics with other neuroendocrine tumors and gastrointestinal stromal tumors. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has been reported as a useful method for the evaluation of gastrointestinal lesions. We report two cases of gastric glomus tumors in which EUS-FNA diagnosis was challenging. Cytologically, neoplastic cells were round to oval, uniform, bland appearing epithelioid cells with delicate chromatin and inconspicuous to vague nucleoli. Both samples lacked worrisome features such as high nuclear grade, high mitotic rate, and necrosis. Neoplastic cells were negative for Cam5.2 and AE1/AE3 with focal expression of synaptophysin in one of the cases. A definitive diagnosis was not made based on FNA. Familiarity with glomus tumors in the GI system and procurement of adequate material for cell block allowing the use of immunohistochemistry may allow an accurate preoperative diagnosis.

Glomus tumor of the duodenum: a rare case report

Background

Glomus tumors (GTs) are mesenchymal neoplastic lesions arising from the glomus bodies and generally occur in the fingers and toes. Gastrointestinal GTs are rare, and most of them originate from the stomach; however, GT arising from the duodenum is exceedingly rare.

Case presentation

A 68-year-old man was admitted due to abdominal pain. Endoscopy showed a round, smooth, elevated mass in the second portion of the duodenum with central ulceration. Abdominal contrast computed tomography showed a hypervascular tumor measuring 26 mm in diameter in the second portion of the duodenum, and pancreatic invasion was suspected. Endoscopic ultrasonography of the lesion confirmed a hypoechoic mass arising from the fourth layer of the duodenal wall. A biopsy was performed for central ulceration, and immunochemical studies showed positive results for smooth muscle actin (SMA) and negative results for S100, C-Kit, and CD34. Leiomyoma or gastrointestinal stromal tumor was suspected and pancreatoduodenectomy was performed. The specimen exhibited a vascular-rich tumor, 24 × 24 × 19 mm in size, with deep ulceration in the duodenum. Histological examination showed uniform small round cells with central nuclei and a pale cytoplasm (glomus cell) with perivascular proliferation. Immunochemical studies showed that the tumor was positive for SMA and collagen type IV, and negative for C-Kit, CD34, desmin, and S100. We diagnosed the tumor as a GT of the duodenum.

Conclusion

GTs of the duodenum are exceedingly rare, but should be considered in the differential diagnoses of duodenal submucosal lesions.

Gastric glomus tumor with a preoperative diagnosis by endoscopic ultrasonography-guided fine needle aspiration: a case report

A gastric glomus tumor (GGT) is a rare gastric submucosal tumor that can become malignant. A preoperative diagnosis would allow for a more informed decision regarding the treatment strategy. We present the case of an asymptomatic man with a GGT that was diagnosed during a preoperative examination. Upper gastrointestinal endoscopy was performed in a 64-year-old man and revealed a submucosal tumor at the lesser curvature of the antrum of the stomach. Endoscopic ultrasonography showed a 12-mm-sized hypoechoic tumor in the second and third layers of the stomach wall. A histologic diagnosis of GGT was made using endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA). Abdominal contrast-enhanced computed tomography was performed, but the identification of the tumor was difficult owing to poor enhancement. The gradual growth of the tumor made it necessary to perform an operation. Laparoscopy and endoscopy cooperative surgery was performed without any complications. The tumor cells were immunohistochemically positive for alpha-smooth muscle actin, h-caldesmon, and collagen type IV but were negative for desmin, discovered on GIST-1, S-100 protein, cluster of differentiation 34, epithelial membrane antigen, and cytokeratin AE1/AE3. The final diagnosis was identical to the preoperative diagnosis made using EUS-FNA. EUS-FNA is a useful method for the preoperative diagnosis of small submucosal tumors, including GGTs.

Nonexposed wall-inversion surgery as a novel local resection method for neoplasms in the gastrointestinal tract

Nonexposed wall-inversion surgery was invented for the treatment of node-negative gastrointestinal tumors that are difficult to be resected using the endoluminal approach alone. The advantages of this surgery include 1. full-thickness resection procedure of gastrointestinal wall with minimum necessary tumor-negative margins and 2. less risk of bacterial contamination and tumor seeding into the abdominal cavity. We conducted a PubMed search to select relevant articles published until the end of October 2019 for pooled case analyses using the keyword “nonexposed wall-inversion surgery,” Based on our search, we enrolled the data of 88 gastric lesions and 1 duodenal lesion retrieved from 7 case report articles and 4 original articles of clinical cases. The gastric lesions consisted of 59 gastrointestinal stromal tumors, 7 ectopic pancreases, 5 leiomyomas, 3 early gastric cancers, and 14 others, with a mean maximal tumor diameter of 25.0 mm. In 5 lesions (5.7%), intraoperative perforation was performed, and 2 lesions (2.3%) were retrieved by the transabdominal route. All 4 major postoperative complications (4.5%) were managed without resurgical interventions. The duodenal case, neuroendocrine tumor, measuring 13 mm in size, was curatively resected without complications. Nonexposed wall-inversion surgery appears to be an acceptable treatment for node-negative gastric and duodenal tumors; however, further accumulation of cases is necessary to confirm the feasibility.

Glomus tumor of the stomach treated by laparoscopic distal gastrectomy: A case report

Glomus tumor of the stomach is a rare submucosal mesenchymal tumor. The present study reports a patient with gastric glomus tumor treated by laparoscopic distal gastrectomy. A 39-year-old male was referred to Kochi Medical School Hospital for examination of a gastric submucosal tumor (SMT) initially diagnosed following a medical check-up. Esophagogastroduodenoscopy revealed a solitary, well-defined, submucosal lesion in the antrum of the stomach. Endoscopic ultrasonography (EUS) revealed a hypoechoic solid mass primarily connected to the gastric muscular layer. Abdominal contrast-enhanced computed tomography confirmed a 1.5 cm, well-defined mass lesion demonstrating homogeneous strong enhancement in the gastric antrum. Subsequent EUS-guided fine-needle aspiration produced a clinical diagnosis of neuroendocrine neoplasm and the patient underwent laparoscopic distal gastrectomy with regional lymph node dissection. Histopathology revealed solid proliferation of round, α-smooth muscle actin-immunopositive tumor cells with dilated vessels lined by endothelial cells without atypia, prompting a diagnosis of gastric glomus tumor. To the best of our knowledge, this is the seventh case of gastric glomus tumor treated by laparoscopy reported in English literature. The present case suggested that glomus tumor should be considered in the differential diagnosis for SMT of the stomach.