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Gastric glomus tumour: A case report
Mridul Tantia1, Pravin R Suryawanshi1, Akshi Gupta2, Praveen Rachakatla2
1 Department of Surgery and Pathology, MGM Medical College and Hospital, Aurangabad, Maharashtra, India
2 Department of Pathology, MGM Medical College and Hospital, Aurangabad, Maharashtra, India
|Date of Submission||23-Nov-2020|
|Date of Acceptance||27-Mar-2021|
|Date of Web Publication||25-May-2021|
Department of Pathology, MGM Medical College and Hospital, Aurangabad, Maharashtra
Source of Support: None, Conflict of Interest: None
Glomus tumours (GTs) are rare, mesenchymal neoplasms arising from the glomus body. Atypical sites, like the stomach, have been reported with extreme rarity since the usual location lies under the nail beds. We report a rare case of gastric GT in a 28-year-old female presenting with upper abdominal pain, intermittent haematemesis and melena. Contrast-enhanced computed tomography indicated a well-defined, heterogeneously enhancing lesion in the antral region of the stomach and a possibility of gastrointestinal (GI) stromal tumour (GIST). Upper GI endoscopy showed a wide-based lesion in the sub-mucosal plane with ulcerated mucosa. Laparoscopic excision of the tumour with primary closure of the defect was performed, with an uneventful post-operative course. Histopathological and immunohistochemical findings confirmed a gastric GT. Follow-up clinical and endoscopic examinations were normal. Gastric GTs should be a rare differential in patients with suspected GIST and upper GI bleed.
Keywords: Gastric glomus tumour, gastrointestinal stromal tumour, glomus body, immunohistochemistry
| ¤ Introduction|| |
Glomus tumours (GTs) are rare, usually benign mesenchymal neoplasms arising from the normal glomus body. Usually found in the distal extremities, their occurrence in the gastrointestinal (GI) tract is extremely rare, accounting for <1% of all GI soft tissue tumours. Owing to their sub-mucosal location, gastric GTs are often mistaken for gastrointestinal stromal tumour (GIST) and other gastric sub-mucosal neoplasms, making their diagnosis largely dependent upon pathological and immunohistochemical findings.
| ¤ Case Report|| |
A 28-year-old female presented to the general surgery outpatient department with complaints of upper abdominal pain for 1 month and intermittent haematemesis.
On examination, she had pallor and mild tenderness over the epigastric region, with no palpable mass in the abdomen.
Other than mild anaemia (haemoglobin – 10.1 g/dL), her laboratory investigations were normal. Contrast-enhanced computed tomography (CECT) of the abdomen showed a well-defined lesion measuring 37 mm × 33 mm in the antrum, with possibility of GIST. Upper GI endoscopy demonstrated a wide-based polypoid growth with ulcerated mucosa [Figure 1]. Diagnostic laparoscopy revealed a lesion approximately 3 cm proximal to the pylorus. A wide local resection was done, and the antral continuity restored by closing it transversely.
Histopathological examination revealed sheets and islands of small round tumour cells involving the mucosa and extending unto the serosa, with margins free for involvement [Figure 2]a. A differential diagnosis of well-differentiated neuroendocrine tumour, GT and GIST was given.
|Figure 1: An endoscopic view of a polypoid growth in the greater curvature, with ulcerated surface|
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|Figure 2: (a) Sheets and islands of small round cell tumour involving the sub-mucosa and muscularis propria and extending up to serosa. Plenty of blood vessels of variable size are seen interspersed within the tumour (H and E, ×20). (b) Tumour cells showing positive membrane staining for smooth muscle actin|
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Immunohistochemistry (IHC) for confirmation stained positive for smooth muscle actin (SMA), caldesmon-H and actin and negative for CD117, DOG1, CD34, pan CK, synaptophysin and chromogranin [Figure 2]b. The final diagnosis of gastric GT was provided.
The postoperative course was uneventful. A check endoscopy after 3 months showed no residual lesion or narrowing of the stomach. At 1 year of follow-up, the patient was asymptomatic.
| ¤ Discussion|| |
The normal glomus body, typically located in the dermis of the skin, is a rich network of arteriovenous anastomoses and nerve fibres, which plays an important role in thermoregulation.
GTs are usually found in the sub-ungal region of the distal extremities however have been described in the GI tract as well. The antral portion of the stomach is the most frequent GI site affected, accounting for 2.2% of gastric sub-mucosal tumours.
The first gastric GT was described in a 64-year-old man in 1928 by Talijeva, and since then, just over 200 cases have been reported in the literature.
It is very difficult to diagnose gastric GT pre-operatively. The symptoms range from asymptomatic to abdominal pain, GI bleed (sometimes massive) and perforation. Imaging modalities like contrast enhanced computed tomography (CECT) scan and magnetic resonance imaging (MRI) can demonstrate the location of the lesion in the stomach with its relation to surrounding structures. These findings are nonspecific and may be seen in other mesenchymal or stromal lesions such as GIST, neuroendocrine tumours and schwannomas.
Endoscopic ultrasound (EUS) can accurately delineate the extent and invasion of GT and is particularly useful when EUS-guided fine-needle aspiration is done.
Mostly diagnosed on histopathology, it is difficult to differentiate benign from malignant in GTs. Accordingly, Folpe et al. proposed criteria for malignancy include deep location, size >2 cm and combination of high nuclear grade and mitotic activity (>5/50 HPFs).
IHC is necessary to accurately diagnose GTs. They demonstrate positive staining with vimentin, SMA and lack of staining with CD117. Our case also demonstrated similar staining patterns enabling us to provide a diagnosis of Gastric GT.
Wedge resection, with a clean margin, is the treatment of choice, and enucleation methods are associated with a high risk of recurrence. The location of the tumour greatly influences the surgical intervention required. In our case, the growth was 3–4 cm proximal to the pylorus, which enabled us to perform a wedge resection with transverse closure, without any lumen compromise. At times, the lesion may require a distal or subtotal gastrectomy with appropriate reconstruction.
Gastric GTs carry a small risk of recurrence, mostly at the site of excision. Therefore, it is recommended to perform endoscopy annually on follow-up.
To conclude, gastric GTs are rare mesenchymal neoplasms, which are difficult to diagnose preoperatively, given their lack of any specific clinical or imaging finding. The histological examination and IHC markers play a vital role in establishing correct diagnosis and optimising the treatment.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]