Successful treatment for the rupture of a hepatic metastasis of GIST

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Successful treatment for the rupture of a hepatic metastasis of GIST

Letters to the Editor

LETTERS TO THE EDITOR

Successful treatment for the rupture

of a hepatic metastasis of GIST

To the Editor,

We read with interest the article by Efremidou et al. (1)

on a patient with a gastrointestinal stromal tumor (GIST) of

the small intestine. After performing a laparotomy, they

found a perforated ileal GIST as a rare cause of acute

abdomen. Perforation or rupture of a primary GIST is rare,

and the choice treatment is immediate surgery. Although

liver is a common organ for metastases from GIST, the rupture

of a hepatic metastasis of GIST is extremely rare. To our

knowledge, only two cases with the rupture of a hepatic

metastasis of GIST have been reported previously with both

of them incurring mortality (2, 3). Here we present a case

with life-threatening iatrogenic rupture of a hepatic

metastasis of GIST which was treated successfully by

transcatheter arterial embolization (TAE).

A 50-year-old woman was admitted to a local hospital

suffering from abdominal pain localized at the right upper

quadrant. Abdominal ultrasonography showed a large mass

in the right lobe of the liver with cystic and solid components.

Diagnostic laparotomy evidenced a tumoral lesion of the

liver and biopsy was performed during laparotomy. On the

same day, the patient was referred to our hospital.

On admission, physical examination revealed blood

pressure of 120/70 mmHg, pulse rate of 85/min and a palpable

mass in the right upper abdominal region. Other physical

findings were normal. The hemoglobin, hematocrit and other

laboratory tests were within normal ranges except a slight

increase of liver function tests. On the next day, blood

pressure was found to be 80/55 mmHg and the pulse rate

120/min. Laboratory investigation revealed a 3g/dL and 9%

decrease of hemoglobin and hematocrit levels, respectively.

An urgently performed abdominal computer tomography

showed subcapsular fluid collection (Fig.1). The diagnosis

was a rupture of the tumorous lesion probably due to liver

biopsy performed before. Celiac arteriography

J Gastrointestin Liver Dis

December 2006 Vol.15 No 4, 419-420

revealed a hypervascularized tumor in the right liver lobe.

The right hepatic artery was catheterized selectively

thereafter. The feeding arteries derivating from the right

hepatic artery were embolized with lipiodol and polyvinyl

alcohol particles. Bleeding was successfully controlled and

did not recur. One month later, abdominal computed

Fig.1 Abdominal CT: subcapsular hematoma in the right liver

lobe.

Fig.2 Abdominal CT: the subcapsular hematoma in the right liver

lobe became smaller one month after the embolization. Black

arrow shows the necrotic part of the tumor.


420

tomography showed shrinkage in the size of the subcapsular

hematoma (Fig.2). Microscopic examination of the biopsy

specimen obtained from the local hospital was consistent

with stromal tumor including spindle-shaped cells showing

positivity of c-kit (CD117), CD34, vimentine and negativity

of desmin, actine, cytoceratine and S-100. Upper

gastrointestinal endoscopy revealed a polypoid tumorous

lesion at the antrum, and the microscopic examination of

this lesion was also consistent with stromal tumor. The

patient is still under imatinib mesylate therapy and no other

medical problems have occurred during the 7 months of

follow-up. To our knowledge, this is the first case with a

rupture of a hepatic metastasis of GIST and treated

successfully by TAE.

Fatih Tekin 1

Omer Ozutemiz 1

Mustafa Parýldar 2

Ege University Medical School

Departments of Gastroenterology 1

and Radiology 2

Izmir, Turkey

References

1. Efremidou EI, Liratzopoulos N, Papageorgiou MS, Romanidis

K. Perforated GIST of the small intestine as a rare cause of

acute abdomen: surgical treatment and adjuvant therapy. J

Gastrointestin Liver Dis 2006; 15: 297-299.

2. Suzuki K, Kaneko G, Kubota K, et al. Malignant tumor of the

gastrointestinal stromal tumor type in the greater omentum. J

Gastroenterol 2003; 38: 985-988.

3. Cegarra-Navarro MF, de la Calle MA, Girela-Baena E, Garcia-

Santos JM, Lloret-Estan F, de Andres EP. Ruptured

gastrointestinal stromal tumors: radiologic findings in six cases.

Abdom Imaging 2005; 30: 535-542.

Oesophago-bronchial fistula secondary

to cancer of the oesophagus

To the Editor,

A 64-year-old gentleman who was recently diagnosed

with cancer of the oesophagus managed with chemotherapy

presented as an emergency with increasing episodes of

coughing and choking particularly on swallowing. He denied

any chest pain, dysphagia or dyspnoea. On clinical

examination, he was haemodynamically stable and afebrile.

Past medical history included left sided Pneumonectomy

for carcinoma of lung about 10 years ago. A prompt upper

gastrointestinal endoscopy revealed no luminal obstruction,

however, a “hole” in the lower end of the oesophagus was

demonstrated (Fig.1). Following this a barium swallow was

performed which showed a fistulous communication

between the oesophagus and the bronchial tree.

Fig.1 Endoscopy shows a hole in the oesophagus.

Letters to the Editor

He was referred to a cardio-thoracic unit where he had

an Oesophageal stent put in. He responded well to the

treatment.

Development of oesophago- bronchial fistula in patients

with cancer of oesophagus is uncommon (1). Association

of this complication with cancer of oesophagus evolves

with increased mortality and morbidity (2). Patients who

had recent radiotherapy and instrumentation are at higher

risk to develop this complication (3). Patients may present

with cough worse on swallowing (Ono’s sign), fever,

dysphagia and aspiration pneumonia. Management involves

keeping the patient nil by mouth and initiation of broadspectrum

antibiotics. An oesophageal stent may be inserted

which may occlude the opening of the fistula and thereby

prevent aspiration into the lungs. Operative techniques,

including oesophageal exclusion or by-pass may offer

palliation, however they are associated with high mortality.

This case highlights that a patient with cancer of the

oesophagus who presents with choking must be appropriately

investigated and the possibility of oesophagobronchial

fistula must be borne in mind.

Muhammed H Thoufeeq MRCP

Sanjiv K Jain

Dept. Medicine and Gastroenterology

Pilgrim Hospital, Boston, UK

Ismail H Mallick

Scunthorpe General Hospital, UK

References

1. Davydov M, Stilidi I, Bokhyan V, et al. Surgical treatment of

esophageal carcinoma complicated by fistulas. Eur J

Cardiothorac Surg 2001; 20: 405-408.

2. Reed MF, Mathieson DJ. Tracheoesophageal fistula. Chest Surg

Clin N Am 2003; 13:271-289.

3. Burt M, Diehl W, Martini N, et al. Malignant esophagorespiratory

fistula: management options and survival. Ann

Thorac Surg 1991; 52:1222–1229.

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