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
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.
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
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
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
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.