|Year : 2015 | Volume
| Issue : 4 | Page : 1037
Gastrointestinal stromal tumor and isolated anterior tibial muscle metastasis as first recurrence
Hasan Mutlu1, Hüseyin Balkarlı2, Fatma Yalçin Musri1, Derya Kıvrak Salim1, Melek Karakurt Eryılmaz1, Betül Ünal3, Hasan Şenol Coşkun1
1 Department of Medical Oncology, Akdeniz University School of Medicine, Antalya, Turkey
2 Department of Orthopedia, Akdeniz University School of Medicine, Antalya, Turkey
3 Department of Pathology, Akdeniz University School of Medicine, Antalya, Turkey
|Date of Web Publication||15-Feb-2016|
Akdeniz University School of Medicine, Department of Medical Oncology, Konyaaltı, Antalya
Source of Support: None, Conflict of Interest: None
In the presented case, we report gastrointestinal stromal tumor (GIST) in a patient using adjuvant imatinib in whom isolated metastasis to anterior tibial muscle as first recurrence was diagnosed. A 66-year-old woman was diagnosed with GIST on October 2012 and was followed up with adjuvant imatinib until June 2014. In this time, there was a nodular and fixed lesion with 1.5-2 cm of diameter in right lateral pre-tibial area. The lesion was resected, and it was reported as GIST metastasis by pathologist. GIST metastasis to muscle under knee is a generally unexpected area for any tumor metastasis. In modern treatment era, due to the increasing survival of the patients with GIST using targeted therapy, the metastatic pattern and behavior of GIST may be changing.
Keywords: Gastrointestinal stromal tumor, muscle, metastasis, recurrence
|How to cite this article:|
Mutlu H, Balkarlı H, Musri FY, Salim DK, Eryılmaz MK, Ünal B, Coşkun H&. Gastrointestinal stromal tumor and isolated anterior tibial muscle metastasis as first recurrence. J Can Res Ther 2015;11:1037
|How to cite this URL:|
Mutlu H, Balkarlı H, Musri FY, Salim DK, Eryılmaz MK, Ünal B, Coşkun H&. Gastrointestinal stromal tumor and isolated anterior tibial muscle metastasis as first recurrence. J Can Res Ther [serial online] 2015 [cited 2020 Sep 22];11:1037. Available from: http://www.cancerjournal.net/text.asp?2015/11/4/1037/151862
| > Introduction|| |
Gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm originating from gastrointestinal tract.  GISTs present most commonly in 60-70% in stomach, followed by 20-25% in small intestine, 5% in colon and rectum, and <5% in esophagus. In local disease, tumor size, mitotic rate and location are the most important prognostic factors.  In the present case, we aim to report a GIST patient in whom isolated anterior tibial muscle was detected as first recurrence area.
| > Case report|| |
A 66-year-old woman was admitted with complaints of dyspeptic problems to our hospital on October 2012. She has had nausea and postprandial bloating during the last one month. During upper endoscopy, a mass in stomach was observed and biopsy was performed. After pathologic examination, she was diagnosed with GIST. Tumor cells were positive for c-kit. We did not find any metastatic area. Gastric mass was completely resected surgically. The surgical margins were clear and there was not any nodal metastasis. Tumor size was 11.5 cm and mitotic rate was >5 per 50 HPF (High Power Field). Due to higher risk according to the Armed Forces Institute of Pathology (AFIP) criteria),  adjuvant imatinib (400 mg p.o./daily) was offered to the patient. In follow-up, she was admitted with complaints of nodular lesion on her right lateral pretibial area on June 2014. The patient said that this lesion appeared the first time one month earlier and has been growing over time. During examination, there was a nodular and fixed lesion with 1.5-2 cm of diameter in right lateral pretibial area. There was no extra finding on physical examination. The laboratory tests were normal. The magnetic resonance imaging revealed a mass with 2 cm diameter. The mass located in right anterior tibial muscle [Figure 1]. To diagnose and treat, the mass was surgically removed by an orthopedist. The intraoperative imagings of the mass are shown in [Figure 2]. Immunohistochemistry revealed a complete loss of c-kit in metastatic specimen. After pathologic reviewing of primary and metastatic tumor specimens, GIST metastasis was reported by pathologist. The mitotic rate of metastasis was 1%. The pathologic imaging is shown in [Figure 3]. The gastroduedonoscopy was performed to evaluate local nux, and it was found to be normal. To detect extra-metastatic areas, the whole 2-[ 18 F]-fluoro-2-deoxy-d-glucose positron emission tomography combined with computerized tomography (18F-FDG PET/CT) was performed. Any other metastatic area was not found on 18F-FDG PET/CT. Therefore, imatinib was suggested in the same dose.
|Figure 3: Pathologic Imaging. Image 1: Tumor composed of pleomorphic spindle cells with coarse chromatin and showing characteristic cytoplasmic vacuoles indenting the nuclear poles (H and E staining, magnification: ×400). Image 2: There is abundant myxoid matrix separating the individual tumor cells (H and E staining, magnification: ×100). Image 3: Strong immunohistochemical CD117 (c-kit) positivity in tumor cells (magnification: ×100)|
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| > Discussion|| |
In primary GIST, surgery is the most important treatment option. Additionally, metastasectomy can be an appropriate option in limited disease.
Most common metastatic areas in patients with GIST: The GIST recurrences were seen mostly within the first 5 years after primary surgery and 5, 10, and 15-year recurrence-free survival were estimated as approximately 70%, 63%, and 60%, respectively.  Tumor recurrence usually occurs in the liver and/or the peritoneum.  It was previously reported that liver (most common), intra-abdominal, abdominal cutaneous deposits and lung metastases were related to GIST.  Generally, local nux or intraperitoneal metastases related to tumor were observed in patients with GIST. In previously, bone (mandible, spine, femur and scapular metastasis), adrenal and cardiac metastases related to GIST were rarely reported. , The metastasis to upper back skeletal muscle, adductor longus muscle and gluteal muscles were reported in literature. ,
In our case, we mentioned GIST metastasis to muscle under knee, a generally unexpected area for any tumor metastasis. In muscle masses coexisting with GIST, primary muscle tumor and GIST metastasis must be distinguished from each other. Additionally, especially intra-abdominal soft tissue tumors should be carefully examinated as misclassification. In a study including 600 patients, it was determined that gastrointestinal tumors, which were firstly classified as other soft tissue tumors (>70%) have been identified as GIST after pathologic reassessment. 
In our case, pathologic evaluation of metastatic specimen revealed a complete loss of c-kit immunoreactivity. This reason was previously mentioned in some studies and they reported that loss of c-kit immunoreactivity may be because of the therapeutic effect of imatinib. ,
Based on the new therapeutic area, due to the increase in survival of patients with GIST, newly metastatic patterns have been described in literature. Perhaps, metastatic pattern and behavior of GIST have been changing after using of imatinib, sunitinib and regorafenib in adjuvant and metastatic setting. Additionally GIST is easily drawn with other muscle tumors, especially leiomyosarcomas. Therefore, new unexpected metastatic areas in patients with GIST should be carefully evaluated as GIST metastasis. The muscle tumors especially leiomyosarcomas should be distinguished from GIST.
| > References|| |
Miettinen M, Lasota J. Gastrointestinal stromal tumors-definition, clinical, histological, immunohistochemical, and molecular genetic features and differential diagnosis. Virchows Arch 2001;438:1-12.
Gold JS, Gönen M, Gutiérrez A, Broto JM, García-del-Muro X, Smyrk TC, et al
. Development and validation of a prognostic nomogram for recurrence-free survival after complete surgical resection of localised primary gastrointestinal stromal tumour: A retrospective analysis. Lancet Oncol 2009;10:1045-52.
Miettinen M, Sobin LH, Lasota J. Gastrointestinal stromal tumors of the stomach: A clinicopathologic, immunohistochemical, and molecular genetic study of 1765 cases with long-term follow-up. Am J Surg Pathol 2005;29:52-68.
Joensuu H, Vehtari A, Riihimäki J, Nishida T, Steigen SE, Brabec P, et al
. Risk of recurrence of gastrointestinal stromal tumour after surgery: An analysis of pooled population-based cohorts. Lancet Oncol 2012;13:265-74.
DeMatteo RP, Lewis JJ, Leung D, Mudan SS, Woodruff JM, Brennan MF. Two hundred gastrointestinal stromal tumors: Recurrence patterns and prognostic factors for survival. Ann Surg 2000;231:51-8.
Patnaik S, Jyotsnarani Y, Rammurti S. Radiological features of metastatic gastrointestinal stromal tumors. J Clin Imaging Sci 2012;2:43-52.
Bashir U, Qureshi A, Khan HA, Uddin N. Gastrointestinal stromal tumor with skeletal muscle, adrenal and cardiac metastases: An unusual occurrence. Indian J Pathol Microbiol. Gastrointestinal stromal tumor with skeletal muscle, adrenal and cardiac metastases: An unusual occurrence. Indian J Pathol Microbiol 2011;54:362-4.
Selcukbiricik F, Tural D, Ozturk MA, Dervisoglu S, Sager S, Hýz M, et al
. Gastrointestinal stromal tumor of the rectum with scapular metastasis: A case report. J Med Case Rep 2012;6:145.
Suzuki K, Yasuda T, Nagao K, Hori T, Watanabe K, Kanamori M, et al
. Metastasis of gastrointestinal stromal tumor to skeletal muscle: A case report. J Med Case Rep 2014;8:256.
Nilsson B, Bümming P, Meis-Kindblom JM, Odén A, Dortok A, Gustavsson B, et al
. Gastrointestinal stromal tumors: The incidence, prevalence, clinical course, and prognostication in the preimatinib mesylate era -a population-based study in western Sweden. Cancer 2005;103:821-9.
Yanagawa S, Tanabe K, Suzuki T, Tokumoto N, Arihiro K, Ohdan H. A large esophageal gastrointestinal stromal tumor that was successfully resected after neoadjuvant imatinib treatment: Case report. World J Surg Oncol 2014;12:47.
Pauwels P, Debiec-Rychter M, Stul M, De Wever I, Van Oosterom AT, Sciot R. Changing phenotype of gastrointestinal stromal tumours under imatinib mesylate treatment: A potential diagnostic pitfall. Histopathology 2005;47:41-7.
[Figure 1], [Figure 2], [Figure 3]