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Gastrointestinal Stromal Tumor (GIST)

Brianna Carden
DMS 497 Clinical
Fall 2015

CERTIFICATE OF AUTHORSHIP: I certify that I am the author of this research paper. I have cited all of the
sources from which I used data, ideas, or words (quoted or paraphrased). I also certify that this paper was
prepared by me specifically for this course.
Signature ___Brianna Carden______

Date ____11/30/15________

Abstract
An African American female in the eighth decade presented with symptoms of abdominal pain
and bloating. The patient had a previous hysterectomy but was unsure if both ovaries had been
removed. A previous computed tomography (CT) was performed in which a heterogeneous, solid
mass was found. Based on the CT findings, the physician ordered a follow-up transvaginal
ultrasound. Ultrasound findings included a well-defined, heterogeneous, round, vascular mass
found posterior to the bladder and to the right of midline. The radiologists impression of this
pathology was a 6 to 7 cm vascular mass posterior to the urinary bladder. If the patient still had
her ovaries, primary ovarian neoplasm would have been favored. Gastrointestinal stromal tumor
(GIST) was also a primary consideration. Clinical approach and management of patient, at the
time of testing, were unknown. Surgery would be the best option for treatment.

Key words
GIST, hysterectomy, sonography, gastrointestinal stromal tumor

GISTs are the most common nonepithelial tumors of the gastrointestinal tract.1 Sonography and
CT are pertinent imaging modalities used in the diagnosis and treatment of this pathology, as
well as continued monitoring. This article will present a case involving a patient who was
experiencing abdominal discomfort and bloating. A review of the clinical findings, sonographic
features, and treatment options for a GIST will also be explained.

Case History
An 88 year old African American female was referred, by the physician, for a follow-up
transvaginal ultrasound of the pelvic area. The patient presented with symptoms of generalized
abdominal pain and bloating. The patient had a history of a hysterectomy but was unsure if both
ovaries had been removed. Coordinating examination, viewed by the sonographer, included a CT
abdomen pelvis with contrast which the patient had about a month prior to the ultrasound
examination. Results from the CT revealed a heterogeneous enhancing, predominately solid
mass, with cystic areas within (Figure 1). Areas of hemorrhage and necrosis were seen in the
lower pelvis, slightly to the right of midline (Figure 1). On CT, the mass measured 5.6 x 7.1 cm
(Figure 2). The physician indicated this was a possible solid ovarian neoplasm or GIST.
Sonographic Findings
The examination was done using a Siemens Acuson machine with a curved transducer utilizing a
frequency of 5 MHz. The sonographic findings included a well-defined, complex, round,
heterogeneous, hypoechoic mass (Figure 3-4). The mass was found posterior to the bladder and
right of midline in the pelvic region (Figure 5). Color Doppler displayed vascularity within the
mass which measured 7.39 x 6.68 x 6.06 cm (Figure 3-5). Other structures appeared unaffected
by the mass.
Discussion
The radiologists impression of this pathology was a 6 to 7 cm vascular mass posterior to the
urinary bladder. If the patient still had her ovaries, primary ovarian neoplasm would have been
favored. GIST tumor was also a primary consideration due to the location of the mass.

Definition/Incidence
GIST is the most common smooth muscle mesenchymal tumor of the gastrointestinal tract.2 The
incidence of GIST is estimated to be 10-20 per million people, per year.3 This tumor arises
mostly in the stomach or small intestine; however these can occur anywhere along the
gastrointestinal tract.4 Malignancy is possible, but the occurrence is rare.3 The precise etiology of
GIST is unknown due to the incomplete definition and classification.3 According to research,
over 90% of these tumors occur in adults over 40 with a median age of 63 years old.3 The
incidence between male and female is equal.3
Clinical Findings
Most gastrointestinal stromal tumors remain asymptomatic until becoming large in size. Upon
reaching a large size, GISTs can cause symptoms according to location and size.5 Symptomatic
patients can present with abdominal pain, fatigue, dyspepsia, nausea, anorexia, weight loss,
fever, and obstruction. Obstruction can be caused from the mass becoming too large and
compressing other structures in the body, such as vessels. Some patients may even experience
gastrointestinal bleeding or a palpable mass.5 With the onset of these symptoms; a
transabdominal or transvaginal ultrasound would need to be ordered in order to evaluate the
pelvic area for a possible pathology.
Sonographic Findings
Many GISTs are found as incidental findings at the time of surgery, sonography, or autopsy.2 As
mentioned above, these vascular tumors can become very large and may undergo ulceration,
degeneration, necrosis, and/or hemorrhage.2 GISTs can occur anywhere along the gastrointestinal
tract especially the stomach and upper small bowel.6 These tumors are usually solid, but cystic

areas have been described in larger tumors, leading to central necrotic cavitation.6 Smooth
muscle stromal tumors typically produce round mass lesions of varying echogenicity.2
Conclusion
GISTs are the most common nonepithelial tumors of the gastrointestinal tract.1 Although they are
the most common nonepithelial tumor, they are rarely found. It is important to be aware of what
a gastrointestinal stromal tumor is if a mass is discovered. They can be small and asymptomatic
or become large and cause complications.
The clinical presentation of the patient matched with the literature findings. According to
the Journal of Gastrointestinal Oncology, most GIST tumors remain silent until becoming large
in size.5 The patients tumor was average in size causing abdominal pain and bloating. Research
from the same source states that many symptomatic GISTs will cause abdominal pain, fatigue,
nausea, weight loss, fever, and obstruction.
The sonographic findings compared with literature findings had a few similarities.
According to Okasha with Endoscopic Ultrasound, GISTs can be found anywhere along the
gastrointestinal tract.6 These vascular tumors are usually solid, but central cystic areas can found
leading to necrosis or hemorrhage.2,6 GISTs typically produce round mass lesions with varying
echogenicities.2 The patients mass was found located posterior to the bladder and to the right of
midline. Also, the mass presented in this case was solid, round, and hypoechoic; but a central
cystic area was unseen.
Some important guidelines for sonographers to consider when pathology is identified
include the following. First, upon discovering a pathology always use Color Doppler to see if the
pathology has vascularity. Second, if absence of flow is seen, Power Doppler should be used to
confirm the absence. If vascularity is present within a pathology, this would provide significant

information for the radiologist in making the diagnosis. Third, if flow is observed, always use
Spectral Doppler in order to express to the radiologist the type of flow present. These settings are
very important in evaluating any pathology. Also, always remember to check previous
examinations and talk with patients about their condition prior to performing the sonogram.
The follow up information was unknown for this patient. Therefore, some possible
management options for a GIST include being monitored with CT or ultrasound to see if the
mass is causing any issues to other structures or to see if it is increasing in size. A biopsy could
be performed to confirm if the mass is a gastrointestinal tumor or a different pathology.
However, surgery with complete removal of the tumor is the primary and preferred treatment for
GIST.4 Recurrence after surgery is common, thus the condition would need to be monitored with
ultrasound.4

References

1. Nilsson B, Dortok A, Gustavsson B, et al. Gastrointestinal Stomal Tumors: Incidence,

Prevalence, Clinical Course, and Prognostication in the Preimatinib Mesylate Era.
Cancer [serial online]. 2005; 103:4. Available at:
http://onlinelibrary.wiley.com/doi/10.1002/cncr.20862/pdf. Accessed Nov 28, 2015.
2. Rumack MD FACR, Wilson MD, J. Charboneau MD, Levine. Et al. Diagnostic
Ultrasound. Vol. 1. 4th ed. C.V. Mosby; 2011: 269.
3. Stamatakos M, Douzinas E, Stefanaki C. Gastrointestinal Stromal Tumor. World Journal
of Surgical Oncology [serial online]. 2009; 7:61. Available at:
http://www.biomedcentral.com/content/pdf/1477-7819-7-61.pdf. Accessed Nov 18, 2015.
4. Deshaies I, Cherenfant J, Gusani N, et al. Gastrointestinal stromal tumor (GIST)
recurrence following surgery: review of the clinical utility of imatinib treatment.
Therapeutics and Clinical Risk Management [serial online]. 2010; 6: 453-458. Available
at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2952484/. Accessed Nov 17, 2015.
5. Zhao X, Yue C. Gastrointestinal Stromal Tumor. Journal of Gastrointestinal Oncology
[serial online]. 2012; 3(3): 189-208. Available at:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3418531/. Accessed Nov 17, 2015.
6. Okasha H, Amin H, Al-Shazli M, et al. A duodenal gastrointestinal stromal tumor with a
large central area of fluid and gas due to fistulization into the duodenal lumen,
mimicking a large duodenal diverticulum. Endoscopic Ultrasound. [serial online]. 2015;
4:3. Available at:
http://web.b.ebscohost.com.bchs.idm.oclc.org/ehost/pdfviewer/pdfviewer?sid=41e96a108afb-4d40-898f-60605a44f862%40sessionmgr111&vid=0&hid=116. Accessed Nov 18,
2015.

Images

Figure 1. CT abdomen/pelvis image with arrows showing the heterogeneous enhancing solid
mass.

Figure 2. CT image showing the mass measuring 5.6 x 7.1 cm.

Figure 3. Sagittal sonogram of the mass demonstrating a length of 6.68 cm and a height of 7.39
cm. Also showing the mass is round, hypoechoic, heterogeneous, and well-defined borders.

Figure 4. Transverse sonogram of the mass demonstrating a width of 6.06 cm. As in figure 3, the
mass is seen as round, hypoechoic, heterogeneous, and well-defined borders.

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Figure 5. Sagittal sonogram of the midline pelvis region showing the solid mass posterior to the
bladder and to the right of midline. Color Doppler shows vascularity within the mass.