CLINICAL CHALLENGES AND IMAGES IN GI An Unusual Perigastric Cyst Todd H. Baron, Ian S. Grimm, and Benjamin F. Calvo Division of Gastroenterology & Hepatology, Department of Surgery, University of North Carolina, Chapel Hill, North Carolina

Question: A 53-year-old man was referred for evaluation of a large cyst found during evaluation for abdominal fullness, early satiety and weight loss, and an abdominal mass on physical examination. Two endoscopic ultrasound (EUS) examinations with cyst fluid aspiration were performed before referral to our center revealing negative cytology with low levels of carcinoembryonic antigen (CEA), and absent levels of amylase and lipase. There was no history of alcohol use, pancreatic disease, family history of pancreatic disease, or personal history of malignancy. An abdominal MRI was performed before referral (Figure A). At our institution EUS was repeated. What is the diagnosis? Look on page 1229 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.07.051

Gastroenterology 2014;147:1228–1229

CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 4 (page 1228): Cystic Gastrointestinal Stromal Cell Tumor

EUS performed at our center revealed a large hypoechoic lesion abutting the stomach. Transgastric aspiration of fluid was performed with a 19-G needle. Fluid analysis including cytology, amylase, lipase and CEA were unrevealing. Irregular mural thickening (Figure B, arrows; C, cyst) similar to that seen on the MRI was targeted for fine needle aspiration. On hematoxylin and eosin staining, a bland spindle cell neoplasm was seen. Immunohistochemical stains were positive for CD34, CD117/ KIT (Golgi-like pattern), DOG, and SMA. An S100 stain was negative. This immunophenotype and histology was felt to be most characteristic of a gastrointestinal stromal cell tumor (GIST). The patient underwent surgical exploration where a cystic mass was found to be adherent to the body of the stomach. The entire 19-cm cyst was resected along with a portion of the gastric wall (Figure C). The mass was confirmed to be a GIST with a mitotic rate of 2/50 HPF (low grade, G1; Figure D, tumor adjacent to cyst wall). This case represents an important but unusual presentation a cystic gastric GIST.1 We propose the term “Gyst” to describe the rare stromal tumor with cystic degeneration. It is notable that the diagnosis was made by aspiration of the cyst wall and not from analysis of the fluid contents. It also highlights that a large cystic lesion has a broad differential diagnosis including pancreatic and nonpancreatic cystic neoplasms. Pancreatic pseudocysts should not be considered likely in the absence of a history of antecedent acute or chronic pancreatitis.

Reference 1.

Chen X, Lv H, Zhang W, et al. Large cystic-based gastrointestinal stromal tumor: a case report. Oncol Lett 2014; 7:846–848.

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An unusual perigastric cyst.

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