194
CLINICAL IMAGING 1992;16:194-197
LEIOMYOBLASTOMA:
VARIED CT APPEARANCE
MARILYN E. LERNER, MD, JACK FARMAN, MB, ChB, MMed, KAY CHO, MD, IRA TYLER, MD, AND DAVID MULLEN, MD
Leiomvoblastoma is an uncommon tumor of the stomach. Usually exogastric in site, the tumor may grow to a significant size before it becomes symptomatic. Various appearances of the tumor include cystic and solid forms as well as a combination of both. Tumor hypervascularity may be identified on computed tomography (CT). The development of calcification in this tumor is rare. Late recurrence of the tumor may occur. The differential diagnosis should include leiomysarcoma, leiomyoma, pancreatic psudocyst, and cystadenoma. KEY WORDS:
Gastric tumor; Large, solid, cystic; Calcification; recurrence; Leiomyoblastoma.
Late
INTRODUCTION Gastric leiomyoblastomas are relatively unusual tumors. They often present as intramural lesions and can be well demonstrated on barium examination are exogastric, these tumors can (1). Some 10%15% grow to a large size and cause difficulty in diagnosis (l-4). For these reasons the tumors have at times been misdiagnosed as hepatic masses and pseudocysts of the pancreas (4, 6). Although cystic leiomyoblastoma is the common
From the Department of Radiology, Columbia-Presbyterian Medical Center. New York. NY [M.E.L.. I.F.l: The Denartment of Radiology, Albert Einstein College of Mgdicine, Bronx, NY (KC., LT.); and The Department of Radiology, Greenwich Hospital, Greenwich, CT (D.M.). Address reprint requests to: Jack Farman, M.B., Ch.B., M.Med. Columbia-Presbyterian Medical Center, Department of Radiology-M3-204,177 Ft. Washington Avenue, New York, NY 100323204. Received February 1992; accepted February 1992. 0 1992 by Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, 0899-7071/92/$5,00
New York, NY 10010
form of presentation on computed axial tomography (CT) (4-8), we encountered one patient whose tumor was totally solid and a second patient whose tumor exhibited calcifications in addition to solid and cystic components. Three other patients presented with the more usually described cystic mass.
CASE REPORTS Case 1 CF., a 70-year-old woman presented with a 5 month history of early satiety, nausea, vomiting, and weight loss. Abdominal ultrasound revealed a large leftupper-quadrant mass with cystic and solid areas. Echogenic foci with shadowing representing calcifications were present as well. The mass extended from the posterior wall of the stomach to involve the spleen and tail of pancreas. Collateral vessels were evident surrounding the mass. Multiple hypoechoic liver lesions were identified and felt to be consistent with metastatic disease. CT revealed a 14 cm x 12 cm x 25 cm mass arising from the posterior wall of the stomach, which involved the pancreas and spleen (Figure 1). Calcification and central necrosis were identified. Collateral vessels were evident along the lateral aspect of the mass, as were multiple low-attenuation lesions within the liver. An omental implant was identified anteriorly. Angiography disclosed a large hypervascular mass that was supplied from the splenic artery, and from a markedly enlarged gastroepiploic artery. There was encasement of the splenic artery and occlusion of the splenic vein and coronary vein collaterals. Ultrasound-guided percutaneous biopsy was performed and the presence of malignant leiomyoblastoma established. At surgery a 12 cm x 25 cm mass was identified arising from the posterior wall of the stomach. A nodular liver was confirmed as well as the omental mass. Multiple lymph nodes were biopsied. Pathologic examination of tissue from multiple biop-
IULY-SEPTEMBER
LEIOMYOBLASTOMA:
1992
VARIED CT APPEARANCE
195
FIGURE 1. (A) CT scan of the abdomen. A calcified mass arises from the fundus and greater curvature of the stomach. (B) There is extension of the mass into the left midabdomen.
sies of lymph nodes, liver, and omentum the presence of metastatic tumor.
Case
confirmed
FIGURE 2. (A) Abdominal CT scan. A large cystic and solid mass is seen arising from the body of the stomach. (B) The tumor extends inferiorly to distend the whole girth of the abdomen.
2
I.J., a 4%year-old black man presented with early satiety and abdominal discomfort. On CT scan a 30 cm exogastric cystic mass was present arising from the lesser curve of the stomach and filled the entire midabdomen (Figure 2). Irregular tumor tissue occupied the left lateral wall of the mass. This mass contained several fluid levels on ultrasound, and was At surgery the huge mass avascular on angiography. contained 8 L of murky brown fluid with debris. There was a small soft-tissue attachment to the lesser curve of the stomach. On pathologic examination the
mass was identified as a nonmalignant leiomyoblastoma. The cystic component consisted of hemorrhagic necrotic debris.
Case
3
M.C., a 70-year-old man presented with upper abdominal pain. His past medical history is significant for local resection of gastric leiomyoblastoma 18 A CT scan on this admission reyears previously. viewed a large soft-tissue exogastric mass arising
196
CLINICAL IMAGING VOL. 16. NO. 3
LERNER ET AL.
antral mass. A high total gastrectomy was performed with gastrojejunostomy. Pathology disclosed the cystic mass to be a leiomyoblastoma and an antral polypoid carcinoma. In addition, two mucosal lesions measuring 0.4 cm were found and shown to be carcinoids on histology.
Case 5
FIGURE 3. CT scan demonstrates a soft-tissue mass arising from the posterior wall of the stomach.
L.G., an 80-year-old man presented with pruritus of unknown etiology. Physical examination revealed a palpable epigastric mass. A CT scan was obtained that demonstrated a 7 cm solid mass with cystic center arising in a predominantly exophytic manner from the lesser curve of the stomach. Barium meal confirmed the mural nature of the mass. At surgery the i’-cm ulcerated mass was removed and a partial gastrectomy with a Bilroth II anastomoses was performed. Pathology disclosed leiomyblastoma.
from
the posterior wall of the stomach (Figure 3). CTguided biopsy confirmed the tumor to be a leiomyoblastoma identical histologically with the original tumor resected 18 years earlier. Case 4 R.S., a 60-year-old asymptomatic man had heme positive stool and anemia on a routine physical examination. Barium meal demonstrated a large extramucosal mass on the lesser curve of the stomach measuring 8 cm, and, in addition, a polypoid 3-cm mass was seen in the antrum. The CT scan confirmed the presence of a large cystic mass arising from the lesser curvature of the stomach (Figure 4) as well as the polypoid
FIGURE 4. A cystic mass with an enhancing is evident on the CT scan.
mural nodule
DISCUSSION
Gastric leiomyoblastoma was first described in 1960 by Martin et al. (9). Stout analyzed 69 cases and considered these lesions to be a new form of smoothmuscle neoplasm, which he termed leiomyoblastoma (10). These rare gastric tumors have a low-grade malignant potential (2). Abramson found malignant cells in 12% of the tumors (2). On gross pathologic examination leiomyoblastomas are usually large, well-circumscribed, and occasionally ulcerated. They contain large pleomorphic cells with either clear or eosinophylic cytoplasm. The nuclei are centrally located and vary in size and shape (12). When the tumor is larger than 6 cm or contains more than 4-5 mitoses per 10 high power fields it is considered to be malignant (11). These epithelial tumors are intramural in 84% of patients (1). The tumor may prolapse into the lumen of the stomach or extend predominantly in an exogastric manner. Compared to gastric leiomyomas and leiomyosarcomas that arise predominantly in the fundus and body, 75% of leiomyoblastomas arise in the antrum (1). Two of our patients with gastric leiomyoblastomas presented with uncommon CT appearances. In one instance calcifications were seen within a mixed cystic and solid mass. In the second patient, the mass was homogeneously solid. Three patients presented with the more usual cystic appearance previously described on CT examination (4-8). The presence of calcification within a leiomyoblastoma is unique, and to our knowledge has not been
JULY-SEPTEMBER
LEIOMYOBLASTOMA:
1992
previously described. Metastatic disease to liver, omentum, and lymph nodes though rare may occur. The angiographic features of these tumors range from being totally avascular to having marked hypervascularity. The findings in our patients would appear to coincide with the extent of cystic degeneration present within the mass. Exogastric leiomyoblastoma should be considered in the differential diagnosis of large left-upper-quadrant masses together with leiomyomas and leiomyosarcomas. Other degenerating sarcomatous tumors, such as neuroembryosarcomas, as well as lymphoma, and rarely carcinoma, may present with this appearance. Contiguous pancreatic pseudocysts and cystadenocarcinomas also enter into the differential diagnosis.
VARIED CT APPEARANCE
3. Lavin P, Hadgu SI, Foote Jr FW. Gastric and extragastric
myoblastomas.
197
leio-
Cancer 1972;29:305-311.
4. Stanley JH, Ravenel
D, Parker TH, et al. Exogastric leiomyoblastoma: rare gastric neoplasm mimicking left hepatic mass on computed tomography. Comput Tomogr 1986;10:187-190.
5. Slasky BS, Denese
L, Skolnick ML. Exogastric leiomyoblastoma: diagnosis by CT and ultrasonography. South Med J 1982;75:1275-1277.
6. Malhotia
R, Evans R, Bhawan J, et al. A malignant gastric leiomyoblastoma presenting as an infected pseudocyst of the pancreas. Am J Gastroenterol 1988;83:452-456.
7. Choi BI, Ok ID, Im JG, et al. Exogastric
oblastoma
with unusual
CT appearance.
cystic gastric leiomyGastrointest Radio1
1988;13:109-111. 8. Postona
CT, Gerlag PGG. Leiomyoblastoma
of the stomach.
Neth J Med 1986;29:126-128. 9. Martin JF, Bazin P, Feroldi J, et al. Tumorous
myoides intramurales de l’estomas; considerations microscopiques a props de 6 cas. Ann Anat Path01 1960;5:484-497.
10. Stout AP. Bizarre smooth muscle tumors of the stomach.
Can-
cer 1962;15:400-409, 11. Appelman
REFERENCES 1. Faegenburg D, Farman J, Dallemand S, et al. Leiomyoblastoma of the stomach. Radiology 1975;117:297-300. 2. Abramson DJ. Leiomyoblastoma Obstet 1973;136:118-125.
of the stomach. Surg Gynecol
HD, Helurg EB. Gastric epithelial leiomyoma and leiomyosarcoma (leiomyoblastoma). Cancer 1976;38:708728.
12. Cotion R, Kumar V, Robbins
S. Robbins Pathologic Basis of Disease, 4th ed. Philadelphia: WB Saunders, 1989, pp. 859-860.
CLINICAL IMAGING 1992;16:194-197
LEIOMYOBLASTOMA:
VARIED CT APPEARANCE
MARILYN E. LERNER, MD, JACK FARMAN, MB, ChB, MMed, KAY CHO, MD, IRA TYLER, MD, AND DAVID MULLEN, MD
Leiomvoblastoma is an uncommon tumor of the stomach. Usually exogastric in site, the tumor may grow to a significant size before it becomes symptomatic. Various appearances of the tumor include cystic and solid forms as well as a combination of both. Tumor hypervascularity may be identified on computed tomography (CT). The development of calcification in this tumor is rare. Late recurrence of the tumor may occur. The differential diagnosis should include leiomysarcoma, leiomyoma, pancreatic psudocyst, and cystadenoma. KEY WORDS:
Gastric tumor; Large, solid, cystic; Calcification; recurrence; Leiomyoblastoma.
Late
INTRODUCTION Gastric leiomyoblastomas are relatively unusual tumors. They often present as intramural lesions and can be well demonstrated on barium examination are exogastric, these tumors can (1). Some 10%15% grow to a large size and cause difficulty in diagnosis (l-4). For these reasons the tumors have at times been misdiagnosed as hepatic masses and pseudocysts of the pancreas (4, 6). Although cystic leiomyoblastoma is the common
From the Department of Radiology, Columbia-Presbyterian Medical Center. New York. NY [M.E.L.. I.F.l: The Denartment of Radiology, Albert Einstein College of Mgdicine, Bronx, NY (KC., LT.); and The Department of Radiology, Greenwich Hospital, Greenwich, CT (D.M.). Address reprint requests to: Jack Farman, M.B., Ch.B., M.Med. Columbia-Presbyterian Medical Center, Department of Radiology-M3-204,177 Ft. Washington Avenue, New York, NY 100323204. Received February 1992; accepted February 1992. 0 1992 by Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, 0899-7071/92/$5,00
New York, NY 10010
form of presentation on computed axial tomography (CT) (4-8), we encountered one patient whose tumor was totally solid and a second patient whose tumor exhibited calcifications in addition to solid and cystic components. Three other patients presented with the more usually described cystic mass.
CASE REPORTS Case 1 CF., a 70-year-old woman presented with a 5 month history of early satiety, nausea, vomiting, and weight loss. Abdominal ultrasound revealed a large leftupper-quadrant mass with cystic and solid areas. Echogenic foci with shadowing representing calcifications were present as well. The mass extended from the posterior wall of the stomach to involve the spleen and tail of pancreas. Collateral vessels were evident surrounding the mass. Multiple hypoechoic liver lesions were identified and felt to be consistent with metastatic disease. CT revealed a 14 cm x 12 cm x 25 cm mass arising from the posterior wall of the stomach, which involved the pancreas and spleen (Figure 1). Calcification and central necrosis were identified. Collateral vessels were evident along the lateral aspect of the mass, as were multiple low-attenuation lesions within the liver. An omental implant was identified anteriorly. Angiography disclosed a large hypervascular mass that was supplied from the splenic artery, and from a markedly enlarged gastroepiploic artery. There was encasement of the splenic artery and occlusion of the splenic vein and coronary vein collaterals. Ultrasound-guided percutaneous biopsy was performed and the presence of malignant leiomyoblastoma established. At surgery a 12 cm x 25 cm mass was identified arising from the posterior wall of the stomach. A nodular liver was confirmed as well as the omental mass. Multiple lymph nodes were biopsied. Pathologic examination of tissue from multiple biop-
IULY-SEPTEMBER
LEIOMYOBLASTOMA:
1992
VARIED CT APPEARANCE
195
FIGURE 1. (A) CT scan of the abdomen. A calcified mass arises from the fundus and greater curvature of the stomach. (B) There is extension of the mass into the left midabdomen.
sies of lymph nodes, liver, and omentum the presence of metastatic tumor.
Case
confirmed
FIGURE 2. (A) Abdominal CT scan. A large cystic and solid mass is seen arising from the body of the stomach. (B) The tumor extends inferiorly to distend the whole girth of the abdomen.
2
I.J., a 4%year-old black man presented with early satiety and abdominal discomfort. On CT scan a 30 cm exogastric cystic mass was present arising from the lesser curve of the stomach and filled the entire midabdomen (Figure 2). Irregular tumor tissue occupied the left lateral wall of the mass. This mass contained several fluid levels on ultrasound, and was At surgery the huge mass avascular on angiography. contained 8 L of murky brown fluid with debris. There was a small soft-tissue attachment to the lesser curve of the stomach. On pathologic examination the
mass was identified as a nonmalignant leiomyoblastoma. The cystic component consisted of hemorrhagic necrotic debris.
Case
3
M.C., a 70-year-old man presented with upper abdominal pain. His past medical history is significant for local resection of gastric leiomyoblastoma 18 A CT scan on this admission reyears previously. viewed a large soft-tissue exogastric mass arising
196
CLINICAL IMAGING VOL. 16. NO. 3
LERNER ET AL.
antral mass. A high total gastrectomy was performed with gastrojejunostomy. Pathology disclosed the cystic mass to be a leiomyoblastoma and an antral polypoid carcinoma. In addition, two mucosal lesions measuring 0.4 cm were found and shown to be carcinoids on histology.
Case 5
FIGURE 3. CT scan demonstrates a soft-tissue mass arising from the posterior wall of the stomach.
L.G., an 80-year-old man presented with pruritus of unknown etiology. Physical examination revealed a palpable epigastric mass. A CT scan was obtained that demonstrated a 7 cm solid mass with cystic center arising in a predominantly exophytic manner from the lesser curve of the stomach. Barium meal confirmed the mural nature of the mass. At surgery the i’-cm ulcerated mass was removed and a partial gastrectomy with a Bilroth II anastomoses was performed. Pathology disclosed leiomyblastoma.
from
the posterior wall of the stomach (Figure 3). CTguided biopsy confirmed the tumor to be a leiomyoblastoma identical histologically with the original tumor resected 18 years earlier. Case 4 R.S., a 60-year-old asymptomatic man had heme positive stool and anemia on a routine physical examination. Barium meal demonstrated a large extramucosal mass on the lesser curve of the stomach measuring 8 cm, and, in addition, a polypoid 3-cm mass was seen in the antrum. The CT scan confirmed the presence of a large cystic mass arising from the lesser curvature of the stomach (Figure 4) as well as the polypoid
FIGURE 4. A cystic mass with an enhancing is evident on the CT scan.
mural nodule
DISCUSSION
Gastric leiomyoblastoma was first described in 1960 by Martin et al. (9). Stout analyzed 69 cases and considered these lesions to be a new form of smoothmuscle neoplasm, which he termed leiomyoblastoma (10). These rare gastric tumors have a low-grade malignant potential (2). Abramson found malignant cells in 12% of the tumors (2). On gross pathologic examination leiomyoblastomas are usually large, well-circumscribed, and occasionally ulcerated. They contain large pleomorphic cells with either clear or eosinophylic cytoplasm. The nuclei are centrally located and vary in size and shape (12). When the tumor is larger than 6 cm or contains more than 4-5 mitoses per 10 high power fields it is considered to be malignant (11). These epithelial tumors are intramural in 84% of patients (1). The tumor may prolapse into the lumen of the stomach or extend predominantly in an exogastric manner. Compared to gastric leiomyomas and leiomyosarcomas that arise predominantly in the fundus and body, 75% of leiomyoblastomas arise in the antrum (1). Two of our patients with gastric leiomyoblastomas presented with uncommon CT appearances. In one instance calcifications were seen within a mixed cystic and solid mass. In the second patient, the mass was homogeneously solid. Three patients presented with the more usual cystic appearance previously described on CT examination (4-8). The presence of calcification within a leiomyoblastoma is unique, and to our knowledge has not been
JULY-SEPTEMBER
LEIOMYOBLASTOMA:
1992
previously described. Metastatic disease to liver, omentum, and lymph nodes though rare may occur. The angiographic features of these tumors range from being totally avascular to having marked hypervascularity. The findings in our patients would appear to coincide with the extent of cystic degeneration present within the mass. Exogastric leiomyoblastoma should be considered in the differential diagnosis of large left-upper-quadrant masses together with leiomyomas and leiomyosarcomas. Other degenerating sarcomatous tumors, such as neuroembryosarcomas, as well as lymphoma, and rarely carcinoma, may present with this appearance. Contiguous pancreatic pseudocysts and cystadenocarcinomas also enter into the differential diagnosis.
VARIED CT APPEARANCE
3. Lavin P, Hadgu SI, Foote Jr FW. Gastric and extragastric
myoblastomas.
197
leio-
Cancer 1972;29:305-311.
4. Stanley JH, Ravenel
D, Parker TH, et al. Exogastric leiomyoblastoma: rare gastric neoplasm mimicking left hepatic mass on computed tomography. Comput Tomogr 1986;10:187-190.
5. Slasky BS, Denese
L, Skolnick ML. Exogastric leiomyoblastoma: diagnosis by CT and ultrasonography. South Med J 1982;75:1275-1277.
6. Malhotia
R, Evans R, Bhawan J, et al. A malignant gastric leiomyoblastoma presenting as an infected pseudocyst of the pancreas. Am J Gastroenterol 1988;83:452-456.
7. Choi BI, Ok ID, Im JG, et al. Exogastric
oblastoma
with unusual
CT appearance.
cystic gastric leiomyGastrointest Radio1
1988;13:109-111. 8. Postona
CT, Gerlag PGG. Leiomyoblastoma
of the stomach.
Neth J Med 1986;29:126-128. 9. Martin JF, Bazin P, Feroldi J, et al. Tumorous
myoides intramurales de l’estomas; considerations microscopiques a props de 6 cas. Ann Anat Path01 1960;5:484-497.
10. Stout AP. Bizarre smooth muscle tumors of the stomach.
Can-
cer 1962;15:400-409, 11. Appelman
REFERENCES 1. Faegenburg D, Farman J, Dallemand S, et al. Leiomyoblastoma of the stomach. Radiology 1975;117:297-300. 2. Abramson DJ. Leiomyoblastoma Obstet 1973;136:118-125.
of the stomach. Surg Gynecol
HD, Helurg EB. Gastric epithelial leiomyoma and leiomyosarcoma (leiomyoblastoma). Cancer 1976;38:708728.
12. Cotion R, Kumar V, Robbins
S. Robbins Pathologic Basis of Disease, 4th ed. Philadelphia: WB Saunders, 1989, pp. 859-860.
