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    • br Discussion GISTs are rare visceral sarcomas arising

    2018-11-12


    Discussion GISTs are rare visceral sarcomas arising in the gastrointestinal tract wall, the muscularis mucosa, and muscularis propria, anywhere from the p2y inhibitor to the rectum. Its most common anatomic sites of origin are the stomach (60–70%), small intestine (20–30%), colon and rectum (5%), abdominal cavity (i.e., the peritoneum and omentum, 5%), esophagus (<5%), and retroperitoneal space (<3%). Surgery is the standard treatment for primary GISTs; however, surgical resection is seldom curative, particularly for large GISTs. Furthermore, >50% of the patients with GIST present with locally advanced, recurrent, or metastatic disease, making treatment difficult. The 5-year survival rate ranges from 50% to 65% following complete resection of a localized primary GIST, although this is reduced to ∼35% for patients with advanced disease who undergo complete surgical resection. The most commonly applied scheme for assessing the risk of recurrence is the consensus approach, which is based on the primary tumor diameter and mitotic count. However, patients whose tumor has ruptured into the abdominal cavity, either before or during surgery, are at a high risk of tumor recurrence. This patient suffered from a GIST with a rupture, implying that the risk of tumor seeding was high. Furthermore, he had not received a regular follow-up at our outpatient clinic (including an abdominal CT scan and postoperative medication). Hence, we could not detect the recurrence earlier and take preventative measures until he presented at our clinic with symptoms mimicking an incarcerated inguinal hernia. Finally, an intraabdominal peritoneal carcinomatosis of the GIST with tumor herniation was identified in the right inguinal region. Curative medication (IM) is available as a follow-up treatment of GISTs. Approximately 80% of GISTs have a mutated KIT gene, and 5% have a mutated alfa-type platelet-derived growth factor gene. Imatinib is a potent, specific inhibitor of KIT exhibiting significant activity and tolerability in the treatment of malignant unresectable or metastatic GISTs. Previous research showed that imatinib either induced tumor shrinkage (≥50%) or stabilized the disease in a majority of patients. Most patients (80–90%) with metastatic disease respond to imatinib or achieve durable tumor growth stabilization with continual therapy by using a daily dose of 400–600 mg. Our negligence resulted in the loss of the patient to regular follow-up (abdominal CT), including the nonprescription of imatinib following the first surgery. However, the patient responded well to imatinib treatment following the second surgery, exhibiting shrinkage of an enlarged lymph node in the pelvis and no tumor recurrence. Therefore, we recommend that other physicians prescribe imatinib and conduct persistent follow-up treatments for the surgical intervention of GISTs, particularly for patients at a high risk of tumor recurrence, including those with ruptured or large tumors, or with a high mitotic index. Incarceration occurs in approximately 5% of hernias. Emergency surgery is typically necessary because differentiating between viable and nonviable contents of the hernia sac is difficult. Previous studies have reported malignancies within the hernial sac when the hernia contains small pieces of the bowel and omentum. The first case of a tumor within a hernia sac was reported in 1749. The most frequently reported tumors are of primary or metastatic colon cancer. Any patient with a history of intraabdominal malignancy presenting with a new hernia should be examined for tumor recurrence. A history of intraabdominal neoplasms and systemic symptoms such as unexplained weight loss, anemia, altered bowel habit, or rectal bleeding indicates the possibility of a malignancy or colonic neoplasm. If an abnormal nodular sac is noted during surgery, it should be examined to exclude a malignancy. The patient approached our outpatient clinic complaining of pain and tenderness. He presented with an irreducible mass lesion over the right inguinal region that mimicked the symptoms and signs of an incarcerated hernia. Had we been unaware of his previous case of the GIST, we could have misdiagnosed the patient\'s illness.