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Laparoscopic resection of incidentally discovered gastric schwannoma: An Egyptian case report and review of literature
Current Medicine Research and Practice 8 (2018) 186e189
Contents lists available at ScienceDirect
Current Medicine Research and Practice journal homepage: www.elsevier.com/locate/cmrp
Case report
Laparoscopic resection of incidentally discovered gastric schwannoma: An Egyptian case report and review of literature Amr Abouzid a, *, Islam H. Metwally a, Omar Hamdy a, Sara Raafat b, Amira K. El-Hawary b, Ahmed Setit a a b
Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Mansoura, Egypt Pathology Department, Faculty of Medicine, Mansoura University, Egypt
a r t i c l e i n f o
a b s t r a c t
Article history: Received 8 July 2018 Accepted 20 August 2018 Available online 21 August 2018
Schwannoma of the GIT commonly arise in the stomach. We present a male patient with gastric schwannoma treated laparoscopically. General surgeons, as well as, surgical oncologists should suspect this diagnosis when dealing with patients with submucosal gastric tumours. © 2018 Sir Ganga Ram Hospital. Published by Elsevier, a division of RELX India, Pvt. Ltd. All rights reserved.
Keywords: Schwannoma Submucosal tumour Laparoscopic gastrectomy Stomach
1. Background
2. Case presentation
Gastric schwannoma (GS) is a rare submucosal tumour arising from Schwann cells in the neural plexus of the stomach. It accounts for only 0.2% of all gastric tumours, 6.3% of gastric mesenchymal tumours, and 4% of all benign tumours of the stomach.1 GS was first described in 1988 in a study by Daimaru et al.2 Schwannomas have been found at almost every location of the human body including extremities, head, neck, retroperitoneum, mediastinum, pelvis, and rectum. Visceral locations, however, are very rare and preoperative diagnosis is challenging, as Schwannomas are often confused with other neoplasms.3 The peak incidence of gastric schwannoma is in the 4th and 5th decades of life, commonly involving females. They can also occur in children. Most of the patients remain asymptomatic for a prolonged period of time and discovered incidentally on imaging or during laparotomy. Symptomatic patients may present with ulcerations, upper GI bleeding, or a palpable mass if the tumour grows exophytically.4 We present the first case of laparoscopic resection of gastric schwannoma from Egypt.
A 73 years old male patient presented to our department with accidental discovery of a focal lesion in the right liver lobe about, 1.3 1.1 cm size, during follow up abdominal ultrasound (US) before starting a new drug for hepatitis C virus (HCV) infection. He had a Triphasic computed tomography (CT) abdomen which revealed a 2 cm haemangioma with a well-defined exophytic soft tissue mass is seen arising from the distal third of the greater curvature of stomach with no wall invasion; it measured about 3.6 cm in diameter with foci of calcification and faint homogenous post contrast enhancement suggesting leiomyoma or gastrointestinal stromal tumour (GIST). The patient had a laparoscopic assessment of the mass then the dissection of the greater omentum was done by Ligasure 10 mm (Covidien), as the mass was attached to the posterior gastric wall (Fig. 1:a), then sleeve gastrectomy was done using 60 mm echelon flex (Eithicon) stapler using blue loads (Fig. 1:b) with reinforcement by intracorporeal seromuscular sutures using Vicryle 3.0 (Fig. 1:c), finally the specimen was retrieved by endcatch gold device (Covidien). (Fig. 1:d). Postoperative pathology showed schwannoma with typical S100 positivity (Fig. 2) and negative staining for CD34, CD117, and SMA (Fig. 3). Both safety margins were free.
* Corresponding author. Oncology Center, Mansoura University, Gehan Street, Mansoura, 35516, Egypt. E-mail address: [email protected] (A. Abouzid). https://doi.org/10.1016/j.cmrp.2018.08.003 2352-0817/© 2018 Sir Ganga Ram Hospital. Published by Elsevier, a division of RELX India, Pvt. Ltd. All rights reserved.
A. Abouzid et al. / Current Medicine Research and Practice 8 (2018) 186e189
187
Fig. 1. (a) Showed the location of gastric schwannoma in the posterior gastric wall. (b) Showed stapling of gastric schwannoma with laparoscopic stapler. (c) Reinforcement with intracorporeal seromuscular sutures (d) Showed schwannoma in the endocatch.
Fig. 2. Showed (a) gastric schwannoma formed of alternating hyercellular and hypocellular spindle cells in loose fibrous matrix (H, E x 100). (b) Showed positive cytoplasmic staining of the tumour cells to S-100 protein (IHC x 100).
The patient started oral intake in the first day postoperative and was discharged on the third day, he was followed up for 36 months thereafter without evidence of recurrence.
3. Discussion It is an interesting case of gastric schwannoma who was
188
A. Abouzid et al. / Current Medicine Research and Practice 8 (2018) 186e189
Fig. 3. Showed (a) negative staining of the tumour cells to CD117 (IHC x 100). (b) Showed negative staining of the tumour cells to DOG1 (IHC x 100). (c) Showed negative staining of the tumour cells for SMA while the smooth muscle of the wall of blood vessels was positive as internal positive control (IHC 100). (d) Showed negative staining of the tumour cells for CD3 while the endothelium of the blood vessels was positive as internal positive control (IHC 200).
discovered accidentally by a follow up abdominal ultrasound for hepatitis C virus infection and planned for an antivirus treatment. Most cases of GS are asymptomatic or present with abdominal pain or discomfort. The other rare symptoms include palpable abdominal mass (3.05%), poor appetite (3.05%), dyspepsia (1.82%), weight loss (1.21%), and nausea or vomiting (0.6%). Recently, Yang et al. reported a case of gastroduodenal intussusception due to GS.5 It appears that GS predominantly affects adults in the fifth to eighth decades of life and males to females ratio is 1: 2.64. Our case was a 73 years old male patient. The commonest sites of GS are the gastric body (59.3%), the gastric antrum (26.7%) and fundus (12.0%). GS arises rarely from the cardia (2%) with variable tumour size (ranged: 0.8e15.5) cm, with a mean of (4.69 ± 2.66) cm. The location of GS in our case was in the gastric body near the greater curvature with tumour size 4 cm.6 Surgical resection is considered to be the curative treatment for GS.7 As GS rarely metastasizes to the lymph nodes, there is no need for surgical lymphadenectomy unless enlarged lymph nodes are observed. In the past gastric mesenchymal tumours where treated by an open approach. However, in the last two decades laparoscopic management became the standard treatment. Recently, minimally invasive approaches, including endoscopic submucosal tunneling resection, endoscopic enucleation, and endoscopic fullthickness resection with or without laparoscopic assistance, have
been used as diagnostic and therapeutic tools for GS without any severe postoperative complications.8 In our scenario the patient had a laparoscopic sleeve gastrectomy. Schwannoma and GIST of the GIT were usually misdiagnosed as leiomyoma/leiomyosarcoma in the past till the era of the immunohistochemistry raised. However, till now the preoperative diagnosis of schwannoma is difficult without a biopsy. The differentiation of schwannoma is based on positive staining for S100 protein (marker of neural crest origin) and negative results for CD117, CD34, desmin, and smooth muscle actin, whereas GIST is classically positive for CD117, DOG-1, and CD34 but negative for S100 protein.9 Hong et al.10 reviewed 137 cases of GS without recurrence or metastasis in any patients during a follow-up period (ranged: 1e336) months. Therefore, the authors concluded that benign GS does not usually recur and frequent follow-up with CT imaging is not recommended , follow-up should be conducted over a period of at least 5 years for cases of malignant GS. Our case was followed up for 36 months. 4. Conclusion Gastric schwannoma is a rare submucosal tumour, masquarding as GIST. Laparoscopic wedge resection with negative margins is the
A. Abouzid et al. / Current Medicine Research and Practice 8 (2018) 186e189
standard of care. Recurrence is almost not documented. Conflicts of interest The authors declare that there are no conflicts of interest regarding the publication of this paper. Appendix A. Supplementary data Supplementary data related to this article can be found at https://doi.org/10.1016/j.cmrp.2018.08.003. References 1. Sreevathsa MR, Pipara G. Gastric schwannoma: a case report and review of literature. Indian J Surg Oncol. 2015;6:123e126. 2. Daimaru Y, Kido H, Hashimoto H, Enjoji M. Benign schwannoma of the gastrointestinal tract: a clinicopathologic and immunohistochemical study. Hum Pathol. 1988;19:257e264.
189
3. Lee NJ, Hruban RH, Fishman EK. Abdominal schwannomas: review of imaging findings and pathology. Abdom Radiol (NY). 2017;42:1864e1870. 4. Lin CS, Hsu HS, Tsai CH, Li WY, Huang MH. Gastric schwannoma. J Chin Med Assoc. 2004;67:583e586. 5. Yang JH, Zhang M, Zhao ZH, Shu Y, Hong J, Cao YJ. Gastroduodenal intussusception due to gastric schwannoma treated by Billroth II distal gastrectomy: one case report. World J Gastroenterol. 2015;21:2225e2228. 6. Hu BG, Wu FJ, Zhu J, et al. Gastric schwannoma: a tumor must Be included in differential diagnoses of gastric submucosal tumors. Case Rep Gastrointest Med. 2017;2017. 7. Takata A, Nakajima K, Kurokawa Y, et al. Single-incision laparoscopic partial gastrectomy for gastric submucosal tumors without compromising transumbilical stapling. Asian J Endosc Surg. 2014;7:25e30. 8. Lu J, Jiao T, Li Y, et al. Heading toward the right directiondsolution package for endoscopic submucosal tunneling resection in the stomach. PLoS One. 2015;10: e0119870. 9. Tao K, Chang W, Zhao E, et al. Clinicopathologic features of gastric schwannoma: 8-year experience at a single institution in China. Medicine (Baltim). 2015;94:e1970. 10. Hong X, Wu W, Wang M, Liao Q, Zhao Y. Benign gastric schwannoma: how long should we follow up to monitor the recurrence? A case report and comprehensive review of literature of 137 cases. Int Surg. 2015;100:744e747.
Contents lists available at ScienceDirect
Current Medicine Research and Practice journal homepage: www.elsevier.com/locate/cmrp
Case report
Laparoscopic resection of incidentally discovered gastric schwannoma: An Egyptian case report and review of literature Amr Abouzid a, *, Islam H. Metwally a, Omar Hamdy a, Sara Raafat b, Amira K. El-Hawary b, Ahmed Setit a a b
Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Mansoura, Egypt Pathology Department, Faculty of Medicine, Mansoura University, Egypt
a r t i c l e i n f o
a b s t r a c t
Article history: Received 8 July 2018 Accepted 20 August 2018 Available online 21 August 2018
Schwannoma of the GIT commonly arise in the stomach. We present a male patient with gastric schwannoma treated laparoscopically. General surgeons, as well as, surgical oncologists should suspect this diagnosis when dealing with patients with submucosal gastric tumours. © 2018 Sir Ganga Ram Hospital. Published by Elsevier, a division of RELX India, Pvt. Ltd. All rights reserved.
Keywords: Schwannoma Submucosal tumour Laparoscopic gastrectomy Stomach
1. Background
2. Case presentation
Gastric schwannoma (GS) is a rare submucosal tumour arising from Schwann cells in the neural plexus of the stomach. It accounts for only 0.2% of all gastric tumours, 6.3% of gastric mesenchymal tumours, and 4% of all benign tumours of the stomach.1 GS was first described in 1988 in a study by Daimaru et al.2 Schwannomas have been found at almost every location of the human body including extremities, head, neck, retroperitoneum, mediastinum, pelvis, and rectum. Visceral locations, however, are very rare and preoperative diagnosis is challenging, as Schwannomas are often confused with other neoplasms.3 The peak incidence of gastric schwannoma is in the 4th and 5th decades of life, commonly involving females. They can also occur in children. Most of the patients remain asymptomatic for a prolonged period of time and discovered incidentally on imaging or during laparotomy. Symptomatic patients may present with ulcerations, upper GI bleeding, or a palpable mass if the tumour grows exophytically.4 We present the first case of laparoscopic resection of gastric schwannoma from Egypt.
A 73 years old male patient presented to our department with accidental discovery of a focal lesion in the right liver lobe about, 1.3 1.1 cm size, during follow up abdominal ultrasound (US) before starting a new drug for hepatitis C virus (HCV) infection. He had a Triphasic computed tomography (CT) abdomen which revealed a 2 cm haemangioma with a well-defined exophytic soft tissue mass is seen arising from the distal third of the greater curvature of stomach with no wall invasion; it measured about 3.6 cm in diameter with foci of calcification and faint homogenous post contrast enhancement suggesting leiomyoma or gastrointestinal stromal tumour (GIST). The patient had a laparoscopic assessment of the mass then the dissection of the greater omentum was done by Ligasure 10 mm (Covidien), as the mass was attached to the posterior gastric wall (Fig. 1:a), then sleeve gastrectomy was done using 60 mm echelon flex (Eithicon) stapler using blue loads (Fig. 1:b) with reinforcement by intracorporeal seromuscular sutures using Vicryle 3.0 (Fig. 1:c), finally the specimen was retrieved by endcatch gold device (Covidien). (Fig. 1:d). Postoperative pathology showed schwannoma with typical S100 positivity (Fig. 2) and negative staining for CD34, CD117, and SMA (Fig. 3). Both safety margins were free.
* Corresponding author. Oncology Center, Mansoura University, Gehan Street, Mansoura, 35516, Egypt. E-mail address: [email protected] (A. Abouzid). https://doi.org/10.1016/j.cmrp.2018.08.003 2352-0817/© 2018 Sir Ganga Ram Hospital. Published by Elsevier, a division of RELX India, Pvt. Ltd. All rights reserved.
A. Abouzid et al. / Current Medicine Research and Practice 8 (2018) 186e189
187
Fig. 1. (a) Showed the location of gastric schwannoma in the posterior gastric wall. (b) Showed stapling of gastric schwannoma with laparoscopic stapler. (c) Reinforcement with intracorporeal seromuscular sutures (d) Showed schwannoma in the endocatch.
Fig. 2. Showed (a) gastric schwannoma formed of alternating hyercellular and hypocellular spindle cells in loose fibrous matrix (H, E x 100). (b) Showed positive cytoplasmic staining of the tumour cells to S-100 protein (IHC x 100).
The patient started oral intake in the first day postoperative and was discharged on the third day, he was followed up for 36 months thereafter without evidence of recurrence.
3. Discussion It is an interesting case of gastric schwannoma who was
188
A. Abouzid et al. / Current Medicine Research and Practice 8 (2018) 186e189
Fig. 3. Showed (a) negative staining of the tumour cells to CD117 (IHC x 100). (b) Showed negative staining of the tumour cells to DOG1 (IHC x 100). (c) Showed negative staining of the tumour cells for SMA while the smooth muscle of the wall of blood vessels was positive as internal positive control (IHC 100). (d) Showed negative staining of the tumour cells for CD3 while the endothelium of the blood vessels was positive as internal positive control (IHC 200).
discovered accidentally by a follow up abdominal ultrasound for hepatitis C virus infection and planned for an antivirus treatment. Most cases of GS are asymptomatic or present with abdominal pain or discomfort. The other rare symptoms include palpable abdominal mass (3.05%), poor appetite (3.05%), dyspepsia (1.82%), weight loss (1.21%), and nausea or vomiting (0.6%). Recently, Yang et al. reported a case of gastroduodenal intussusception due to GS.5 It appears that GS predominantly affects adults in the fifth to eighth decades of life and males to females ratio is 1: 2.64. Our case was a 73 years old male patient. The commonest sites of GS are the gastric body (59.3%), the gastric antrum (26.7%) and fundus (12.0%). GS arises rarely from the cardia (2%) with variable tumour size (ranged: 0.8e15.5) cm, with a mean of (4.69 ± 2.66) cm. The location of GS in our case was in the gastric body near the greater curvature with tumour size 4 cm.6 Surgical resection is considered to be the curative treatment for GS.7 As GS rarely metastasizes to the lymph nodes, there is no need for surgical lymphadenectomy unless enlarged lymph nodes are observed. In the past gastric mesenchymal tumours where treated by an open approach. However, in the last two decades laparoscopic management became the standard treatment. Recently, minimally invasive approaches, including endoscopic submucosal tunneling resection, endoscopic enucleation, and endoscopic fullthickness resection with or without laparoscopic assistance, have
been used as diagnostic and therapeutic tools for GS without any severe postoperative complications.8 In our scenario the patient had a laparoscopic sleeve gastrectomy. Schwannoma and GIST of the GIT were usually misdiagnosed as leiomyoma/leiomyosarcoma in the past till the era of the immunohistochemistry raised. However, till now the preoperative diagnosis of schwannoma is difficult without a biopsy. The differentiation of schwannoma is based on positive staining for S100 protein (marker of neural crest origin) and negative results for CD117, CD34, desmin, and smooth muscle actin, whereas GIST is classically positive for CD117, DOG-1, and CD34 but negative for S100 protein.9 Hong et al.10 reviewed 137 cases of GS without recurrence or metastasis in any patients during a follow-up period (ranged: 1e336) months. Therefore, the authors concluded that benign GS does not usually recur and frequent follow-up with CT imaging is not recommended , follow-up should be conducted over a period of at least 5 years for cases of malignant GS. Our case was followed up for 36 months. 4. Conclusion Gastric schwannoma is a rare submucosal tumour, masquarding as GIST. Laparoscopic wedge resection with negative margins is the
A. Abouzid et al. / Current Medicine Research and Practice 8 (2018) 186e189
standard of care. Recurrence is almost not documented. Conflicts of interest The authors declare that there are no conflicts of interest regarding the publication of this paper. Appendix A. Supplementary data Supplementary data related to this article can be found at https://doi.org/10.1016/j.cmrp.2018.08.003. References 1. Sreevathsa MR, Pipara G. Gastric schwannoma: a case report and review of literature. Indian J Surg Oncol. 2015;6:123e126. 2. Daimaru Y, Kido H, Hashimoto H, Enjoji M. Benign schwannoma of the gastrointestinal tract: a clinicopathologic and immunohistochemical study. Hum Pathol. 1988;19:257e264.
189
3. Lee NJ, Hruban RH, Fishman EK. Abdominal schwannomas: review of imaging findings and pathology. Abdom Radiol (NY). 2017;42:1864e1870. 4. Lin CS, Hsu HS, Tsai CH, Li WY, Huang MH. Gastric schwannoma. J Chin Med Assoc. 2004;67:583e586. 5. Yang JH, Zhang M, Zhao ZH, Shu Y, Hong J, Cao YJ. Gastroduodenal intussusception due to gastric schwannoma treated by Billroth II distal gastrectomy: one case report. World J Gastroenterol. 2015;21:2225e2228. 6. Hu BG, Wu FJ, Zhu J, et al. Gastric schwannoma: a tumor must Be included in differential diagnoses of gastric submucosal tumors. Case Rep Gastrointest Med. 2017;2017. 7. Takata A, Nakajima K, Kurokawa Y, et al. Single-incision laparoscopic partial gastrectomy for gastric submucosal tumors without compromising transumbilical stapling. Asian J Endosc Surg. 2014;7:25e30. 8. Lu J, Jiao T, Li Y, et al. Heading toward the right directiondsolution package for endoscopic submucosal tunneling resection in the stomach. PLoS One. 2015;10: e0119870. 9. Tao K, Chang W, Zhao E, et al. Clinicopathologic features of gastric schwannoma: 8-year experience at a single institution in China. Medicine (Baltim). 2015;94:e1970. 10. Hong X, Wu W, Wang M, Liao Q, Zhao Y. Benign gastric schwannoma: how long should we follow up to monitor the recurrence? A case report and comprehensive review of literature of 137 cases. Int Surg. 2015;100:744e747.