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Small, duodenal, GI stromal tumor showing large, extraluminal, exophytic growth
At the Focal Point
pertriglyceridemia, myelodyplastic syndrome, various leukemias and lymphomas, thalassemias, hepatic disease, parenteral nutrition (with fat emulsion), and certain infections, notably lepromatous leprosy and now perhaps leishmaniasis. The staining of the sea-blue histiocyte may, in fact, be either dark blue (coarse cytoplasmic granules) or light blue (homogeneous cytoplasmic staining), but the interesting question is why is the sea blue when water in a glass appears colorless? Both the sky and the sea appear blue, especially on clear sunny days, because they both reflect the shorter blue wavelength of light more than the other wavelengths that constitute the visible light spectrum. Blue wavelength light also is transmitted to greater depths of the sea than are yellow, red, and green wavelengths, thus allowing its scattering and subsequent re-emission. The relative contribution of reflected skylight and the light scattered back from the depths is strongly dependent on the angle of observation and wind currents, and the various particulate matters in the water also can influence the perceived color of the sea. The Italian actress Eleanora Duse (1858-1924) said that if the sight of the blue skies fills you with joy, if the simplest things of nature have a message that you understand, rejoice, for your soul is alive. The sea-blue color in one’s histiocytes do not, per se, call for rejoicing, but one still should try to enjoy all things wonderful about life. Lawrence J. Brandt, MD Associate Editor for Focal Points
Small, duodenal, GI stromal tumor showing large, extraluminal, exophytic growth A 39-year-old woman presented to our hospital because of melena. A physical examination was unremarkable, and her hemoglobin level was 7.3 g/dL (normal 12-16 g/dL). EGD revealed an 8-mm, centrally ulcerated, bleeding, submucosal tumor in the third portion of the duodenum (A, B). Abdominal CT www.giejournal.org
showed that there also was a well-enhanced, heterogeneous, 5-cm mass at the third portion of the duodenum (C). The tumor was seen to be a hypermetabolic, soft-tissue mass by positron emission tomography. A wedge resection of the tumor was performed for diagnosis and treatment. The excised mass was Volume 72, No. 6 : 2010 GASTROINTESTINAL ENDOSCOPY
1267
At the Focal Point
an ovoid, solid, nodular, spindle cell, mesenchymal tumor measuring 5.8 ⫻ 4 ⫻ 4 cm that involved the submucosal and muscular layers of the duodenal wall (D). The tumor extended to just beneath the mucosal layer, but there was no mucosal invasion. Immunohistochemistry showed the tumor to be positive for c-kit, CD34, and smooth muscle actin but only focally positive for S-100. Only one mitotic figure was noted during a survey of 50 high-power fields. The final diagnosis was GI stromal tumor with an intermediate risk for malignant change. Follow-up on this patient is occurring on a regular basis.
DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Hang Lak Lee, MD, Young Taek Kim, MD, Yong Won Joo, MD, Department of Gastroenterology, Hanyang University College of Medicine, Seoul, Korea doi:10.1016/j.gie.2010.04.046
Commentary Only 3% to 5% of GI stromal tumors are localized in the duodenum, and they are a rare cause of upper GI bleeding. Mesenchymal tumors may present as endophytic, exophytic, or endo-exophytic growths with both intraluminal and extraluminal components; another term for the latter is “dumbbell” tumor. The term dumbbell originated in the Tudor period (1485-1603) of English history, when athletes used hand-held church bells to develop their upper bodies. Because use of the bells would have made a great deal of noise, the athletes would remove the clappers so they could practice quietly; hence the name dumb, as in “no sound,” and “bell,” in other words, dumbbell. The name has persisted to the present, even though the shape of the apparatus has changed. As for treatment, wedge resection of the duodenum bearing the dumbbell tumor is an alternative to a duodenopancreatectomy when the tumor is of low-to-intermediate risk. Lawrence J. Brandt, MD Associate Editor for Focal Points
1268 GASTROINTESTINAL ENDOSCOPY
Volume 72, No. 6 : 2010
www.giejournal.org
pertriglyceridemia, myelodyplastic syndrome, various leukemias and lymphomas, thalassemias, hepatic disease, parenteral nutrition (with fat emulsion), and certain infections, notably lepromatous leprosy and now perhaps leishmaniasis. The staining of the sea-blue histiocyte may, in fact, be either dark blue (coarse cytoplasmic granules) or light blue (homogeneous cytoplasmic staining), but the interesting question is why is the sea blue when water in a glass appears colorless? Both the sky and the sea appear blue, especially on clear sunny days, because they both reflect the shorter blue wavelength of light more than the other wavelengths that constitute the visible light spectrum. Blue wavelength light also is transmitted to greater depths of the sea than are yellow, red, and green wavelengths, thus allowing its scattering and subsequent re-emission. The relative contribution of reflected skylight and the light scattered back from the depths is strongly dependent on the angle of observation and wind currents, and the various particulate matters in the water also can influence the perceived color of the sea. The Italian actress Eleanora Duse (1858-1924) said that if the sight of the blue skies fills you with joy, if the simplest things of nature have a message that you understand, rejoice, for your soul is alive. The sea-blue color in one’s histiocytes do not, per se, call for rejoicing, but one still should try to enjoy all things wonderful about life. Lawrence J. Brandt, MD Associate Editor for Focal Points
Small, duodenal, GI stromal tumor showing large, extraluminal, exophytic growth A 39-year-old woman presented to our hospital because of melena. A physical examination was unremarkable, and her hemoglobin level was 7.3 g/dL (normal 12-16 g/dL). EGD revealed an 8-mm, centrally ulcerated, bleeding, submucosal tumor in the third portion of the duodenum (A, B). Abdominal CT www.giejournal.org
showed that there also was a well-enhanced, heterogeneous, 5-cm mass at the third portion of the duodenum (C). The tumor was seen to be a hypermetabolic, soft-tissue mass by positron emission tomography. A wedge resection of the tumor was performed for diagnosis and treatment. The excised mass was Volume 72, No. 6 : 2010 GASTROINTESTINAL ENDOSCOPY
1267
At the Focal Point
an ovoid, solid, nodular, spindle cell, mesenchymal tumor measuring 5.8 ⫻ 4 ⫻ 4 cm that involved the submucosal and muscular layers of the duodenal wall (D). The tumor extended to just beneath the mucosal layer, but there was no mucosal invasion. Immunohistochemistry showed the tumor to be positive for c-kit, CD34, and smooth muscle actin but only focally positive for S-100. Only one mitotic figure was noted during a survey of 50 high-power fields. The final diagnosis was GI stromal tumor with an intermediate risk for malignant change. Follow-up on this patient is occurring on a regular basis.
DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Hang Lak Lee, MD, Young Taek Kim, MD, Yong Won Joo, MD, Department of Gastroenterology, Hanyang University College of Medicine, Seoul, Korea doi:10.1016/j.gie.2010.04.046
Commentary Only 3% to 5% of GI stromal tumors are localized in the duodenum, and they are a rare cause of upper GI bleeding. Mesenchymal tumors may present as endophytic, exophytic, or endo-exophytic growths with both intraluminal and extraluminal components; another term for the latter is “dumbbell” tumor. The term dumbbell originated in the Tudor period (1485-1603) of English history, when athletes used hand-held church bells to develop their upper bodies. Because use of the bells would have made a great deal of noise, the athletes would remove the clappers so they could practice quietly; hence the name dumb, as in “no sound,” and “bell,” in other words, dumbbell. The name has persisted to the present, even though the shape of the apparatus has changed. As for treatment, wedge resection of the duodenum bearing the dumbbell tumor is an alternative to a duodenopancreatectomy when the tumor is of low-to-intermediate risk. Lawrence J. Brandt, MD Associate Editor for Focal Points
1268 GASTROINTESTINAL ENDOSCOPY
Volume 72, No. 6 : 2010
www.giejournal.org