A previously healthy 77-year-old woman presented with a 2-month history of anorexia,
fever, and weight loss. On physical examination, she had diminished breath sounds
in the lower two-thirds of the left hemithorax; her chest radiograph revealed a left
pleural effusion ([Fig. 1]). Laboratory work-up showed a hemoglobin of 9.6 g/dL, C-reactive protein (CRP) of
9.5 mg/dL, and erythrocyte sedimentation rate (ESR) of 70 mm/hour. Because of a family
history of pulmonary tuberculosis, a tuberculous pleural effusion was suspected.
Fig. 1 Chest radiograph in a 77-year-old woman with a 2-month history of anorexia, fever,
and weight loss showing a left pleural effusion.
A thoracentesis and pleural biopsy were performed, which revealed clear pleural fluid
with the characteristics of an exudate, without malignant cells. A thoracic contrast-enhanced
computed tomography (CT) scan incidentally showed a large gastric mass, with no fistulous
tract to the pleura. Upper gastrointestinal endoscopy showed a bilobed mass of 5 cm
in the posterior aspect of the gastric fundus that was spontaneously discharging a
large amount of purulent material from a small central orifice ([Fig. 2]; [Video 1]). For better characterization and staging, an abdominopelvic contrast-enhanced CT
was performed, which showed a mass of 14 × 12 × 11 cm, with central necrosis, originating
in the posterior gastric wall and in contact with the spleen, suggestive of a gastrointestinal
stromal tumor (GIST) complicated by an abscess ([Fig. 3]). No nodal or distant metastases were seen.
Fig. 2 Images from upper gastrointestinal endoscopy showing a bilobed mass of 5 cm in the
posterior aspect of the gastric fundus that was spontaneously discharging a large
amount of purulent material from a small central orifice.
Upper gastrointestinal endoscopy showing a bilobed mass of 5 cm in the posterior
aspect of the gastric fundus that was spontaneously discharging a large amount of
purulent material from a small central orifice.
Fig. 3 Abdominal contrast-enhanced computed tomography (CT) scan showing a mass of 14 × 12 × 11 cm,
with central necrosis, originating in the posterior gastric wall and in contact with
the spleen, suggestive of a gastrointestinal stromal tumor (GIST) complicated by an
abscess.
Forceps biopsies of the mass were inconclusive and no infectious agent was isolated
in either pleural or gastric fluids, including from culture for Mycobacterium tuberculosis. The patient was put on antibiotics and an urgent surgical approach was planned.
A superior polar gastrectomy and splenectomy were performed, with histology showing
a high grade gastric GIST (positive on immunostaining for CD34, CD117, and DOG1, with
< 5 mitosis/50 high power fields [hpf], and Ki-67 20/50 hpf) with negative surgical
margins. The patient was started on adjuvant therapy with imatinib.
Very few cases of gastric GIST complicated by an abscess have been reported in the
literature [1]
[2]
[3]
[4]
[5]. To the best of our knowledge, this is the first case presenting with a large pleural
effusion.
Endoscopy_UCTN_Code_CCL_1AB_2AD_3AB
