Gastric GIST with progressive mitotic index

Gastrointestinal stromal tumors (GISTs) account for less than 1% of gastrointestinaltumors;they are the most common mesenchymal neoplasms of the gastrointestinal(GI) tract. GISTs areusually located in the stomach,but can occur anywhere along the gastrointestinal tract.GIST ranks third ashistology after adenocarcinomas and lymphomas among the gastrointestinal tract.Case presentation.Thepatient, aged 58 years, is transferred from the Gastroenterology Clinic with symptoms of stenosis andhemorrhage from a endophytic submucosal tumor located on the posterior gastric wall, under the eso-gastricjunction, objectified endoscopically and CT scan. Laparoscopic wedge resection was performed with threelinear Endo-GIA staplers. The evolution was favorable. After 7 months (without chemotherapy because pTNMwas T1NoMo), the patient is sent back by the gastroenterologist for „CT scan:perigastric lymphadenopathies”.The patient was operated laparoscopically converted.We found 10 tumors with typical malignant GISTs 3-10cm diameter,on the peritoneal serosa:in the right subhepatic space, perigastric, left interhepato-phrenic,hepato-gastric;these were excised R0; with simple evolution. The immuno-histo-chemical examinationspecifies the diagnosis of GIST at the first and the second operation (DOG1,CD117,CD34-positively intumor).Ki 67 was 15% in the tumor and the mitotic index <5/5 square mm at the moment of the first operationbut in the metastatic tumor at the reintervention Ki 67 was 80% and mitotic index >5/5 squaremm.Discutions.GIST tumours can be classified into low-risk and high-risk categories of recurrencedepending on size, location, capsule rupture and mitotic activity. Disseminated metastases in the abdominalcavity are the most common clinical manifestations of malignancy. Complete surgical resection isrecommended if bleeding or other symptoms are present. Tumour perforation, spontaneous or produced atthe time of surgical resection, should be recorded because it has a high negative prognostic value due toperitoneal contamination. The average survival rate in localized disease is 5 years but in metastatic orrecurrent disease is about 10-20 months. Conclusion. Complete excision of residual metastatic lesions hasbeen shown to be associated with a favourable prognosis, provided that the patient responds to imatinibtreatment; resection of tumour recurrence is accompanied by an average survival of 15 months. Gastric GISTrecurrence risk depends of localisation, tumor size, mitotic index and capsular rupture.