Case discussion

Stomach GIST

 Laki laki 44 tahun Dirujuk dari SpPD RSUD Kabupaten Recurrent Hematemesis melena & transfusi berulang Terapi dengan PPI : respon temporer Riwayat penurunan BB (-) Riwayat keganasan dalam kelg (-) Riwayat operasi sebelumnya (-)

Pemeriksaan Fisik : N Hb 9,8 g% post transfusi PRC 3 kolf USG abdomen : dbn Hasil lab & CEA : N

Usulan/rencana ?

Usulan/rencana :
Workup lab darah : koagulasi study USG CT scan abdomen pelvis dg iv intralumen contrast, CT enteroclysis Gastroscopy Colonoscopy Laparotomi ekplorasi

Usulan/rencana :
Workup lab darah : koagulasi study USG CT scan abdomen pelvis dg iv intralumen contrast, CT enteroclysis Gastroscopy Colonoscopy Laparotomi ekplorasi

 Hasil biopsi : Gastritis kronis, metaplasia (-) Helicobacter pylorii (+) Tidak didapatkan sel ganas

Langkah selanjutnya ?

Operasi ? Imaging ?

Operasi ?

Rencana operasi ?
Radikal gastrectomy Total gastrectomy deseksi limfonodi Sub total gastrectomy deseksi limfonodi Partial gastrectomy / eksisi lokal dengan batas / margin berapa cm ? ? Deseksi limfonodi

Niche

Rencana operasi ?
Radikal gastrectomy Total gastrectomy deseksi limfonodi Sub total gastrectomy deseksi limfonodi Partial gastrectomy / eksisi lokal dengan batas / margin berapa cm ? ? Deseksi limfonodi

Primary (resectable) GIST

Segmental / wedge resection to obtain negative margins is often appropriate. Lymphadenectomy is usually not required given the low incidence of nodal mets. As GIST tends to be very friable, every effort should be made not to violate the pseudocapsule of the tumor. Re-resection is generally is not indicated for microscopically positive margins on final pathology.

Hasil PA
Leiomyoma Tidak didapatkan sel ganas Batas reseksi bebas tumor

Langkah selanjutnya ?
- Watchfull waiting - Re-resection - Chemotherapy / radiasi

- Alternatif

IHC
CD 117 / Kit + 80% sesuai dg Gastrointestinal Stroma Tumor Mitosis > 50/LPB

Rencana ?

Follow up
Watchfull waiting every 3-6 mo for 5 y, then annually (Clinical CT) Re-scope Re-resection Chemotherapy

Adjuvant Imantinib
At least 36 months High risk GIST >5cm, mitosis >5/50 HPF Risk of recurrence tumor rupture, uncertain residual tumor Less frequent surveillance may be acceptable for very small tumors (<2cm)

Laki laki 48 tahun Keluhan utama : cepat kenyang 3 bulan nafsu makan berkurang dan makin lama kapasitas makan juga makin berkurang karena cepat merasa kenyang, sudah pernah dapat obat lambung tidak membaik 2 bulan terasa ada benjolan daerah uluhati yang makin membesar dg cepat Penurunan berat badan 6 kg dlm 3 bulan

Pemeriksaan fisik
Gizi kurang & tampak pucat Tidak didapatkan pembesaran limfonodi Abdomen : massa pd epigastrium 15x20cm bergerak saat nafas, berbenjol benjol, keras, nyeri tekan (-), pulsasi (-), pekak

Usulan ?

Tindakan
Gastroscopy + biopsi FNAB guided US/CT Gastrectomy TACE Paliatif, chemo radiasi

Tindakan
Gastroscopy + biopsi FNAB guided US/CT Gastrectomy TACE Paliatif diagnosa jaringan / PA

Differential diagnosa
AdenoCa gaster Lymphoma Leiomyoma ? GIST Leiomyosarcoma Neuroendokrin tumor

Unresectable, recurrent / metastatic GIST

Neoadjuvant Imatinib 400 mg daily oral for 1218 months, can increase up to 800 mg (400 mg twice daily). Just stop 1 day before surgery & continue as soon as tolerate oral intake.