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Brief HistoryBrief History
�� Identification : Identification :
–– Name : Name : 陳陳x x -- Admission : 94/10/06Admission : 94/10/06
–– Gender : maleGender : male
–– Age : 75 y/o Age : 75 y/o
ChiefChief Complaint : Complaint :
–– Urinary difficulty for months.Urinary difficulty for months.
�� Past History : HTN without regular treatment.Past History : HTN without regular treatment.
Brief HistoryBrief History
�� Lower urinary tract symptoms for months, Lower urinary tract symptoms for months,
diagnosed of BPH, under medical treatment diagnosed of BPH, under medical treatment
at at 三總三總 Hospital.Hospital.
�� PSA checked at PSA checked at 三總三總 H. : 2.0 H. : 2.0 ngng/dl (< 4.0)/dl (< 4.0)
�� Acute urinary retention few days ago.Acute urinary retention few days ago.
�� Admitted on 94/10/06 to receive TURP. Admitted on 94/10/06 to receive TURP.
�� 10/07 : TURP10/07 : TURP
Brief HistoryBrief History
�� Pathology : Pathology :
–– Spindle cell with Spindle cell with hyperchromatichyperchromatic and and pleomorphicpleomorphic nucleus.nucleus.
–– Common with mitotic figures.Common with mitotic figures.
–– VimentinVimentin (+), CK ((+), CK (--), PSA(), PSA(--), ER (), ER (--), PR (), PR (--))
–– Pathologic Diagnosis : SarcomaPathologic Diagnosis : Sarcoma
�� 10/25 : Abdominal and pelvic CT10/25 : Abdominal and pelvic CT
–– No LN or visceral organ involved but local No LN or visceral organ involved but local invasion to rectum cannot be ruled out.invasion to rectum cannot be ruled out.
Brief HistoryBrief History
�� 11/03 : Bone scan11/03 : Bone scan
–– Left ileum bone metastasis was suspected.Left ileum bone metastasis was suspected.
(trauma to left side body 3 months ago)(trauma to left side body 3 months ago)
�� 11/10 : Colonoscopy11/10 : Colonoscopy
–– Biopsy x 5 : Biopsy x 5 : AdenomatousAdenomatous Polyps.Polyps.
�� 11/14 : MRI11/14 : MRI
–– Tumor invades rectum (+)Tumor invades rectum (+)
–– Left iliac wing fracture (+)Left iliac wing fracture (+)
Laboratory DataLaboratory Data
�� PrePre--OP PSA (at OP PSA (at 三總三總) : 2.0 ) : 2.0 ngng/dl/dl
�� 10/06 (admission)10/06 (admission)
–– U/AU/A
–– Glucose : 113 mg/dlGlucose : 113 mg/dl
22--448080--90903+3++/+/--
WBCWBCRBCRBCOBOBProteinProtein
ImagingImaging
�� Abdominal and pelvic CT : (94/10/25)Abdominal and pelvic CT : (94/10/25)
Encapsulated
prostate
mass
Heterogeneous
enhancement
T2W T2W
FSE FSE
sagitalsagital
6.7x5.6x5.5 cm
heterogeneous
enhancement
Suspect
extracapsule
extension
T1W T1W
FSPGR FSPGR
coronalcoronal
Low signal
intensity
prostatic
mass
T2W T2W
FSE FSE
coronalcoronal
High signal
Intensity
prostatic mass
with focal
low attenuation
T1W T1W
FSPGR FSPGR
axialaxial
R/O rectum
invasion
T2WT2W
FSEFSE
AxialAxial
Heterogenous
Appearance —
High intensity
With focal
Low intensity
Differential DiagnosisDifferential Diagnosis
�� Prostate Prostate adenocarcinomaadenocarcinoma
–– TRU : TRU : hypoechoichypoechoic in the peripheral zone.in the peripheral zone.
–– MRI : MRI :
�� T1W T1W -- No No intraprostaticintraprostatic pathology is displayed pathology is displayed
�� T2W T2W -- Low signal intensity in the hyperintense Low signal intensity in the hyperintense
peripheral zone peripheral zone
�� ComedocarcinomaComedocarcinoma
–– TRU TRU ---- hypoechoichypoechoic lesions that contained lesions that contained
multiple small multiple small hyperechoichyperechoic foci.foci.
�� MucinousMucinous CarcinomaCarcinoma
–– The size of the gland lumens is increasedThe size of the gland lumens is increased
–– Mucoid secretions raised the overall T2 signal.Mucoid secretions raised the overall T2 signal.
�� SquamousSquamous CarcinomaCarcinoma
–– bony metastases are usually bony metastases are usually osteolyticosteolytic
�� RhabdomyosarcomaRhabdomyosarcoma ––
CT CT ––
Heterogeneous attenuation. Invasion. Heterogeneous attenuation. Invasion.
Calcification is rareCalcification is rare
MRI MRI ––
Tumor from central area of the prostate.Tumor from central area of the prostate.
Enhance heterogeneouslyEnhance heterogeneously
T2W : wellT2W : well--defined lowdefined low--signalsignal--intensity intensity
pseudocapsulepseudocapsule
�� CystosarcomaCystosarcoma PhyllodesPhyllodes
–– Cystic spaces within the tumorCystic spaces within the tumor
–– A large, relatively noninvasive A large, relatively noninvasive prostaticprostatic massmass
�� Malignant LymphomaMalignant Lymphoma
–– US US ---- large large hypoechoichypoechoic masses within both the masses within both the
central and peripheral zones in a young man.central and peripheral zones in a young man.
–– CT CT ---- homogeneous soft tissue masses.homogeneous soft tissue masses.
–– MRI MRI ---- involvement of the bone marrow involvement of the bone marrow
�� Prostate AbscessProstate Abscess
–– TRU : TRU : �� HypoechoicHypoechoic zone with zone with septationseptation or internal echoes at or internal echoes at
TZ.TZ.
�� Less easily definable during initial phases.Less easily definable during initial phases.
�� Occasional Occasional perilesionalperilesional halo.halo.
�� High High perilesionalperilesional vascularityvascularity detect by Doppler.detect by Doppler.
–– CT : CT : �� Single of multiple Single of multiple hypointensityhypointensity lesion.lesion.
�� PerilesionalPerilesional hyperintensityhyperintensity..
Surgical TreatmentSurgical Treatment
�� 94/12/09 : LPS radical 94/12/09 : LPS radical prostectomyprostectomy
(No rectum involvement)(No rectum involvement)
�� Pathology : Pathology :
–– spindle cells with mild to moderate spindle cells with mild to moderate pleomorphismpleomorphism, ,
frequent mitoses, and prominent tumor necrosis. frequent mitoses, and prominent tumor necrosis.
–– vimentinvimentin (strongly +), CD34 (strongly +), CD117 (strongly +), CD34 (strongly +), CD117
(strongly +), smooth muscle (strongly +), smooth muscle actinactin (weakly +), S(weakly +), S--100 (100 (--), ),
CK (CK (--), PSA (), PSA (--), PR (), PR (--), ER (), ER (--).).
–– Pathology diagnosis : GIST (more favor) or Pathology diagnosis : GIST (more favor) or ProstaticProstatic
stromalstromal sarcoma.sarcoma.
DiscussionDiscussion
GISTsGISTs
Gastrointestinal Gastrointestinal StromalStromal TumorsTumors
IntroductionIntroduction
� The most common mesenchymal neoplasm of the gastrointestinal tract
� From primitive stem cells resemble the native KIT-positive gut pacemaker cell or interstitial cell of Cajal.
� Expression of KIT (CD117), a tyrosine kinasegrowth factor receptor.
� KIT is important to distinguish GISTs from other mesenchymal neoplasms such as leiomyomas, leiomyosarcomas, schwannomas, and neurofibromas.
IntroductionIntroduction
Am J Surg Pathol 1999; 23:82–87
IntroductionIntroduction
Am J Surg Pathol 1999; 23:82–87
GISTsGISTs from Prostatefrom Prostate
–– Case report : Case report : Urology. 2005 Feb;65(2):388Urology. 2005 Feb;65(2):388
�� Clinical presentation : Clinical presentation :
–– 49 y/o man with acute urinary retention49 y/o man with acute urinary retention
–– One transient episode of One transient episode of dysuriadysuria
–– Lost 5 kg in 1monthLost 5 kg in 1month.
GISTsGISTs from Prostatefrom Prostate
�� Laboratory tests : Laboratory tests :
–– Elevated white blood cell count and CRP. Elevated white blood cell count and CRP.
–– All other values were normal.All other values were normal.
–– ProstateProstate--specific antigen was 1.36 specific antigen was 1.36 ng/mLng/mL
GISTsGISTs from Prostatefrom Prostate
�� Imaging : Imaging :
–– TRU : TRU :
�� solid mass with focal liquefaction in prostatesolid mass with focal liquefaction in prostate
�� Mass was isolated from surrounding structures.Mass was isolated from surrounding structures.
–– CT & MRI: CT & MRI:
�� The mass not involved the surrounding structures.The mass not involved the surrounding structures.
�� Multiple liver metastasis.Multiple liver metastasis.
GISTsGISTs from Prostatefrom Prostate
Well-defined
Encapsulated
Prostatic tumor
GISTsGISTs from Prostatefrom Prostate
Huge heterogenous
mass Compressing
Bladder anteriorly
And rectum
posteriorly
Imaging of Imaging of stomochstomoch GISTGIST
�� CTCT
–– SubdiaphragmaticSubdiaphragmatic cavitarycavitary mass of heterogeneous mass of heterogeneous attenuation. The cavity (attenuation. The cavity (**) is air) is air--filled. Liver meta (+)filled. Liver meta (+)
Imaging of Imaging of stomochstomoch GISTGIST
�� CTCT
–– Central areas of low attenuation correspond to Central areas of low attenuation correspond to hemorrhage, necrosis, or cyst formationhemorrhage, necrosis, or cyst formation
Imaging of Imaging of stomochstomoch GISTGIST
�� MRIMRI
–– Low signal intensity on T1Low signal intensity on T1--weighted images,weighted images,
–– High signal intensity on T2High signal intensity on T2--weighted images,weighted images,
–– Enhance after administration of gadolinium.Enhance after administration of gadolinium.
–– Hemorrhage within tumor vary from high to low Hemorrhage within tumor vary from high to low signal intensity on both T1W and T2W images, signal intensity on both T1W and T2W images, depending on the age of the hemorrhagedepending on the age of the hemorrhage..
–– MRI is useful in determining the organ of origin MRI is useful in determining the organ of origin and the relationship of the tumor to other organs and the relationship of the tumor to other organs and major blood vessels.and major blood vessels.
Imaging of Imaging of stomochstomoch GISTGIST
�� MRIMRI
–– Focal high signal intensity within mass Focal high signal intensity within mass ---- hemorrhage hemorrhage (arrow).(arrow).
Treatment of GISTTreatment of GIST
�� Surgical resection for the primary diseaseSurgical resection for the primary disease
�� Conventional systemic and Conventional systemic and intraperitonealintraperitoneal
chemotherapy, arterial chemotherapy, arterial chemoembolizationchemoembolization, ,
surgery, and irradiation have been ineffective in surgery, and irradiation have been ineffective in
treating treating metastaticmetastatic and recurrent disease.and recurrent disease.
�� ImatinibImatinib (STI(STI--571, 571, GleevecGleevec) targets the overactive ) targets the overactive
tyrosine receptor ctyrosine receptor c--kit found on all GIST cells, kit found on all GIST cells,
leading regression of leading regression of metastaticmetastatic lesions.lesions.
Prognosis factorPrognosis factor
� Tumor size
� Mitotic rate
� Anatomic site
(best : esophagus ; worse : small bowel)
�� Recurrence indicated poor prognosisRecurrence indicated poor prognosis
But aBut a small number of GISTs recur or metastasize despite a histologically benign appearance (ie, small size and absence of mitoses or low mitotic rate).
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�� Imaging of Gastrointestinal Imaging of Gastrointestinal StromalStromal Tumors.Tumors. J J
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