Hypercalcaemia in gastrointestinal stromal tumour and sarcoidosis: a case report.

BACKGROUND: Hypercalcaemia is a common manifestation of sarcoidosis but is sparingly described in gastrointestinal stromal tumours (GISTs). We describe a case of acute kidney injury and hypercalcemia resulting from simultaneous diagnosis of GIST and sarcoidosis, the presentation of which has not yet been reported. CASE PRESENTATION: A 61-year-old male presented with acute kidney injury and hypercalcemia, with elevated 1,25-dihydroxyvitamin D levels. Investigations demonstrated a large gastric antral mass which was resected and proven to be GIST. Histopathology of incidentally found liver nodules revealed non-necrotising epithelioid granulomas consistent with concomitant sarcoidosis. The hypercalcemia was successfully treated with bisphosphonate therapy, resection of the GIST and a four month course of corticosteroids, which was truncated due to a mycobacterial infection. CONCLUSIONS: Our case report is the first to describe hypercalcemia due to GIST and biopsy-proven sarcoidosis, thereby raising the possibility of a common pathophysiological pathway relating the two entities. We review the literature describing the mechanisms of hypercalcaemia in GIST and the association between GIST and sarcoidosis.

Colonic gastrointestinal stromal tumor (GIST) presenting with colocolonic intussusception: A rare case report.

An 8-year-old spayed female British bulldog was presented with vomiting, hyporexia, and large-bowel diarrhea. Abdominal ultrasound revealed a focal colonic mass with an intussusception located immediately oral to the mass. The intussusception encompassed the ascending and transverse colon and was non-reducible. Colonic resection and anastomosis were completed to include the intussusception and colonic mass. Histopathological examination of the mass demonstrated a spindle cell neoplasm arising within the muscular wall of the intussuscepted segment that obliterated normal architecture. Mild-to-moderate cytoplasmic immunoreactivity of the tumor cell population for CD117 and smooth muscle actin was consistent with a diagnosis of a gastrointestinal stromal tumor. The dog described herein remains alive and free of progressive disease at the time of writing. Key clinical message: The entire gastrointestinal tract should be evaluated in any animal with gastrointestinal symptoms. A gastrointestinal stromal tumor remains a plausible differential diagnosis, regardless of the intestinal segment affected, and tumorassociated intussusception is a rare but urgent clinical finding.

Tumeur stromale gastro-intestinale du côlon (GIST) présentant une invagination colocolique : un rapport de cas rare. Une femelle bouledogue anglais stérilisée de 8 ans a présenté des vomissements, une hyporexie et une diarrhée d'origine du gros intestin. L'échographie abdominale a révélé une masse colique focale avec une invagination située immédiatement oralement à la masse. L'intussusception englobait le côlon ascendant et transverse et était non réductible. La résection colique et l'anastomose ont été réalisées pour inclure l'intussusception et la masse colique. L'examen histopathologique de la masse a révélé un néoplasme à cellules fusiformes apparaissant dans la paroi musculaire du segment invaginé qui a oblitéré l'architecture normale. L'immunoréactivité cytoplasmique légère à modérée de la population de cellules tumorales pour le CD117 et l'actine des muscles lisses étaient compatibles avec un diagnostic de tumeur stromale gastro-intestinale. Le chien décrit ici est toujours vivant et exempt de maladie évolutive au moment de la rédaction.Message clinique clé :L'ensemble du tractus gastro-intestinal doit être évalué chez tout animal présentant des symptômes gastrointestinaux. Une tumeur stromale gastro-intestinale reste un diagnostic différentiel plausible, quel que soit le segment intestinal atteint, et l'intussusception associée à la tumeur est une constatation clinique rare mais urgente.(Traduit par Dr Serge Messier).

Rehabilitation of Social Communication Skills in Patients With Acquired Brain Injury With Intensive and Standard Group Interactive Structured Treatment: A Randomized Controlled Trial.

OBJECTIVE: To determine the efficacy of group interactive structured treatment (standard GIST) for improving social communication difficulties in a wider acquired brain injury (ABI) population compared to a waitlist control (WL). Secondary objectives were to (a) explore GIST across delivery formats by comparing the results to an intensive inpatient version of GIST (intensive GIST) and (b) compare the within-subject results for WL and intensive GIST. DESIGN: Randomized controlled trial with WL and repeated measures (pre- and posttraining, 3- and 6-month follow-ups). SETTING: Community and rehabilitation hospital. PARTICIPANTS: Forty-nine persons (27-74 years) with ABI and social communication difficulties (26.5% traumatic brain injury, 44.9% stroke, 28.6% other), minimum 12 months postinjury. INTERVENTION: Standard GIST (n=24) consisted of 12 weekly outpatient interactive group sessions (2.5 hours/session) and follow-up. Intensive GIST (n=18) consisted of 4 weeks with daily 4-hour inpatient group sessions (2 × 3 d/wk, 2 × 4 d/wk) and follow-up. MAIN OUTCOME MEASURES: La Trobe Questionnaire, a self-report questionnaire measuring social communication. Secondary measures: Social Communication Skills Questionnaire-Adapted, Goal Attainment Scale, Mind in the Eyes test, and questionnaires addressing mental and cognitive health, self-efficacy, and quality of life. RESULTS: When comparing the standard GIST and WL results, a trend of improvement was found for the main outcome, La Trobe Questionnaire, and a statistically significant improvement was found for the secondary outcome Social Communication Skills Questionnaire-Adapted. Comparing standard GIST and intensive GIST, improvement in social communication skills after both treatments was detected and maintained at 6-month follow-up. No statistically significant difference was found between groups. Goal attainment was achieved and maintained during follow-up for both standard and intensive GIST. CONCLUSIONS: Social communication skills were improved after both standard and intensive GIST, indicating that GIST can be delivered across treatment formats and to a wider ABI population.

Multiple GIST and pheochromocytoma - A rare association in neurofibromatosis type 1.

We describe a case of coexistence of multiple gastrointestinal stromal tumors (GIST) and pheochromocytoma in a 32-year-old patient with neurofibromatosis type 1. The coexistence of these two conditions in patients with this syndrome is extremely rare.

[Small intestinal hemorrhage in a patient with Neurofibromatosis type 1]. / Hemorragia de intestino delgado en un paciente con Neurofibromatosis tipo 1.

We present the case of a 32-year-old male patient with a history of Neurofibromatosis type 1, who presented with active small bowel bleeding, initially diagnosed by observing bleeding in ileoscopy, presenting with hemodynamic instability, abdominal angiotomography was performed, identifying a mass with contrast enhancement and active bleeding at the middle jejunum level, for which an angiography with arterial embolization of the branch that supplies said area is performed. With the patient stable, a double-balloon antegrade enteroscopy was performed, observing a subepithelial, ulcerated lesion, endoscopic tattooing was performed and finally surgery was sent for resection by laparoscopy. The pathology study was compatible with a jejunal gastrointestinal stromal tumor (GIST).

[A case of multiple duodenal gastrointestinal stromal tumors associated with neurofibromatosis type 1].

Gastrointestinal stromal tumors (GISTs) associated with von Recklinghausen's disease (neurofibromatosis type 1 [NF1]) have different pathogenesis and characteristics from common GISTs. Furthermore, no treatment strategy for this type of GIST has been established. This study presents the case of a 76-year-old man previously diagnosed with NF1 who was later diagnosed with GISTs. A resection of the horizontal leg of the duodenum was performed, and no recurrence was observed 18 months after the surgery.

[Metastatic brain lesion following gastrointestinal stromal tumor of the stomach complicated by coma.( A case report and literature review)]. / Metastaticheskoe porazhenie golovnogo mozga gastrointestinal'noi stromal'noi opukhol'yu zheludka, oslozhnivsheesya razvitiem komatoznogo sostoyaniya. (Opisanie sluchaya i obzor literatury).

The authors present an extremely rare case of metastatic brain lesion in a patient with gastrointestinal stromal tumor of the stomach. There are literature data on 23 cases of metastatic lesions of the brain, skull and soft tissues of the head in similar patients. Atypical localization of metastases can lead to some diagnostic difficulties, unreasonable cancellation of chemotherapy and delayed surgical treatment. A feature of our observation was postoperative coma determined by the features of the underlying disease.

Sarcopenia as a novel prognostic factor in the patients of primary localized gastrointestinal stromal tumor.

BACKGROUND: Sarcopenia predicts poor prognosis of a variety of gastrointestinal malignancies. However, there is a lack of study on the association between skeletal muscle index (SMI) and the prognosis of gastrointestinal stromal tumor (GIST). The aim of this study is to develop a novel nomogram based on sarcopenia for GIST patients to predict overall survival (OS). METHODS: SMI was measured by computed tomography scan of 107 patients who underwent resection for primary localized gastrointestinal stromal tumor (GIST). Sarcopenia was defined by cutoff values for SMI as 40.1 cm2/m2 and 39.8 cm2/m2 using optimum stratification for males and females respectively. Factors were included in the nomogram were specified by univariate and multiple Cox proportional hazard analysis. Concordance index (C-index) and calibration curves were conducted to measure the discrimination and accuracy of the nomogram. The utility of the nomogram was assessed by the decision curve analysis (DCA). RESULTS: Twenty-eight (26.2%) of 107 patients were sarcopenic. Sarcopenia was correlated significantly with body mass index, albumin, female sex, resection style, mitotic index, rupture status, survival. Sarcopenia was significantly related to decreased overall survival (p = 0.003).The nomogram including sarcopenia status, resection style and mitotic index had an excellent discrimination with C-index 0.794. The calibration curves represented a good accordance between the actual observation and nomogram prediction for overall survival. Decision curve analysis illustrated that the nomogram was helpful in clinic. CONCLUSIONS: We developed a nomogram based on sarcopenia to predict overall survival after resection of GISTs which is an effective and favorable prognostication tool.

Minimal change disease associated with gastrointestinal stromal tumor accompanied by significantly elevated serum IgE level: a case report.

BACKGROUND: Minimal change disease (MCD) is a common cause of the nephrotic syndrome. Several studies have shown an increased incidence of cancer in patients with MCD. However, there are no reports on the association between MCD and gastrointestinal stromal tumor (GIST). CASE PRESENTATION: We report a case of a 66-year-old female with severe nephrotic syndrome and concomitant duodenal GIST. Immunoglobulin test showed a significant increase of IgE levels. The diagnosis of renal histopathology was MCD with subacute tubulointerstitial injury. The combination of preoperative Imatinib mesylate chemotherapy and tumor excision was accompanied by significant remission of proteinuria, and IgE level decreasing, without immunosuppressivetherapy. CONCLUSIONS: It is the first case report that MCD was associated with GIST and elevated IgE level. Clinically, in patients with elevated IgE level associated with nephrotic syndrome, the possibility of tumor must be taken into account when allergic factors are excluded.

A Rare Case of Multiple Gastrointestinal Stromal Tumors Coexisting with a Rectal Adenocarcinoma in a Patient with Attenuated Familial Adenomatous Polyposis Syndrome and a Mini Review of the Literature.

BACKGROUND: Multiple gastrointestinal stromal tumors (GISTs) are extremely rare entities that exist either as spontaneous GISTs or as part of various syndromes, such as Carney's triad and type I neurofibromatosis (NF1). Attenuated familial adenomatous polyposis (AFAP) is a variant of familial adenomatous polyposis (FAP) with a milder clinical presentation. Both GISTs and AFAP have been reported to coexist with colorectal cancer, but the coexistence of GISTs and AFAP has never been reported in the literature before. CASE REPORT: A 45-year-old male patient with known AFAP arrived scheduled for a total colectomy and ileo-rectal anastomosis due to the malignancy of one of the previously biopsied polyps of the upper rectum. Intraoperatively, multiple nodular tumors were found at the jejunum within a length of 45 cm, for which an enterectomy and enteroanastomosis were performed. A histopathological examination of the whole colectomy specimen confirmed the presence of multiple polyps in the large intestine along with a rectal invasive adenocarcinoma. At the same time, in the examined part of the small intestine, 15 GISTs sized from 0.5 to 2.0 cm of prognostic group I, were identified. The patient's postoperative course was uncomplicated. CONCLUSION: Multiple GISTs may present as an asymptomatic disease, and the same thing is true for colorectal cancer. Therefore, the appropriate screening is crucial for entities such as AFAP, since the surgery was performed because of the malignant transformation in one of the polyps and revealed multiple GISTs, as well.

[Jejunal stromal tumor concomitant ectopic pancreas in a young man with sarcoidosis:a case report].

During a medical health check, a 29-year-old man was presented to our hospital with iron deficiency anemia. He had no significant medical history in his family. Despite being diagnosed with ocular sarcoidosis 5 years ago, he had no vision problems. Physical examination revealed normal vital signs and a nontender abdomen;however, his eyelid conjuvitis was pale, and he became aware of fatigue when moving vigorously. He had upper gastrointestinal endoscopy and colonoscopy, but there was no evidence of bleeding detected. A contrasted mass 30mm in size was discovered on abdominal contrast-enhanced computed tomography at the dorsal wall of the proximal jejunum. Positron emission tomography showed an accumulation image in the bilateral hilar lymph and upper jejunum. A 30-mm submucosal tumor with a central depression in the upper jejunum was discovered using a double-balloon enteroscopy. We performed biopsies from the depression margin and tattoo marking on the oral side of the tumor. Even though the biopsies specimen revealed granulation tissue, the patient was referred to surgery and underwent a partial jejunum resection because the tumor was diagnosed as the cause of anemia. The operation went smoothly, and the patient was discharged on the seventh postoperative day. Histological examination showed a proliferation of densely packed spindle cells with prominent nuclear palisading. The immunohistochemical examination revealed that c-kit and CD34 were highly expressed, whereas desmin and S-100 proteins were not. Ki-67 expression demonstrated a very low proliferative index (2%). We discovered gastrointestinal stromal tumors (GIST), as well as an ectopic pancreas. GIST is extremely rare in young people, and the coexistence of ectopic pancreas and sarcoidosis has never been reported.

Imatinib-induced pancreatic hypertrophy in patients with gastrointestinal stromal tumor: Association with overall survival.

OBJECTIVES: To investigate the frequency of imatinib-induced pancreatic complications and determine whether these are survival prognostic factors in patients with gastrointestinal stromal tumor (GIST). METHODS: This retrospective multicenter study included patients with histopathologically diagnosed GIST treated with imatinib who underwent computed tomography (CT) within 100 days before (pretreatment CT) and 500 days after (post-treatment CT) imatinib initiation (January 2004-December 2019). Forty-eight patients (63.0 ± 12.1 years, 30 men) were included. Two blinded radiologists independently measured pancreatic volumes. Pancreatic volume on pretreatment CT was compared with that of the control (within 1 year prior to pretreatment CT) and the first two post-treatment CTs using paired t-tests. Thresholds for pancreatic hypertrophy and atrophy were defined using a log-rank test. The prognostic importance of pancreatic hypertrophy was further analyzed using multivariate Cox proportional hazard regression models. RESULTS: Pancreatic volume was significantly higher for the first post-treatment CT than pretreatment CT (71.5 cm3 vs. 67.4 cm3, P = .027), whereas no significant difference was observed between the pretreatment and control CTs. Optimal thresholds for pancreatic hypertrophy and atrophy were defined as an 22% increase and 30% decrease and found in 20 and three patients, respectively. Pancreatic hypertrophy was significantly associated with reduced survival [hazard ratio = 2.9 (95% confidence interval, 1.3-6.5), P = .0088]. No patients showed serum lipase elevation, nor were they suspected of having acute pancreatitis. CONCLUSION: There was frequent asymptomatic pancreatic swelling in patients with GIST after imatinib treatment, and a ≥22% increase in pancreatic volume was a predictor of reduced survival.

Clinical outcomes of tumor bleeding in duodenal gastrointestinal stromal tumors: a 20-year single-center experience.

BACKGROUND: Duodenal gastrointestinal stromal tumors (GISTs) are rare, and reports on duodenal GIST bleeding are few. We analyzed the risk factors and clinical outcomes of hemorrhagic duodenal GISTs and compared them with those of gastric GISTs. METHODS: Primary duodenal GISTs surgically diagnosed between January 1998 and December 2017 were retrospectively reviewed. Furthermore, patients with duodenal GIST were compared with those with primary gastric GIST histopathologically diagnosed between January 1998 and May 2015 using previously published data. RESULTS: Of the 170 total patients with duodenal GISTs, 48 (28.2%) exhibited tumor bleeding. Endoscopic intervention, embolization, and non-interventional conservative treatment were performed for initial hemostasis in 17, 1, and 30 patients, respectively. The 5-year survival rate was 81.9% in the bleeding group and 89.4% in the non-bleeding group (P = 0.495). Multivariate analysis showed that p53 positivity was a significant risk factor for duodenal GIST bleeding (hazard ratio [HR] 2.781, P = 0.012), and age ≥ 60 years (HR 3.163, P = 0.027), a large maximum diameter (comparing four groups: < 2, 2-5, 5-10, and ≥ 10 cm), and mitotic count ≥ 5/high-power field (HPF) (HR 3.265, P = 0.032) were risk factors for overall survival. The incidence of bleeding was significantly higher in duodenal GISTs than in gastric GISTs (28.2% vs. 6.6%, P < 0.001), and the re-bleeding rate after endoscopic hemostasis was also higher in duodenal GISTs than in gastric GISTs (41.2% vs. 13.3%, P = 0.118). CONCLUSION: In patients with duodenal GIST with old age, large tumor diameter, and mitotic count ≥ 5/HPF, a treatment plan should be established in consideration of the poor prognosis, although tumor bleeding does not adversely affect the prognosis. Duodenal GISTs have a higher incidence of tumor bleeding and re-bleeding rate after endoscopic hemostasis than gastric GISTs.

The Incidence of Gastrointestinal Stromal Tumors in Obese Patients-A Large Single Center Experience.

Background and Objectives: Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms located mainly in the fundus (60-70%). The incidence of GIST is approximately 10 per million population per year in Europe, with a peak incidence at the age of 63. Recent studies suggest that morbidly obese patients have a higher incidence of GIST than the general population. The aim of this study was to analyze the incidence of GIST in patients undergoing laparoscopic sleeve gastrectomy (LSG) in our department. Materials and Methods: this paper present the retrospective study of prospectively collected data of 1564 patients who underwent LSG in a single large bariatric center from October 2013 to September 2021. After surgery, each sample of the resected stomach was sent for histopathological examination. For the analysis, we included patients diagnosed with GIST intraoperatively or postoperatively. Results: GISTs were found in five patients (0.31%). There were three men and two women. The mean age was 50.2 (range 32-63 ± 11.8) and the mean preoperative body mass index was 43.3 kg/m2 (40-49.4 ± 3.2). In four cases, GISTs were found in the fundus (80%), and in one in the pylorus (20%). None of the tumors were larger than 7 mm in diameter and all were diagnosed as a very low-risk category. No adjuvant treatment was required. All patients achieved good or satisfactory bariatric and metabolic results. Conclusions: The incidence of GIST in our study was estimated at 0.31%. All patients had a very low-risk GIST and no recurrence until follow-up. Recent literature suggests that the risk of GIST is higher in the obese population, and therefore surgeons should be aware of the risk of incidental GIST during LSG.

[A Case of Multiple Small Bowel GIST Complicated with von Recklinghausen's Disease].

The case was a 55-year-old woman. She have been pointed out von Recklinghausen's disease for several years. She was referred to our hospital due to multiple abdominal tumor and severe anemia. Enhanced CT examination revealed multiple intraabdominal tumors with central necrosis. The tumors diagnosed mesenchymal tumors associated with von Recklinghausen's disease, and tumor resection was indicated under laparotomy. Tumors were resected together with small and large bowel. The tumor in the pelvic space was resected together with the uterus and right ureter. She was discharged without any postoperative complications at 15 days after the operation. Because immunostaining was positive for CD34, c-kit and DOG1 and Ki-67-positive cells were 18%, the tumors were diagnosed with high-risk GIST for small bowel.

A case of insulin-like growth factor 2-producing gastrointestinal stromal tumor with severe hypoglycemia.

BACKGROUND: Non-islet cell tumor hypoglycemia (NICTH) is a rare paraneoplastic syndrome that secretes incompletely processed high molecular weight insulin growth factor 2 (big-IGF2), which results in stimulation of the insulin receptor and subsequently induces hypoglycemia. Gastrointestinal stromal tumor (GIST) is a common intestinal mesenchymal neoplasm of the gastrointestinal tract. The most frequent site of GIST is the stomach; NICTH induced by IGF2-producing stomach GISTs is rare. CASE PRESENTATION: An 84-year-old man was admitted to the hospital due to impaired consciousness (JCS II-10) in the morning. At the time of admission, his serum glucose was 44 mg/dL; his consciousness was restored with 20 ml of 50% glucose. To avoid hypoglycemia, a continuous intravenous infusion of glucose as well as dietary intervention was required. At the time of hypoglycemia, the levels of insulin and C-peptide were suppressed. Additionally, IGF1 levels were below the normal range. Abdominal computed tomography revealed that he had a large lobulated mass (116 × 70 × 72 mm) around the gastric corpus. Pathological analysis of biopsy specimens identified disarray of spindle cells and positivity for c-kit as well as strong positivity for DOG-1. Further analysis revealed high levels of Ki-67 (Mib-1 index: 15.5%) and mitotic index (7/50HPF); the tumor was diagnosed as high-risk GIST, and complete surgical resection was performed. Hypoglycemia resolved immediately after tumor resection. The resected tumor specimen was positive for IGF2 staining, and big-IGF2 (11-18 kDa) was detected in preoperative serum and tumor samples; the patient was diagnosed with NICTH due to an IGF2-producing tumor. CONCLUSIONS: NICTH is rare in GIST of the stomach; however, the large GIST could produce big-IGF2 and subsequently cause severe hypoglycemia, requiring prompt evaluation and complete tumor resection.

Clinical outcomes of upper gastrointestinal bleeding in patients with gastric gastrointestinal stromal tumor.

BACKGROUND: Upper gastrointestinal bleeding (UGIB) is one of the major manifestations of gastrointestinal stromal tumor (GIST) of the stomach. Several studies have reported that GIST bleeding is associated with poor prognosis. However, only case reports have reported hemostasis modalities for treating hemorrhagic gastric GIST. To identify clinical outcome of gastric GIST bleeding, we analyzed risk factors and prognosis of hemorrhagic GIST evaluating hemostasis methods. METHODS: Total 697 patients histopathologically diagnosed with primary gastric GIST between January 1998 and May 2015 were enrolled to the study, retrospectively. RESULTS: Of 697 total patients, 46 (6.6%) patients had UGIB. Endoscopic intervention, transarterial embolization, or surgical intervention was performed for initial hemostasis in 15, 2, and 1, respectively. Over a median of 68 months of follow-up, 16 patients in bleeding group and 88 patients in non-bleeding group died; the 5-year survival rate was 79.4% in bleeding group and 91.8% in non-bleeding group (p = 0.004). Multivariate analysis showed that significant risk factors for gastric GIST bleeding included the maximal tumor diameter > 5 cm and Ki-67 positivity. Age ≥ 60 [hazard ratio (HR) = 8.124, p = 0.048], necrosis (HR = 5.093, p = 0.027), and bleeding (HR 5.743, p = 0.034) were significant factors for overall survival of gastric GIST patients. CONCLUSIONS: Bleeding risk of gastric GIST was higher when tumor had diameter > 5 cm or Ki-67 positivity. In addition, tumor bleeding, necrosis, and age ≥ 60 years were associated with poor overall survival. Endoscopic intervention can be considered as an effective method for initial hemostasis of hemorrhagic gastric GIST.

Coexistence of Von Willebrand disease and gastrointestinal stromal tumor (G.I.S.T): Case report of a rare and challenge association.

Von Willebrand disease (VWD) is the most common inherited bleeding disorder and is caused by a quantitative (type 1 and 3) or qualitative (type 2) defect of Von Willebrand factor (VWF). Bleeding from the gastrointestinal (GI) tract is not uncommon in VWD and is usually associated with angiodysplasia. We report herein on the management of a patient affected by VWD2B with severe GI bleeding secondary to gastrointestinal stromal tumor (GIST) complicated by deep vein thrombosis (DVT). The current case demonstrated that the hemostatic balance, in RBDs under specific circumstances, can range from a tendency toward a hemorrhagic to normal or prothrombotic state. In these patients, a close collaboration between hematologists and surgeons can guarantee appropriate management in high-risk clinical scenarios.

Early gastric cancer with three gastric gastrointestinal stromal tumors combined with synchronous colon cancer: a case report.

BACKGROUND: There have been very few reports of patients with early gastric cancer (EGC) and colorectal cancer combined with gastric gastrointestinal stromal tumors (GISTs). CASE PRESENTATION: We report the case of a patient with multiple tumors that were found at the same time in the abdomen. The patient was a 77-year-old man who was referred for a gastric GIST. Esophagogastroduodenoscopy showed the known lesion (a gastric GIST) on the lesser curvature of the upper body and a new lesion on the lesser curvature of the lower body of the stomach with suspicion of EGC. Computed tomography findings confirmed the presence of a GIST in the stomach and revealed two new lesions. One of these lesions was suspected to be a 4-cm submucosal tumor on the anterior wall of the upper body of the stomach. The other was a wall thickening of the descending colon that demonstrated the possibility of malignancy. Synchronous colon cancer was confirmed on colonoscopy. Laparoscopic near-total gastrectomy with D1+ lymph node dissection and left hemicolectomy were performed sequentially without significant events. The patient was discharged without any postoperative complications. CONCLUSIONS: We reported a rare case of EGC with multiple gastric GISTs combined with synchronous colon cancer.

Pemphigus foliaceus in a patient with gastrointestinal stromal tumor treated with adjuvant imatinib mesylate.

Pemphigus is an autoimmune bullous disease with a number of described associations, including medications, which have been grouped into three structural categories - thiol drugs, phenol drugs, and drugs with neither functional group [1]. Discontinuation of the offending medication is considered a mainstay of therapy. We report a patient in whom the onset of pemphigus foliaceus was associated with initiation of imatinib mesylate adjuvant therapy in a patient with resected gastrointestinal stromal tumor (GIST). Imatinib was continued because of the survival benefit to the patient with a resected, high risk GIST. Treatment with rituximab resulted in near resolution of his blistering rash and follow up enzyme-linked immunosorbent assay (ELISA) demonstrated reference range immunoreactivity for both desmoglein 1 and desmoglein 3. After dose increase of imatinib therapy owing to tumor growth, the patient subsequently again developed a similar eruption. Re-biopsy and ELISA were consistent with recurrence of pemphigus. In conclusion, although the patient's pemphigus was cleared with a single cycle of rituximab infusions while continuing imatinib therapy, the disease returned after imatinib dose was increased a year later, suggesting a dose-response relationship.