J Gastrointestin Liver Dis June 2008 Vol.17 No 2, 213-215 Address for correspondence: Nikolaos S. Salemis, MD, PhD 2nd Dept Surgery 417 Army Vet Gen Hospital Athens, Greece Email: nikos_salemis@hotmail.com Synchronous Occurrence of Advanced Adenocarcinoma with a Stromal Tumor in the Stomach: A Case Report Nikolaos S. Salemis 1,2 , Stavros Gourgiotis 2 , Evangelos Tsiambas 3 , Andreas Karameris 3 , Efstathios Tsohataridis 1 1) 2nd Department of Surgery, 417 Army Veterans General Hospital NIMTS; 2) 2nd Department of Surgery Army General Hospital; 3) Department of Pathology, 417 Army Veterans General Hospital NIMTS, Athens, Greece Abstract Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms of the digestive tract. Synchronous occurrence of a gastrointestinal stromal tumor with a tumor of different histogenesis is very rare and has been documented in the literature mainly in case reports. We present the case of a 78-year old female patient who underwent surgery for an advanced gastric carcinoma during which a gastric stromal tumor was incidentally discovered. A review of the literature is also conducted on the extremely rare synchronous occurrence of malignant tumors of different histogenesis in the stomach. Key Words Gastric adenocarcinoma – gastrointestinal stromal tumor – synchronous occurrence Introduction Gastrointestinal stromal tumors (GISTs) are the most common non epithelial tumors of the digestive tract, accounting for only 1% of all gastrointestinal malignancies [1,2] and for 5.7 % of all sarcomas [3]. They strongly express the KIT (CD117) protein, a type III tyrosine kinase receptor encoded by the c-kit proto-ongogene [4-6]. GISTs have been reported in the literature to coexist with tumors of different histogenesis such as adenocarcinomas, carcinoids, MALT lymphomas and Burkitt’s lymphomas [7-11], as well as with different mesenchymal tumors [12-15]. This paper reports a rare synchronous occurrence of a stromal tumor with an advanced adenocarcinoma in the stomach, in a 78 year old female. Case presentation A 78 year old female was admitted to our department complaining of a progressively worsening epigastric pain of three weeks duration, nausea and vomiting. She also complained of an 8 kg weight loss during the last two months prior to admission. She did not have any significant medical history. On clinical examination a mild upper abdominal tenderness was apparent and a small mass was palpated in the epigastrium. Blood count test revealed anemia, while liver function tests and serum electrolytes were normal. Chest and abdominal X-rays were unremarkable, while abdominal CT scan showed thickening of the gastric wall. Esophagogastroduodenoscopy revealed an ulcerative mass in the gastric antrum measuring approximately 5cm x 6cm, located 4cm proximally to the pylorus. Histological examination of the biopsies revealed fragments of a poorly differentiated intestinal type gastric adenocarcinoma. An exploratory laparotomy followed and the patient underwent total gastrectomy with esophagojejunal Roux- en-Y reconstruction and splenectomy. During gastrectomy a well defined nodular lesion measuring 1cm was palpated 3cm proximally to the adenocarcinoma in the lesser curvature. Histological examination of the whole resected stomach confirmed the presence of a poorly differentiated intestinal type adenocarcinoma located in the antrum measuring 6.5cm x 5.5cm (Fig. 1). The tumor was infiltrating the full thickness of the gastric wall and extended to the serosal fat of the lesser curvature. Five of the 15 resected lymph nodes were found to contain metastases. Histologically, the second lesion of 1cm diameter consisted of spindle to ovoid-shaped mesenchymal cells arranged in interlacing bundles or sheets. Those cells demonstrated cyanophilic or eosinophilic cytoplasm and single elongated nuclei with moderate level of pleomorphism, and mitotic activity (5-7 mitoses per/10HPF) (H&E stain). Chromatin was predominantly finely granular. Perinuclear vacuolization was also observed. Immunohistochemical analysis was performed for the identification of the tumor’s origin. CD 117 (c-kit protein) was moderately to strongly positive demonstrating a combined membranous and diffuse