Gastric Schwannoma El Salvador Atlas of Gastrointestinal VideoEndoscopy
Gastric Schwannoma

Video Endoscopic Sequence 1 of 15.

Upper gastrointestinal bleeding due to a Gastric Schwannoma

This is a 73 year-old female, who was referred to our unit because she had been presenting two upper tract digestive bleedings. When the endoscopy was performed an active bleeding was observed. The exact site of the bleeding was located; it looked like an ulcerated mass in the sub-mucosa and gave an impression to be a GIST. A blood vessel that was actively bleeding and pulsating was also observed. Hemostatic therapy with injections of absolute alcohol was initiated, infiltrating the ulcer.

Gastric Schwannoma: A Rare but Important Differential Diagnosis of a Gastric Submucosal Mass.

Schwannomas, also known as neurinomas or neurilemmomas, are generally benign, slow-growing neoplasms originating in any nerve that has a Schwann cell sheath. These neoplasms are rare among the spindle cell mesenchymal tumors of the gastrointestinal tract, but develop most commonly in the stomach representing 0.2% of all gastric tumors. 

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Gastric Schwannoma

Video Endoscopic Sequence 2 of 15.

Active bleeding pulsating submucosal ulcerated neoplasm is observed, with active bleeding blood vessel.

Schwannoma is a rare gastrointestinal mesenchymal tumor, as the vast majority of gastric mesenchymal tumors are gastrointestinal stromal tumors.

Schwannomas also known as neurinomas or neurilemmomas, are tumors originating from any nerve that has a Schwann cell sheath. These rarely develop in the gastrointestinal tract, and the most common site along the GI tract is the stomach. Schwannomas make-up 0.2% of all gastric neoplasm. The tumors are usually benign, slow-growing, and asymptomatic, but in some cases, bleeding or a palpable mass is present. Gastrointestinal endoscopy is the principal diagnostic tool. However, when the tumor has the characteristics of an exophytic mass from the gastric wall to the abdominal cavity, the differentiation of a schwannoma from other submucosal tumors is very difficult on pre-operative examination.

 

 

 

Gastric Schwannoma

Video Endoscopic Sequence 3 of 15.

Hemostatic therapy with injections of absolute alcohol is initiated, infiltrating the ulcer.

In a study that included 33 cases of schwannomas of the GIT, four tumours were located in the esophagus, 24 in the stomach, two in the colon and three in the rectum, with no cases being reported from the small intestine. With the stomach being the most common site of origin in the GIT, schwannomas represent 6.3% of gastric mesenchymal tumours and only 0.2% of all gastric tumours. They are usually located in the middle third of the stomach along the lesser curvature. The majority of the tumours are usually encased by intact mucosa and principally involve the submucosa and muscularis propria, without invading adjacent structures. About half of them show central ulceration.

 

 

Gastric Schwannoma

Video Endoscopic Sequence 4 of 15.

The bleeding actively persists.

Schwannomas generally present asymptomatically; however, in some cases they can cause abdominal discomfort, pain or digestive symptoms, as in our case. A palpable mass may also be present when the tumour is large and exophytic. Dysphagia or obstipation are possible symptoms when the site of origin is esophagus or rectum. In cases of deep ulceration bleeding may also be present.

 

Gastric Schwannoma

Video Endoscopic Sequence 5 of 15.

Another image and video clip of Gastric Schwannoma

 

Gastric Schwannoma

Video Endoscopic Sequence 6 of 15.

More infiltrations with absolute alcohol

 

 

 

 

Gastric Schwannoma

Video Endoscopic Sequence 7 of 15.

On the final state of the hemostasis, we stopped this bleeding with several infiltrations of absolute alcohol. It is to be mentioned that we could have used other methods of treatment to stop the bleeding such as dermabond infiltrations, drug sclerotherapy, and argon plasma coagulator. We have all these in hand. All endoscopic units should have them

 

 

Gastric Schwannoma

Video Endoscopic Sequence 8 of 15.

14 days later, a new biopsies were performed since it was not taken on the first one because of the hemorrhage.
Multiple biopsies were extracted from the ulcer.

 

Gastric Schwannoma

Video Endoscopic Sequence 9 of 15.

Retroflexed Image showing the neoplasia

 

 

 

 

 

 

Gastric Schwannoma

Video Endoscopic Sequence 10 of 15.

Multiple biopsies are extracted through the ulcer

The sub-mucosal tumors sometimes give problems in the pre-surgical diagnosis, but on our series, we have obtained some GIST making an accurate diagnosis through the ulceration, reaching the muscularis propria.

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Cancer Células en Anillo de sello

Video Endoscopic Sequence 11 of 15.

Low magnification features of gastric schwannoma

Sample obtained by endoscopy. 4x. cellular neoformation is seen without the presence of glands.
Peripheral lymphoid cuff with occasional germinal centers


Cancer Células en Anillo de sello

Video Endoscopic Sequence 12 of 15.

H&E-stained image representative of typical fascicular pattern

40x shows proliferation fusocelular with swirling pattern and suggestive areas of nuclear pallisading Verocay bodies, hyalinized vessels. 

 





Cancer Células en Anillo de sello

Video Endoscopic Sequence 13 of 15.

Immunohistochemically typical features include positivity for S100 protein 

 




Cancer Células en Anillo de sello

Video Endoscopic Sequence 14 of 15.

H&E-stained image representative of typical fascicular pattern

40x shows proliferation fusocelular with swirling pattern and suggestive areas of nuclear pallisading Verocay bodies, hyalinized vessels,


Cancer Células en Anillo de sello

Video Endoscopic Sequence 15 of 15.

The tumor cells are negative for CD 117 immunostain 

Fluorescence in situ hybridization studies revealed multiple signals with BCR probe (chromosome 22) and centromeric probes for chromosomes 2 and 18 suggesting polyploidy. These findings indicate that gastric schwannoma is a distinctive form of peripheral nerve sheath tumor that in many ways differs from soft tissue schwannoma. It should be distinguished from gastrointestinal stromal tumor and other mesenchymal tumors of the gastrointestinal tract, such as the S100 protein-positive gastrointestinal clear cell sarcoma and metastatic melanoma.



La tinción para cd117 fue negativa con inmunohistoquímica.
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