Background

Gastrointestinal stromal tumors (GISTs) are the most common sarcoma of the gastrointestinal tract. Most are found incidentally, located within the stomach, and involve KIT mutations. Possible symptoms include abdominal pain, early satiety, and gastrointestinal bleeding secondary to tumor friability. Size, location, and mitotic index affect prognosis. Primary resection is the treatment of choice if unlikely to result in significant morbidity; otherwise, neoadjuvant imatinib is indicated. Lesser curve gastric GIST resection is more challenging due to proximity to the vagus nerve, left gastric artery, and gastroesophageal junction.

Methods

We present a 67-year-old female with morbid obesity, atrial fibrillation on anticoagulation, and hypertension presenting with gastrointestinal bleeding, initially managed with embolization of the left gastric artery. Workup revealed a 15cm solid tumor seemingly originating from the lesser curvature of the stomach, with possible liver involvement and encroachment on the gastroesophageal junction. Biopsy confirmed diagnosis of GIST. Neoadjuvant imatinib was begun with initial size regression to 12cm, but eventual stabilization; the decision was made to proceed to laparoscopic surgery. Intraoperatively, there was no involvement of the liver or gastroesophageal junction. Wedge resection of the tumor resulted in a 'reverse sleeve gastrectomy' with negative margins. The patient continued adjuvant imatinib with no evidence of recurrence or metastatic disease at 10 months post-operatively. Additionally, she lost 18kg and discontinued her antihypertensive medication as a result of this procedure.

Conclusions

This case is notable for our multidisciplinary management of this large GIST and ability to maintain a minimally invasive approach with a lesser curve tumor.