DOI:10.2214/AJR.04.1531
AJR 2005; 185:1190-1192
© American Roentgen Ray Society
Glomus Tumor of the Stomach: MRI Findings
Kao-Lang Liu1,
Hsiu-Po Wang2,
Wen-Yin Isaac Tseng1,
Chia-Tung Shun3,
Shyh-Jye Chen1 and
Yuk-Ming Tsang1
1 Department of Medical Imaging, National Taiwan University Hospital, College of
Medicine, National Taiwan University, No. 7, Chung-Shan S Rd., Taipei 100,
Taiwan, ROC.
2 Department of Emergency Medicine, National Taiwan University Hospital, College
of Medicine, National Taiwan University, Taipei, Taiwan.
3 Department of Pathology, National Taiwan University Hospital, College of
Medicine, National Taiwan University, Taipei, Taiwan.
Received September 28, 2004;
accepted after revision November 19, 2004.
Address correspondence to Y.-M. Tsang.
Introduction
Glomus tumors are mesenchymal tumors, arising from modified smooth-muscle
cells of the glomus body, a type of neuromyoarterial receptor that is
sensitive to variations in temperature and plays a role in the regulation of
arteriolar blood flow [1]. Most
of the tumors are located at the subungual regions of the fingertips, the
palms, the wrists, and the toes. The tumors have also been reported in the
gastrointestinal, urogenital, cardiovascular, and respiratory tracts and in
the hepatobiliary system. In the gastrointestinal tract, they occur most often
in the stomach. Glomus tumors of the stomach typically appear as a submucosal
nodule or mass on the greater curvature side of the antrum. To our knowledge,
there has been no previous report regarding the MRI features of a gastric
glomus tumor, although the upper gastrointestinal series and CT features of
the tumor have been described
[2–4].
In combination with the tumor size, location and MR signal intensity can
suggest the diagnosis of gastric glomus tumor.
Case Report
A 60-year-old man presented with abdominal discomfort. The upper
gastrointestinal barium study revealed a submucosal mass at the greater
curvature aspect of the antrum (Fig.
1A). Endoscopy disclosed a gastric submucosal tumor. Triphasic
abdominal CT (HiSpeed, GE Healthcare) showed a well-defined hypervascular
tumor at the antrum (Fig. 1B). MRI was performed on a 1.5-T MR imager (Magnetom Sonata, Siemens Medical
Solutions) using a phased-array coil; the following pulse sequences were
performed: a T2-weighted balanced true fast imaging with steady-state
free-precession (FISP) sequence (TR/TE, 4.3/2.1; flip angle, 72°); a
T1-weighted spoiled gradient-echo sequence (2D fast low-angle shot; 150/1.8;
flip angle, 70°) either with or without a saturation pulse for fat signal;
a T2- and a heavily T2-weighted turbo spin-echo sequence (2,300/94; flip
angle, 150°; and 2,300/180; flip angle, 150°, respectively); and 3D
spoiled gradient-echo sequence (3D volumetric interpolated breathhold
examination [VIBE]; 3.15/1.25; flip angle, 15°) for triphasic dynamic
enhancement study. The acquisition time for each phase was 13 sec, and the
interval between the consecutive phases was 10 sec. At the start of scanning,
gadopentetate dimeglumine (Magnevist, Schering) at a dosage of 0.1 mmol/kg was
injected manually as a rapid bolus and flushed with 20 mL of normal
saline.
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Fig. 1A —60-year-old man who presented with abdominal discomfort.
Image from upper gastrointestinal series shows well-defined indentation
(arrows) at greater curvature side of antrum. Mucosa is intact.
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Fig. 1B —60-year-old man who presented with abdominal discomfort.
Triphasic contrast-enhanced CT scan shows well-defined tumor (arrows)
with persistent hypervascular enhancement. Attenuation values were 28, 108,
and 110 H on precontrast, arterial phase, and portal venous phase images,
respectively.
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A submucosal gastric mass that was approximately 2.0 cm was identified at
the greater curvature side of the antrum; it appeared slightly hypointense on
T1-weighted (Fig. 1C) and
slightly hyperintense on T2-weighted (Fig.
1D) images and was hypervascular and exhibited persistent
enhancement on axial (Fig. 1E)
and coronal (Fig. 1F) images.
Because the differential diagnosis of this gastric submucosal mass included
carcinoid, glomus, and gastrointestinal stromal tumor (GIST), laparoscopic
gastric wedge resection was performed. The pathology report revealed a glomus
tumor of the stomach. Microscopically, it showed uniform small round cells
with central nuclei and pale cytoplasm composed of many irregular vascular
spaces in the muscular layer of the stomach. Immunohistochemically, the tumor
cells were positive for smooth-muscle actin stain and negative for CD34,
CD117, S-100 protein, synaptophysin, and chromogranin stain. There was no
evidence of mitosis or lymphovascular permeation.
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Fig. 1C —60-year-old man who presented with abdominal discomfort.
Axial T1-weighted image without fat saturation shows lesion (arrow)
with moderately low signal intensity. Image was acquired with spoiled
gradient-echo sequence before administration of contrast medium.
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Fig. 1D —60-year-old man who presented with abdominal discomfort.
Axial T2-weighted image reveals tumor (arrow) with mildly high signal
intensity. Image was acquired with fat-suppressed turbo spin-echo sequence
before administration of contrast medium.
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Fig. 1E —60-year-old man who presented with abdominal discomfort.
Contrast-enhanced axial T1-weighted image shows tumor (arrow) with
vivid enhancement. Image was acquired with fat-suppressed spoiled
gradient-echo sequence.
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Fig. 1F —60-year-old man who presented with abdominal discomfort.
Contrast-enhanced coronal T1-weighted image shows that tumor (arrow)
is located at greater curvature side of antrum. Image was acquired with
fat-suppressed spoiled gradient-echo sequence.
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Discussion
Glomus tumors originate in the neuromyoarterial glomus, a normal
arteriovenous shunt that is abundantly supplied with nerve fibers and fulfills
a temperature-regulating function. The tumors consist of vascular channels
lined by normal endothelium surrounded by round glomus cells. However, they
should not be confused with tumors of the glomus jugulare or
hemangiopericytomas [2]. Glomus
jugulare tumors or carotid body tumors (i.e., chemodectomas) are rare tumors
arising from the chemoreceptor system in the head and neck region and present
as mass effect and are rarely functioning. Hemangiopericytomas are vascular
tumors arising from pericytes that surround capillaries and usually present as
an intraosseous, soft-tissue, or muscular mass. Glomus tumors were first
described by Barre and Masson in 1924, and the classic location of a glomus
tumor is the subungual region of a digit, but it may occur anywhere in the
body, including the skin, soft tissues, nerves, stomach, nasal cavity,
trachea, and liver [3].
Glomus tumors of the stomach are rare lesions, arising in the intramuscular
layer, and typically occur as a solitary submucosal nodule in the region of
the antrum and pylorus. At barium study, most reported cases are localized at
the greater curvature side of the antrum
[2–4],
and they appear as smooth submucosal masses with or without ulceration. On CT,
they manifest as well-circumscribed submucosal masses with homogeneous density
on unenhanced study and may contain tiny flecks of calcifications
[4]. After contrast medium
administration, these tumors show strong enhancement on arterial phase images
and persistent enhancement on portal venous phase images. The sonographic
findings have been described as a hypoechoic mass in the third or fourth
submucosal layers with internal heterogeneous echogenicity mixed with
hyperechoic spots and lacking a capsule
[5].
To our knowledge, this is the first report about the MRI features of glomus
tumors of the stomach. The tumor is slightly hypointense on T1-weighted images
and slightly hyperintense on T2-weighted images and is hypervascular and
exhibits persistent enhancement after gadopentetate dimeglumine
administration.
The tumor in our patient was removed by laparoscopic wedge resection;
however, endoscopic enucleation using an insulated-tip electrosurgical knife
is another alternative [6].
Microscopically, glomus tumors appear as highly vascular tumors with dilated,
probably modified capillaries and are covered by nests, strands, or sheets of
glomus cells. Because they are derived from modified smooth-muscle cells, the
tumor cells are phenotypically similar to peripheral glomus tumors and exhibit
a similar immunocytochemical and ultrastructural profile. Nearly all tumors
express muscle actin isoforms and vimentin. Expression of desmin is variable,
and tumors are negative for chromogranin, neuron-specific enolase, factor
VIII–related antigen, keratin, carcinoembryonic antigen, and epithelial
membrane antigen [1,
7]. Pathologically the
differential diagnosis includes the hemangiopericytoma and epithelioid GIST.
The hemangiopericytoma arises from the pericytes, and its morphology is
different from that of a glomus tumor. Immunocytochemical stain of actin is
negative. The epithelioid GIST may be morphologically similar to glomus tumor,
but the negative CD34 and CD117 (c-kit) exclude the possibility of
GIST.
Although glomus tumor of the stomach is a pathologic diagnosis, it should
be included in the differential diagnosis if there is a solitary,
hypervascular submucosal tumor at the greater curvature side of the antrum.
Other mesenchymal tumors, such as carcinoid tumor, GIST, neurilemmoma, and
hemangioma, may show a similar pattern. The incidence of gastric carcinoid
tumors is increasing and the tumors may be multiple, from the fundus to
antrum. The imaging features of GISTs are variable, ranging from a small
nodule with signal changes similar to gastric muscle to a large mass with
cystic change, intratumoral hemorrhage, necrosis, or ulceration with
air–fluid level. Neurilemmoma has moderately or markedly higher
hyperintensity on T2-weighted imaging
[8]. The hemangioma shows color
change as vessels, blue or red, on endoscopy and may contain phleboliths that
are more readily identified on CT. The constellation of tumor size, location,
enhanced pattern, and intrinsic soft-tissue content resolution of MRI can help
in the diagnosis of gastric glomus tumors.
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Introduction
Case Report
