This case is a nice example of teamwork in medicine. Enter the quintafecta. The radiologist for the CT scan initially demonstrated the lesion, although its location was not quite on target. The presence of arterial enhancement, also noted by the radiologist, potentially shed some light on the nature of the lesion, but, alas, did not provide a specific diagnosis. Enter the EUS technician who sampled the lesion and enabled the diagnosis of Gl stromal tumor (GIST), followed by the endoscopist who determined the intestinal site of its origin. The surgeon removed the lesion, providing the means whereby the patient might then go on to resume good health, while the pathologist told us the precise nature of the lesion. GISTs arise from the intestinal cells of Cajal and are a type of mesenchymal tumor defined by typical histologic appearance and immunohistochemical staining pattern with c-kit and CD34. Prognosis is related mainly to tumor size and mitotic activity, but also to tumor necrosis, immunohistochemical profile, and invasion. GISTs arise in the stomach (60%), small intestine (30%), and from the esophagus and rectum (10%), although it is debated whether the Gl organ of origin is an important prognostic factor. Treatment for such a localized lesion, as in this case, is surgery, and prognosis is excellent for a GIST <2 cm in diameter with a low mitotic index (<50 per high power field) and no extraluminal spread. I am reminded of Nietzsche's parable that "the end of a melody is not its goal, and yet if a melody has not reached its end, it has not yet reached its goal."
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