2024 FSA Podium and Poster Abstracts
P085: MANAGEMENT OF GASTROINTESTINAL STROMAL TUMOR AND ACUTE APPENDICITIS IN PREGNANCY: A CASE REPORT
Wendy Yang, MPH1; Anastasia Jones, MD2; Daniel A Nahrwold, MD2; 1University of South Florida Morsani College of Medicine; 2H. Lee Moffitt Cancer Center & Research Institute
Introduction: Gastrointestinal stromal tumors (GISTs) commonly present in the stomach or large intestine in older adults 50-70 years old. Though early stage GISTs can be surgically removed, large tumor burden can be reduced with imatinib, a tyrosine kinase inhibitor. GISTs in young adult patients are very rare and treatment planning requires careful individualization. Here, we present the first case of metastatic GIST in pregnancy with appendicitis and describe the management challenges for such patients.
Case Course: A 28-year-old woman presented to the emergency department with acute upper abdominal pain, bloating, and vomiting. CT abdomen demonstrated a 10.4 cm intra-abdominal mass with multiple peritoneal nodules consistent with stage IV disease. Biopsy and pathology evaluation confirmed metastatic epithelioid GIST. She started imatinib with a partial response resulting in 50% reduction of the abdominal mass. Subsequently she underwent tumor debulking, partial omentectomy, and bowel resection. However, three weeks postoperatively, the patient returned with acute appendicitis and was managed with antibiotics.
Six months later, prior to follow-up CT scan, she was found to be pregnant and decided to stop imatinib therapy. Several days later, the patient returned with acute appendicitis and underwent an appendectomy, which was uneventful.
The patient went on to deliver a healthy child. Unfortunately, new peritoneal and new bilateral breast nodules were present on her first CT scan post-pregnancy. She is currently breastfeeding and will resume imatinib therapy afterwards.
Discussion/Conclusion: This is the first recorded case of acute appendicitis in a pregnant young adult patient with metastatic GIST. We emphasize the importance of early diagnosis of GISTs in young patients, given the low prevalence of GISTs in this age group as well as the occurrence of confounding conditions with overlapping symptomatology. In this case, presentation and diagnosis of appendicitis was complicated by pregnancy and the history of GIST.
Further, treatment considerations for GIST and appendicitis in pregnancy present a challenge as halting imatinib is associated with increased risk of GIST progression. CT scans are contraindicated in pregnancy, leaving MRI as an option to monitor GIST progression, which can be less accurate than CT. Anesthetic management in appendectomy in early pregnancy is also modified, with more vigilance given to the airway and physiological changes of pregnancy.