Consumptive hypothyroidism: an unusual paraneoplastic manifestation of a gastric gastrointestinal stromal tumor
A 42-year-old hypothyroid shepherd presented with a progressive abdominal lump accompanied by nausea and abdominal fullness. In addition, he had worsening hypothyroidism, despite supranormal doses of thyroxine. Computed tomography of the abdomen was suggestive of a mass lesion in relation to the sto...
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Інститут експериментальної патології, онкології і радіобіології ім. Р.Є. Кавецького НАН України
2017
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| Цитувати: | Consumptive hypothyroidism: an unusual paraneoplastic manifestation of a gastric gastrointestinal stromal tumor / T. Patial, K. Sharma, D. Thakur, G. Gupta // Experimental Oncology. — 2017 — Т. 39, № 4. — С. 319–321. — Бібліогр.: 10 назв. — англ. |
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irk-123456789-1392522018-06-20T03:04:40Z Consumptive hypothyroidism: an unusual paraneoplastic manifestation of a gastric gastrointestinal stromal tumor Patial, T. Sharma, K. Thakur, D. Gupta, G. Case report A 42-year-old hypothyroid shepherd presented with a progressive abdominal lump accompanied by nausea and abdominal fullness. In addition, he had worsening hypothyroidism, despite supranormal doses of thyroxine. Computed tomography of the abdomen was suggestive of a mass lesion in relation to the stomach. A resection of the mass was done and the histopathology was suggestive of gastrointestinal stromal tumor. After surgery, the patient became euthyroid. We believe the patient had consumptive hypothyroidism due to the tumor. 2017 Article Consumptive hypothyroidism: an unusual paraneoplastic manifestation of a gastric gastrointestinal stromal tumor / T. Patial, K. Sharma, D. Thakur, G. Gupta // Experimental Oncology. — 2017 — Т. 39, № 4. — С. 319–321. — Бібліогр.: 10 назв. — англ. 1812-9269 http://dspace.nbuv.gov.ua/handle/123456789/139252 en Experimental Oncology Інститут експериментальної патології, онкології і радіобіології ім. Р.Є. Кавецького НАН України |
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Case report Case report |
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Case report Case report Patial, T. Sharma, K. Thakur, D. Gupta, G. Consumptive hypothyroidism: an unusual paraneoplastic manifestation of a gastric gastrointestinal stromal tumor Experimental Oncology |
| description |
A 42-year-old hypothyroid shepherd presented with a progressive abdominal lump accompanied by nausea and abdominal fullness. In addition, he had worsening hypothyroidism, despite supranormal doses of thyroxine. Computed tomography of the abdomen was suggestive of a mass lesion in relation to the stomach. A resection of the mass was done and the histopathology was suggestive of gastrointestinal stromal tumor. After surgery, the patient became euthyroid. We believe the patient had consumptive hypothyroidism due to the tumor. |
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Article |
| author |
Patial, T. Sharma, K. Thakur, D. Gupta, G. |
| author_facet |
Patial, T. Sharma, K. Thakur, D. Gupta, G. |
| author_sort |
Patial, T. |
| title |
Consumptive hypothyroidism: an unusual paraneoplastic manifestation of a gastric gastrointestinal stromal tumor |
| title_short |
Consumptive hypothyroidism: an unusual paraneoplastic manifestation of a gastric gastrointestinal stromal tumor |
| title_full |
Consumptive hypothyroidism: an unusual paraneoplastic manifestation of a gastric gastrointestinal stromal tumor |
| title_fullStr |
Consumptive hypothyroidism: an unusual paraneoplastic manifestation of a gastric gastrointestinal stromal tumor |
| title_full_unstemmed |
Consumptive hypothyroidism: an unusual paraneoplastic manifestation of a gastric gastrointestinal stromal tumor |
| title_sort |
consumptive hypothyroidism: an unusual paraneoplastic manifestation of a gastric gastrointestinal stromal tumor |
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Інститут експериментальної патології, онкології і радіобіології ім. Р.Є. Кавецького НАН України |
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2017 |
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Case report |
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http://dspace.nbuv.gov.ua/handle/123456789/139252 |
| citation_txt |
Consumptive hypothyroidism: an unusual paraneoplastic manifestation of a gastric gastrointestinal stromal tumor / T. Patial, K. Sharma, D. Thakur, G. Gupta // Experimental Oncology. — 2017 — Т. 39, № 4. — С. 319–321. — Бібліогр.: 10 назв. — англ. |
| series |
Experimental Oncology |
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2025-07-10T07:10:42Z |
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2025-07-10T07:10:42Z |
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1837242981723144192 |
| fulltext |
Experimental Oncology 39, 319–321, 2017 (December) 319
CONSUMPTIVE HYPOTHYROIDISM: AN UNUSUAL
PARANEOPLASTIC MANIFESTATION OF A GASTRIC
GASTROINTESTINAL STROMAL TUMOR
T. Patial1, *, K. Sharma2, D. Thakur3, G. Gupta4
1Department of General Surgery, Indira Gandhi Medical College, Shimla, Himachal Pradesh 171001,
India
2Department of Radiation Oncology, Rajiv Gandhi Cancer Institute & Research Centre, Sector 5, Rohini,
New Delhi 110085, Delhi, India
3Department of General Surgery, Indira Gandhi Medical College, Shimla, Himachal Pradesh 171001,
India
4Department of Pathology, School of Medical Sciences & Research, Sharda University, Greater Noida,
Uttar Pradesh 201306, India
A 42-year-old hypothyroid shepherd presented with a progressive abdominal lump accompanied by nausea and abdominal fullness. In ad-
dition, he had worsening hypothyroidism, despite supranormal doses of thyroxine. Computed tomography of the abdomen was suggestive
of a mass lesion in relation to the stomach. A resection of the mass was done and the histopathology was suggestive of gastrointestinal
stromal tumor. After surgery, the patient became euthyroid. We believe the patient had consumptive hypothyroidism due to the tumor.
Key Words: gastrointestinal stromal tumors, CD117, hypothyroidism, imatinib mesylate, paraneoplastic syndrome.
Gastrointestinal stromal tumors (GIST) are me
senchymal tumors that are believed to originate from
the interstitial cells of Cajal or from mesenchymal
stem cells present throughout the body. Owing to the
physical effects of the tumor, the usual presentation
can be abdominal discomfort, bleeding, nausea,
vomiting, or early satiety. Very rarely do these tumors
present with paraneoplastic syndrome. We report the
case of a patient who had hypothyroidism due to a GIST
of the stomach, which resolved after surgery.
A 42yearold shepherd was referred to our hospital
by his internist with the chief complaints of awareness
of a progressive upper abdominal lump for 2 months
and postprandial nausea with abdominal fullness for
2 weeks. The patient was a known case of hypothy
roidism, and had been on 25 µg of thyroxine (T4) for
the past 15 months, but for the past 1 month, his se
rum thyroid stimulating hormone (TSH) levels failed
to return to previous levels despite taking 200 µg of T4.
His most recent thyroid profile at the time was, TSH —
49 µIU/ml, triiodothyronine (T3) — 0.37 ng/ml, T4 —
4.3 µg/dl and reverse T3 — 292.4 ng/dl (normal range:
TSH — 0.30–0.50 µIU/ml, T3 — 0.60–1.81 ng/ml, T4 —
5.01 to 12.45 µg/dl and reverse T3 — 10–40 ng/dl). The
patient had been compliant with medication and follow
up. The patient was a teetotaller, and had no history
of tobacco use. On examination of the abdomen, there
was a 10 × 6 cm intraabdominal lump present in the
epigastrium, extending to the left hypochondrium,
umbilical and the left lumbar regions. The lump was
firm, nontender, nonpulsatile, and mobile. Labora
tory tests, including a complete blood cell count, blood
biochemistry, liver enzymes, and serum amylase and
lipase levels, were within normal limits. On computed
tomography of the abdomen, a solid mass of size
14.8 × 9.6 cm with heterogeneous nonenhancing
low attenuation areas was identified in relation to the
stomach (Fig. 1). On upper gastrointestinal endo
scopy, a submucosal mass lesion was found in relation
to the posterior wall of the stomach, without evidence
of mucosal involvement. The patient underwent a distal
gastrectomy with retrieval of a gastric mass arising from
the posterior wall of the stomach without rupture of the
mass during handling (Fig. 2). Other solid organs were
normal. No lymphadenopathy or ascites was present.
Fig. 1. Computed tomography of the abdomen showing a solid
mass of size 14.8 × 9.6 cm with heterogeneous non enhancing
low attenuation areas identified in relation to the stomach
Submitted: October 04, 2016.
*Correspondence: E-mail: drtusharpatial@gmail.com
Abbreviations used: GIST — gastrointestinal stromal tumors; T3 —
triiodothyronine; T4 — thyroxine; TSH — thyroid stimulating hormone.
Exp Oncol 2017
39, 4, 319–321
CASE REPORT
320 Experimental Oncology 39, 319–321, 2017 (December) Experimental Oncology 39, 319–321, 2017 (December) 321
A peculiar consequence of GIST is consumptive hypo
thyroidism. First reported in children with infantile hae
mangiomas, this condition results from accelerated
degradation of circulating thyroid hormone at rates
higher than the synthetic capacity of the normally
stimulated thyroid gland. In cases of tyrosine kinase
inhibitor naive patients, consumptive hypothyroidism
is caused by overexpression of the thyroid hormone
inactivating enzyme iodothyronine deiodinase 3. The
diagnosis of consumptive hypothyroidism requires
evidence of either elevated levels of serum reverse
T3 or supranormal requirements for exogenous thyroid
hormone [8]. In our patient, the patient’s requirement
for supranormal doses of T4 was abolished soon after
surgery, thus supporting this diagnosis.
On contrastenhanced computed tomography,
peripheral enhancement is present in the 75% of the
cases of GIST. This represents an enhancement of pe
ripheral areas of viable tumor. However, in a minority
of patient’s areas of low attenuation may be present
corresponding to haemorrhage, necrosis, or cyst for
mation, as present in our case. We do not believe this
is of consequence with respect to consumptive hypo
thyroidism, as the imaging finding has been described
without the paraneoplastic syndrome as well [9].
Surgery has been treatment of choice with 60%
of patients being cured by surgery alone. Laparo
scopic resection is considered a feasible procedure
for patients with gastric GIST 5 cm or smaller, if not
contraindicated by comorbidities. Locally advanced
GIST may be candidates for surgical resection after
neoadjuvant treatment with Imatinib, a cKit inhibitor.
In cases of inoperable, metastatic or recurrent GIST,
Imatinib remains the firstline treatment [1, 10].
Although hypothyroidism is a frequent clinical
scenario, the astute clinician must remember that hy
pothyroidism can often be the herald of a much more
sinister diagnosis such as a GIST. In cases of patients
requiring supranormal doses of T4, a measurement
of reverse T3 should be considered to establish the
diagnosis of consumptive hypothyroidism.
ACkNOwLEDGEMENTS
Nothing to disclose.
CONFLICT OF INTEREST
No conflict of interest.
REFERENCES
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testinal stromal tumors: correlation between symptoms at pre-
sentation, tumor location and prognostic factors in 47 consecu-
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2. Rammohan A, Sathyanesan J, Rajendran K, et al. A gist
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8. Maynard MA, Marino-Enriquez A, Fletcher JA, et al.
Thyroid hormone inactivation in gastrointestinal stromal
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9. Afifi AH, Eid M. Gastrointestinal stromal tumors
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Fig. 2. Gross pathology specimen of the removed GIST, following
a distal gastrectomy, with tumor free margins
On macroscopic examination, there was a solitary,
round tumor measuring 11 × 8 × 6 cm in size. The
lesion was well demarcated and had a pseudocap
sule. On cut sectioning, the surface was mostly solid
with a few cystic areas. Interspersed within were foci
of necrosis and hemorrhage. Microscopic evaluation
revealed a cellular proliferation of spindleshaped cells
with high nucleus:cytoplasm ratio. Cellular and nuclear
pleomorphism was also present. Few areas of necrosis
were also seen. Mitotic figures were seen occasionally
embedded within areas of increased mitosis (9/50 high
power field) (Fig. 3–5). On immunohistochemistry, the
tissue was positive for CD117 (Fig. 6), but negative for
desmin and S100. Based on the macroscopic findings
(size > 10 cm), histopathology (mitosis > 5/50 high
power field) and immunohistochemistry a diagnosis
of the GIST of the stomach with a high risk of neoplastic
progression was made. The patient had an unevent
ful recovery and was discharged 3 days after surgery
on adjuvant imatinib mesylate. Postoperative thyroid
function tests after 6 weeks were, TSH — 3.9 µIU/ml,
T3 — 0.74 ng/ml, T4 — 7.2 µg/dl, and reverse T3 —
252.3 ng/dl. After gradual reduction of exogenous T4,
the drug has been withdrawn and the patient has been
euthyroid since.
Fig. 3. Microphotograph of gastrectomy specimen (hemato
xylineosin) showing features of a spindle cell type GIST with
nuclear pleomorphism
DISCUSSION
The median age of GIST presentation is 55–60 years
and these tumors represent 80% of all mesenchymal
gastrointestinal tumors and 0.1–3% of all gastrointe
stinal malignancies [1]. About 70% of the patients with
GIST are symptomatic, 20% are asymptomatic and
in 10% the lesions are detected only at autopsy. The
tumor may present as abdominal discomfort, bleeding,
nausea, vomiting, or early satiety. Tumor spread is usu
ally intraabdominal, and metastasis to lymph nodes
is rare. Symptoms are usually dependant on the site
involved, with the most common being the stomach
(60%) and the small intestine (30–20%) [2].
Although rare, paraneoplastic syndromes have
been described with GIST. These include autoimmune
haemolytic anaemia, hypoglycaemia, hyponatremia,
nephrotic syndrome, headache and diplopia [3–7].
Fig. 4. Microphotograph of specimen (hematoxylineosin)
showing normal gastric mucosa with underlying spindle
shaped cells
Fig. 5. Microphotograph of the tumor (hematoxylineosin) at low
magnification of microscope
Fig. 6. Microphotograph of CD117 expression in tumor cells
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