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Case history

image An 80-year-old woman presented to the accident and emergency department with a sudden collapse followed by large-volume melaena. Her past medical history included age-related macular degeneration, for which she was registered blind, drug-controlled type 2 diabetes, hypothyroidism, osteoporosis and hypertension, and she had a permanent pacemaker. Investigations revealed an Hb level of 40 g/l. She was supported with urgent red blood cell replacement. Her antihypertensive medication and bisphosphonate were stopped. An urgent upper gastrointestinal endoscopy revealed a large distal gastric tumour actively oozing blood from multiple locations. A CT scan showed a large 15 cm mass involving the distal stomach with five subcentimetre indeterminate liver lesions. The radiological appearances were of a gastrointestinal stromal tumour (GIST), which was confirmed by biopsy.

Her case was discussed by the specialist sarcoma multidisciplinary team. As the tumour was deemed operable, radical surgery was recommended pending anaesthetic review. The patient agreed to surgery and proceeded to an open laparotomy and partial distal gastrectomy. The surgery was complicated by an intraoperative acute myocardial infarction.

During a postoperative stay in the ITU she was reviewed by a cardiologist. An echocardiogram revealed moderate left ventricular systolic failure. She was commenced on an ACE inhibitor, beta-blocker, diuretic and an antiplatelet agent. Outpatient cardiology follow-up was arranged.

Four weeks later, at her initial oncology appointment, she was found to have New York Heart Association (NYHA) class III heart failure. She had returned home with extra home support following surgery. Her daughter had given up work to become her full-time carer. She had lost 6 kg in weight, despite developing bilateral lower limb oedema. Her diabetic control had become erratic due to poor nutritional intake, resulting in hypoglycaemic episodes. She complained of early satiety and diarrhoea after eating. The oncologist referred her for a Comprehensive Geriatric Assessment. This identified an increased risk of falls secondary to blindness, diuretic-related urinary frequency, weight loss and post-ITU muscle wasting resulting in generalized weakness and frailty. Her diuretics were increased and a downstairs and a bedside commode were provided to help manage her bladder and bowel. Antimotility medications were prescribed to reduce the diarrhoea. Gliclazide was discontinued, and her daughter was taught how to monitor blood glucose. A dietitian carried out a review and provided her with supplements and strategies to manage early satiety with frequent smaller meals. Home-based physiotherapy was arranged to increase strength and balance and she was referred to the community heart failure team.

Her tumour was found to be fully resected with negative microscopic margins and without rupture. The mitotic rate was high. Mutation analysis of the tumour showed a KIT exon 11 deletion. Arrangements were made for re-review in a further 4 weeks. At this appointment, her weight loss had stabilized, her heart failure had improved and she had had no further hypoglycaemic episodes. However, she had not recovered her preoperative performance status. Further treatment options were discussed, namely adjuvant imatinib for up to 3 years versus continued close ...

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