What is the management approach for a diagnosed glomus tumor in an adult woman, considering its bleeding and pulsatile nature?

Management of Gastric Glomus Tumor

Surgical excision via wedge resection with adequate free margins is the definitive treatment for gastric glomus tumors, with a laparoscopic approach preferred when technically feasible. 1, 2

Diagnostic Approach

Clinical Presentation

• Epigastric pain is the most common presenting symptom (33.9% of cases), followed by bleeding manifestations 2
• The pulsatile nature relates to the tumor's rich vascular supply originating from modified smooth muscle cells 1
• Gastric glomus tumors typically present as well-circumscribed hypoechoic masses on endoscopic ultrasound (EUS), located in the third and/or fourth EUS layer (muscularis propria and serosa) 1

Preoperative Diagnosis

• EUS-guided fine needle aspiration (FNA) should be performed to establish diagnosis preoperatively 1, 2
• Immunohistochemical staining is critical: positive for smooth muscle actin and vimentin, negative for CD117 (c-kit), which differentiates glomus tumors from gastrointestinal stromal tumors (GISTs) 1
• Endoscopic elastosonography is emerging as a promising tool for differential diagnosis of gastric submucosal lesions 2

Surgical Management

Primary Treatment Strategy

• Wedge resection with adequate free margins is the treatment of choice (performed in 62% of cases) 2
• Laparoscopic approach is warranted when technically feasible, offering reduced morbidity 2
• The gastric antrum is the most frequently involved site (75.3%), with mean tumor size of 2.82 cm 2

Rationale for Surgical Excision

• These lesions are usually benign but have potential for malignant behavior 1
• Malignant gastric glomus tumors have been reported in 11 cases in contemporary literature, necessitating complete excision 2
• Glomus tumors can present with ulceration and hemorrhage, making surgical removal essential for symptom control 1

Critical Clinical Considerations

Malignant Potential

• While most gastric glomus tumors are benign, malignant transformation occurs and cannot be predicted by EUS findings alone 1, 2
• One retrospective study of 31 gastric glomus tumors reported one patient death due to liver metastases 1
• Long-term follow-up is mandatory after surgical excision due to documented cases of malignant gastric glomus tumors 2

Differential Diagnosis Pitfall

• The primary diagnostic challenge is distinguishing glomus tumors from GISTs, as both present as hypoechoic submucosal masses 1
• Immunohistochemistry is essential: glomus tumors are CD117-negative while GISTs are CD117-positive 1

Postoperative Management

Surveillance Strategy

• Long-term follow-up with periodic imaging is suggested given the documented cases of malignant behavior 2
• Monitor for recurrence, though recurrence rates are low with adequate surgical margins 2
• Assess for metastatic disease, particularly hepatic metastases, which have been reported 1

Expected Outcomes

• Complete surgical excision typically provides definitive treatment for benign lesions 2
• Resolution of bleeding and pain symptoms is expected after complete resection 2