Correlation between tumor volume doubling time and histologic findings in gastric smooth muscle tumors: clinical implications of tumor volume doubling time

The natural history of gastrointestinal subepithelial tumors arising from muscularis propria: an endoscopic ultrasound survey

AIM

The majority of lesions originating from muscularis propria of stomach, duodenum, and colon are gastrointestinal stromal tumors (GISTs). Surgery is indicated when endosonographic criteria of malignancy are met, but little is known about the natural history of lesions with benign endosonographic features. Aim of this study was to evaluate the natural course of benign-appearing lesions originating from muscularis propria in organs where GISTs significantly overcome leiomyomas.

MATERIALS AND METHODS

A total of 49 asymptomatic patients with hypoechoic lesions originating from the fourth layer of the gastrointestinal tract entered a follow-up program by means of endoscopic ultrasonography. All lesions were nonulcerated, <3 cm in maximal diameter, with regular margins, and cystic spaces of <3 mm.

RESULTS

After a mean follow-up of 31+/-20.8 months and a median of 2 (range, 1 to 5) endosonographies/patient, no change in echostructure or dimensions was seen in 44 subjects whereas in 5, an increase of at least 25% in 1 diameter occurred. Surgical removal was proposed to all: 1 patient refused (she is still alive and symptom-free after 4 y), 3 of the 4 lesions removed proved to be GISTs with very low or low risk of malignancy and 1 lesion was classified as a glomus tumor with no malignant appearance.

CONCLUSIONS

Even small and benign-appearing lesions from muscularis propria may increase in size over time but this increase cannot be considered as an index of malignancy. As most of these lesions are GISTs, a policy of surveillance is advisable.

Submucosal lesions

Most of the submucosal lesions encountered on endoscopy are benign; however, the fact that some of them may be malignant considerably influences the attitude toward the whole group. This article reviews the current status of endosonography in the management of submucosal lesions and focuses on determining the risk of malignancy. The predictive value of various endoscopic ultrasonography (EUS) features and their combinations and the capabilities and limitations of EUS-guided fine needle biopsy are discussed. Other issues addressed include differentiation between extraluminal compressions and true submucosal lesions, EUS-assisted endoscopic removal of submucosal lesions, and the potential role of catheter-based endosonography in the setting of submucosal lesions. Problems related to the surveillance of patients with submucosal lesions who are not candidates for surgical treatment are outlined. An overview of the recent changes in the pathologic classification of gastrointestinal mesenchymal tumors and their impact on the role of EUS in the management of submucosal lesions is given.

Laparoscopic wedge resection with handsewn closure for gastroduodenal tumors

PURPOSE

To evaluate the feasibility and efficacy of laparoscopic wedge resection with handsewn closure in gastroduodenal tumors.

METHODS

Laparoscopic wedge resection was performed in 16 patients with gastroduodenal tumor between May 2000 and December 2002. Every case, except one, was performed via an extragastric approach; a transgastric approach was adopted in a single case. Excision of the lesion was performed manually by means of electrocautery or ultrasonic coagulating shears and closed by manual intracorporeal running suture.

RESULTS

Among the 16 cases, two cases were treated using a laparoscope-assisted method, but there was no case of conversion to open surgery. Mean size of lesions was 27.9 mm in diameter and the mean operation time was 219 minutes. In all cases, a complete tumor excision with negative surgical margins was obtained. The final pathologic diagnoses were ectopic pancreas (4 cases), gastrointestinal stromal tumor (3 cases), leiomyoma (2 cases), adenomyoma (2 cases), tubular adenoma (1 case), Brunner's gland hyperplasia (1 case), carcinoid tumor (1 case), eosinophilic granuloma (1 case), and post-endoscopic mucosectomy state for early gastric cancer (1 case). The average numbers of days to first postoperative oral food intake and hospital stay were 3.1 days and 6.0 days, respectively. There were no postoperative complications.

CONCLUSIONS

Laparoscopic wedge resection with handsewn closure should be considered as a valid treatment option for selected gastroduodenal tumors in terms of feasibility, safety, and cost. A more efficient surgical instrument and technique should be developed in future.

Laparoscopic vs open resection of gastric stromal tumors

BACKGROUND

Gastric stromal tumors are rare neoplasms that may be benign or malignant. Given that malignant gastric stromal tumors rarely involve lymph nodes and require excision with negative margins, they appear amendable to laparoscopic excision. There are few reports of laparoscopic resection, and no comparisons have been done between laparoscopic and open surgery. This study compares the relative efficacy of the two approaches.

METHODS

Between May 1994 and December 2000, 33 patients underwent 35 operations for gastric stromal tumors. Laparoscopic resections were performed in 21 patients; open resections were done in 12 patients. The medical records of the patients were reviewed retrospectively with regard to operating time, blood loss, length of stay, and clinical course.

RESULTS

Patient demographics, tumor characteristics (mean tumor size, benign vs malignant), and presenting symptoms were similar for both groups. In the laparoscopic group, 15 wedge resections; three partial gastrectomies, and three transgastric needlescopic enucleations were performed. In the open group, six wedge resections, four antrectomies, and two partial proximal gastrectomies were performed. There were no significant differences in mean operative time (169 vs 160 min), mean estimated blood loss (106 vs 129 cc), or perioperative complication rate (9.5% vs 8.3%) between the laparoscopic and open groups, respectively. The mean length of stay was significantly less (p<0.05) in the laparoscopic group (3.8 vs 6.2 days). Average follow-up was 1.5 years. One patient in each group has died due to metastatic disease. There have been no trocar site recurrences.

CONCLUSIONS

Laparoscopic resection of gastric stromal tumors is safe and appropriate. Tumor size, operating time, and estimated blood loss were equivalent to the open approach, and there was a statistically shorter hospital stay in the laparoscopic group.

Doubling time of serum CA 19-9 in the clinical course of patients with pancreatic cancer and its significant association with prognosis

BACKGROUND AND OBJECTIVES

Pancreatic cancer is generally a disease with a poor prognosis, and relationship between change of serum CA 19-9 level and progression of this disease was investigated with regard to clinical pace of disease and tumor growth.

METHODS

CA 19-9 doubling time was examined in 75 patients with pancreatic cancer, including 41 inoperable cases. Then, its relation with their prognosis and change in tumor was evaluated.

RESULTS

The doubling time of CA 19-9 and CEA could be calculated in 90.2% and 58.5% of patients with inoperable pancreatic cancer. CA 19-9 doubling time was clearly associated with survival time in inoperable and palliatively operated cases, but not with sex, age, site of the lesion, or liver metastasis, and was significantly correlated with the tumor volume doubling time.

CONCLUSIONS

Examination of CA 19-9 doubling time may be useful in clinical evaluation of the prognosis for patients with pancreatic cancer and could possibly prove valuable in terms of the analysis of the growth process in this disease.