Overt lymph node metastases from a gastrointestinal stromal tumor of the esophagus

Gastrointestinal stromal tumor of the esophagus: current issues of diagnosis, surgery and drug therapy

Gastrointestinal stromal tumors (GISTs) often arise in the stomach and small intestine, while esophageal GISTs are rare. Due to their rarity, clinicopathological data on esophageal GISTs are extremely limited, and this results in a lack of clear recommendations concerning optimal surgical management for esophageal GISTs. It is difficult to distinguish esophageal GIST from leiomyoma, the most frequent esophageal mesenchymal tumor, prior to resection, because the two types of tumors appear similar on computed tomography (CT), endoscopic ultrasound (EUS), and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET). Fine-needle aspiration biopsy (FNAB) under EUS enables definitive diagnosis, but it is often avoided because scarring could make enucleation more difficult and increase the risk of tumor dissemination by capsule destruction. Esophageal segmental and wedge resections are not usually performed due to the anatomical peculiarity of the esophagus, and the surgical options are limited to the highly invasive esophagectomy or the much less invasive surgical tumor enucleation. The decision as to which surgical procedure should be performed for esophageal GISTs is still under debate. Tumor enucleation may be permitted for smaller tumors, and esophagectomy may be recommended for larger GISTs or high-risk tumors with a high mitotic rate. The purpose of neoadjuvant imatinib administration is downsizing of the GIST to reduce the extent of resection and to reduce the risk of intraoperative complications, including tumor rupture. The efficacy of neoadjuvant/adjuvant imatinib therapy for esophageal GISTs is poorly understood, because the reports are limited to case reports or case series with small numbers. More clinicopathological data and clinical trials for esophageal GIST are expected.

Supraclavicular lymph node metastases from malignant gastrointestinal stromal tumor of the jejunum: A case report with review of the literature

Gastrointestinal stromal tumors (GISTs) represent the most common mesenchymal tumors of the alimentary tract. These tumors may have different clinical and biological behaviors. Malignant forms usually spread via a hematogenous route, and lymph node metastases rarely occur. Herein, we report a patient with a jejunal GIST who developed supraclavicular lymph node metastasis. We conclude that lymphatic diffusion via the mediastinal lymphatic station to the supraclavicular lymph nodes can be a potential metastatic route for GISTs.

Clinicopathologic Features and Clinical Outcomes of Esophageal Gastrointestinal Stromal Tumor: Evaluation of a Pooled Case Series

Clinicopathologic features and clinical outcomes of gastrointestinal stromal tumors (GISTs) in esophagus are limited, because of the relatively rare incidence of esophageal GISTs. Therefore, the aim of the current study was to investigate the clinicopathologic features and clinical outcomes of esophageal GISTs, and to investigate the potential factors that may predict prognosis.Esophageal GIST cases were obtained from our center and from case reports and clinical studies extracted from MEDLINE. Clinicopathologic features and survivals were analyzed and compared with gastric GISTs from our center.The most common location was lower esophagus (86.84%), followed by middle and upper esophagus (11.40% and 1.76%). The majority of esophageal GISTs were classified as high-risk category (70.83%). Mitotic index was correlated with histologic type, mutational status, and tumor size. The 5-year disease-free survival and disease-specific survival were 65.1% and 65.9%, respectively. Tumor size, mitotic index, and National Institutes of Health risk classification were associated with prognosis of esophageal GISTs. Only tumor size, however, was the independent risk factor for the prognosis of esophageal GISTs. In comparison to gastric GISTs, the distribution of tumor size, histologic type, and National Institutes of Health risk classification were significantly different between esophageal GISTs and gastric GISTs. The disease-free survival and disease-specific survival of esophageal GISTs were significantly lower than that of gastric GISTs.The most common location for esophageal GISTs was lower esophagus, and most of the esophageal GISTs are high-risk category. Tumor size was the independent risk factor for the prognosis of esophageal GISTs. Esophageal GISTs differ significantly from gastric GISTs in respect to clinicopathologic features. The prognosis of esophageal GISTs was worse than that of gastric GISTs.

Extraabdominal lymph node metastasis in gastrointestinal stromal tumors (GIST)

BACKGROUND

The two principal ways of metastases in gastrointestinal stromal tumors (GISTs) are diffuse intraabdominal spread and liver metastasis whereas lymph node metastases (LNM) are extremely rare. Accordingly, nodal dissection is generally not recommended for GISTs' surgical treatment.

METHODS

We present two unique cases of GIST with synchronous and metachronous extraabdominal LNM, whose clinical, macro-/microscopic, and immunohistochemical criteria, surgical and neo- or adjuvant therapy were investigated in retrospective analysis.

RESULTS

A 76-year-old man was presented with an inguinal mass and a simultaneously detected intraabdominal mass. Pathological evaluation of the core needle biopsy from the inguinal lymph node confirmed metastatic GIST. Partial resection of the ileum and inguinal lymph node dissection (LND) showed a spindle cell GIST in the ileum with inguinal LNM. Imatinib mesylate therapy was administered, which was interrupted 2 years later because of patient's intolerance. A 35-year-old man underwent extended gastrectomy, atypical liver resection, splenectomy, and LND because of a huge gastric fundus GIST. Postoperative imatinib mesylate therapy was administered. Histology showed multiple regional lymph node metastasis. Two years later, a left hemihepatectomy was performed for liver metastases. During follow-up, new axillary LNM were detected, and a sunitinib therapy was initiated. Thereafter, he developed progressive axillary, mediastinal, hepatic, abdominal, osseous, and cutaneous metastases, and he was treated by palliative cytoreductive surgery.

CONCLUSION

These two cases demonstrate that extraabdominal node metastasis may rarely occur in GIST, either initially or in the setting of widespread disease. In selected cases with confirmed or suspected LNM, LND should be considered. Metachronous extraabdominal lymph node metastasis represents a late event in high-risk GISTs and cannot be controlled by drug therapy alone.