Laparoscopic approach of gastric gastrointestinal stromal tumors (GISTs): is it still a courageous choice? Report of two cases

Large inflammatory fibroid polyp of cardia managed laparoscopically - a case report and review of the literature

Inflammatory fibroid polyp or Vanek's tumor of the gastrointestinal tract is a rare, benign neoplasm. The lesion may occur at any age but is commonest in the sixth and seventh decades and is more often found in women. It is mostly situated in the stomach, especially in the antrum. Symptoms depend on the location and the size of the lesion. We present a case of a 67-year-old woman with a large inflammatory polyp of the cardia with a diameter of 10 cm × 5.5 cm × 7.5 cm imitating gastrointestinal stromal tumor (GIST). The patient complained of abdominal pain, nausea and mild anemia. We performed laparoscopic topical excision of the tumor. The postoperative course was uneventful. The 6-month follow-up did not reveal recurrence. The clinical image of a large Vanek's tumor can imitate symptoms of gastric cancer or GIST. Topical laparoscopic excision with a 1-2 cm healthy wall margin is a sufficient and adequate way of treatment.

Pattern of recurrence in patients with ruptured primary gastrointestinal stromal tumour

BACKGROUND

This study assessed the outcomes of patients with a gastrointestinal stromal tumour (GIST) that ruptured before or during resection.

METHODS

The records of 23 patients (8 women, 15 men; median age 54 years) with ruptured primary non-metastatic GIST were retrieved from a database of 554 patients. The written surgical and pathology reports were analysed. Review pathology was performed in all 23 cases, and mutational analysis of KIT and platelet-derived growth factor α (PDGFRA) genes was performed in 21 patients. Median follow-up was 52 months.

RESULTS

Tumour rupture was spontaneous in 16 patients, following abdominal trauma in two and occurred during resection in five. Primary tumour location was the stomach in six patients, duodenum in one and small bowel in 16. Mean tumour size was 10·2 (range 4-28) cm. According to the Miettinen and Lasota risk classification, the distribution of very low-, low-, intermediate- and high-risk cases was one, two, five and 15 respectively. One patient remained disease-free at 83 months. Fifteen of 16 patients who did not receive adjuvant therapy developed tumour recurrence after a median of 19 months. Median recurrence-free survival in patients with KIT mutations involving codons 557-558 was 11 months.

CONCLUSION

Patients with a rupture of GIST into the abdominal cavity have a risk of recurrence of nearly 100 per cent. In patients with deletion mutations involving codons 557-558, recurrence-free survival was less than 1 year. All patient groups are clear candidates for adjuvant drug therapy.

Full-thickness endoscopic resection of nonintracavitary gastric stromal tumors: a novel approach

BACKGROUND

Until now, the conventional treatment of stromal tumors has been primarily open surgery or laparoscopic excision. The use of combined laparoscopic/endoscopic surgeries has been investigated, but endoscopic therapy alone has been limited to en bloc resection or nucleus removal of intracavitary tumors with diameters<2 cm. Nonintracavitary and intramural gastric stromal tumors preclude the use of endoscopic resection due to the risk of gastric perforation. This study was designed to show the safety and effectiveness of full-thickness endoscopic resection of nonintracavitary stromal tumors based on our direct experience.

METHODS

A total of 109 consecutive patients with nonintracavitary gastric stromal tumors<4 cm in diameter underwent surgical treatment; 66 patients received endoscopic surgery and 43 patients received laparoscopic surgery.

RESULTS

No significant differences existed between the two groups in terms of demographics and clinical characteristics, and no tumor exceeded 3.5 cm in size. Median operation times (endoscopic group, 53.6 min; laparoscopic group, 139 min) and hospitalization fees of the endoscopic group were significantly lower than those of the laparoscopic group with significant median hospital stays (8 days for endoscopic group; 6 days for laparoscopic group). No intraoperative complications occurred in the laparoscopic group and complete removal of tumors was achieved in the endoscopic group. Postoperative complications occurred in 6 patients of 43 who underwent laparoscopic surgery and 17 patients of 66 who underwent endoscopic surgery, representing a significant difference; the size of the lesion correlated positively with the occurrence of complications.

CONCLUSIONS

Endoscopic resection is safe and effective for treating nonintracavitary stromal tumors. The endoscopic natural-cavity technique produced less surgical injury to the patients and preserved the anatomy of intra-abdominal structures. In addition, the endoscopic technique reduced operative times, postoperative bleeding, and costs.

Prevalence and Management of Gastrointestinal Stromal Tumors

The prevalence and characteristics of patients with confirmed gastrointestinal stromal tumor (GIST) in a community hospital over a 6-year period are described. Our objective was to communicate our experience managing this rare tumor of the gastrointestinal tract. A retrospective chart review was performed. Patients were selected based on International Classification of Diseases, 9th Revision codes in correlation with their respective confirmational pathology. Patients with a diagnosis of GIST, cells of Cajal tumor, and/or different varieties of gastrointestinal sarcoma were included in this study. These tumors had to have a positive C-kit on immunohistochemistry. Demographic and clinical data were collected from medical records as well as pathology reports. Follow up from attendings’ office records and telephone interviews complemented our data. A total of 61 patients was identified in our institution (averaging 10 patients per year). Females represented 63 per cent of our series. The average ages were 70.2 ± 19.1 years for females and 59.4 ± 13.5 years for males ( P < 0.01). The most common clinical presentation was an intra-abdominal nonobstructing mass followed by an endoscopically detected mass or incidental tumors found during unrelated surgery. Surgical emergencies such as acute abdomen and gastrointestinal bleed were rare. Over half of these tumors were located in the stomach. Other sites were the small intestine, colon, esophagus, and rectal–vaginal septum. Opened surgical resection was performed in two-thirds of treated cases, whereas laparoscopic resection was done in the remainder. Only 18 per cent of these tumors were considered benign, whereas 35 per cent were considered to have some malignant potential and 47 per cent were of undetermined potential. In surgically resected tumors, we found a 42 per cent recurrence rate with a median average time of recurrence of 22 months. Pathologic grading and type of surgery were not predictors of rate and timing of recurrence. However, the disease tended to be more aggressive in white males and age older than 70 years. Imatinib was used mainly in attempts to downstage, control recurrent disease, and make surgery possible. With the improvement of immunohistochemical techniques, the diagnosis of GIST is increasing. Preoperative diagnosis is highly uncertain and dependent on clinical suspicion. Surgical resection is still the main form of curative therapy. Our experience is similar to large-volume centers. GIST, once recognized, can be treated in community hospitals without compromise of their care.