Clinicopathological characteristics of gastrointestinal mesenchymal tumors and diagnostic value of endoscopic ultrasonography

Inflammation-related indicators to distinguish between gastric stromal tumors and leiomyomas: A retrospective study

BACKGROUND

Gastric leiomyomas and gastric stromal tumors are the most common types of gastric tumors encountered. In recent years, the incidence of the two types of tumors has been increasing, but the differential diagnosis is still a challenge in clinical work. However, as there are many reports on stromal tumors and inflammation-related indicators are gradually being paid attention to as important factors in predicting tumor prognosis, the two main purposes of this study were to explore the inflammation-related differences between the two types of tumors and to develop a nomogram as a predictive model.

AIM

To explore the differences in platelet-lymphocyte ratio (PLR), neutrophil-lymphocyte ratio (NLR), lymphocyte mononuclear cell ratio (LMR), and SII between the two types of tumors, and simultaneously create the nomogram model.

METHODS

This study enrolled 88 patients in the gastric stromal tumor group and 56 patients in the gastric leiomyoma group, and the relevant data of the two groups were entered into the system for an integrated analysis. The primary objective of this study was to identify the differences in the inflammation index between the two types of tumors.

RESULTS

There were statistically significant differences between the two groups in sex, age, and tumor location. In comparison, gastric leiomyomas seem to be more common in women, young patients, and gastric cardia, which is in line with our previous research; the groups showed the following statistical differences: PLR (158.2% vs 134.3%, P = 0.028), NLR (2.35 vs 1.68, P = 0.000), LMR (5.75 vs 10.8, P = 0.004), and SII (546.2 vs 384.3, P = 0.003). The results of the multivariate logistic regression analysis showed that sex, age, tumor location, and LMR were independent risk factors for the identification of the two types of tumors. After considering the risk factors selected by the above analysis into the predictive model, a predictive model for distinguishing gastrointestinal stromal tumors from gastric leiomyomas was established as the nomogram.

CONCLUSION

Gastric leiomyomas and gastric stromal tumors are not only different in factors such as age of the patient, but also in inflammatory indicators such as LMR and PLR. We have established a predictive model related to the laboratory indicators and are looking forward to further research conducted in this clinical area.

Transvaginal Excision of Rectal Gastrointestinal Stromal Tumor: A Safe Minimally Invasive Approach

Introduction: Gastrointestinal stromal tumors (GISTs), the specific kit-positive mesenchymal tumors, are rarely found in the anorectum and account for 5% of all GIST cases. Surgical excision remains the main treatment for anorectal GIST. The available techniques include enucleation transanal excision or sometimes an abdominoperineal resection for large or low tumors. Case Study: We present a middle-aged female with a complaint of intermittent rectal pain for 1 year. Diagnostic workup detected a mass in the rectovaginal septum. A transvaginal excision was performed. Final histopathology showed rectal GIST. On regular follow-up visits, there was no detectable recurrence, and her anal pain disappeared completely. Discussion: Colorectal GIST accounts for only 0.1% of all colorectal tumors; this infrequency has led to a controversy in its diagnosis and management. Nevertheless, surgery remains a cornerstone element in the management of rectal GISTs. Different resection methods have been described in the literature, ranging from less-invasive approach such as transanal excision to a more radical one like an abdominoperineal resection. As there is no standard approach, choosing which one to perform depends on the tumor size, its location, and the surgeon’s preference. Conclusion: Transvaginal excision could be considered a safe minimally invasive approach for low-lying rectal GISTs.

Correlation of Endoscopic Ultrasonography Features with the Mitotic Index in 2- to 5-cm Gastric Gastrointestinal Stromal Tumors

BACKGROUND

Predicting the malignancy potential of gastrointestinal stromal tumor (GIST) before resection could improve patient management strategies as gastric GISTs with a low malignancy potential can be safely treated endoscopically, but surgical resection is required for those tumors with a high malignancy potential. This study aimed to evaluate endoscopic ultrasound (EUS) features of 2- to 5-cm gastric GISTs that might be used to predict their mitotic index using surgical specimens as the gold standard.

PATIENTS AND METHODS

Forty-nine patients (30 females and 19 males; mean age 55.1 ± 12.7 years) who underwent EUS examinations, followed by surgical resections of 2- to 5-cm gastric GISTs, were retrospectively reviewed.

RESULTS

The mean tumor size was 3.44 ± 0.97 (range 2.1-5.0) cm. A univariate analysis revealed no significant differences in age, sex, and tumor location in the low mitotic index and high mitotic index groups (all p > 0.05). In terms of EUS features, there were no significant differences in the mitotic indexes with respect to the shape, surface lobulation, border regularity, echogenicity, homogeneity, growth patterns, presence of mucosal ulceration, hyperechogenic foci, anechoic spaces, and hypoechoic halos (all p > 0.05). However, the tumor size was larger in the high mitotic index group than that in the low mitotic index group (3.97 ± 1.05 vs. 3.27 ± 0.9 cm, p = 0.03).

CONCLUSION

Conventional EUS features are not reliable for predicting the mitotic index of 2- to 5-cm gastric GISTs. Further modalities for predicting the mitotic index are needed to prevent unnecessary surgical resections in patients with a low risk of malignancy.

Comparison of Endoscopic Submucosal Dissection Application on Mucosal Tumor and Subepithelial Tumor in stomach

Background: Endoscopic submucosal dissection is minimal invasive endoscopic procedure to deal with gastric tumor. Initially, it was developed to resect mucosal neoplasm since 2000 and extended its application to submucosal tumor in the following years. Although the basic ESD skills are similar in gastric mucosal tumor and subepithelial tumor, the success rate, complication may be different between the two types of gastric tumor resection. This retrospective study is conducted to analyze the ESD procedure in gastric mucosal tumor and subepithelial tumor.

Methods: From 2007 to 2016, we reviewed all patients who underwent endoscopic submucosal dissection for gastric mucosal tumor and subepithelial tumor in Kaohsiung Medical University Hospital.

Results: Totally, 35 patients with gastric subepithelial tumor and 41 patients with gastric mucosal tumor received endoscopic submucosal dissection are enrolled. Among 35 patients with subepithelial tumor, 32 (91.4%) patients achieved curative treatment. 1 patient received emergent operation and 2 patients received salvage operation to complete tumor resection. 8 patients (22.9%) occurred perforation and no delay bleeding was found. Among 41 patients with mucosal neoplasm, 30 (71.4%) patients achieved curative treatment. 2 patients received emergent operation and 9 patients received salvage operation to complete tumor resection. 9 patients (21.9%) occurred complication, 6 patients occurred delay bleeding and 3 patients had perforation.

Conclusions: Comparing ESD between gastric mucosal tumor and subepithelial tumor, ESD had similar efficiency in curative treatment. However, ESD in subepethelial tumor encountered higher perforation and lesser delay bleeding.

Diagnosis and Endoscopic Treatment of Gastrointestinal Stromal Tumors Arising from Esophagus

Aim: The primary purpose of this study was to investigate the diagnosis and endoscopic treatment of gastrointestinal stromal tumors (GISTs) arising from esophagus. Materials and Methods: From January 2013 to December 2017, 16 cases of GISTs of esophagus were retrospectively identified from a total of >3000 GISTs treated in our center. Demographic characteristics, clinical data, endoscopic therapy outcomes, histopathology, and follow-up were analyzed. Results: The mean age of the patients was 53 years (range 35-71 years), mostly female (56.3%). Seven tumors were in the lower esophagus, five in the middle esophagus, and one in the upper esophagus. The most common symptom was abdominal discomfort (8/16; 50.0%), followed by acid reflux (6/16; 37.5%). All of the patients underwent CT scan, gastroscopy, and/or endoscopic ultrasound. Two patients were diagnosed with esophageal GISTs with a preoperative endoscopic biopsy. Tumors were resected completely in all patients by endoscopic surgery. The median operating time was 85 minutes (range 28-153 minutes), and the average tumor size was 11.6 mm (range 6-21 mm). Postoperative histopathology demonstrated esophageal GISTs were positive for CD117 and CD34. The mean length of postoperative hospital stay was 4.7 days (range 2-7 days). The median postoperative follow-up duration was 28 months (range 1-59 months). Conclusion: Endoscopic treatment seems to be safe and effective for tumors size <20 mm in diameter. However, long-term prospective randomized controlled trials are further needed.

Characterization of subepithelial lesions of the stomach and esophagus by contrast-enhanced EUS: A retrospective study

Background and Objectives:

Subepithelial lesions (SELs) of the upper part of the digestive tract are rare, and it can be difficult to characterize them. Recently, contrast-enhanced endosonography (EUS) and elastometry have been reported as useful adjuncts to EUS and EUS-guided fine needle aspiration (EUS-FNA) in cases of pancreatic mass and lymph node involvement. The aim of this retrospective analysis was to evaluate whether contrast-enhanced EUS can discriminate benign submucosal lesions from malignant ones. We describe our retrospective experience using the contrast agent SonoVue^® (Bracco Imaging, Milan, Italy) in an attempt to increase the diagnostic yield.

Patients and Methods:

Between May 2011 and September 2014, 14 patients (5 men, 9 women; median age 64 years, range 31–80 years) with SELs of the stomach or esophagus underwent EUS with SonoVue^® (low mechanical index). There were 3 esophageal lesions and 11 gastric lesions. Mean size of the lesions was 30 mm (range 11–50 mm). They were discovered after anemia (n = 5), dysphagia (n = 1), and pain (n = 4) and during follow-up for resected gastrointestinal stromal tumors (GISTs) (n = 1) and a standard upper gastrointestinal endoscopy (n = 3). On endoscopic sonograms, 10 of these lesions were hypoechoic and located in the fourth layer (muscularis), and 4 were in the second or third layer (mucosa and submucosa). Contrast enhancement was assessed in the early phase (after several seconds) and late phase (>30 seconds); a final diagnosis was made based on the findings of EUS-FNA using a 19-gauge ProCore (Cook Medical, Bloomington, IN) (n = 9) or 22-gauge FNA system (Cook Medical) (n = 1), the resected specimen (n = 3), or deep biopsy (n = 1). Different immunostaining was used in the pathologic studies (RNA was analyzed later using the C-kit, CD-117, CD-34, desmin, DOG-1, α-smooth actin, caldesmon, PS-100, and Ki-67 antibodies).

Results:

Final diagnoses were leiomyoma (n = 4), GIST (n = 5), schwannoma (n = 1), inflammatory tumor of Helvig (n = 1), pancreas rest (n = 2), and fibrosis (n = 1). No complications occurred. All 5 GISTs showed enhancement in the early and late phases, whereas the 8 remaining lesions did not show any enhancement. Only 1 leiomyoma showed heterogeneous enhancement.

Limitations:

The monocentric and retrospective study design and small number of patients.

Conclusions:

In cases of SELs of the stomach or esophagus, SonoVue^® could be a complementary tool to endosonography to differentiate GISTs (early and clear enhancement) from other SELs (few or no enhancement), such as leiomyomas or pancreatic rest. These results are similar to those of the few, small studies published on this topic, but more studies with a larger number of patients are needed to confirm these findings.

Clinicopathologic features and prognostic grouping of gastrointestinal stromal tumors (GISTs) in Pakistani patients: an institutional perspective

Objectives

Gastrointestinal stromal tumors (GISTs) are rare tumors of gastrointestinal tract, prognosis of which largely depends upon histopathologic characteristics of resection specimens, which were not widely studied in our population. Therefore we aimed to evaluate the histopathologic characteristics of GISTs in our population and their prognostic grouping according to college of American pathologist’s guidelines.

Results

Mean age of patients was 53.4 years (18–71 years). 92% of cases were of primary GISTs and stomach was the most common site (57.7%). 75% of cases were of spindle cell morphology and 53.8% belonged to high risk prognostic group. Comparison of stomach and intestinal GISTs showed that intestinal GISTs were found to be of high grade (70%) and of high risk prognostic group (75 and 80%) compared to stomach GISTs (43% were of high risk prognostic group), however this finding was not statistically significant. GISTs are infrequent gastrointestinal tumors but early diagnosis and identification of adverse histological features are key to successful treatment. We found a large majority of GISTs to be located in stomach, however intestinal GISTs were found more likely to be associated with adverse prognostic parameters. However more large scale studies are warranted to establish this finding.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3562-8) contains supplementary material, which is available to authorized users.

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.

Contrast-enhanced (endoscopic) ultrasound and endoscopic ultrasound elastography in gastrointestinal stromal tumors

Background and Objectives:

Gastrointestinal stromal tumors (GISTs) represent the largest group of subepithelial tumors (SET) of the upper gastrointestinal (GI) tract. They may show malignant behavior, in contrast to other SET. Endoscopic ultrasound (EUS) is frequently used to characterize SET. With the introduction of contrast-enhanced ultrasound (CEUS) into EUS (CE-EUS), distinct enhancement patterns can be detected. In the presented study, the characteristic features of CE-EUS in GIST are analyzed and compared with those of other SET.

Materials and Methods:

Consecutive patients from four centers with SET of the upper and middle GI tract were included and received endoscopic or transcutaneous CEUS. The results were compared with EUS-guided tissue acquisition, forceps biopsy, or surgical resection.

Results:

Forty-two out of 62 (68%) patients had SET of the stomach, 17/62 (27%) of the small intestine, 2/62 (3%) of the esophagus, and 1/62 (2%) extraintestinal. Eighty-one percent underwent surgery. Leiomyoma was found in 5/62 (8%) and GIST in 57/62 patients (92%). Thirty-nine out of 57 (68%) patients had GIST lesions in the stomach, 17/57 (30%) had GIST of the small intestine, and 1/57 (2%) patients had extraintestinal GISTs. GIST size was 62.6 ± 42.1 (16–200) mm. Hyperenhancement had a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 98%, 100%, 100%, 93%, and 98% for the diagnosis of GIST. Fifty out of 57 patients with GIST (88%) showed avascular areas in the center of the lesions.

Conclusion:

CE-EUS and CEUS show hyperenhancement and avascular areas in a high percentage of GIST but not in leiomyoma. Thus, GIST and leiomyoma can be discriminated accurately.

Diagnostic yield of endoscopic ultrasonography-guided single-incision needle knife biopsy for gastric subepithelial tumors: comparison with resected specimens

BACKGROUND

Several techniques are recommended for the histologic diagnosis of gastric subepithelial tumors (SETs). The purpose of our study was to evaluate the diagnostic yield and safety of endoscopic ultrasonography-guided single-incision needle knife (SINK) biopsy for the diagnosis of gastric SETs.

METHODS

A retrospective review of patients who received biopsy for gastric SETs from August 2012 to May 2015 was conducted. Patients who received endoscopic ultrasonography and were found to have a SET originating from the muscularis propria of the stomach were included in the study. The aim of our study was to investigate the safety and diagnostic yield of SINK biopsy for gastric SETs.

RESULTS

A total of 31 patients received SINK biopsy for SETs. The diagnostic yield of SINK biopsy was 87 % (95 % CI 75-100 %), and the diagnostic accuracy was 89 % (95 % CI 74-105 %). The sensitivity of SINK biopsy to identify gastrointestinal stromal tumors was 83 % (95 % CI 52-98 %); the specificity was 100 % (95 % CI 59-100 %); the positive predictive value was 100 % (95 % CI 69-100 %); and the negative predictive value was 78 % (95 % CI 40-97 %). There were no procedure-related adverse events during and after procedure.

CONCLUSION

The use of SINK biopsy technique in patients with SETs is a good diagnostic tool with high diagnostic yield and accuracy. The method is simple, safe, and associated with few complications.

Association of endoscopic ultrasonographic parameters and gastrointestinal stromal tumors (GISTs): can endoscopic ultrasonography be used to screen gastric GISTs for potential malignancy?

BACKGROUND

Previous research shows that only 10-30% of gastrointestinal stromal tumors (GISTs) are malignant. Nonetheless, some reports suggest that all of them have some degree of potential for malignancy. Endoscopic ultrasonography (EUS) is a useful technique for differentiation of subepithelial lesions in the gastrointestinal tract. We explored EUS characteristics that might predict the malignancy potential of GISTs.

METHODS

In this retrospective review of the medical records from 1999 through 2007, patients who had gastric stromal tumors diagnosed prior to surgery using EUS were enrolled. The EUS images, procedure records and tissue histopathology were reviewed. All patients were positive for C-kit.

RESULTS

Of the 110 patients enrolled, 57 were males, and 53 were females. Most (67%) of the GISTs were located in the gastric body. The lesion size ranged from 6.3 to 150 mm (mean ± SD: 39.73 ± 22.49 mm). The high-risk GIST group had 19 (17.3%) patients, the intermediate-risk group had 12 (10.9%) patients and the low/very low-risk group had 79 (71.8%) patients. Thirty patients had cystic lesions (27.3%), while six patients had calcification in the lesion (5.5%). Additionally, 27 patients (24.5%) had surface ulceration visible on endoscopy. GISTs at high risk for malignancy were highly associated with lesion size (p < 0.0001), cystic change (p = 0.015) and surface ulceration (p = 0.036) but not with calcification (p = 0.667). We also found that mitosis was associated with lesion size (p < 0.0001) rather than other parameters. Age was not predictive of malignancy potential (p = 0.316). However, tumor size is the only one independent risk factor for malignancy (p ≤ 0.0001).

CONCLUSIONS

The preliminary results show that large gastric GISTs with cystic change and surface ulceration may associate with a risk of malignancy, warranting more aggressive management. Nevertheless, the tumor size is more important than other factors.

Feasibility of endoscopic submucosal dissection for upper gastrointestinal submucosal tumors treatment and value of endoscopic ultrasonography in pre-operation assess and post-operation follow-up: a prospective study of 224 cases in a single medical center

BACKGROUND AND AIMS

Diagram, diagnosis, and treatment with endoscopic submucosal dissection (ESD) for upper gastrointestinal submucosal tumors (SMTs) remain controversial, although endoscopic ultrasonography (EUS) and ESD have been established in diagnosis and treatment of SMTs in decades, respectively. In this study, we have investigated prospectively the profile of upper gastrointestinal SMTs, assessed the effect and feasibility of ESD in upper gastrointestinal SMTs treatment, as well as value of EUS in pre-ESD diagnosis and post-ESD follow-up for gastrointestinal SMTs.

METHODS

The upper gastrointestinal SMTs patients detected with endoscopy were further checked by EUS, then received series ESD treatment, and fulfilled 3- and 12-month follow-up EUS detection between July 2011 and March 2015. The parameters of SMTs with EUS examination (size, original layer) and treatment with ESD (en bloc resection rate, procedure time, procedure-related complications) were investigated and analyzed.

RESULTS

A total number of 224 patients with upper gastrointestinal SMTs were enrolled, and 108 (48.2 %) were men. The mean age was 50.4 ± 12.0 years (range 19-77 years). In total, 92 (41.1 %), 14 (6.3 %), 61 (27.2 %), 22 (9.8 %), 25 (11.2 %), and 10 (4.5 %) SMTs were located in esophagus, cardiac, fundus, body and antrum of stomach, duodenum, respectively. Two hundred and eight (92.9 %) patients were successfully treated with an en bloc ESD, while other 16 patients (7.1 %) suffered ESD failure (5.3 %, 12 case) or severe complications (1.8 %, 4 cases). The mean procedure time of ESD was 47.4 ± 27.3 min (range 10-180 min). The mean size of the SMTs measured with ESD samples was 13.6 ± 9.5 mm (range 4-113 mm). In total, 87 (38.8 %), 23 (10.3 %), and 114 (50.9 %) tumors originated from muscularis mucosa, submucosa, and muscularis propria, respectively. The majority of SMTs were leiomyoma (109, 48.7 %) and gastrointestinal stromal tumors (GIST) (77, 34.4 %), while other SMTs were confirmed as ectopic pancreas (21, 9.4 %), adenoid tumor (8, 3.6 %), lipoma (5, 2.2 %), neuroendocrine tumor (3, 1.3 %), and granulosa cell tumor (1, 0.4 %). The accuracy rate of EUS in pathological diagnosis or original layer was 82.6 % (185/224) or 74.6 % (167/224). Residual tumors were detected with EUS in 3 patients (1.3 %) in 3-month follow-up and no recurrence during 12-month follow-up period.

CONCLUSIONS

The predominant SMTs in upper gastrointestinal tract were leiomyoma in esophageal tumors which originated from muscularis mucosae and GIST in stomach which originated from muscularis propria detected satisfactorily with EUS. This study showed that ESD was a safe and effective treatment for upper gastrointestinal SMTs.

Pancreatic Gastrointestinal Stromal Tumor after Upper Gastrointestinal Hemorrhage and Performance of Whipple Procedure: A Case Report and Literature Review

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors in the gastrointestinal system. These types of tumors originate from any part of the tract as well as from the intestine, colon, omentum, mesentery or retroperitoneum. GIST is a rare tumor compared to other types of tumors, accounting for less than 1% of all gastrointestinal tumors.

CASE REPORT

A 56-year-old male patient was hospitalized due to an upper gastrointestinal hemorrhage and the start of abdominal pain on the same day. In the upper gastrointestinal endoscopy that was performed, a solitary mass was found in the second section of the duodenum and a blood vessel (Forrest type 2a) was seen. The extent and location of the mass was detected by abdominal tomography. After hemodynamic recovery, a Whipple procedure was performed without any complications. A subsequent histopathological examination detected a c-kit-positive (CD117) pancreatic GIST with high mitotic index.

CONCLUSIONS

The most effective treatment method for GISTs is surgical resection. In patients with a head of pancreatic GIST, the Whipple procedure can be used more safely and effectively.

Relationship of preoperative neutrophil lymphocyte ratio with prognosis in gastrointestinal stromal tumors

OBJECTIVE

Gastrointestinal stromal tumors are believed to play a role in immunosuppression with their local effect. In some cancers with associated inflammation, an increased pretreatment neutrophil lymphocyte ratio is considered as an indicator of poor prognosis. The aim of our study was to assess the relationship of increased blood neutrophil lymphocyte ratio with disease prognosis in patients with gastrointestinal stromal tumors.

MATERIAL AND METHODS

The data of 78 patients who underwent surgery with the diagnosis of primary gastrointestinal stromal tumor in our clinic were evaluated retrospectively. The preoperative neutrophil lymphocyte ratio in the peripheral blood was determined. The neutrophil lymphocyte ratio and its relationship with tumor risk and prognosis were compared. The data were evaluated by Pearson's correlation analysis and the Welch ANOVA test.

RESULTS

The preoperative neutrophil lymphocyte ratio was significantly increased in the high-risk groups (p<0.05). An increased preoperative neutrophil lymphocyte ratio was associated with shorter survival (r=-0.32, p=0.009). In addition, an increase in the neutrophil lymphocyte ratio was associated with an increase in the mitotic activity of the tumor (r=-0.364, p=0.025).

CONCLUSION

The preoperative neutrophil lymphocyte ratio in gastrointestinal stromal tumors can be used as an indicator of high-risk tumors and poor prognosis.

Esophageal gastrointestinal stromal tumor: is tumoral enucleation a viable therapeutic option?

OBJECTIVE

The primary objective was to evaluate the feasibility of surgical enucleation of esophageal gastrointestinal stromal tumors (E-GISTs). Secondary objectives evaluated (i) the impact of tumor enucleation on oncological outcomes, (ii) the effect of pretherapeutic biopsy on the feasibility of E-GIST enucleation, and (iii) the impact of mucosal ulceration on outcome.

BACKGROUND

E-GISTs are very rare tumors and esophageal resection has been the recommended approach. The feasibility and impact on outcomes of tumor enucleation are unknown.

METHODS

Through a large national multicenter retrospective study, 19 patients with E-GISTs were identified between 2001 and 2010. Patients who underwent either enucleation or esophagectomy were compared.

RESULTS

Of over 19 patients identified with E-GISTs, curative treatment was surgical for 16 patients, with enucleation in 8 and esophagectomy in 8. In the enucleation group, median tumoral diameter was 40 mm (18-65 mm), without any mucosal ulceration, preoperative capsular ruptures, or incomplete resections. In the esophagectomy group, the median tumoral diameter was 85 mm (55-250 mm), with mucosal ulceration in 4 patients, preoperative capsular rupture in 1, and no incomplete resections. Severe postoperative complication rates were 50% and 25% in the esophagectomy and enucleation groups, respectively, with 2 postoperative deaths after esophagectomy. After a median follow-up of 6.4 years, 2 recurrences were observed after esophagectomy versus 0 after enucleation. Endoscopic biopsies did not expose patients to complications or local recurrence after enucleation. Endoscopic mucosal ulceration was associated with more aggressive tumors.

CONCLUSIONS

E-GIST enucleation seems safe for tumors of less than 65 mm in diameter.

Endoscopic ultrasonography for gastrointestinal submucosal lesions

Advances in endoscopic imaging technology have led to the detection of more cases of gastrointestinal submucosal lesions (SMLs). Endoscopic ultrasonography (EUS) was previously known as the best imaging procedure to characterize SMLs. However, the progress of endoscopic submucosal dissection (ESD) has raised some new questions concerning the role of EUS in the diagnosis of SMLs. What is the diagnostic accuracy of EUS for SMLs? How is the nature of SMLs determined? How is the layer of origin identified? What is the preoperative value of EUS for ESD? In this review, we will discuss the endosonographic features of SMLs, the diagnostic accuracy of EUS, the ability of EUS to distinguish benign and malignant SMLs, the value of EUS-guided fine-needle aspiration (FNA), and the value of EUS in clinical surveillance.

Gastric schwannoma diagnosed by endoscopic ultrasonography-guided trucut biopsy

Schwannomas of the gastrointestinal (GI) tract are rare subepithelial tumors comprising approximately 3.3% to 12.8% of all mesenchymal tumors of the GI tract. On endoscopic ultrasound (EUS) they are seen as hypoechoic tumors arising most commonly from the 4th proper muscle layer. Although EUS helps to distinguish tumor characteristics, tissue sampling is required for differentiation with other more common tumors such as GI stromal tumors. Both EUS-guided fine needle aspiration and EUS-guided trucut biopsy (EUS-TCB) can be used for tissue sampling. However, only EUS-TCB allows core biopsy and a high yield of immunohistochemical staining. We report a case of a gastric schwannoma diagnosed by EUS-TCB.

Gastrointestinal tumors of the colon and rectum

Gastrointestinal stromal tumors (GISTs) of the colon and rectum are the most common mesenchymal tumors of the gastrointestinal tract. GISTs of the colon and rectum constitute ~5% of all cases. Although colorectal GISTs can be small and found incidentally, the majority appear to be high risk and carry a significant likelihood of recurrent and metastatic disease. Surgery remains the mainstay of treatment for primary disease. There is now considerable interest in GISTs because they can be treated effectively with targeted molecular therapies, specifically tyrosine kinase inhibitors (TKIs), such as imatinib mesylate and sunitinib malate. GISTs are best treated by a multidisciplinary team comprised of the surgeon, medical oncologist, pathologist, and radiologist in the initial evaluation, management, and in continued follow-up. Increasing the number of resectable cases through pharmacologic debulking, optimizing the timing of surgery and organ preservation, reducing recurrence and surgical morbidity, prolonging survival, and possibly enhancing response to imatinib through surgical cytoreduction are all potential benefits of multidisciplinary management.

Gastric gastrointestinal stromal tumors: an analysis of 114 cases

AIM: To investigate the clinical characteristics, diagnosis, treatment and prognosis of gastrointestinal stromal tumors (GISTs) of the stomach.

METHODS: The clinical and pathological data for 114 patients with GISTs of the stomach who were treated from January 2005 to September 2010 at Wuhan Union Hospital were analyzed retrospectively.

RESULTS: GISTs of the stomach were mainly located in the cardia or fundus (53.5%) and the stomach body (36.8%). The common presenting symptoms included gastrointestinal hemorrhage and abdominal pain. EUS and CT had a high accuracy of preoperative diagnosis. Pathological and immunohistochemical examinations were necessary for a clear diagnosis. All but one patient received complete surgical resection. Immunohistochemistry demonstrated that tumor cells were positive for CD117 in 112 cases (98.2%) and for CD34 in 105 cases (92.1%). The follow-up period ranged from 3 to 68 months, with a mean value of 26.2 months. Twenty-four cases received imatinib mesylate after surgery. The 5-year survival rate and tumor-free survival rate were 100% and 98.0%, respectively.

CONCLUSION: Gastric GISTs have atypical clinical features. EUS and CT are effective diagnostic methods. Surgery is the main therapy and targeted therapy can significantly improve the survival of patients with gastric GISTs.

EUS for choosing best endoscopic treatment of mesenchymal tumors of upper gastrointestinal tract

AIM: To evaluate the value of endoscopic ultrasonography (EUS) in the choice of endoscopic therapy strategies for mesenchymal tumors of the upper gastrointestinal tract.

METHODS: From July 2004 to September 2010, 1050 patients with upper gastrointestinal mesenchymal tumors (GIMTs) were diagnosed using EUS. Among them, 201 patients underwent different endoscopic therapies based on the deriving layers, growth patterns and lesion sizes.

RESULTS: Using EUS, we found 543 leiomyomas and 507 stromal tumors. One hundred and thirty-three leiomyomas and 24 stromal tumors were treated by snare electrosection, 6 leiomyomas and 20 stromal tumors were treated by endoloop, 10 stromal tumors were treated by endoscopic mucosal resection and 8 stromal tumors were treated by endoscopic submucosal dissection. Complete resection of the lesion was achieved in all cases. Of the mesenchymal tumors, 90.38% diagnosed by EUS were also identified by pathohistology. All wounds were closed up nicely and no recurrence was found in the follow-up after 2 mo.

CONCLUSION: EUS is an effective means of diagnosis for upper GIMTs and is an important tool in choosing the endoscopic therapy for GIMTs, by which the lesions can be treated safely and effectively.

Small bowel emergency surgery: literature's review

Emergency surgery of the small bowel represents a challenge for the surgeon, in the third millennium as well. There is a wide number of pathologies which involve the small bowel. The present review, by analyzing the recent and past literature, resumes the more commons. The aim of the present review is to provide the main indications to face the principal pathologies an emergency surgeon has to face with during his daily activity.

Long-term clinical outcome of patients with gastric gastrointestinal stromal tumors

BACKGROUND

About 10-30% of gastrointestinal stromal tumors prove to be malignant. Nevertheless, the natural history of gastric gastrointestinal stromal tumors has not been fully elucidated.

AIMS

To determine the long-term clinical outcome of nonresected gastric gastrointestinal stromal tumors.

METHODS

Clinical follow-up of patients with endosonographic characteristics compatible with gastric gastrointestinal stromal tumors was conducted based on Israeli population registry. Lesions with features suggesting malignancy were usually referred to surgery. Follow-up endoscopic ultrasound examinations of nonoperated patients were reviewed.

RESULTS

Seventy-one patients with presumable gastric gastrointestinal stromal tumors were followed. Seventeen patients underwent operation; median tumor size was 43 mm (range 29-70 mm). Within a median of 43 months (range 2-131 months) ten patients died of causes unrelated to gastrointestinal stromal tumor. Forty-four patients with endosonographic diagnosis of gastric gastrointestinal stromal tumors were followed expectantly for a median of 12 years (range 5-15 years). All these patients are alive and without complications associated with gastrointestinal stromal tumor. Follow-up endoscopic ultrasound examinations demonstrated no change in tumor size in six, decrease (by 1-5 mm) in six, and increase (by 2-21 mm) in eight.

CONCLUSIONS

Therapeutic decisions guiding surgical interventions may be based on clinical presentation, comorbidity, and endosonographic characteristics. Nonoperated patients may be safely followed conservatively.

Gastric oncology: an update

PURPOSE OF REVIEW

As the field of endoscopy progresses, new tools and techniques continue to be developed for gastroenterology in general and gastrointestinal oncology in particular. Some of these include enhancements in diagnostic optics such as chromoendoscopy, magnification endoscopy, and confocal laser endomicroscopy. Others include advanced therapeutics such as endoscopic mucosal resection and endoscopic submucosal dissection. In this review, we will update the reader on these latest of technologies, their benefits and risks, as well as their role in evaluating, staging, and treating gastric neoplasms, especially gastric adenocarcinoma, gastrointestinal stromal tumors, and primary gastric lymphoma.

RECENT FINDINGS

Noteworthy studies in this review indicate that in properly selected patients with gastric adenocarcinoma, endoscopic submucosal dissection is a viable alternative to gastric resection with 100% 5-year survival rates; in patients with metastatic gastrointestinal stromal tumors, imatinib can provide effective treatment with reasonable outcome; and in patients with low grade mucosa-associated lymphoid tissue lymphoma, eradication therapy with antibiotics is curative with a very low recurrence rate.

SUMMARY

The advances discussed in this review have significantly improved the care we can offer our patients in gastric oncology. With continued advancement in the field, it will be crucial to continue to study outcomes and safety of these techniques and to develop structured training for those looking to perform these procedures.

The role of endosonography in submucosal tumours

Submucosal tumours (SMTs) are relatively common findings in patients undergoing endoscopy, especially in upper gastrointestinal (GI) tract. This term includes various non-neoplastic and neoplastic conditions. Endoscopic ultrasonography (EUS) is the best imaging procedure to characterise SMT and to determine the need for further explorations. In this review, the following issues will be addressed: the endosonographic features of SMT; the diagnostic accuracy of EUS; the ability of EUS to distinguish benign and malignant SMTs; the value of EUS-guided fine-needle aspiration (FNA); and the influence of EUS on clinical management.

[Gastrointestinal stroma tumours (GIST) and the gastroenterologist]

Gastrointestinal stromal tumours are frequently incidental findings at gastrointestinal endoscopy. The most common location is the stomach. Larger tumours may cause abdominal pain or obscure or overt bleeding. Diagnosis and distinction from other submucosal tumours is usually done by the means of endoscopic ultrasound with fine needle aspiration. Lesions with a diameter of more than 3 cm at endosonography are associated with a high malignant potential. Today, endoscopic resection of gastrointestinal stromal tumours is not (yet) routinely performed.

Predicting malignant potential of gastrointestinal stromal tumors using endoscopic ultrasound

BACKGROUND

The aim of this study was to determine which EUS characteristics correlate with malignant potential of GISTs.

METHODS

All patients with a diagnosis of GIST based on surgical resection and preoperative EUS at our institution from January 2000 to July 2006 were identified. Pathology reports were used to determine NIH classification of each GIST and EUS exams were reviewed. EUS features were compared to NIH classification of very low/low risk malignant potential or intermediate/high risk malignant potential.

RESULTS

Fourteen patients had lesions of very low or low risk malignant potential, and 12 patients had lesions of intermediate or high-risk malignant potential. EUS features of tumor size (P = 0.002), irregular extraluminal border (P = 0.005), local invasion (P = 0.02), and heterogeneity (P = 0.02) were statistically significant correlates of intermediate or high risk malignant potential.

CONCLUSIONS

EUS characteristics of tumor size, extraluminal border, depth, and heterogeneity can be used to predict malignant potential of GISTs.

Surgical resection of esophageal gastrointestinal stromal tumors

BACKGROUND

Due to the rarity of esophageal gastrointestinal stromal tumors (GISTs), their clinical course and treatment are poorly understood. We have assessed our experience in the diagnosis and management of esophageal GISTs.

METHODS

We performed a retrospective chart review of patients diagnosed with esophageal GISTs who underwent surgical resection.

RESULTS

We identified 7 patients (6 males and 1 female) who underwent surgical procedures due to esophageal GISTs between 2001 and 2003; their median age was 46 years (range, 39 to 68 years). Four patients presented with dysphagia. Two patients were diagnosed with GIST by endoscopic biopsy before surgery. Five patients underwent enucleation, and two underwent esophagectomy. All tumors were resected completely and no patient received perioperative imatinib therapy. Median postoperative follow-up was 4.4 years (range, 2.2 to 7.0 years), during which two patients were diagnosed with recurrences.

CONCLUSIONS

Esophageal GIST is a rare disease, and complete surgical resection is the standard treatment. Regular follow-up is needed even if resection is complete and negative margins are achieved.

Early endoscopic diagnosis and laparoscopic surgery for gastric stromal tumors

AIM: To explore the value of combination of gastroscopy, endoscopic ultrasonography (EUS) and laparoscopy in discovering, diagnosing and treating small gastrointestinal stromal tumors (GIST) of stomach (diameter < 2 cm).

METHODS: From August 2004 to September 2008, 23 patients were found with gastric submucosal tumors by gastroscopy, 16 of which were primarily diagnosed with GIST by EUS. The diameters of tumors are from 0.89 cm to 1.95 cm with an average of 1.42 cm. All of the 16 patients received laparoscopic partial gastrectomy under gastroscope. Following up after operation was carried out to check for tumor recurrence and metastases.

RESULTS: All operations were successfully accomplished within 45-90 min (60 min on average). There were no complications and mortalities. The median postoperative hospital stay was 4 days (range 3-7 d). Of all the 16 cases, 15 cases (93.8%) were verified with GIST by immunohistochemistry and pathology, and 1 case was with schwannoma. For patients suffering from gastric stromal tumors, there were no tumor recurrence and metastases at a mean postoperative following-up of 27 months (range 3-52 mo).

CONCLUSION: It is helpful to diagnose small GIST of stomach and predict the risk before operation by combination of gastroscopy and EUS. Laparoscopic partial gastrectomy under the localization of gastroscopy is safe and effective and the prognosis is favorable.