Gastrointestinal stromal tumors: correlation between symptoms at presentation, tumor location and prognostic factors in 47 consecutive patients

Unraveling the site-specific features in small intestinal stromal tumors: a retrospective study

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are a rare and less well-characterized disease. There is limited information on the clinical features of small intestinal GISTs at different sites.

AIMS

To enhance the understanding of the clinical characteristics and disease behavior of small intestinal GISTs based on their sites.

METHODS

We conducted a retrospective review of medical records for 317 patients diagnosed with primary small intestinal GISTs confirmed by surgical pathology, comparing their clinical features and tumor characteristics.

RESULTS

According to this cohort's data, duodenal GISTs presented with longer disease durations and higher prevalence of melena (44.6%), while jejunal GISTs manifested as abdominal masses (11.5%) and acute gastrointestinal bleeding (GIB) (13.3%), with the highest rate of emergency surgeries (16.8%). Ileal GISTs were associated with an older age of onset and a higher prevalence of hematochezia (19.6%), with one-third of cases discovered incidentally during gynecological procedures. Notably, the biological behavior of small intestinal GISTs varied significantly by sites. Tumors demonstrated different immunochemical markers and a progressive increase in diameter, mitotic activity, T and M stages, and risk classification from the duodenum to the jejunum and ileum. These findings warrant further validation in prospective multicenter studies.

CONCLUSIONS

Small intestinal GISTs might exhibit distinct clinical presentations and oncological features depending on their sites.

The Prediagnostic General Practitioners' Pathway of Gastrointestinal Stromal Tumor Patients: A Real-World Data Study

Background/Objectives: Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors of the gastrointestinal (GI) tract, predominantly driven by KIT or PDGFRα oncogene mutations. Nonspecific symptoms contribute to diagnostic delays, with general practitioners (GPs) playing a pivotal role in early detection. However, studies on GIST-specific primary care pathways are limited. This study examines GP contacts, diagnoses, and prescribed drugs in primary care during the 12 months preceding GIST diagnosis. Methods: This case-control study utilized data from the Netherlands Cancer Registry and Nivel Primary Care Database. It included 294 GIST patients diagnosed between 2010 and 2020 and 576 matched cancer-free controls. GP contacts, diagnoses, and newly prescribed drugs were analyzed across two time intervals: 0-4 and 5-12 months prediagnosis. Statistical comparisons were conducted using the Wilcoxon rank-sum test and descriptive analyses. Results: GIST cases had a median of six GP contacts (IQR 4-11) in the 12 months prediagnosis versus three (IQR 2-6) for controls (p < 0.05). Contacts increased 4 months before diagnosis, peaking 1 month prior. Common diagnoses in the 4-month interval included malignant neoplasms of the stomach (27.9%) and other digestive sites (27.6% and 11.2%), abdominal pain (9.5%), and iron deficiency anemia (9.5%). Newly prescribed drugs included proton pump inhibitors (13.9%) and osmotically acting laxatives (15.0%). Conclusions: This study highlights increased GP visits and specific reasons for these visits before GIST diagnosis. Future research should further examine GP records, not only through coded data but also unstructured data, and incorporate patient and GP perspectives to explore potential improvements in the diagnostic process.

Survival outcome and impact of delayed imatinib therapy in gastric gastrointestinal stromal tumors

Background

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract, with the stomach being the predominant site. Surgical resection is the primary treatment for localized disease, but recurrence remains a concern, particularly in high-risk patients. Tyrosine kinase inhibitors (TKIs), such as imatinib, improve disease-free survival (DFS), yet their accessibility is often limited in resource-constrained settings.

Methods

This retrospective cohort study included gastric GIST patients who underwent surgical resection between 2015 and 2020 at a tertiary referral center. DFS and overall survival (OS) were analyzed using Kaplan-Meier curves and Cox proportional hazards regression.

Results

A total of 86 patients were included, with 40 (46%) classified as high-risk. The 5-year DFS was significantly lower in high-risk patients (40% vs. 95.7%, p < 0.001). Imatinib therapy group was associated with worse DFS in high-risk patients (p = 0.003), likely due to delayed initiation after recurrence rather than adjuvant use. Significant predictors of poor DFS included smoking (p < 0.001), prolonged operative time (p = 0.034), and advanced tumor stage (p < 0.001).

Conclusion

Delayed imatinib therapy negatively impacts DFS in high-risk gastric GIST patients, highlighting the need for improved access to early TKI treatment. Additionally, smoking cessation and optimized perioperative management may enhance survival outcomes. Addressing modifiable risk factors and ensuring timely posoperative treatment could improve prognosis in this population.

A Large Gastrointestinal Stromal Tumor under the Disguise of a Gastric Diverticulum: Report of a Case and Review of the Literature

INTRODUCTION

Gastrointestinal stromal tumors (GISTs) are a relatively rare clinical entity. They usually appear as solid masses in numerous locations throughout the gastrointestinal tract, varying in size and typically exhibiting extraluminal expansion along with a range of nonspecific symptoms. The exophytic growth pattern of these tumors may occasionally complicate the differential diagnosis from other medical conditions with similar clinical and imaging findings.

CASE PRESENTATION

We describe a case of a 46-year-old male patient who presented to the emergency department with symptoms of upper gastrointestinal tract hemorrhage. Initial endoscopic findings suggested a large gastric diverticulum. Surprisingly, further investigation with computed tomography and a second endoscopy with biopsy sampling revealed that the stomach wall outpouching was actually a disguised, oversized gastric GIST. The patient underwent a posterior wall sleeve gastrectomy en bloc with the mass, the spleen, and the tail of the pancreas and recovered uneventfully. Daily administration of imatinib as adjuvant therapy was included in the treatment plan. No recurrence was observed even up to the 4-year follow-up period.

CONCLUSIONS

GISTs are uncommon tumors with the ability to masquerade as gastrointestinal tract diverticula, causing diagnostic confusion. Nevertheless, high clinical suspicion combined with a thorough clinical and imaging evaluation can ultimately lead to the correct diagnosis and an appropriate treatment plan.

A Rare Case of Massive Gastrointestinal Hemorrhage Caused by an Ileal Gastrointestinal Stromal Tumor

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors of the gastrointestinal tract. Although gastrointestinal bleeding is a common complication of GISTs, life-threatening hemorrhage is rare, particularly with intestinal GISTs. We report a rare case of an ileal GIST in a 71-year-old female patient who presented with massive lower gastrointestinal bleeding. Initial CT angiography (CTA) demonstrated a brisk gastrointestinal bleed in the ileal region. Despite embolization of the associated distal ileal artery branches, the patient experienced persistent hemoglobin drops and hematochezia. Repeat CTA revealed a hyper-enhancing exophytic lesion in the proximal ileum. This 4.7cm ileal tumor had to be excised, and histopathology confirmed a low-grade GIST. This case highlights the diagnostic complexity of ileal GISTs and the importance of imaging modalities such as CTA in managing active gastrointestinal bleeding.

Gastrointestinal stromal tumor causing bleeding and intussusception: A case report

INTRODUCTION

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors that originate from interstitial cells of Cajal. They most commonly occur in the stomach, followed by the small bowel. Jejunal GISTs are particularly rare and often present with nonspecific symptoms. However, they can also present with gastrointestinal bleeding and intussusception, complicating diagnosis and treatment.

PRESENTATION OF CASE

We report a case of a 58-year-old male who presented with melena and anemia due to a bleeding intussuscepting jejunal gastrointestinal stromal tumor (GIST). The patient underwent jejunal resection and anastomosis. The postoperative course was uncomplicated, and the patient made a full recovery.

DISCUSSION

Gastrointestinal stromal tumors (GISTs) can present with melena and acute or chronic anemia due to gastrointestinal bleeding. The bleeding typically results from ulceration or erosion of blood vessels within the tumor. The diagnosis is often challenging, as the symptoms are nonspecific. Imaging techniques such as CT scans are essential for identifying the tumor, and surgical resection is the primary treatment, providing favorable outcomes for localized, low-risk cases.

CONCLUSION

Gastrointestinal stromal tumors (GISTs), although rare, should be considered in the differential diagnosis of patients presenting with gastrointestinal bleeding and anemia.

Analysis of demographics and treatment outcomes for gastrointestinal leiomyosarcoma based on the SEER database

Knowledge of patients with gastrointestinal leiomyosarcoma (GILMS) is lacking. In this study, we aimed to clarify the disease features and prognosis of GILMS based on the Surveillance, Epidemiology, and End Results database. The clinicopathological, treatment, survival, and prognostic data of GILMS from 2000-2020 were retrieved. Appropriate statistical approaches were used to evaluate demographic characteristics and survival outcomes. A total of 479 individuals with GILMS met the screening criteria. The median age of patients was 64 (15-90) years. Only 7.9% of these cases were diagnosed with lymph node metastasis. T2 or higher primary tumor extension was diagnosed in 78.1% of the patients. The 5-year cancer-specific survival (CSS) of patients who had and had not undergone surgery was 66.5% and 0%, respectively. Multivariate Cox proportional hazards analysis based on overall survival and CSS showed that female sex was a significant independent protective factor. Significant independent risk factors included age 65-79, age ≥ 80, poor differentiation, T2 and higher T stage, distant metastasis, and no surgery. Neither chemotherapy nor radiotherapy influenced survival or prognosis. This comprehensive analysis underscored the necessity of surgical excision for prolonging survival times and highlighted the urgent need to explore effective systematic treatments.

Gastrointestinal Stromal Tumors

PURPOSE OF REVIEW

This review aims to outline the current understanding of the molecular drivers and treatment paradigms of gastrointestinal stromal tumors, with a focus on recent developments in treatment in the advanced disease setting.

RECENT FINDINGS

There have been recent advancements in our understanding of the molecular biology of gastrointestinal stromal tumors, including the identification of new genetic drivers and complex resistance mechanisms. We review the most recent findings in these areas, focusing on how new research insights are reshaping treatment strategies. Recent advancements in our understanding of the biology and treatment of GIST are paving the way for more personalized and effective therapeutic options. As knowledge of rare molecular subtypes, resistance mechanisms, and novel genomic techniques grows, new approaches are emerging in an effort to improve patient outcomes.

Surgical Management of Gastric Gastrointestinal Stromal Tumors

Gastrointestinal stromal tumors (GISTs) are sarcomas that arise from the muscular layer of the gastrointestinal tract. The stomach is the most common location, followed by the small intestine. Surgical resection is the cornerstone of treatment; extensive margins and lymphadenectomy are not routinely required. Commonly utilized resection techniques include wedge gastrectomy, excision and closure of the gastrotomy, and anterior gastrotomy access with internal wedge resection. Tyrosine kinase inhibitors can be utilized in the neoadjuvant setting for cases where a reduction in tumor size would optimize resection, and in the adjuvant setting for high-risk tumors. In select cases, metastasectomy may improve prognosis.

Jejunal gastrointestinal stromal tumor (GIST) with profound anemia

Gastrointestinal stromal tumors (GISTs) are uncommon tumors typically found in the stomach, with an even rarer appearance in the jejunum. These tumors are often discovered incidentally, given their nonspecific presentation. We present a case of chronic iron deficiency anemia in a patient with symptomatic GIST involving the proximal jejunum requiring robot-assisted resection with primary anastomosis. Pathological examination of the excised GIST revealed positive immunoreactivity for cKIT, DOG1, and CD37. This case highlights the importance of considering GIST as a differential diagnosis for chronic anemia and emphasizes the critical role of CT imaging in its detection and management.

Huge Gastrointestinal Stromal Tumor (GIST) in Upper Gastrointestinal Masquerade Anaemia

Gastrointestinal stromal tumor (GIST) represents a rare neoplasm affecting the gastrointestinal (GI) tract and is classified as a common nonepithelial tumor within the GI tract. It originates from the interstitial cells of Cajal, and GIST typically manifests with symptoms such as abdominal pain, weight loss, and gastrointestinal bleeding. This case involves a 33-year-old male who presented with GI bleeding symptoms after eight months of treatment for anemia. Oesophagogastroduodenoscopy (OGDS) revealed a singular ulcerated mass measuring 4x4cm while a computed tomography (CT) scan identified a large fundal exophytic component extending from the gastroesophageal junction to the stomach. Subsequently, the patient underwent a laparotomy and proximal gastrectomy with Roux-en-Y reconstruction, which revealed a 12x10 cm tumor located at the fundus of the stomach. This report aims to underscore the potential for misdiagnosis in the initial presentation of GIST, emphasizing the importance of raising clinical awareness in such cases.

Digestive bleeding due to jejunal stromal tumor: A train can hide another-A case report

Gastrointestinal mesenchymal tumors (GIST) are the most prevalent sarcoma tumors affecting the digestive tract. GIST originates from Cajal cells located within the digestive tract's wall. These cells play a crucial role in regulating digestive peristaltism as they are considered pacemaker cells. These tumors are especially located in the stomach (60%) but can also be seen in the small bowel (30%), in which jejunal stromal tumors are estimated to reach (40%). In this case report, we describe a jejunal GIST, which was initially discovered due to active bleeding, serving as the primary symptom, along with an underlying small loop intussusception. In our knowledge, GIST causing an intussusception is a rare entity in literature as well as GIST causing active bleeding. For that aim, we present a 36-year-old male patient, presented to our department with melena. An abdominal computed tomography scan was performed, revealing a small bowel intussusception associated with a 2 cm tumor. Despite the imprecise cause of the bleeding, due to the ongoing active hemorrhage, we decided to proceed with an emergency laparotomy, suspecting a tumorous origin of the bleeding. During the surgery, the tumor was located in the jejunum. The affected jejunal segment containing the tumor was resected, and an anastomosis was performed. Pathology examination confirmed a stromal tumor. The postoperative follow-up was uneventful.

Exploring Perforated Jejunal GIST: A Rare Case Report and Review of Molecular and Clinical Literature

This case report details a rare instance of a perforated jejunal gastrointestinal stromal tumor (GIST) in a 76-year-old female patient. The patient presented with acute abdominal pain and distension without any changes in bowel habits or episodes of nausea and vomiting. Initial diagnostics, including abdominal plain radiography and ultrasonography, were inconclusive; however, a computed tomography (CT) scan revealed pneumoperitoneum and an irregular fluid collection suggestive of small intestine perforations. Surgical intervention uncovered a 35 mm jejunal GIST with a 10 mm perforation. Histopathological examination confirmed a mixed cell type GIST with high malignancy potential, further substantiated by immunohistochemistry markers CD117, DOG1, and vimentin. Molecular analysis illuminated the role of key oncogenes, primarily KIT and PDGFRA mutations, emphasizing the importance of molecular diagnostics in GIST management. Despite the severity of the presentation, the patient's postoperative recovery was favorable, highlighting the effectiveness of prompt surgical and multidisciplinary approaches in managing complex GIST cases.

A gist on an obscure neoplasm in Ghana: gastrointestinal stromal tumours

BACKGROUND

Gastrointestinal Stromal Tumour is a rare but potentially curable tumour of the gastrointestinal tract accounting for up to 1% of all gastrointestinal tumours. The discovery of Imatinib mesylate, a novel tyrosine kinase inhibitor has improved the chances even for unresectable, recurrent, or metastatic diseases.

METHODS

This study sought to document the clinical and pathological characteristics of GISTs from two tertiary hospitals in Ghana that have undergone immunohistochemistry confirmation between 2014 and 2021.

RESULTS

The median age of the subjects was 50 years with most of them (28.0%) being above 61 years. There were more females than males (64.0% vs. 36.0%). Abdominal mass and abdominal pain made up the majority of the clinical presentations. The majority of the subjects had partial gastrectomy (32.0%) which was followed by wedge resection (28.0%). Appendectomy and sleeve gastrectomy were the least performed procedures (8% each). Four of the 25 patients (16.0%) had resections of involved contiguous organs done with splenectomy being the most common procedure. The majority of GISTs were found in the stomach (68.0%) followed by the appendix (12.0%) and small bowel (12.0%). Gastrointestinal bleeding (55.8%) and abdominal pain (38.5%) were the most reported symptoms. Free resection margins were observed in 84.0% of the subjects and only 3/25 (12.0%) experienced tumour recurrence.

CONCLUSION

GIST is a potentially curable tumour that once was obscure but currently gaining popularity. Surgical resection offers the hope of a cure for localized disease while targeted therapies is a viable option for recurrent, metastatic, or unresectable tumours.

Comparing clinical characteristics and surgical outcomes of gastric and small bowel GIST: A single center experiences

OBJECTIVE

Gastrointestinal stromal tumor (GIST) is a rare kind of neoplasm at the gastrointestinal tract. There are few studies regarding the comparison of gastric and small bowel GIST in Korea. We aimed to analyze clinical characteristics and outcomes between gastric and small bowel GIST after curative resection.

METHODS

Between May 2005 and Dec 2017, 165 patients who underwent curative resection for gastric GIST (n = 115) and small bowel GIST (n = 50) were retrieved from a retrospective database. They were compared with respect to clinical, pathologic and oncological outcomes.

RESULTS

The mean age at surgery in both two group was similar (58.8 vs. 58.6, p = 0.772). The rate of emergency admission and surgery was higher in small bowel GIST group (p < 0.005). The mitotic rate and risk category were not significantly different between the two groups. However, the T stage was higher in small bowel GIST compared to the T stage of gastric GIST (22.6% vs. 44.0%, p = 0.025). During the follow-up, 5-year disease free survival rate was worse in small bowel GIST (82.0%) compared gastric GIST (93.7%) (p = 0.032). 5-year survival rate was not significantly different between the two groups (100.0% vs. 97.7%, p = 0.578). The T stage, mitotic count, and risk category were independent prognostic factors for disease free survival of Gastric and small bowel GIST in Cox multivariate analysis.

CONCLUSION

Small bowel GIST has more advanced T stage and higher rate of emergency surgery. Disease free survival rate was worse in small bowel GIST. Larger scaled prospective study of small bowel GIST is needed.

SEOM-GEIS clinical guideline for gastrointestinal stromal tumors (2022)

Gastrointestinal stromal tumor (GIST) is the most common malignant neoplasm of mesenchymal origin, and a paradigmatic model for a successful rational development of targeted therapies in cancer. The introduction of tyrosine kinase inhibitors with activity against KIT/PDGFRA in both localized and advanced stages has remarkably improved the survival in a disease formerly deemed resistant to all systemic therapies. These guidelines are elaborated by the conjoint effort of the Spanish Society of Medical Oncology (SEOM) and the Spanish Sarcoma Research Group (GEIS) and provide a multidisciplinary and updated consensus for the diagnosis and treatment of GIST patients. We strongly encourage that the managing of these patients should be performed within multidisciplinary teams in reference centers.

Outcomes of Patients with Gastrointestinal Stromal Tumors in the Past Decade

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms of the gastrointestinal tract (GIT) that represent approximately 1 to 2 percent of primary gastrointestinal (GI) cancers. Owing to their rarity, very little is known about their overall epidemiology, and the prognostic factors of their pathology. The current study aimed to evaluate the independent determinants of mortality in patients diagnosed with GISTs over the past decade.

METHODS

Our study comprised 2374 patients diagnosed with GISTs from 2000 to 2017 from the Surveillance, Epidemiology, and End Results (SEER) database. We analyzed the baseline characteristics, and overall mortality (OM), as well as the cancer-specific mortality (CSM) of GISTs. Variables with a p value < 0.01 in the univariate Cox regression were incorporated into the multivariate Cox model, to determine the independent prognostic factors.

RESULTS

Multivariate Cox proportional hazard regression analyses of factors affecting the all-cause mortality and GIST-related mortality among US patients between 2010 and 2017 revealed a higher overall mortality in non-Hispanic Black patients (HR = 1.516, 95% CI 1.172-1.961, p = 0.002), patients aged 80+ (HR = 9.783, 95% CI 4.185-22.868, p = 0), followed by those aged 60-79 (HR = 3.408, 95% CI 1.488-7.807, p = 0.004); male patients (HR = 1.795, 95% CI 1.461-2.206, p < 0.001); patients with advanced disease with distant metastasis (HR = 3.865, 95% CI 2.977-5.019, p < 0.001), followed by cases with regional involvement via both direct extension and lymph node involvement (HR = 3.853, 95% CI 1.551-9.57, p = 0.004); and widowed patients (HR = 1.975, 95% CI 1.494-2.61, p < 0.001), followed by single patients (HR = 1.53, 95% CI 1.154-2.028, p = 0.003). The highest CSM was observed in the same groups, except widowed patients and patients aged 60-79. The highest CSM was also observed among patients that underwent chemotherapy (HR = 1.687, 95% CI 1.19-2.392, p = 0.003).

CONCLUSION

In this updated study on the outcomes of patients with GISTs, we found that non-Hispanic Black patients, male patients, and patients older than 60 years have a higher mortality with GISTs. Furthermore, patients who have received chemotherapy have a higher GIST-specific mortality, and married patients have a lower mortality. However, we do not know to what extent these independent prognostic factors interact with each other to influence mortality. This study paves the way for future studies addressing these interactions. The results of this study may help treating clinicians to identify patient populations associated with a dismal prognosis, as those may require closer follow-up and more intensive therapy; furthermore, with married patients having a better survival rate, we hope to encourage clinicians to involve family members of the affected patients early in the disease course, as the social support might impact the prognosis.

Correlation Between Tumor Volume and Hemoglobin Level in Gastrointestinal Stromal Tumor

INTRODUCTION

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors. Anemia is a common finding in GIST, but the relationship between tumor volume and anemia severity is not well established.

METHODS

This study aimed to investigate the correlation between the severity of anemia and various factors, mainly tumor volume, in GIST patients who underwent surgical resection. The study included 20 patients with GIST who underwent surgical resection at a tertiary care center. Demographic data, clinical presentation, hemoglobin level, radiological findings, surgical procedure, tumor characteristics, pathological findings, and immunohistochemical analysis were recorded. The tumor volume was calculated from the final resected tumor dimensions.

RESULTS

The mean age of the patients was 53.8 ± 12 years. Eleven were males, and nine were females. The most common presentation was upper gastrointestinal bleeding (50%), followed by pain in the abdomen (35%). The most common tumor location was the stomach (75%). The mean hemoglobin level was 10.29 ± 1.9 g/dL. The mean tumor volume was 470.8 ± 1269.07 cc. R0 resection was achieved in 18 (90%) patients. There was no significant correlation between tumor volume and hemoglobin level (r=0.227, p=0.358).

CONCLUSION

This study found no significant correlation between tumor volume and the severity of anemia in patients with GIST. Further studies with larger sample sizes are needed to validate these findings.

Gastrointestinal stromal tumors of the small intestine: the challenge of diagnosis and the outcome of management

PURPOSES

Gastrointestinal stromal tumor (GIST) is a rare small intestinal tumor. Most patients usually report long-period complaints due to difficult diagnoses. A high grade of suspicion is required for early diagnosis and initiation of the proper management.

METHODS

A retrospective study of all patients with small intestinal GIST who were operated in the period between January 2008 and May 2021 at Mansoura University Gastrointestinal Surgical Center (GIST).

RESULTS

Thirty-four patients were included in the study with a mean age of 58.15 years (± 12.65) with a male to female ratio of 1.3:1. The mean duration between onset of symptoms and diagnosis was 4.62 years (± 2.34). Diagnosis of a small intestinal lesion was accomplished through abdominal computed tomography (CT) in 19 patients (55.9%). The mean size of the tumor was 8.76 cm (± 7.76) ranging from 1.5 to 35 cm. The lesion was of ileal origin in 20 cases (58.8%) and jejunal in 14 cases (41.2%). During the scheduled follow-up period, tumor recurrence occurred in one patient (2.9%). No mortality was encountered.

CONCLUSION

Diagnosis of a small bowel GISTs requires a high grade of suspicion. Implementing new diagnostic techniques like angiography, capsule endoscopy, and enteroscopy should be encouraged when suspecting these lesions. Surgical resection is always associated with an excellent postoperative recovery profile and very low recurrence rates.

An atypical presentation of gastrointestinal stromal tumour: a case report

Gastrointestinal stromal tumours (GIST) occur more commonly in the stomach and make up ~80% of the GI mesenchymal neoplasms. They are very rare in young adults and in males. The diagnosis is confirmed histologically and immunohistochemically. Once diagnosed, survival rates are dependent on various factors. The main treatment is resection, but targeted therapy can be used pre or post-operatively. This case is of a 35-year-old female with no significant medical history presenting to her general practitioner with lethargy, malaise and mild weight loss. Initially, she was investigated for a haematological malignancy, but upon further investigations, her computed tomography (CT)  scan showed an abdominal mass, which was resected and found to be a high-grade perforated gastrointestinal stromal tumour in her proximal ileum. This is a good example of an atypical presentation of GIST and emphasizes the importance of thorough workup and prompt surgical intervention in achieving a satisfactory outcome.

Management of pelvic sarcoma

Pelvic sarcomas are a rare and heterogenous group of tumors divided into two groups: soft tissue sarcomas and bone sarcomas. Soft tissue sarcomas of the pelvis include most commonly liposarcoma, leiomyosarcoma, gastrointestinal stromal tumors, malignant peripheral nerve sheath tumors, and solitary fibrous tumors. Bone sarcomas of the pelvis most commonly include osteosarcoma and chondrosarcoma. Multidisciplinary treatment at a center experienced in the treatment of sarcoma is essential. Management is dictated by histologic type and grade. Surgical resection with wide margins is the cornerstone of treatment for pelvic sarcomas, although this is often challenging due to anatomic constraints of the pelvis. Multimodal treatment is critical due to the high risk of local recurrence in the pelvis.

Malignant inflammatory myofibroblastic tumor: a rare case presentation

Malignant inflammatory myofibroblastic tumors (IMT) are extremely rare, aggressive tumors with variable presentation. This is a case of a 29-year-old female presented with severe anemia and a large abdominal mass presumed to be a gastrointestinal stromal tumor (GIST). Severe anemia, leukocytosis and thrombocytosis accompanied the presentation. Final pathological assessment yielded a diagnosis of malignant IMT. Given the rarity of these tumors, no established diagnostic criteria exist aside from histological analysis of the tissue, which may result in delays or inappropriate treatment. As these tumors are aggressive in nature, a high index of suspicion is critical to improve outcomes. Further reports on the presentation, diagnosis and treatment of such rare tumors are important to develop clinical diagnostic guidelines to improve diagnosis and treatment and improve outcomes.

Angiogenesis in gastrointestinal stromal tumors: From bench to bedside

Gastrointestinal stromal tumors (GISTs) are rare neoplasms with an estimated incidence from 0.78 to 1-1.5 patients per 100000. They most commonly occur in the elderly during the eighth decade of life affecting predominantly the stomach, but also the small intestine, the omentum, mesentery and rectosigmoid. The available treatments for GIST are associated with a significant rate of recurrent disease and adverse events. Thorough understanding of GIST's pathophysiology and translation of this knowledge into novel regimens or drug repurposing is essential to counter this challenge. The present review summarizes the existing evidence about the role of angiogenesis in GIST's development and progression and discusses its clinical underpinnings.

Gastrointestinal Stromal Tumors and the General Surgeon

Gastrointestinal stromal tumors (GISTs) are rare malignancies of the gastrointestinal tract but are the most common sarcoma. This review covers aspects of the care of patients with GIST relevant to surgeons. In particular, management of sub-2 cm GISTs, the utility of neoadjuvant and adjuvant therapy for primary GISTs, and indications for surgery in the setting of metastatic disease are discussed.

A case of jejunal GIST revealed by hematemesis: Unusual situation

Introduction

Gastrointestinal stromal tumors (GISTs) are rare tumors of the gastrointestinal (GI) tract, which can occur in majorly stomach, and rarely in the small intestine, rectum, and large intestine. We report a jejunal GIST presented with massive hematemesis in the current study.

Case presentation

A 39-years-old male, without any underlying history, was presented to our center with the complaint of massive hematemesis. Given the unstable hemodynamics of the patient, an upper GI endoscopy was requested, associated with a large amount of blood in the duodenal bulb without any sign of bleeding. The patient was sent to the operation room, and after laparotomy, a mass was seen in the jejunum, revealed as GIST after pathological study.

Discussion

Small-intestine-related etiologies are rare conditions related to upper GI bleeding (UGIB). Jejunal GIST usually manifests as asymptomatic subepithelial mass and is associated with abdominal discomfort or GI bleeding. Sudden unset bleeding is a rare manifestation of jejunal GIST, but it can be associated with the emergency outcome and may need emergency intervention.

Conclusion

UGIB can occur in jejunal GIST, which should be considered in the management of UGIB.

•

Gastrointestinal stromal tumors (GISTs) are rare tumors of the gastrointestinal (GI) tract.

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GISTs are rarely found in the small intestine, compatible with abdominal discomfort.

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Jejunal GISTs usually manifest as intestinal obstruction and abdominal pain.

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Massive hematemesis is rare in jejunal GISTs and should be consider in the management of upper GI bleeding.

Unusual Gastrointestinal Hemorrhaging Mimicking a Rupture of Solitary Gastric Varices Due to a Gastric Gastrointestinal Stromal Tumor with Exogenous Growth

Gastric gastrointestinal stromal tumors can lead to upper gastrointestinal hemorrhaging, which is usually caused by dimpling or ulceration on the tumor surface. While rare, pedunculated gastric gastrointestinal stromal tumors outside the stomach can present as a huge mass with delayed complaints. We herein report an unusual hemorrhaging mimicking a rupture of solitary gastric varices due to a pedunculated gastric gastrointestinal stromal tumor. In this case, contrast-enhanced computed tomography (CECT) was essential for tumor detection. An endoscopic investigation revealed dilated, aberrant veins and arteries in the submucosa of this tumor, recognized as solitary gastric varices.

Assessment of Systemic Inflammation and Nutritional Indicators in Predicting Recurrence-Free Survival After Surgical Resection of Gastrointestinal Stromal Tumors

Background

Recent studies have shown that the systemic inflammation and nutritional indicators are prognostic for a variety of malignancies. However, only limited data have so far demonstrated their usefulness in gastrointestinal mesenchymal tumors (GIST).

Methods

We retrospectively analyzed the data of GIST patients who underwent radical surgery in Beijing hospital from October 2004 to July 2018. The area under the receiver operating characteristic curve (AUC) was used to compare several commonly used inflammatory and nutritional indicators. The indicators with largest AUC were further analysis. Optimal cut-off values of those indicators in predicting recurrence-free survival (RFS) were determined. Kaplan-Meier curve and the time-dependent receiver operating characteristic (ROC) curve were used to assess the prognostic values. We then used univariate and multivariate Cox regression analyses to identify prognostic factors that were associated with RFS.

Results

In total, 160 patients who underwent surgery for GIST were included in the study. The median survival time was 34.5 months, with 1-, 3-, and 5-year RFS rates of 96.1%, 84.7%, and 80.8%, respectively. The inflammatory and nutritional indicators with largest AUC were Systemic immunoinflammatory Index (SII) and Geriatric Nutrition Risk Index (GNRI), reached 0.650 and 0.713, respectively. The optimal cutoff of GNRI and SII were 98.3, and 820.0, respectively. Univariate analysis showed that GNRI, SII, KI67, surgery method, tumor location, tumor size, and mitotic index were all significant prognostic indicators of RFS. After multivariate Cox analysis, independent prognostic factors for RFS in GIST included tumor location, mitotic index, tumor size, and GNRI (HR=2.802,95% CI: 1.045 to 7.515, p = 0.041). Besides, SII also tended to be associated with RFS (HR = 2.970, 95% CI: 0.946 to 9.326, p = 0.062).

Conclusions

High GNRI is an independent prognostic factor for RFS in GIST, while SII can be considered as a prognostic factor. GNRI and SII can be used as tools to evaluate the prognosis of patients before surgery, helping doctors to better treat high-risk patients.

Gastric gastrointestinal stromal tumors. Is there a necessity to use imatinib in the intermediate-risk group?

BACKGROUND

A gastrointestinal stromal tumor (GIST) is a tumor that occurs in the gastrointestinal tract, most frequently in the stomach or small intestine. This study aimed to reveal the clinical, histopathological, and immunohistochemical features of patients with GIST and to determine the effect of adjuvant tyrosine kinase inhibitor (TKI) use on survival rates in intermediate-risk gastric GIST cases.

METHODS

Clinical characteristics, histopathological findings, and oncological outcomes of 51 patients operated on for gastric GIST between 2010 and 2019 were analyzed retrospectively. Patients treated with neoadjuvant and adjuvant TKI were identified. The effect of adjuvant therapy on survival in the intermediate-risk group was examined.

RESULTS

There were 33 females and 18 males, with a mean age of 64.9 ± 12.8 years. The most common surgical procedure was gastric wedge resection. Three cases were treated with laparoscopy, and 48 underwent open surgery. A multi-visceral resection was carried out in three cases. All cases underwent R0 resection. In the intermediate-risk group, there were no statistical differences between individuals receiving adjuvant therapy (n =12) and those not receiving adjuvant therapy (n =6) regarding survival rates (p =0.157). The average follow-up period was 54.9 (min: 2 - max: 106) months. Over this period, in three and five patients, recurrence and metastases occurred, respectively, and seven patients succumbed to the disease. Disease-free survival for five years was 93.7 %, metastasis-free survival was 83.4 %, and overall survival was 86.7 %. HIPPOKRATIA 2021, 25 (3):113-118.

CONCLUSIONS

This study showed that adjuvant TKI therapy did not affect survival rates in intermediate-risk gastric GIST.

Gastrointestinal leiomyosarcoma demonstrate a predilection for distant recurrence and poor response to systemic treatments

BACKGROUND

Primary leiomyosarcoma (LMS) of the gastrointestinal (GI) tract is rare. Limited literature exists regarding the clinical characteristics and outcome for patients with localised and metastatic disease.

METHODS

A retrospective chart review was performed for patients greater than 18 years of age diagnosed with GI LMS at The Royal Marsden Hospital between 1 January 2000-1 May 2020. Descriptive statistics were performed. Patients were censored at data cut-off date of 27 June 2020.

RESULTS

Forty-six patients with a median age at diagnosis of 54 years (range 25-85) were identified. Fifteen percent (n = 7) of patients previously received abdominal radiation for an unrelated cancer. All patients with localised disease (n = 36) had resection with oncological margins. For patients who underwent potentially curative surgery, median recurrence-free survival (mRFS) was 13 months (0.4-183 months), and half of these patients (n = 18) developed recurrent disease post resection (distant n = 16, local n = 2). Median overall survival (mOS) was 27 months for patients with distant recurrence. Twenty-one percent (n = 10) of patients presented with synchronous metastatic disease and their mOS was 19 months. Median progression-free survival (mPFS) for patients treated with conventional chemotherapy ranged from 2.0 to 8.0 months.

CONCLUSION

The risk of recurrence is significant, and recurrence-free survival was short even with complete oncologic resection. The relationship of prior abdominal radiotherapy to the development of GI LMS warrants further investigation. Outcomes with systemic therapy for metastatic disease were poor and there is a need for the development of more effective systemic therapies.

Evaluation of risk classifications for gastrointestinal stromal tumor using multi-parameter Magnetic Resonance analysis

BACKGROUND

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal malignancy of the gastrointestinal tract. At present, it is generally believed that the prognosis of GIST is closely related to its risk classification. It may add value to correctly diagnose and evaluate the risk of invasion using a noninvasive imaging examination prior to surgery. MRI has the advantages of multiple parameters and high soft tissue resolution, which may be the potential method to preoperatively evaluate the risk of GIST.

PURPOSE

To retrospectively evaluate the diagnostic accuracy of multi-parameter MR analysis for preoperative risk classification of GIST.

MATERIALS AND METHODS

In this 6-year retrospective study, full MRI examination was performed on all 60 GIST cases confirmed classified by pathology, including 35 cases of very low-to-low-risk GIST and 25 cases of intermediate-to-high-risk GIST. Dynamic contrast-enhanced T1- and T2-weighted images, and apparent diffusion coefficient (ADC) maps were reviewed independently by two radiologists blinded to pathologic results. Volume, ADC ratio, three wash-in indexes (WII) were calculated and compared using t-test or Kruskal-Wallis nonparametric test. Sensitivity and specificity analyses were performed to calculate diagnostic accuracy using ROC analyses. Differences were considered significant at p < 0.05.

RESULTS

All GISTs were resected. Patient age, sex, tumor location and tumor shape did not differ significantly across the two groups (p = 0.798, 0.767, 0.822 and 0.096, respectively). GIST in the intermediate-to-high-risk group presented significantly greater volume (p = 0.0045), lower ADC ratio (p = 0.0125) and faster enhancement (for WII2, p < 0.0001; for WII3, p = 0.0358) than that of GIST in the very low-to-low-risk group. This combination of the volume, ADC ratio and WII2 provided sensitivity of 88%, specificity of 94.29%, and accuracy of 91.7% for the risk classification of GIST.

CONCLUSION

Multi-parameter MR analysis provides a preoperative imaging standard for accurately distinguishing very low-to-low-risk GIST from intermediate-to-high-risk GIST.

Comparison of Cancer Prevalence in Patients With Neurofibromatosis Type 1 at an Academic Cancer Center vs in the General Population From 1985 to 2020

IMPORTANCE

Neurofibromatosis type 1 (NF1) is a complex genetic disorder that is associated with not only neurofibromas, but also an increased susceptibility to other neoplasms.

OBJECTIVE

To evaluate the prevalence of neoplasia and outcomes among patients with NF1.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted among patients with NF1 at a single academic cancer center from 1985 to 2020 with median (range) follow-up of 2.9 years (36 days to 30.5 years). Of 2427 patients evaluated for NF1, 1607 patients who met the National Institutes of Health consensus criteria for NF1 were included. This group was compared with estimates from Surveillance, Epidemiology, and End Results (SEER) Cancer Statistics Review 1975 to 2015 and SEER participants database unless otherwise specified. Data were analyzed from August 2018 to March 2020.

MAIN OUTCOMES AND MEASURES

Disease-specific survival (DSS) was measured from diagnosis date to date of neoplasm-specific death or censorship and calculated using the Kaplan-Meier method. Survival curves were compared using the log-rank test. Deaths from disease were considered a DSS end point; other deaths were considered censored observations. Secondary outcome measures were comparisons of (1) overall survival of patients with NF1 with neurofibroma neoplasms vs those without nonneurofibroma neoplasms, (2) neoplasm prevalence in the NF1 group vs general population estimates, and (3) age at diagnosis in the NF1 group vs general population estimates for the most common neoplasms in the NF1 group.

RESULTS

Among 1607 patients with NF1, the median (range) age at initial visit was 19 years (1 month to 83 years) and 840 (52.3%) were female patients. Among 666 patients who developed other neoplasms in addition to neurofibromas (41.4%), 295 patients (18.4%) developed glioma and 243 patients (15.1%) developed malignant peripheral nerve sheath tumor (MPNST), the most common neoplasms. Patients with NF1, compared with the general population, developed several neoplasms at a younger mean (SD) age (low-grade glioma: 12.98 [11.09] years vs 37.76 [24.53] years; P < .0001; high-grade glioma [HGG]: 27.31 [15.59] years vs 58.42 [19.09] years; P < .0001; MPNST: 33.88 [14.80] years vs 47.06 [20.76] years; P < .0001; breast cancer: 46.61 [9.94] years vs 61.71 [13.85] years; P < .0001). Patients with NF1 developed neoplasms more frequently compared with the general population (odds ratio, 9.5; 95% CI, 8.5-10.5; P < .0001). Among patients with NF1, significantly lower 5-year DSS rates were found among those with undifferentiated pleomorphic sarcoma (1 of 5 patients [20.0%]), HGG (8 of 34 patients [23.1%]), MPNST (72 of 228 patients [31.6%]), ovarian carcinoma (4 of 7 patients [57.1%]), and melanoma (8 of 12 patients [66.7%]) compared with those who had neoplasms classified as other (110 of 119 patients [92.4%]) (all P < .001) .

CONCLUSIONS AND RELEVANCE

This cohort study found that among patients with NF1, those who developed undifferentiated pleomorphic sarcoma, HGG, MPNST, ovarian carcinoma, or melanoma had significantly lower DSS rates compared with those who developed other neoplasms. This study also found that patients with NF1 developed some neoplasms more frequently and at a younger age compared with individuals without NF1. HGGs and MPNST were noteworthy causes of death among patients NF1. This information may be useful for NF1 patient counseling and follow-up.

Role of Multidetector CT Imaging in the Risk Stratification of Gastrointestinal Stromal Tumors (GISTs)–A Retrospective Analysis

Background Gastrointestinal stromal tumors (GISTs) are the most common gastrointestinal mesenchymal neoplasms which can arise from any part of the gastrointestinal tract (GIT) or an extraintestinal location. Size and the organ of origin are the major imaging inputs expected from the radiologist. However, it is worthwhile to find out which imaging characteristics on MDCT correlate with risk stratification. This knowledge would help the clinician in treatment planning and prognostication. The aim of this retrospective study is to evaluate the various MDCT imaging characteristics of GISTs and find out which parameters have significant association with risk and subsequent development of metastasis on follow-up whenever it was possible.

Materials and Methods This is a retrospective study conducted on 45 histopathologically proven cases of GIST from two institutions by searching from the digital archives. The following imaging parameters were analyzed: maximum size in any plane, organ of origin, shape (round, ovoid or irregular), margin (well-defined or ill-defined), surface (smooth or lobulated), percentage of necrosis, growth pattern, enhancement characteristics–both intensity (mild, moderate or significant) and pattern (homogenous vs. heterogenous), calcification, infiltration into adjacent organs, and presence of metastasis at presentation or on follow-up.

Results CT morphological parameters of significance in risk stratification as per our study include tumor necrosis, predominant cystic change, irregular and lobulated shape/surface characteristics, and adjacent organ infiltration.

The parameters which were associated with development of metastasis were size > 5 cm, necrosis > 30%, and the presence of adjacent organ infiltration.

Conclusion The radiologist has an important role in ascertaining the size of tumor as well as the organ of origin accurately to guide the clinician in risk calculation and subsequent prognostication. In addition, certain CT characteristics mentioned above, namely, tumor size, significant necrosis/cystic changes, irregular/lobulated contour, and invasion of adjacent organs, help in risk stratification and in predicting metastasis/poor prognosis.

Recent advances in the management of gastrointestinal stromal tumor

Gastrointestinal stromal tumor (GIST) is a rare but an important clinical entity seen in our clinical practice. It is the most common mesenchymal tumor of the gastrointestinal tract and most common malignancy of the small intestine. Although the exact prevalence of GIST is not known, the incidence of GIST has been increasing. GISTs arise from interstitial cells of Cajal. Most of the GISTs occur due to mutation in c-kit gene or platelet derived growth factor receptor alpha gene. 15% of GISTs do not have these mutations and they are called wild-type GISTs. Almost all GISTs express KIT receptor tyrosine kinase. Histologically, GISTs look like spindle cell tumors most of the time but they can be epitheloid or mixed type. The median size of GISTs varies from 2.7 cm to 8.9 cm. Clinically, patients with small GISTs remain asymptomatic but as the GIST size increases, patients present with various symptoms depending on the location of the GIST. Most of GISTs are located in the stomach or small bowel. Diagnosis is suspected on imaging and endoscopic studies, and confirmed by tissue acquisition with immunohistochemical staining. The aggressiveness of GISTs depends on the size, mitotic index and location. Surgical resection is the treatment of choice. But various endoscopic modalities of resection are increasingly being tried. Tyrosine kinase inhibitors are extremely useful in the management of large GISTs, unresectable GISTs and metastatic GISTs. Treatment options for metastatic GISTs also include radiotherapy, chemotherapy, hepatic artery embolization, chemoembolization and radiofrequency ablation.

Clinical features and immunohistochemistry profile of biopsy-proven gastric gastrointestinal stromal tumor (GIST): a description of 5 years case series and literature review of GIST

Background

Gastrointestinal stromal tumor (GIST) was the most common mesenchymal tumor of the gastrointestinal tract predominately occurring in the stomach. Although GIST was a rare disease, it was considered to be a life-threatening malignancy.

Objective

To explore the current status of gastric GIST in Thai patients.

Method

The medical records of patients who were diagnosed with histologically proven gastric GIST from 2012 to 2016 in King Chulalongkorn Memorial Hospital were reviewed.

Results

Of 22 patients, there were 14 (63.6%) females and 8 (36.4%) males with the mean age of 62.6 ± 14.8 years. The average duration before the first presentation was 12 weeks. The initial symptoms were upper gastrointestinal bleeding (50.0%) followed by abdominal pain (31.8%). Tumor mostly located at the proximal part (fundus and cardia) in 20 (90.9%) patients. At the time of the diagnosis, three patients (13.6%) had distant metastasis. Of this group, 77.3% underwent surgical treatment.

Discussion

Although gastric GIST was an uncommon disease, early diagnosis and prompt treatment could save the lives of many patients.

Clinical outcomes of tumor bleeding in duodenal gastrointestinal stromal tumors: a 20-year single-center experience

BACKGROUND

Duodenal gastrointestinal stromal tumors (GISTs) are rare, and reports on duodenal GIST bleeding are few. We analyzed the risk factors and clinical outcomes of hemorrhagic duodenal GISTs and compared them with those of gastric GISTs.

METHODS

Primary duodenal GISTs surgically diagnosed between January 1998 and December 2017 were retrospectively reviewed. Furthermore, patients with duodenal GIST were compared with those with primary gastric GIST histopathologically diagnosed between January 1998 and May 2015 using previously published data.

RESULTS

Of the 170 total patients with duodenal GISTs, 48 (28.2%) exhibited tumor bleeding. Endoscopic intervention, embolization, and non-interventional conservative treatment were performed for initial hemostasis in 17, 1, and 30 patients, respectively. The 5-year survival rate was 81.9% in the bleeding group and 89.4% in the non-bleeding group (P = 0.495). Multivariate analysis showed that p53 positivity was a significant risk factor for duodenal GIST bleeding (hazard ratio [HR] 2.781, P = 0.012), and age ≥ 60 years (HR 3.163, P = 0.027), a large maximum diameter (comparing four groups: < 2, 2-5, 5-10, and ≥ 10 cm), and mitotic count ≥ 5/high-power field (HPF) (HR 3.265, P = 0.032) were risk factors for overall survival. The incidence of bleeding was significantly higher in duodenal GISTs than in gastric GISTs (28.2% vs. 6.6%, P < 0.001), and the re-bleeding rate after endoscopic hemostasis was also higher in duodenal GISTs than in gastric GISTs (41.2% vs. 13.3%, P = 0.118).

CONCLUSION

In patients with duodenal GIST with old age, large tumor diameter, and mitotic count ≥ 5/HPF, a treatment plan should be established in consideration of the poor prognosis, although tumor bleeding does not adversely affect the prognosis. Duodenal GISTs have a higher incidence of tumor bleeding and re-bleeding rate after endoscopic hemostasis than gastric GISTs.

Comparative clinical features and short-term outcomes of gastric and small intestinal gastrointestinal stromal tumours: a retrospective study

Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours of the gastrointestinal tract. Recent research has shown that small intestinal GISTs exhibit more aggressive features than gastric GISTs. To compare the clinical features of gastric and small intestinal GISTs for the further prediction of different prognoses, we conducted a retrospective study. 43 patients in the small intestine group and 97 in the gastric group were collected between January 2016 and December 2017. Data on demographics, preoperative lab results, clinicopathological results and surgical management were compared between groups. Significant elements were subsequently included in logistic regression analysis for further identification. The Kaplan-Meier method and log-rank test were used to calculate the relapse-free survival (RFS) rate and cumulative survival rate. Univariable analysis demonstrated that underlying disease, gastrointestinal (GI) bleeding, lymphocyte count, haemoglobin (Hb), albumin (ALB), platelet-to-lymphocyte ratio (PLR), thrombin time (TT), National Institutes of Health (NIH) category, Dog1, surgical procedure types and postoperative hospitalization were different between the two groups. Among these factors, logistic regression analysis identified that patients in small intestinal group exhibited significantly higher GI bleeding rate (p = 0.022), NIH category (p = 0.031), longer postoperative hospitalization time (p = 0.001) with lower TT value (p = 0.030) than those in gastric group. The log-rank test indicated that the location of the GIST (p = 0.022), GIST with GI bleeding (p = 0.027) and NIH category (p = 0.031) were independent prognostic predictors for poor outcome regarding RFS. Regarding cumulative survival, only the location of the GIST (p = 0.027) was an independent prognostic predictor for poor outcome. Thus, we concluded that small intestine GISTs were associated with lower TT, recurrent GI bleeding, advanced NIH category and extended postoperative hospitalization. Nevertheless, future multicentre prospective study are expected to validate our results.

[Multiple gastrointestinal stromal masses in the small bowel detected in a patient with peritonitis]

We here report a case of multiple gastrointestinal stromal tumors (GIST) in the small bowel detected in a patient with peritonitis. The peculiarity of this case study is the intraoperative detection of multifocal small bowel tumor masses, suggesting gastrointestinal stromal tumors on postoperative CT scan. Tumor couldn't be suspected clinically on the basis of peritonitis.

Clinical outcomes of upper gastrointestinal bleeding in patients with gastric gastrointestinal stromal tumor

BACKGROUND

Upper gastrointestinal bleeding (UGIB) is one of the major manifestations of gastrointestinal stromal tumor (GIST) of the stomach. Several studies have reported that GIST bleeding is associated with poor prognosis. However, only case reports have reported hemostasis modalities for treating hemorrhagic gastric GIST. To identify clinical outcome of gastric GIST bleeding, we analyzed risk factors and prognosis of hemorrhagic GIST evaluating hemostasis methods.

METHODS

Total 697 patients histopathologically diagnosed with primary gastric GIST between January 1998 and May 2015 were enrolled to the study, retrospectively.

RESULTS

Of 697 total patients, 46 (6.6%) patients had UGIB. Endoscopic intervention, transarterial embolization, or surgical intervention was performed for initial hemostasis in 15, 2, and 1, respectively. Over a median of 68 months of follow-up, 16 patients in bleeding group and 88 patients in non-bleeding group died; the 5-year survival rate was 79.4% in bleeding group and 91.8% in non-bleeding group (p = 0.004). Multivariate analysis showed that significant risk factors for gastric GIST bleeding included the maximal tumor diameter > 5 cm and Ki-67 positivity. Age ≥ 60 [hazard ratio (HR) = 8.124, p = 0.048], necrosis (HR = 5.093, p = 0.027), and bleeding (HR 5.743, p = 0.034) were significant factors for overall survival of gastric GIST patients.

CONCLUSIONS

Bleeding risk of gastric GIST was higher when tumor had diameter > 5 cm or Ki-67 positivity. In addition, tumor bleeding, necrosis, and age ≥ 60 years were associated with poor overall survival. Endoscopic intervention can be considered as an effective method for initial hemostasis of hemorrhagic gastric GIST.

Treatment recommendations for small gastric gastrointestinal stromal tumors: positive endoscopic resection

Objectives: To evaluate the safety and efficacy of endoscopic resection and discuss the treatment strategy of small gastric gastrointestinal stromal tumors (GISTs) less than 2 cm. Material and methods: The data of 713 patients, who underwent endoscopic submucosal dissection (ESD) for gastric submucosal tumors (SMTs), were retrospectively analyzed. We investigated the clinicopathological features and analyzed the risk potential of small gastric GISTs, and documented therapeutic and follow-up outcomes. We also compared the follow-up results between operated patients and 58 patients who were suspected of small gastric GISTs and underwent regular surveillance under endoscopic ultrasound (EUS) in the same period. Results: GISTs were the most common gastric SMTs (289 cases, 40.5%), of which small GISTs were found in 250 cases. The mitotic index was less than 5 in all cases. However, 122 out of 250 cases (48.8%) had adverse factors under EUS, which were related to tumor size (p < .01). ESD was successfully performed in all patients, and no serious complication or perioperative death occurred. The follow-up period for 42.07 ± 22.49 months revealed improvement of symptoms in 80.2% patients and showed no recurrence or metastasis. Of the 58 patients selected for EUS surveillance, 48 (82.8%) presented with gastrointestinal symptoms and 41 out of 48 (85.4%) were not relieved during follow-up and 16 (27.6%) with severe psychological problems. Conclusions: ESD is a safe and effective treatment for small GISTs, which helps to confirm the diagnosis, improve symptoms and reduce the psychological pressure. Thus, we recommend endoscopic resection is a good option for small gastric GISTs once diagnosed.

The roles of CT and EUS in the preoperative evaluation of gastric gastrointestinal stromal tumors larger than 2 cm

OBJECTIVE

This study aimed to investigate the endoscopic ultrasound (EUS) and computed tomography (CT) features of gastric gastrointestinal stromal tumors (GISTs) for assessing potential malignancy and prognosis.

METHODS

Fifty consecutive patients with primary gastric GISTs larger than 2 cm were retrospectively enrolled in this study. The association of CT and EUS features with malignancy was analyzed using univariate and stepwise logistic regression method. The agreement between EUS/CT lesion size and pathologic tumor size was analyzed by calculating the intraclass correlation coefficient (ICC) value, and the association of imaging features with mitotic counts was further analyzed using univariate analysis. The Kaplan-Meier method and Cox proportional hazards models were used to assess the value of imaging features for predicting the prognosis of GIST patients.

RESULTS

Tumor size > 5 cm and an exophytic/mixed growth pattern on CT as well as tumor size > 5 cm and the presence of cystic spaces on EUS were independent predictors of highly malignant GISTs (all p < 0.05). The ICC values of CT/EUS lesion size relative to pathologic tumor size showed very good reliability (0.853 for EUS and 0.831 for CT). Only tumor shape and growth pattern on CT were significant for predicting mitotic index (both p < 0.05). Direct organ invasion on CT (p = 0.036; hazard ratio [HR] = 11.891) and serosal invasion on EUS (p = 0.015; HR = 8.223) were independent adverse prognostic factors.

CONCLUSIONS

CT features may be more useful than EUS features for predicting tumor mitotic index. In addition, preoperative imaging features can help predict the prognosis of gastric GISTs.

KEY POINTS

• Both CT and EUS features can be used for risk stratification of gastric GISTs larger than 2 cm. • CT features performed better than EUS features for predicting tumor mitotic index. • Preoperative imaging features can help predict the prognosis of gastric GISTs.

Clinicopathological and morphological spectrum of gastrointestinal stromal tumours on multi-detector computed tomography

PURPOSE

To describe the clinicopathological and morphological features of gastrointestinal stromal tumours (GISTs) on multi-detector computed tomography (MDCT).

MATERIAL AND METHODS

MDCT (plain and post contrast) images of 25 confirmed cases of GISTs were retrospectively evaluated from our hospital database. The images were analysed for the location, size, growth pattern, attenuation pattern, relation to adjacent structures, presence or absence of ulceration, calcification, metastases, lymphadenopathy, and for any complications such as haemorrhage, intestinal obstruction, etc. Institutional Ethics Committee clearance was obtained prior to the commencement of the study. Statistics used included percentage frequency.

RESULTS

Our study group comprised 14 males and 11 females. The mean age of our study population was 60 years (age range: 40 to 82 years). The mean tumour size was 11.7 cm. The stomach and small bowel accounted for 76% of the primary tumour site. The commonest imaging appearance of GIST observed in our study was that of an exophytic mass (76%) with a heterogenous pattern of enhancement (96%) with intratumoural necrosis (76%). MDCT demonstrated complications in three patients (12%). Six patients presented with metastatic foci (five to the liver and one to the lung), while lymphadenopathy was observed in five patients (20%). Associated complications included intestinal obstruction (8%) and retrogastric haematoma (4%). Incidental findings included uterine fibroid (n = 1), ovarian dermoid (n = 1), and chronic pancreatitis (n = 1).

CONCLUSIONS

GISTs are predominantly large tumours with a well circumscribed and exophytic pattern on MDCT, with or without cystic/necrotic areas, and they mostly show a heterogenous pattern of enhancement on post-contrast administration.

Giant gastrointestinal stromal tumor of the mediastinum associated with an esophageal hiatal hernia and chest discomfort: a case report

Background

Gastrointestinal stromal tumors (GISTs) grow relatively slowly and without specific symptoms; therefore, they are typically incidental findings. We report a rare gastric GIST in the mediastinum associated with chest discomfort and an esophageal hiatal hernia.

Case presentation

An 81-year-old woman with chest discomfort was admitted to the hospital, where barium esophagography showed a sliding esophageal hiatal hernia and a tumor of the lower esophagus and gastric wall. Esophagogastroscopy confirmed the presence of a huge submucosal tumor that extended from the lower esophagus to the gastric fundus. According to computed tomography, the mediastinal mass measured 12.7 cm and had heterogeneous low-density areas. A submucosal gastric tumor, which we suspected to be a GIST, was diagnosed in association with an esophageal hiatal hernia. Using thoracolaparotomy, we performed a total gastrectomy, a lower esophagectomy, and a Roux-en-Y reconstruction with the jejunum. The presumptive diagnosis was confirmed through immunohistochemical examination; immunostaining yielded results positive for CD34 and c-kit. The patient was discharged from the hospital 13 days after surgery with no complications and remained disease-free at follow-up 24 months after surgery.

Conclusions

GIST should be considered in the differential diagnosis of tumors growing in the mediastinum.

Clinical Presentation of Gastrointestinal Stromal Tumors

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract. They constitute 1-2% of all gastrointestinal neoplasms but are the most common subtype of soft tissue sarcomas, accounting for 20-25%. In the late 1990s, GISTs were more and more recognized as a particular tumor entity. The tumors are supposed to originate from the interstitial pacemaker cells of Cajal. They are usually well circumscribed and can be located in every part of the tubular gastrointestinal tract. Most often GISTs occur in the stomach, followed by the small bowel and colon/rectum. In contrast to epithelial tumors, GISTs grow transmurally and submucosal. GISTs can be found with highly variable growth features including tumors with intraluminal, intra- or transmural, and pedunculated appearance. Here we describe the most common clinical presentation of GISTs on the basis of our 809 patients managed from 2004 to 2017. The median age of our patients was 59 years and the average size of GIST was 75 mm (range: 4 mm to 35 cm). The clinical presentation is very heterogeneous, depending on tumor site, size, and growth pattern. GISTs of the stomach is the group with the lowest rate of acute or emergency symptoms with 31%, followed by GISTs of the duodenum with 42%, whereas GISTs of the small bowel show acute symptoms in more than 50% of the cases and have an emergency surgery rate of almost 15%. Many patients are diagnosed accidentally, through screening examinations, or with latent, unspecific symptoms.

Gastrointestinal Stromal Tumors: Clinical Symptoms, Location, Metastasis Formation, and Associated Malignancies in a Single Center Retrospective Study

BACKGROUND AND AIMS

Gastrointestinal stromal tumors (GISTs) are rare malignancies but the most common mesenchymal tumors of the digestive tract. Recent advances in diagnostic imaging and an increasing incidence will confront us more frequently with stromal tumors. This single center study aimed to characterize GIST patients in terms of tumor location, clinical presentation, metastasis formation, as well as associated secondary malignancies.

METHODS

In a retrospective study, 104 patients with a histologically confirmed diagnosis of GIST, collected between 1993 and 2011, were characterized for several clinical features.

RESULTS

The most common GIST location was the stomach (67.6%) followed by the small intestine (16.2%). Gastrointestinal bleeding (55.8%) and abdominal pain (38.5%) were the most frequently reported symptoms whereas about one-third of patients remained clinically asymptomatic (31.6%); 14.4% of patients had either synchronous or metachronous metastases and there was a significant prevalence also in the low risk group. The proportion of secondary malignant associated neoplasms was 31% in our GIST cohort, among which gastrointestinal, genitourinary tumors, and breast cancer were the most prevalent.

CONCLUSION

There was a considerable risk for metastasis formation and the development of secondary neoplasias that should encourage discussion about the appropriate surveillance strategy after surgery for GIST.

Management of hemorrhage in gastrointestinal stromal tumors: a review

Gastrointestinal stromal tumors (GISTs) are relatively common mesenchymal tumors. They originate from the wall of hollow viscera and may be found in any part of the digestive tract. The prognosis of patients with stromal tumors depends on various risk factors, including size, location, presence of mitotic figures, and tumor rupture. Emergency surgery is often required for stromal tumors with hemorrhage. The current literature suggests that stromal tumor hemorrhage indicates poor prognosis. Although the optimal treatment options for hemorrhagic GISTs are based on surgical experience, there remains controversy with regard to optimum postoperative management as well as the classification of malignant potential. This article reviews the biological characteristics, diagnostic features, prognostic factors, treatment, and postoperative management of GISTs with hemorrhage.

Laparoscopic Versus Open Resection for Gastric Gastrointestinal Stromal Tumors (GISTs): A Size-Location-Matched Case-Control Study

BACKGROUND

Laparoscopic resection for gastric gastrointestinal stromal tumors (GISTs) is technically feasible, but the long-term effect remains uncertain. This study aims to compare the long-term oncologic outcomes of laparoscopic versus open resection of GISTs by larger cases based on tumor size-location-matched study.

METHODS

Between 2006 and 2015, 63 consecutive patients with a primary gastric GIST undergoing laparoscopic resection were enrolled in and matched (1:1) to patients undergoing open resection by tumor size and location. Clinical and pathologic parameters and surgical outcomes associated with each surgical type were collected and compared.

RESULTS

The operation time, intraoperative blood loss, return of bowel function and oral intake, nasogastric tube retention time and postoperative stay were all shorter/faster in laparoscopic group than those in open group (P < 0.001). Postoperative complications were comparable except for the higher incidence of abdominal/incision pain in open group (9.52 vs 27%, P = 0.01). There was no statistical difference in recurrence rate (9.52 vs 15.87%, P = 0.29) and long-term recurrence-free survival between the two groups (P = 0.39).

CONCLUSIONS

The long-term oncologic outcome of laparoscopic resection of primary gastric GISTs is comparable to that of open procedure, but laparoscopic procedure has the advantage of minimal invasion and is superior in postoperative recovery.

Gastrointestinal stromal tumour as a rare association with neurofibromatosis type 1

Gastrointestinal stromal tumours (GIST) are rare tumours of mesenchymal origin. These can be associated with neurofibromatosis type 1 (NF1), which is an autosomal dominant disorder. The prevalence of GIST in NF1 is estimated at 3.9–25%. This paper describes the presentation of a GIST arising from the jejenum in a 75-year-old lady with NF1, who presented with gastrointestinal bleeding. This was diagnosed by CT angiography. She was managed with laparotomy, with resection of small bowel, and an ischaemic segment of large bowel with two primary anastomoses. Pathology showed GIST of spindle cell type (Figs 3 and 4), 90 mm in size, with complete local excision. The patient was discharged on the eighth post-operative day and is currently undergoing regular clinic follow-up after multidisciplinary team meeting discussion.

Prognostic Analysis of Duodenal Gastrointestinal Stromal Tumors

AIM

This study aims to analyze factors possibly related to the prognosis of duodenal gastrointestinal stromal tumors (DGISTs).

METHODS

We collected and retrospectively analyzed clinical and pathological data of 62 patients with primary DGISTs. All the patients were hospitalized and received complete surgical resection at Shanghai Ruijin Hospital from September 2003 to April 2015. We followed up the patients to determine survival outcomes. We also analyzed the effect of clinical and pathological factors on disease-free survival (DFS) and overall survival (OS) of the patients.

RESULTS

Kaplan-Meier univariate survival analysis demonstrated that tumor size, mitotic index, Ki-67 index, and pathological risk were correlated with the DFS and OS of the patients (DFS P = 0.039, 0.001, <0.001, and 0.005, resp.; OS P = 0.027, 0.007, <0.001, and 0.012, resp.). Cox multivariate regression analysis revealed that Ki-67 index was an independent prognostic factor affecting DFS and OS (P = 0.007 and 0.028, resp.). Moreover, Kaplan-Meier survival analysis showed that imatinib treatment for patients with recurrence was correlated with prolonged OS (P = 0.002).

CONCLUSION

Prognosis for DGIST treated by R0 resection is favorable. High level of Ki-67 can be an independent risk factor of DGIST prognosis. Adjuvant imatinib therapy for patients with tumor recurrence could probably lead to prolonged survival.

Surgical treatment of gastrointestinal stromal tumors of the stomach: current status and future perspective

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract, with the majority found in the stomach. Surgical resection of the primary gastric GISTs with complete resection margin has been the forefront of curative treatment. The indications for surgical resection are usually related to symptomatic gastric GISTs at presentation. Primary gastric GISTs resection performed conventionally through an open surgery can now be frequently achieved by minimal invasive surgery with similar oncological outcome. Surgeon's selection of the type of surgical techniques such as open, laparoscopic and endoscopic resections depends on the site, size and local invasion of gastric GISTs to the adjacent organ. Similarly those factors dictate the extent of gastric resections in the form of wedge, partial or total gastrectomy. All these inherent tumor factors (size and mitotic index), patient factors (older age, male) and surgical factors (incomplete resection margin, tumor rupture or spillage) play an important role in stratifying the malignant potential risk of primary gastric GISTs and their chances of recurrence. The understanding of gene mutation driving the growth of GISTs and the discovery of tyrosine kinase inhibitors (TKIs) has altered the surgical management of advanced and metastatic GISTs. Multi-modal therapy incorporating the surgical resection of GISTs and utilizing the molecular targeted therapy in the adjuvant, neoadjuvant and palliative settings can offer optimal personalized outcome and prolong patient's overall survival (OS).