Clinicopathologic features and outcomes of gastrointestinal stromal tumors arising from the esophagus and gastroesophageal junction

Robot-assisted laparoscopic combined with endoscopic partial gastrectomy (RALE-PG) for the treatment of gastric gastrointestinal stromal tumors in challenging anatomical locations: single-center experience

Background

Gastric gastrointestinal stromal tumors in challenging anatomical locations are difficult to remove.

Methods

This study retrospectively analyzed the clinical data of 12 patients with gastric GISTs in challenging anatomical locations who underwent robot-assisted laparoscopic combined with endoscopic partial gastrectomy (RALE-PG) and manual suturing of the gastric wall.

Results

This study included 12 patients with a mean age of 56.8 ± 9.8 years and a mean BMI of 23.9 ± 1.9 kg/m2. Tumors were located in the GEJ (n = 3), lesser curvature (n = 3), posterior gastric wall (n = 3) and antrum (n = 3). The cardia and pylorus were successfully preserved in all patients regardless of the tumor location. The mean tumor size was 4.5 ± 1.4 cm. The mitotic-count/50 mm2 was less than 5 in all patients (100%). There was no intraoperative tumor rupture (0%) and no conversion to open surgery (0%). The median operation time was 122 (97-240) min, and the median blood loss volume was 10 (5-30) ml. The median postoperative VAS score was 2 (2-4). The median time to first flatus was 2 (2-3) days. The median time to first fluid intake was 2 (2-3) days. The median time to first ambulation after the operation was 3 (2-4) days. No cases of anastomotic stenosis or leakage were found. The median time to drain removal for 6 patients was 5 (4-7) days. The median time to nasogastric tube removal for all patients was 2 (1-5) days. The median postoperative hospital stay was 5 (4-8) days. One patient (female/41 year) developed moderate anemia (Clavien-Dindo grade II complication). There was no unplanned readmission within 30 days after the operation. The median distance from the tumor to the resection margin was 1 (1-2) cm. R0 resection was achieved in all patients. The median follow-up period was 19 (10-25) months, and all patients survived with no recurrence or metastasis.

Conclusions

RALE-PG is a safe, feasible and advantageous technique for treating GISTs in challenging anatomical locations. It can be used to accurately remove the tumor while preserving gastric function to the greatest extent, but long-term oncologic outcomes need to be evaluated in a study with a larger sample size and longer follow-up period.

A nomogram for predicting liver metastasis in patients with gastric gastrointestinal stromal tumor

BACKGROUND

Liver metastasis (LIM) is an important factor in the diagnosis, treatment, follow-up, and prognosis of patients with gastric gastrointestinal stromal tumor (GIST). There is no simple tool to assess the risk of LIM in patients with gastric GIST. Our aim was to develop and validate a nomogram to identify patients with gastric GIST at high risk of LIM.

METHODS

Patient data diagnosed as having gastric GIST between 2010 and 2019 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database and randomly divided into training cohort and internal validation cohort in a 7:3 ratio. For external validation, retrospective data collection was performed on patients diagnosed as having gastric GIST at Yunnan Cancer Center (YNCC) between January 2015 and May 2023. Univariate and multivariate logistic regression analyses were used to identify independent risk factors associated with LIM in patients with gastric GIST. An individualized LIM nomogram specific for gastric GIST was formulated based on the multivariate logistic model; its discriminative performance, calibration, and clinical utility were evaluated.

RESULTS

In the SEER database, a cohort of 2341 patients with gastric GIST was analyzed, of which 173 cases (7.39%) were found to have LIM; 239 patients with gastric GIST from the YNCC database were included, of which 25 (10.46%) had LIM. Multivariate analysis showed tumor size, tumor site, and sex were independent risk factors for LIM (P < .05). The nomogram based on the basic clinical characteristics of tumor size, tumor site, sex, and age demonstrated significant discrimination, with an area under the curve of 0.753 (95% CI, 0.692-0.814) and 0.836 (95% CI, 0.743-0.930) in the internal and external validation cohort, respectively. The Hosmer-Lemeshow test showed that the nomogram was well calibrated, whereas the decision curve analysis and the clinical impact plot demonstrated its clinical utility.

CONCLUSION

Tumor size, tumor subsite, and sex were significantly correlated with the risk of LIM in gastric GIST. The nomogram for patients with GIST can effectively predict the individualized risk of LIM and contribute to the planning and decision making related to metastasis management in clinical practice.

Robotic Function-Preserving Resection of Gastric Gastrointestinal Stromal Tumor

INTRODUCTION

Gastric gastrointestinal stromal tumors (GISTs) located at the gastroesophageal junction (GEJ), lesser curvature, posterior gastric wall, or antrum present challenges for gastric function preservation. The aim of this study was to evaluate safety and effectiveness of robot-assisted resection of gastric GIST in challenging anatomic locations.

METHODS

This was a single-center case series of robotic gastric GIST resections in challenging anatomic locations performed from 2019 to 2021. GEJ GISTs are defined as tumors within 5 cm of the GEJ. Location of the tumor and distance from the GEJ were determined from the endoscopy report and/or cross-sectional imaging and operative findings.

RESULTS

There were 25 consecutive patients who underwent a robot-assisted partial gastrectomy for a gastric GIST in challenging anatomic locations. Tumors were located at the GEJ (n = 12), lesser curvature (n = 7), posterior gastric wall (n = 4), fundus (n = 3), greater curvature (n = 3), and antrum (n = 2). Median distance of tumor from GEJ was 2.5 cm. Both GEJ and pylorus were successfully preserved in all patients regardless of tumor location. Median operative time was 190 min with a median estimated blood loss of 20 mL and no conversion to open approach. Median hospital stay was 3 d with solid diet intake starting 2 d after surgery. Two (8 %) patients had Grade III or higher postoperative complications. Median tumor size upon resection was 3.9 cm. Negative margins were obtained in 96.3%. There was no evidence of recurrent disease with a median follow-up of 11.3 mo.

CONCLUSIONS

We demonstrate the safety and feasibility of using the robotic approach to facilitate function preservation gastrectomy in challenging anatomic locations without compromising oncologic resection.

Gastrointestinal stromal tumors of the upper GI tract: population-based analysis of epidemiology, treatment and outcome based on data from the German Clinical Cancer Registry Group

BACKGROUND

Gastrointestinal stromal tumors (GIST) are rare mesenchymal tumors. They are most frequently located in the stomach but are also found in the esophagus and the gastroesophageal junction (GEJ). Information regarding the prognostic factors associated with upper gastrointestinal GIST is still scarse.

METHODS

In this study, datasets provided by the German Clinical Cancer Registry Group, including a total of 93,069 patients with malignant tumors in the upper GI tract (C15, C16) between 2000 and 2016 were analyzed to investigate clinical outcomes of GIST in the entire upper GI tract.

RESULTS

We identified 1361 patients with GIST of the upper GI tract. Tumors were located in the esophagus in 37(2.7%) patients, at the GEJ in 70 (5.1%) patients, and in the stomach in 1254 (91.2%) patients. The incidence of GIST increased over time, reaching 5% of all UGI tumors in 2015. The median age was 69 years. The incidence of GIST was similar between males and females (53% vs 47%, respectively). However, the proportion of GIST in female patients increased continuously with advancing age, ranging from 34.7% (41-50 years) to 71.4% (91-100 years). Male patients were twice as likely to develop tumors in the esophagus and GEJ compared to females (3.4% vs. 1.9% and 6.7% vs. 3.4%, respectively). The median overall survival of upper gastrointestinal GIST was 129 months. The 1-year, 5-year, and 10-year OS was 93%, 79%, and 52% respectively. Nevertheless, tumors located in the esophagus and GEJ were associated with shorter OS compared to gastric GIST (130 vs. 111 months, p = 0.001). The incidence of documented distant metastasis increased with more proximal location of GIST (gastric vs. GEJ vs. esophagus: 13% vs. 16% vs. 27%) at presentation.

CONCLUSION

GIST of the esophagus and GEJ are rare soft tissue sarcomas with increasing incidence in Germany. They are characterized by worse survival outcomes and increased risk of metastasis compared to gastric GIST.

A CT-based nomogram for predicting the malignant potential of primary gastric gastrointestinal stromal tumors preoperatively

PURPOSE

To develop and validate a computerized tomography (CT)-based nomogram for predicting the malignant potential of primary gastric gastrointestinal stromal tumors (GISTs).

METHODS

The primary and validation cohorts consisted of 167 and 39 patients (single center, different time periods) with histologically confirmed primary gastric GISTs. Clinical data and preoperative CT images were reviewed. The association of CT characteristics with malignant potential was analyzed using univariate and stepwise logistic regression analyses. A nomogram based on significant CT findings was developed for predicting malignant potential. The predictive accuracy of the nomogram was determined by the concordance index (C-index) and calibration curves. External validation was performed with the validation cohort.

RESULTS

CT imaging features including tumor size, tumor location, tumor necrosis, growth pattern, ulceration, enlarged vessels feeding or draining the mass (EVFDM), tumor contour, mesenteric fat infiltration, and direct organ invasion showed significant differences between the low- and high-grade malignant potential groups in univariate analysis (P < 0.05). Only tumor size (> 5 cm vs ≤ 5 cm), location (cardiac/pericardial region vs other), EVFDM, and mesenteric fat infiltration (present vs absent) were significantly associated with high malignant potential in multivariate logistic regression analysis. Incorporating these four independent factors into the nomogram model achieved good C-indexes of 0.946 (95% confidence interval [CI] 0.899-0.975) and 0.952 (95% CI 0.913-0.977) in the primary and validation cohorts, respectively. The cutoff point was 0.33, with sensitivity, specificity, and diagnostic accuracy of 0.865, 0.915, and 0.780, respectively.

DISCUSSION

Primary gastric GISTs originating in the cardiac/pericardial region appear to be associated with higher malignant potential. The nomogram consisting of CT features, including size, location, EVFDM, and mesenteric fat infiltration, could be used to accurately predict the high malignant potential of primary gastric GISTs.

Gastrointestinal Stromal Tumors of the Stomach and Esophagus

Gastrointestinal stromal tumors (GISTs) arise anywhere along the gastrointestinal tract, most commonly as a result of c-kit or PDGFRA proto-oncogene mutations. Surgical resection is an important component of treatment. However, molecular profiling of GISTs has provided many insights into adjuvant and neoadjuvant therapy options. Imatinib, the most frequently studied medical therapy, has been shown in numerous studies to provide benefit to patients in both the neoadjuvant and adjuvant setting. Interval imaging is an important component of the treatment of GISTs and national surveillance recommendations should be followed.

Clinical Overview of GIST and Its Latest Management by Endoscopic Resection in Upper GI: A Literature Review

Aims

To review the clinical presentation, diagnosis, assessment of risk of malignancy, and recent advances in management (mainly focusing on the role of endoscopic resection) of gastrointestinal stromal tumors (GISTs) in upper GI.

Method

We searched Embase, Web of science, and PubMed databases from 1993 to 2018 by using the following keywords: “gastrointestinal stromal tumors,” “GIST,” “treatment,” and “diagnosis.” Additional papers were searched manually from references of the related articles.

Findings

The improvement of endoscopic techniques in treating upper gastrointestinal subepithelial tumors especially gastrointestinal tumors has reduced the need for invasive surgery in patients unfit for surgery. Many studies have concluded that modified endoscopic treatments are effective and safe. These treatments permit minimal tissue resection, better dissection control, and high rates of en bloc resection with an acceptable rate of complications.