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Vasilakis T, Ziogas D, Tziatzios G, Gkolfakis P, Koukoulioti E, Kapizioni C, Triantafyllou K, Facciorusso A, Papanikolaou IS. EUS-Guided Diagnosis of Gastric Subepithelial Lesions, What Is New? Diagnostics (Basel) 2023; 13:2176. [PMID: 37443568 DOI: 10.3390/diagnostics13132176] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/18/2023] [Accepted: 06/23/2023] [Indexed: 07/15/2023] Open
Abstract
Gastric subepithelial lesions (SELs) are intramural lesions that arise underneath the gastric mucosa. SELs can be benign, but can also be malignant or have malignant potential. Therefore, correct diagnosis is crucial. Endosonography has been established as the diagnostic gold standard. Although the identification of some of these lesions can be carried out immediately, solely based on their echo characteristics, for certain lesions histological examination is necessary. Sometimes histology can be inconclusive, especially for smaller lesions. Therefore, new methods have been developed in recent years to assist decision making, such as contrast enhanced endosonography, EUS elastography, and artificial intelligence systems. In this narrative review we provide a complete overview of the gastric SELs and summarize the new data of the last ten years concerning the diagnostic advances of endosonography on this topic.
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Affiliation(s)
- Thomas Vasilakis
- Hepatology and Gastroenterology Clinic, Charité Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Dimitrios Ziogas
- 1st Department of Internal Medicine, 251 Hellenic Air Force & VA General Hospital, 3 Kanellopoulou Str., 11525 Athens, Greece
| | - Georgios Tziatzios
- Department of Gastroenterology, "Konstantopoulio-Patision" General Hospital, 3-5, Theodorou Konstantopoulou Str., Nea Ionia, 14233 Athens, Greece
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, "Konstantopoulio-Patision" General Hospital, 3-5, Theodorou Konstantopoulou Str., Nea Ionia, 14233 Athens, Greece
| | - Eleni Koukoulioti
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Christina Kapizioni
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Antonio Facciorusso
- Department of Medical Sciences, University of Foggia, Section of Gastroenterology, 71122 Foggia, Italy
| | - Ioannis S Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
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Meng R, Ni M, Ren W, Zhou T, Zhang X, Yan P, Ding X, Xu G, Lv Y, Zou X, Zhou L, Wang L. Comparison of Modified Cap-Assisted Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection in Treating Intraluminal Gastric Gastrointestinal Stromal Tumor (≤20 mm). Clin Transl Gastroenterol 2023; 14:e00589. [PMID: 37019655 PMCID: PMC10299766 DOI: 10.14309/ctg.0000000000000589] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 03/23/2023] [Indexed: 04/07/2023] Open
Abstract
INTRODUCTION A modified cap-assisted endoscopic mucosal resection (mEMR-C), introduced in this study, was a novel variation of the standard EMR. We aimed to compare the outcomes of mEMR-C and endoscopic submucosal dissection (ESD) for the treatment of small (≤20 mm) intraluminal gastric gastrointestinal stromal tumors (gGISTs). METHODS This retrospective study included 43 patients who underwent mEMR-C and 156 patients who received ESD at Nanjing Drum Tower Hospital. Baseline characteristics, adverse events, and clinical outcomes were compared between the 2 groups. Univariate and multivariable analyses were conducted to adjust for confounders. After propensity score matching using sex, year, location, and tumor size, outcomes were compared with 41 patients in each group. RESULTS A total of 199 patients underwent endoscopic resection and the en bloc resection rate was 100%. The complete resection rate was comparable in both groups ( P = 1.000). Approximately 9.5% of all patients had a positive margin. There was no significant difference in positive margin for patients undergoing mEMR-C or ESD (9.3% vs 9.6%, P = 1.000). No difference in adverse events in both groups ( P = 0.724). The mEMR-C was associated with shorter operation time and lower cost than the ESD. Recurrence was reported in 2 patients at 1 and 5 years after ESD during a median follow-up of 62 months. No metastasis and disease-related death were identified in both groups. Propensity score matching analysis revealed similar results. DISCUSSION The mEMR-C was found to be the preferable technique for small (≤20 mm) intraluminal gGISTs with shorter operation time and lower cost as compared with ESD.
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Affiliation(s)
- Rui Meng
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Muhan Ni
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Wei Ren
- Department of Geriatric Medicine, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Ting Zhou
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Xiang Zhang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Peng Yan
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Xiwei Ding
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Guifang Xu
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Ying Lv
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Xiaoping Zou
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Lin Zhou
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Lei Wang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
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Wu J, Zhuang M, Zhou Y, Zhan X, Xie W. The value of contrast-enhanced harmonic endoscopic ultrasound in differential diagnosis and evaluation of malignant risk of gastrointestinal stromal tumors (<50mm). Scand J Gastroenterol 2022; 58:542-548. [PMID: 36369879 DOI: 10.1080/00365521.2022.2144437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) has been used in the differential diagnosis of benign and malignant tumors by visualization of tumor microcirculation and perfusion. However, its diagnostic role in submucosal tumors (SMTs), especially leiomyomas and gastric submucosal tumors (GISTs) was rarely studied. The aim of this study was to analyze the diagnostic role of CEH-EUS for SMTs (<50 mm) and the value of assessing the malignant potential of GISTs. MATERIALS AND METHODS We retrospectively included patients with tumors <50 mm in diameter who underwent preoperative EUS and CEH-EUS examination and had pathologically confirmed as leiomyomas and GISTs. To analyze the imaging features of CEH-EUS with pathological diagnosis as the gold standard and evaluate its diagnostic value. RESULTS This study included 10 cases of leiomyomas and 38 cases of GISTs. Under CEH-EUS detection, 86.9% of GISTs showed hyper-enhancement, 89.5% showed diffuse enhancement, 39.5% showed non-enhancing spots, and 97.4% showed obvious capsule enhancement. In contrast, the leiomyoma cases mostly showed hypo-enhancement (50.0%) or non-enhancement (30.0%) (p < 0.05). Then, the value of CEH-EUS in the differential diagnosis of benign and malignant tumors based on blood flow is significantly higher than that of B-EUS. Signal appearance time was significantly faster in the intermediate-high risk GISTs than in the very low-low risk group (5.1 s versus 15.5 s, p < 0.05), and the AUROC values predicted the risk at this time to be 0.903 (0.763-0.975). Heterogeneous perfusion and non-enhancing spots were also more common in the intermediate-high risk group. Univariate and multivariate analysis revealed that intratumoral irregularitie was an independent predictor of moderate to high risk (OR 3.99, 95%CI 1.04-90.95), with sensitivity, specificity and accuracy of 73.33%, 91.30% and 84.21%, respectively. CONCLUSIONS Through this study, CEH-EUS has a good differential diagnostic ability for leiomyomas and GISTs, and has a high value in predicting the risk of GISTs.
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Affiliation(s)
- Jiali Wu
- Department of Gastroenterology, The Second Hospital of Anhui Medical University, Hefei, China
| | - Mengqi Zhuang
- Department of Gastroenterology, The Second Hospital of Anhui Medical University, Hefei, China
| | - Yubao Zhou
- Department of Gastroenterology, The Second Hospital of Anhui Medical University, Hefei, China
| | - Xiang Zhan
- Department of Gastroenterology, The Second Hospital of Anhui Medical University, Hefei, China
| | - Weiwei Xie
- Department of Gastroenterology, The Second Hospital of Anhui Medical University, Hefei, China
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Yang D, Ren H, Yang Y, Niu Z, Shao M, Xie Z, Yang T, Wang J. Risk stratification of 2- to 5-cm gastric stromal tumors based on clinical and computed tomography manifestations. Eur J Radiol 2022; 157:110590. [DOI: 10.1016/j.ejrad.2022.110590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 09/12/2022] [Accepted: 10/29/2022] [Indexed: 11/06/2022]
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Cruz Centeno N, Suarez Dominguez A, Mojica Mañosa P, Carlo VP. Incidental finding of a gastric schwannoma: a case report. J Surg Case Rep 2021; 2021:rjab509. [PMID: 34804489 PMCID: PMC8599024 DOI: 10.1093/jscr/rjab509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/22/2021] [Indexed: 12/29/2022] Open
Abstract
Gastric schwannomas are rare peripheral nerve sheath tumors which are usually found incidentally while undergoing workup for other conditions. Despite their benign nature, they require surgical resection with negative margins. It is important to differentiate gastric schwannomas from gastrointestinal stromal tumors prior to surgical excision, as this can alter the recommended surgical plan. This can be achieved with endoscopic ultrasound and fine needle aspiration with analysis of the sampled tissue using immunohistochemical stains. We present the case of a 68-year-old female patient with an incidental finding of a gastric fundus schwannoma. Laparoscopic gastric wedge resection was performed with complete excision of the tumor and negative margins. Pathology was confirmed with immunohistochemical stains positive for S-100 and negative for CD117 and DOG1. Post-operative recovery was uneventful without tumor recurrence.
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Affiliation(s)
- Nelimar Cruz Centeno
- Department of General Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico
| | - Albert Suarez Dominguez
- Department of General Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico
| | - Pablo Mojica Mañosa
- Department of General Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico
| | - Victor P Carlo
- Department of Anatomic Pathology, Auxilio Mutuo Hospital, San Juan, Puerto Rico
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Recent Progress and Challenges in the Diagnosis and Treatment of Gastrointestinal Stromal Tumors. Cancers (Basel) 2021; 13:cancers13133158. [PMID: 34202544 PMCID: PMC8268322 DOI: 10.3390/cancers13133158] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 06/18/2021] [Accepted: 06/22/2021] [Indexed: 12/31/2022] Open
Abstract
Simple Summary Gastrointestinal stromal tumors (GIST) are potentially malignant tumors and require evidence-based surgical and/or medical treatment. Laparoscopy has similar safety and prognostic outcomes to those of laparotomy and is currently a standard procedure for localized GISTs. However, surgery for gastric GISTs less than 2 cm may be re-evaluated due to the indolent nature of the GIST and other competing risks among GIST patients. A work-up with endoscopy and endoscopic ultrasonography as well as endoscopic or percutaneous biopsy is important for the preoperative diagnosis of GISTs. Medical treatment with tyrosine kinase inhibitors is the mainstay for recurrent/metastatic GISTs. The activity of an individual drug is well correlated with gene alterations, and, in the era of precision medicine, cancer genome profiling should be considered before medical treatment. Abstract Gastrointestinal stromal tumors (GISTs) are the most frequent malignant mesenchymal tumors in the gastrointestinal tract. The clinical incidence of GISTs is estimated 10/million/year; however, the true incidence is complicated by frequent findings of tiny GISTs, of which the natural history is unknown. The initial work-up with endoscopy and endoscopic ultrasonography plays important roles in the differential diagnosis of GISTs. Surgery is the only modality for the permanent cure of localized GISTs. In terms of safety and prognostic outcomes, laparoscopy is similar to laparotomy for GIST treatment, including tumors larger than 5 cm. GIST progression is driven by mutations in KIT or PDGFRA or by other rare gene alterations, all of which are mutually exclusive. Tyrosine kinase inhibitors (TKIs) are the standard therapy for metastatic/recurrent GISTs. Molecular alterations are the most reliable biomarkers for TKIs and for other drugs, such as NTRK inhibitors. The pathological and genetic diagnosis prior to treatment has been challenging; however, a newly developed endoscopic device may be useful for diagnosis. In the era of precision medicine, cancer genome profiling by targeted gene panel analysis may enable potential targeted therapy even for GISTs without KIT or PDGFRA mutations.
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Could computed tomography be used as a surrogate of endoscopic ultrasonography in the screening and surveillance of small gastric Gastrointestinal stromal tumors? Eur J Radiol 2020; 135:109463. [PMID: 33338760 DOI: 10.1016/j.ejrad.2020.109463] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 11/26/2020] [Accepted: 11/30/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE To investigate whether computed tomography (CT) could be used for screening and surveillance of small gastric gastrointestinal stromal tumors (gGISTs). METHOD A total of 162 pathologically confirmed small gGISTs (≤2 cm) between September 2007 and November 2019 were retrospectively enrolled. Thirty-six lesions received contrast-enhanced CT after they were identified by endoscopy and EUS, and forty-three lesions received CT alone before surgery. The detection rate of CT for ≤1 cm gGISTs (micro-gGISTs) and 1-2 cm gGISTs (mini-gGISTs) was investigated, and the detection rate of CT alone was compared with that of CT following endoscopy and EUS. The relationship between EUS- and CT-detected high-risk features were assessed. RESULTS CT demonstrated a favorable detection rate for mini-gGISTs previously identified by EUS and endoscopy, whereas CT alone showed an inferior detection rate (100 % vs. 75 %, p = 0.02). CT showed a poor detection rate for micro-gGISTs, both for lesions received CT after identified by EUS and endoscopy, and those received CT alone (33.3 % vs. 14.8 %, p = 0.372). CT-detected heterogeneous enhancement pattern and presence of calcification were strongly correlated with heterogeneous echotexture (Spearman's ρ=0.66, p < 0.001) and echogenic foci (Spearman's ρ=0.79, p < 0.001) on EUS, respectively. CT-detected necrosis was moderately correlated with cystic spaces on EUS (Spearman's ρ=0.42, p = 0.02). No correlation was found between EUS- and CT- assessed irregular border. CONCLUSIONS CT could potentially be considered as a surrogate of EUS for surveillance of mini-gGISTs instead of micro-gGISTs, whereas couldn't be used as a screening modality for either micro- or mini-gGISTs.
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Xu JX, Ding QL, Lu YF, Fan SF, Rao QP, Yu RS. A scoring model for radiologic diagnosis of gastric leiomyomas (GLMs) with contrast-enhanced computed tomography (CE-CT): Differential diagnosis from gastrointestinal stromal tumors (GISTs). Eur J Radiol 2020; 134:109395. [PMID: 33310552 DOI: 10.1016/j.ejrad.2020.109395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 10/13/2020] [Accepted: 11/01/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To investigate CT findings and develop a diagnostic score model to differentiate GLMs from GISTs. METHODS This retrospective study included 109 patients with pathologically confirmed GLMs (n = 46) and GISTs (n = 63) from January 2013 to August 2018 who received CE-CT before surgery. Demographic and radiological features was collected, including lesion location, contour, presence or absence of intralesional necrosis and ulceration, growth pattern, whether the tumor involved EGJ, the long diameter (LD) /the short diameter (SD) ratio, pattern and degree of lesion enhancement. Univariate analyses and multivariate logistic regression analyses were performed to identify independent predictors and establish a predictive model. Independent predictors for GLMs were weighted with scores based on regression coefficients. A receiver operating characteristic (ROC) curve was created to determine the diagnostic ability of the model. Overall score distribution was divided into four groups to show differentiating probability of GLMs from GISTs. RESULTS Five CT features were the independent predictors for GLMs diagnosis in multivariate logistic regression analysis, including esophagogastric junction (EGJ) involvement (OR, 367.9; 95 % CI, 5.8-23302.8; P = 0.005), absence of necrosis (OR, 11.9; 95 % CI, 1.0-138. 1; P = 0.048) and ulceration (OR, 151.9; 95 % CI, 1.4-16899.6; P = 0.037), degree of enhancement (OR, 9.3; 95 % CI, 3.2-27.4; P < 0.001), and long diameter/ short diameter (LD/SD) ratio (OR,170.9; 95 % CI, 8.4-3493.4; P = 0.001). At a cutoff of 9 points, AUC for this score model was 0.95, with 95.65 % sensitivity, 79.37 % specificity, 77.19 % PPV, 96.15 % NPV and 86.24 % diagnostic accuracy. An increasing trend was showed in diagnostic probability of GLMs among four groups based on the score (P < 0.001). CONCLUSIONS The newly designed scoring system is reliable and easy-to-use for GLMs diagnosis by distinguishing from GISTs, including EGJ involvement, absence of ulceration and necrosis, mild enhancement and high LD/SD ratio. The overall score of model ranged from 1 to 17 points, which was divided into 4 groups: 1-7 points, 7-10 points, 10-13 points and 13-17 points, with a diagnostic probability of GLMs 0%, 45 %, 83 % and 100 %, respectively.
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Affiliation(s)
- Jian-Xia Xu
- Department of Radiology, The Second Affiliated Hospital of Zhejiang Chinese Medical University, 318 Chao-Wang Road, Hangzhou, 310005, China
| | - Qiao-Ling Ding
- Department of Radiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, NO. 88 Jie-Fang Road, Hangzhou, 310009, China
| | - Yuan-Fei Lu
- Department of Radiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, NO. 88 Jie-Fang Road, Hangzhou, 310009, China
| | - Shu-Feng Fan
- Department of Radiology, The Second Affiliated Hospital of Zhejiang Chinese Medical University, 318 Chao-Wang Road, Hangzhou, 310005, China
| | - Qin-Pan Rao
- Department of Radiology, The Second Affiliated Hospital of Zhejiang Chinese Medical University, 318 Chao-Wang Road, Hangzhou, 310005, China
| | - Ri-Sheng Yu
- Department of Radiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, NO. 88 Jie-Fang Road, Hangzhou, 310009, China.
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Cannella R, La Grutta L, Midiri M, Bartolotta TV. New advances in radiomics of gastrointestinal stromal tumors. World J Gastroenterol 2020; 26:4729-4738. [PMID: 32921953 PMCID: PMC7459199 DOI: 10.3748/wjg.v26.i32.4729] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/16/2020] [Accepted: 08/01/2020] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal stromal tumors (GISTs) are uncommon neoplasms of the gastrointestinal tract with peculiar clinical, genetic, and imaging characteristics. Preoperative knowledge of risk stratification and mutational status is crucial to guide the appropriate patients’ treatment. Predicting the clinical behavior and biological aggressiveness of GISTs based on conventional computed tomography (CT) and magnetic resonance imaging (MRI) evaluation is challenging, unless the lesions have already metastasized at the time of diagnosis. Radiomics is emerging as a promising tool for the quantification of lesion heterogeneity on radiological images, extracting additional data that cannot be assessed by visual analysis. Radiomics applications have been explored for the differential diagnosis of GISTs from other gastrointestinal neoplasms, risk stratification and prediction of prognosis after surgical resection, and evaluation of mutational status in GISTs. The published researches on GISTs radiomics have obtained excellent performance of derived radiomics models on CT and MRI. However, lack of standardization and differences in study methodology challenge the application of radiomics in clinical practice. The purpose of this review is to describe the new advances of radiomics applied to CT and MRI for the evaluation of gastrointestinal stromal tumors, discuss the potential clinical applications that may impact patients’ management, report limitations of current radiomics studies, and future directions.
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Affiliation(s)
- Roberto Cannella
- Section of Radiology - BiND, University Hospital “Paolo Giaccone”, Palermo 90127, Italy
| | - Ludovico La Grutta
- Section of Radiology - BiND, University Hospital “Paolo Giaccone”, Palermo 90127, Italy
| | - Massimo Midiri
- Section of Radiology - BiND, University Hospital “Paolo Giaccone”, Palermo 90127, Italy
| | - Tommaso Vincenzo Bartolotta
- Section of Radiology - BiND, University Hospital “Paolo Giaccone”, Palermo 90127, Italy
- Department of Radiology, Fondazione Istituto Giuseppe Giglio, Ct.da Pietrapollastra, Cefalù (Palermo) 90015, Italy
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