Endoscopic Enucleation Is Effective and Relatively Safe in Small Gastric Subepithelial Tumors Originating from Muscularis Propria

A multicentre, prospective cohort study comparing two endoscopic procedures for the treatment of gastric muscularis propria lesions

To date, no prospective study has been conducted to compare the safety and effectiveness of endoscopic snare resection with an elastic band (ESR-EB) and endoscopic snare resection with a transparent cap (ESR-C) for treating gastric muscularis propria lesions. We aimed to compare the safety and effectiveness of ESR-EB with those of ESR-C for gastric muscularis propria lesions less than 10 mm in diameter. A total of 64 patients were enrolled prospectively from May 2023 to November 2023 at Shenzhen Hospital of Southern Medical University, the First Affiliated Hospital of Shantou University, and the People's Hospital of Zhongshan City. The study compared clinical characteristics, tumour features, and surgical outcomes between the two groups. Of 64 patients, 29 underwent ESR-C, and 35 underwent ESR-EB. There were no differences in age, gender, location, tumour size, growth pattern, resection time, histology diagnosis, or follow-up time (P > 0.05). Complete resection was achieved in all the patients. The operation time was significantly greater in the ESR-C group than in the ESR-EB group (41.31 ± 9.87 min vs. 26.26 ± 10.32 min, P = 0.000). In the ESR-C cohort, 21 patients (72.41%) had perforation, and 1 patient (3.45%) had bleeding. In the ESR-EB group, 7 patients (20.00%) had perforation. The complication rate varied significantly between the two groups (P = 0.000). No recurrence or metastasis was observed in either group during the follow-up period. Both ESR-C and ESR-EB achieved a 100% complete resection rate for gastric muscularis propria lesions less than 10 mm in diameter.ESR-EB had the potential to reduce the operation time and lower the occurrence of complications. Chinese Clinical Trial Registry Identifier ChiCTR2300072856.

Comparison analysis of two different types of endoscopic resection procedures in small gastric subepithelial tumours originating frommuscularis propria

BACKGROUND

For small gastric subepithelial tumours originating from the muscularis propria, there is no uniform standard for selecting the best endoscopic resection method.

OBJECTIVE

To compare the efficacy and safety of endoscopic snare resection with a transparent cap (ESR-C) and endoscopic snare resection with an elastic band (ESR-EB) for small gastric subepithelial tumours originating from the muscularis propria to determine which method is more suitable for these tumours.

METHODS

The data from small gastric subepithelial tumours originating from the muscularis propria treated from Jan 2020 to Dec 2022 were collected. A total of 34 eligible patients were enrolled. Sixteen of these patients were treated with ESR-C, and eighteen were treated with ESR-EB. The general clinical characteristics, tumour location, tumour size,growth pattern,operation time, complete resection rate, and complication rate were compared between the two groups.

RESULTS

There was no difference in age, sex, tumour location, tumour size, growth pattern, or histological diagnosis after resection (p > 0.05). There was no significant difference in operation time, complete resection rate, or follow-up time (p > 0.05). Eight patients (50.5%) in the ESR-C group had complications (6 perforations and 2 bleeding), and 2 (11.11%) in the ESR-EB group had complications (2 perforations). There were significant differences between the two groups (p = 0.037). All perforations were successfully treated. No recurrence or metastasis was observed in either group during the follow-up period.

CONCLUSION

Both ESR-C and ESR-EB are effective and safe in treating small gastric subepithelial tumours originating from the muscularis propria. However, ESR-EB can significantly reduce the incidence of complications. ESR-EB is likely a better option for small gastric subepithelial tumours originating from the muscularis propria.

Advances of endoscopic and surgical management in gastrointestinal stromal tumors

As one of the most common mesenchymal malignancies in the digestive system, gastrointestinal stromal tumors (GISTs) occur throughout the alimentary tract with diversified oncological characteristics. With the advent of the tyrosine kinase inhibitor era, the treatment regimens of patients with GISTs have been revolutionized and GISTs have become the paradigm of multidisciplinary therapy. However, surgery resection remains recognized as the potentially curative management for the radical resection and provided with favorable oncological outcomes. The existing available surgery algorithms in clinical practice primarily incorporate open procedure, and endoscopic and laparoscopic surgery together with combined operation techniques. The performance of various surgery methods often refers to the consideration of risk evaluation of recurrence and metastases; the degree of disease progression; size, location, and growth pattern of tumor; general conditions of selected patients; and indications and safety profile of various techniques. In the present review, we summarize the fundamental principle of surgery of GISTs based on risk assessment as well as tumor size, location, and degree of progress with an emphasis on the indications, strengths, and limitations of current surgery techniques.

Advances in endoscopic resection techniques of small gastric tumors originating from the muscularis propria

Gastrointestinal stromal tumors are common gastrointestinal tumors typically originating from the muscularis propria layer of the stomach. Small gastric stromal tumors are usually detected incidentally during routine endoscopic examination. Although they may have malignant potentially, controversies remain regarding the need for endoscopic resection of small gastric stromal tumors originating from the muscularis propria. According to the guidelines of the European Society of Medical Oncology, all gastrointestinal stromal tumors >2 cm in size should be resected with endoscopic surveillance recommended for tumors <2 cm. Endoscopic resection including endoscopic mucosal dissection (EMD), endoscopic submucosal dissection (ESD), submucosal tunneling endoscopic resection and snare assisted endoscopic resection. However, EMD and ESD procedures may be accompanied with serious complications including perforation, bleeding, and abdominal infection. Snare-assisted endoscopic resection is an alternative approach and has the advantages of a shorter procedure time and a low rate of perforation or bleeding. This study summarizes the safety and feasibility of a novel snare-assisted endoscopic resection technique and highlights the pros and cons of the different endoscopic approaches currently used for subepithelia small gastric tumors.

The necessarity of treatment for small gastric subepithelial tumors (1-2 cm) originating from muscularis propria: an analysis of 972 tumors

BACKGROUND AND OBJECTIVES

Up till now, there are still controversies about the specific indication of endoscopic resection for small gastric subepithelial tumors (gSETs) originating from muscularis propria. We aimed to investigate the safety of endoscopic resection and postoperative pathology analysis.

METHOD

The patients with primary small gSETs originating from muscularis propria, treated by endoscopic resection in the endoscopic center of Shengjing Hospital between January, 2011 and September, 2019 were enrolled. The complete resection rate, adverse events and clinicopathological features were recorded.

RESULT

A total of 936 patients with 972 gastric SETs ≤ 2 cm originating from muscularis propria were included in our study. All the lesions were successfully treated by endoscopic resection. Nearly half of lesions were proved to be gastrointestinal stromal tumor (GIST) [n = 411 (42.3%)] according to postoperative pathology. All the objects were further subdivided into 2 groups, ≤ 1 cm, > 1 and ≤ 2 cm gSETs. The risk of gastric GIST of intermediate/high risk in the group (> 1 and ≤ 2 cm gSETs) is 8.41 times as that of gastric GIST in the group (the size of gastric ≤ 1 cm gSETs) (P < 0.05).

CONCLUSION

Endoscopic resection is a safe and effective treatment for small gSETs. gSETs (1-2 cm) is more risky than gSETs (≤ 1 cm) and should be resected. This should be evaluated by further studies.

Recent Progress and Challenges in the Diagnosis and Treatment of Gastrointestinal Stromal Tumors

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.