Surgical treatment of GIST--an institutional experience of a high-volume center

Synchronous local recurrence and liver metastasis from extragastrointestinal stromal tumor in the rectovaginal septum: a unique case presentation

The rectovaginal septum is a rare location for gastrointestinal stromal tumors (GIST) to occur. The aim of this study was to present a case of synchronous local recurrence of solitary liver metastasis originating from an extra gastrointestinal tumor (E-GIST) of the rectovaginal space.

Long-term survival outcomes of endoscopic therapy vs. surgical resection in patients with cardia gastrointestinal stromal tumor

The ideal surgical approach for treating cardia gastrointestinal stromal tumor (GIST) is not clearly established. This study aimed to assess the long-term survival results among patients who received endoscopic therapy (ET) or surgical resection (SR) for cardia GIST. Cardia GIST patients from 2000 to 2019 were selected from the surveillance, epidemiology, and end result (SEER) database. Multiple imputation (MI) was applied to handle missing data, and propensity score matching (PSM) was carried out to mitigate selection bias during comparisons. Demographic and clinical characteristics' effects on overall survival (OS) and cancer-specific survival (CSS) were assessed using Kaplan-Meier analyses and multivariate Cox proportional hazard models. A total of 330 patients with cardia GIST were enrolled, including 47 (14.2%) patients with ET and 283 (85.8%) patients with SR. The 5-year OS and CSS rates in the ET and SR groups were comparable [before PSM, (OS) (76.1% vs. 81.2%, P = 0.722), (CSS) (95.0% vs. 89.3%, P = 0.186); after PSM, (OS) (75.4% vs. 85.4%, P = 0.540), (CSS) (94.9% vs. 92.0%, P = 0.099)]. Moreover, there was no significant difference between ET and SR in terms of long-term OS (hazard ratio [HR] 0.735, 95% confidence interval [CI] 0.422-1.282) and CSS (HR 1.560, 95% CI 0.543-4.481). Our study found no significant disparity in long-term survival outcomes between ET and SR in cardia GIST patients, implying that ET could be a valid surgical strategy for treating cardia GIST.

Minimally Invasive Approach to Gastric GISTs: Analysis of a Multicenter Robotic and Laparoscopic Experience with Literature Review

Background: Gastrointestinal stromal tumors (GISTs) are most frequently located in the stomach. In the setting of a multidisciplinary approach, surgery represents the best therapeutic option, consisting mainly in a wedge gastric resection. (1) Materials and methods: Between January 2010 to September 2020, 105 patients with a primary gastrointestinal stromal tumor (GISTs) located in the stomach, underwent surgery at three surgical units. (2) Results: A multi-institutional analysis of minimally invasive series including 81 cases (36 laparoscopic and 45 robotic) from 3 referral centers was performed. Males were 35 (43.2%), the average age was 66.64 years old. ASA score ≥3 was 6 (13.3%) in the RS and 4 (11.1%) in the LS and the average tumor size was 4.4 cm. Most of the procedures were wedge resections (N = 76; 93.8%) and the main operative time was 151 min in the RS and 97 min in the LS. Conversion was necessary in five cases (6.2%). (3) Conclusions: Minimal invasive approaches for gastric GISTs performed in selected patients and experienced centers are safe. A robotic approach represents a useful option, especially for GISTs that are more than 5 cm, even located in unfavorable places.

Laparoscopic resection of gastrointestinal stromal tumors: Does laparoscopic surgery provide an adequate oncologic resection?

Gastrointestinal stromal tumors (GISTs) are rare tumors of the GI tract. Surgical resection remains the mainstay of non-metastatic disease. However, the ability to provide an adequate oncologic resection using laparoscopic surgery is still an area of debate. This is a thorough review of the current literature, looking particularly at the use of laparoscopic surgery for larger GISTs and the long-term oncologic outcomes compared to the results of open surgery. Laparoscopic resections provide an adequate oncologic result for GISTs of all sizes, including those greater than 5 cm in size.

Comparison of short- and long-term outcomes of laparoscopic vs open resection for gastric gastrointestinal stromal tumors

AIM

To compare the short- and long-term outcomes of laparoscopic (LR) vs open resection (OR) for gastric gastrointestinal stromal tumors (gGISTs).

METHODS

In total, 301 consecutive patients undergoing LR or OR for pathologically confirmed gGISTs from 2005 to 2014 were enrolled in this retrospective study. After exclusion of 77 patients, 224 eligible patients were enrolled (122 undergoing LR and 102 undergoing OR). The demographic, clinicopathologic, and survival data of all patients were collected. The intraoperative, postoperative, and long-term oncologic outcomes were compared between the LR and OR groups following the propensity score matching to balance the measured covariates between the two groups.

RESULTS

After 1:1 propensity score matching for the set of covariates including age, sex, body mass index, American Society of Anesthesiology score, tumor location, tumor size, surgical procedures, mitotic count, and risk stratification, 80 patients in each group were included in the final analysis. The baseline parameters of the two groups were comparable after matching. The LR group was significantly superior to the OR group with respect to the operative time, intraoperative blood loss, postoperative first flatus, time to oral intake, and postoperative hospital stay (P < 0.05). No differences in perioperative blood transfusion or the incidence of postoperative complications were observed between the two groups (P > 0.05). No significant difference was found in postoperative adjuvant therapy (P = 0.587). The mean follow-up time was 35.30 ± 26.02 (range, 4-102) mo in the LR group and 40.99 ± 25.07 (range, 4-122) mo in the OR group with no significant difference (P = 0.161). Survival analysis showed no significant difference in the disease-free survival time or overall survival time between the two groups (P > 0.05).

CONCLUSION

Laparoscopic surgery for gGISTs is superior to open surgery with respect to intraoperative parameters and postoperative outcomes without compromising long-term oncological outcomes.

Urgency surgical treatment for duodenal GISTs: analysis of aged patients and review of the literature

INTRODUCTION

Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal neoplasms (85%) of the gastrointestinal (GI) tract; duodenal GISTs constitute 3-5% of all GISTs and represent 10-30% of all malignant tumours of the duodenum. Rarely, patients present severe bowel obstruction, perforation or severe bleeding. The radical resection with complete removal of the tumour remains the main therapeutic approach. We performed a local resection in patients with suspected GIST admitted for emergency treatment for GI bleeding.

CASES

We present three cases of patients admitted for GI bleeding. The cause could be a GIST bleeding. In all cases, local resection was performed without a pancreaticoduodenectomy. Histological examination on surgical preparations showed that in two cases it was a GIST and in one case, it was a leiomyoma.

DISCUSSION

Surgery remains the treatment of choice in the case of a GIST primitive without evidence of metastases, even for patients who are hospitalized for a bleeding emergency. Wide resections are not needed; it is important to remove completely the disease. In the case of duodenal GIST, it is important to get negative margins near the head of the pancreas, and this could take a PD. According to our experience and to the literature review, we believe that if the duodenal papilla or the periampullary region is not interested, you must perform a local resection. This is also because non-malignant tumours may present as GISTs and in these cases it is not recommended to run a PD.

CONCLUSION

The treatment of choice for duodenal GISTs is complete surgical resection with negative resection margins. When the papilla or the periampullary region is involved we choose to perform pancreaticoduodenectomy; otherwise it is better to perform a local resection. In fact, local resection has lower morbidity and mortality, with a comparable outcome.

Robot-assisted intersphincteric resection for rectal submucosal tumour

BACKGROUND

Rectal submucosal tumours are rare. The purpose of this study was to evaluate the safety and feasibility of robot-assisted rectal surgery.

METHODS

Patients who received robot-assisted intersphincteric resection (ISR) were included in the present study. Clinical outcomes, operating time, length of hospital stay and pathological status were analysed.

RESULTS

There were three patients with gastrointestinal tumours and three patients diagnosed with neuroendocrine tumours. The mean operating time was 369.2 min and the estimated blood loss was 66.7 ml. There were neither intraoperative complications nor conversions. On pathological examination, the mean number of lymph nodes harvested was 10.3 (range 3-16), the mean distal resection margin was 1.1 (range 0.1-3) cm and all six patients had the circumferential resection margins clear.

CONCLUSIONS

Our data show that robotic surgery is feasible and safe, with no morbidity or mortality, and that ISR provides bowel continuity and eliminates the need for colostomy. Copyright © 2015 John Wiley & Sons, Ltd.

Two cases of advanced gastric carcinoma mimicking a malignant gastrointestinal stromal tumor

Gastric cancer that mimics a submucosal tumor is rare. This rarity and the normal mucosa covering the protuberant tumor make it difficult to diagnosis with endoscopy. We report two cases of advanced gastric cancer that mimicked malignant gastrointestinal stromal tumors preoperatively. In both cases, the possibility of cancer was not completely ruled out. In the first case, a large tumor was suspected to be cancerous during surgery. Therefore, total gastrectomy with lymph node dissection was performed. In the second case, the first gross endoscopic finding was of a Borrmann type II advanced gastric cancer-like protruding mass with two ulcerous lesions invading the anterior wall of the body. Therefore, subtotal gastrectomy with lymph node dissection was performed. Consequently, delayed treatment of cancer was avoided in both cases. If differential diagnosis between malignant gastrointestinal stromal tumor and cancer is uncertain, a surgical approach should be carefully considered due to the possible risk of adenocarcinoma.

Review article: the biology, diagnosis and management of gastrointestinal stromal tumours

BACKGROUND

Gastrointestinal stromal tumours (GIST) are the most common mesenchymal tumours of the gastrointestinal tract with an increasing incidence.

AIMS

To review the biology, diagnosis and treatment of gastrointestinal stromal tumours.

METHODS

A PubMed search using the phrases 'Gastrointestinal stromal tumor', 'imatinib', 'c-kit'.

RESULTS

The diagnosis of GIST is established by histology supplemented by the immunohistochemical marker CD117, which is positive in 95% of cases. The most common site of the tumour is the stomach. Most GIST are benign with 20-30% malignant. Five-year survival for malignant GIST ranges between 35% and 65% and depends primarily on tumour size, mitotic index and location. The malignant behaviour of GIST is best assessed by invasion of adjacent structures and distant metastases. The gold standard for treatment is surgical resection. Imatinib, a tyrosine kinase inhibitor, is the primary therapy for unresectable, recurrent or metastatic disease.

CONCLUSIONS

Gastrointestinal stromal tumours are rare tumours of the gastrointestinal tract and they vary in presentation. When surgical resection is not achievable, imatinib is the treatment of choice.

Advances in research of gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract, arising from the interstitial cells of Cajal (ICCs), primarily in the stomach and small intestine. The growth of most GISTs is driven by the mutations of genes encoding oncogenic receptor tyrosine kinase KIT or platelet derived growth factor receptor alpha (PDGFRα). The pathogenesis of GISTs may involve ICCs, microRNAs (miRNAs), signaling pathways, DNA methylation, and KIT or PDGFRα gene mutations. This article systematically describes the advances in research of GISTs in terms of clinical features, imaging characteristics, endoscopic features, histopathological features, diagnosis and therapies.