Gastrointestinal stromal tumors (GIST) related emergencies. Int J Surg. 2014;12:269-280. [PMID: 24530605 DOI: 10.1016/j.ijsu.2014.02.004]

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.

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.

Acute abdomen due to a perforated giant GIST of the small intestine evolving slowly for 6 years: A case report

INTRODUCTION

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms, comprising less than 1 % of gastrointestinal tumors. Arising from interstitial cells of Cajal, GISTs are frequently found in the stomach and small intestine. Typically asymptomatic, GISTs can occasionally present as acute abdominal emergencies, including hemorrhage, obstruction, or perforation. This report presents a case of spontaneous perforation of a large ileal GIST, leading to peritonitis.

CASE PRESENTATION

An 82-year-old man arrived at the emergency department with severe abdominal pain, fever, vomiting, and diarrhea. Physical examination showed abdominal tenderness and distension, and laboratory findings indicated elevated inflammatory markers. A computed tomography (CT) scan revealed a 15 cm mass in the lower right abdomen, with free fluid and extraluminal air suggesting perforation. Emergency laparotomy confirmed a perforated tumor, with purulent peritonitis. Surgical resection of the affected ileum and cecum was performed, followed by anastomosis and enterostomy. Histopathology confirmed a high-risk GIST, and the patient recovered well post-operatively, subsequently beginning adjuvant imatinib therapy.

DISCUSSION

GISTs commonly remain asymptomatic until complications arise. Peritonitis due to tumor perforation is rare and necessitates prompt surgical intervention. Surgical resection remains the standard treatment for localized GISTs, with adjuvant imatinib recommended for high-risk cases. CT imaging is critical for diagnosis and surgical planning.

CONCLUSION

While GIST perforation leading to peritonitis is rare, it requires urgent surgery. High-risk GIST patients benefit from adjuvant imatinib and should undergo long-term follow-up. This case highlights the importance of a multidisciplinary approach for complex GIST presentations and associated complications.

Impact of Gastrointestinal Bleeding on Prognosis and Associated Risk Factors in Gastrointestinal Stromal Tumors: A Systematic Review and Meta-Analysis

BackgroundGastrointestinal stromal tumors (GISTs) are common mesenchymal tumors of the digestive tract. The impact of gastrointestinal bleeding on the prognosis of GISTs remains controversial. This study aims to evaluate the prognostic significance of gastrointestinal bleeding in GIST patients and analyze associated risk factors.MethodsA systematic review and meta-analysis were conducted according to the PRISMA guidelines. PubMed, MEDLINE, Web of Science, EMBASE, and Cochrane Library databases were searched for relevant studies published up until December 31, 2023. The pooled hazard ratio (HR) with a 95% confidence interval (CI) was used to estimate the relationship between gastrointestinal bleeding and prognosis. Subgroup analyses were performed based on bleeding location and other risk factors.ResultsTwelve studies involving 3475 patients were included. Gastrointestinal bleeding significantly affected the prognosis of GIST patients, including recurrence-free survival (RFS) (HR = 1.57, 95% CI: 0.98-2.52, P < .01) and overall survival (OS) (HR = 3.04, 95% CI: 1.33-6.97, P < .01). Patients with gastric GIST bleeding had significantly worse prognoses (HR = 4.37, 95% CI: 2.36-8.11, P < .01), while small intestinal bleeding showed no significant difference. The bleeding risk was lower in the small intestine compared to the stomach (HR = .63, 95% CI: 0.48-0.83, P < .01). Age under 65, male gender, tumor size ≥5 cm, and mitotic index ≥5 HPF were identified as high-risk factors for GIST bleeding.ConclusionsGastrointestinal bleeding significantly impacts the prognosis of GIST patients, particularly in those with gastric bleeding.

Ileal Gastrointestinal Stromal Tumor (GIST) Presenting With a Liver Abscess: A Case Report and Review of the Literature

Gastrointestinal stromal tumors (GISTs) are rare small intestinal tumors. Due to challenging diagnoses, the majority of patients typically report chronic problems. Early diagnosis and the start of appropriate treatment depend on high suspicion. We present a case of a 47-year-old male patient who first experienced fever, nausea, vomiting, and pain in the right upper quadrant. Radiologic examinations showed an intra-abdominal tumor containing oral contrast and a liver lesion, indicating gastrointestinal tract involvement. He had an ileal GIST that created a fistula between the tumor and the small intestine, complicated by a liver abscess. We surgically removed the tumor and intra-operatively drained the liver abscess. A liver lesion found in conjunction with a small intestine GIST should cause concern for both the possibility of infectious complications such as a pyogenic liver abscess and metastatic illness. The uncommon appearance of an ileal GIST with a tumor-intestinal fistula, accompanied by a liver abscess, is reviewed in this case report.

Influence of lymph node removal on the prognosis of high malignancy potential gastric gastrointestinal stromal tumors: Insights from population-based study

High malignancy potential gastric gastrointestinal stromal tumors (HMP-gGISTs) generally require surgical resection. However, the necessity of lymph node removal (LR) for patients with such tumors remains unclear. Therefore, we conducted a population-based study to analyze the impact of LR on the long-term prognosis of patients with HMP-gGISTs. Patients with HMP-gGISTs were gathered from the Surveillance, Epidemiology, and End Results (SEER) database. Propensity score matching (PSM) was utilized to address potential selection bias. Overall survival (OS) and cancer-specific survival (CSS) were evaluated using Kaplan-Meier analyses and multivariate Cox proportional hazards models. A total of 840 patients with HMP-gGISTs were included in the study, with 317 undergoing LR and 523 not undergoing LR. The prognosis for OS (P = 0.026) and CSS (P < 0.001) in the LR group was worse compared to the No-LR group. After PSM, 634 patients were matched for comparison. The results showed that the OS (P = 0.028) and CSS (P = 0.006) in the LR group remained poorer than those in the No-LR group. Subgroup analysis further indicated that patients who did not undergo LR had a better prognosis. Our findings suggest that LR may not improve the prognosis of patients with HMP-gGISTs, implying that LR may not be necessary for these patients.

Unusual case report of bifocal gastrointestinal stromal tumor in the first jejunal loop uncovered by severe hemorrhage

INTRODUCTION AND IMPORTANCE

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors, constituting 1 % of gastrointestinal tumors. Jejunal GISTs are even rarer. This article describes a unique bifocal jejunal GIST case, revealed by an exceptionally rare instance of massive hemorrhage.

CASE PRESENTATION

We present a 60-year-old female admitted for two days of melena. Despite being hemodynamically stable, severe anemia was noted. Initial endoscopy was normal, but further imaging and jejunoscopy revealed two jejunal GISTs. Surgical resection confirmed the diagnosis. Postoperative recovery was uneventful, with no bleeding recurrence after one year.

CLINICAL DISCUSSION

Gastrointestinal stromal tumors (GISTs) are rare but the most common mesenchymal neoplasms in the gastrointestinal tract, originating from interstitial cells of Cajal. Jejunal GISTs are particularly rare but can cause severe gastrointestinal bleeding, even if small. Diagnosis is challenging and often confirmed by angio-CT. Upper and lower endoscopies are initial steps in evaluating gastrointestinal bleeding, but jejunal GISTs may not be visible due to limited access. In such cases, jejunoscopy and video capsule endoscopy can be particularly valuable for direct visualization and assessment of the jejunum, as demonstrated in our patient, where jejunoscopy enabled precise diagnosis. Complete surgical resection is the recommended treatment, with CD-117 positivity confirming the diagnosis.

CONCLUSION

This case highlights the rare presentation of bifocal jejunal GISTs with severe hemorrhage and emphasizes the need for prompt surgical intervention and awareness of atypical cases.

Spontaneous haemoperitoneum caused by a bleeding gastric gastrointestinal stromal tumour

Spontaneous haemoperitoneum is described as a collection of blood in the peritoneal cavity due to non-traumatic aetiology. Common causes in the literature include splenic, hepatic and gynaecological pathology. Patients with spontaneous haemoperitoneum usually present with non-specific dull aching abdominal pain. Spontaneous haemoperitoneum can only be radiologically diagnosed and, if not treated in time, is life threatening. Rupture of a gastrointestinal stromal tumour (GIST) presenting as a spontaneous haemoperitoneum is a rare event. Gastric GIST presents as ambiguous abdominal pain, complications of which include melena, obstruction and rupture. This is a report of a male patient in his early 60s who presented with acute abdominal pain. A contrast-enhanced CT of the abdomen showed haemoperitoneum with an unknown source of origin. Diagnostic laparoscopy showed a bleeding exophytic mass arising from the stomach, which was resected. Thus, early diagnosis with proper imaging and prompt treatment has a favourable outcome.

Gastrointestinal Stromal Tumors (GISTs) in Pediatric Patients: A Case Report and Literature Review

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms that primarily affect adults, with pediatric cases constituting only 0.5-2.7% of the total. Pediatric GISTs present unique clinical, genetic, and pathological features that distinguish them from adult cases. This literature review aims to elucidate these differences, emphasizing diagnostic and therapeutic challenges. We discuss the resistance of pediatric GISTs to conventional chemotherapy and highlight the importance of surgical intervention, especially in emergency situations involving intra-abdominal bleeding. The review also explores the molecular characteristics of pediatric GISTs, including rare mutations such as quadruple-negative wild-type GIST with an FGF3 gene gain mutation. To illustrate these points, we conclude with a case from our clinic involving a 15-year-old female with multiple CD117-positive gastric GISTs and a quadruple-negative wild-type genetic profile who required urgent surgical intervention following a failed tumor embolization. This case underscores the critical need for early diagnosis and individualized therapeutic strategies combining oncologic and surgical care to improve outcomes in pediatric GIST patients.

Acute abdomen due to perforated jejunal gastrointestinal stromal tumor: A case report

INTRODUCTION

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors, with jejunal GISTs being particularly uncommon. Jejunal GISTs causing perforation and acute diffuse peritonitis is rare.

CASE PRESENTATION

A 53-year-old female with a history of hypertension presented with severe, acute abdominal pain and vomiting. Examination revealed abdominal distension, tenderness, and guarding, with imaging suggestive of gastrointestinal perforation. Emergency laparotomy revealed a 9 cm × 8 cm mass with perforation in the jejunum, which was resected which on histopathological examination confirmed a low-grade GIST. The postoperative course was complicated by a wound infection, managed with antibiotics and secondary suturing. At one-year follow-up, the patient remained disease-free without the need for adjuvant therapy.

CLINICAL DISCUSSION

The most common symptoms of jejunal GISTs include vague abdominal pain or discomfort, early satiety, obstruction or hemorrhage. Preoperative diagnosis and confirmation of GIST is difficult due to nonspecific symptoms and none of the radiographic procedures can establish the diagnosis with certainty. The surgical excision of the tumor along with infiltrated tissues is the treatment of choice for GIST.

CONCLUSION

This case underscores the necessity of considering GISTs in differential diagnoses of acute abdomen and the critical role of prompt surgical management and multidisciplinary care in achieving favorable outcomes.

Gastrointestinal Stromal Tumor (GIST) Masquerading as a Pancreatic Pseudocyst: A Rare Case Report

Despite their relative rarity, gastrointestinal stromal tumors (GIST) are the most common type of mesenchymal tumor in the gastrointestinal (GI) tract. Here, we describe a rare case of a 62-year-old hypertensive female presenting with abdominal pain and a palpable mass, initially suspected to be a pancreatic pseudocyst based on radiological findings. Subsequent histopathological (HPE) examination following surgical resection revealed a large cystic lesion originating from the stomach, characterized as a malignant epithelioid GIST. Based on these findings and taking into consideration the symptomatology of the patient, the decision was made to post the patient for an upfront, open surgical exploration without pre-operative biopsy studies. Frozen section facilities were kept on standby considering the differential diagnosis. Since the frozen section revealed a gastric GIST, a decision was made to perform subtotal gastrectomy, followed by gastrojejunostomy (GJ) and jejunojejunostomy (JJ). In addition, the part of the cyst adherent to the left lobe of the liver was dealt with with a non-anatomical wedge resection. Immunohistochemical (IHC) analysis showed positivity for Cluster of Differentiation 117 (CD117) with negativity for Cluster of Differentiation 34 (CD34), Desmin, and Discovered On Gastrointestinal Stromal Tumors 1 (DOG-1). The tumor exhibited aggressive features, including high mitotic activity, i.e., >5/10 high power field (hpf), hemorrhagic areas, and infiltration into the liver parenchyma. The patient then received adjuvant imatinib-based chemotherapy and was maintained on strict follow-up.

Understanding Gastric GIST: From Pathophysiology to Personalized Treatment

Background: Gastric gastrointestinal stromal tumors (GISTs) represent a subset of gastrointestinal tumors predominantly found in the stomach. Despite their rarity, these tumors carry significant implications for patient health and management. GISTs are potentially malignant tumors with unpredictable progression. They originate from the interstitial cells of Cajal, which are positioned between the intramural neurons and the smooth muscle cells of the digestive tract. These tumors are characterized primarily by mutations in the c-Kit gene, as well as other mutations such as those in the platelet-derived growth factor receptor alpha (PDGFRA) gene. Methods: Our comprehensive search across five databases initially yielded 2976 articles. After eliminating 197 duplicates, we screened the titles and abstracts of 2779 articles, excluding 2692 for not meeting the inclusion criteria. During the full-text screening, 16 more articles were excluded. Ultimately, 71 papers met the inclusion criteria and were included in our analysis. Results: Due to differences in study designs, inclusion criteria for patients, and reported outcomes, a meta-analysis was not conducted. The accurate diagnosis of GIST is established through histopathological examination and immunohistochemistry. Histopathologically, GISTs are classified into three main types: spindle cell, epithelioid, and mixed. The therapeutic management of GIST involves surgery, endoscopic treatment, and chemotherapy. Conclusions: The prognosis for GIST patients depends on various factors, including risk category, disease stage, applied treatments, and recurrence post-treatment. A significant recent advancement comes from artificial intelligence, which can be increasingly involved in both the diagnosis and treatment of this tumor.

Co-relation of gastrointestinal stromal tumors in a patient with leiomyoma cutis- A rare association

INTRODUCTION AND IMPORTANCE

Cutaneous leiomyomas, benign tumors from smooth muscle fibers, constitute about 5 % of all leiomyomas. They exhibit diverse inheritance patterns and can be linked to systemic malignancies. Gastrointestinal stromal tumors (GISTs), arising from the interstitial cells of Cajal, are the most common mesenchymal tumors in the gastrointestinal tract. Despite their prevalence, simultaneous occurrences of cutaneous leiomyomas and GISTs are rare, necessitating exploration of their potential relationship.

CASE PRESENTATION

A 25-year-old male with no significant medical history presented with multiple painful erythematous nodules on his chest, upper back, and arms. Histopathological analysis diagnosed these as multiple cutaneous piloleiomyomatosis. Despite recommendations for surgical intervention, the patient chose medical management and experienced significant pain relief with nifedipine. Later, the development of abdominal symptoms led to the discovery of multiple gastric lesions, diagnosed as benign spindle cell neoplasms, necessitating partial gastrectomy.

CLINICAL DISCUSSION

The differential diagnosis of cutaneous leiomyomas includes various soft tissue tumors, requiring histopathological confirmation. Genetic mutations affecting proteins critical to cellular energy production and tumor suppression underlie these conditions. Treatment options include pharmacological management and surgical excision. The discovery of GISTs in this patient aligns with rare literature reports, emphasizing the need for vigilant evaluation of systemic malignancies in patients with leiomyomatosis.

CONCLUSION

This case highlights the potential of cutaneous leiomyomas to indicate deeper malignancies like GISTs, stressing the importance of interdisciplinary collaboration in diagnosis and treatment. It underscores the interconnectedness of benign dermatological conditions and internal malignancies, advocating for comprehensive evaluation in patients with leiomyomatosis.

METHODS

This case report meticulously follows the SCARE 2023 guidelines: updating consensus Surgical Case Report guidelines (Sohrabi et al., 2023 [1]). These guidelines ensure high-quality reporting in surgical case reports. The report details the evaluation, diagnosis, and a comprehensive review of the literature pertaining to a patient with multiple leiomyoma cutis associated with gastrointestinal stromal tumors. By employing a multidisciplinary approach, this report achieves a thorough and standardized presentation of the case, serving as an additional tool for raising awareness regarding such rare conditions.

MicroRNA expression signature in gastrointestinal stromal tumour & their molecular & histological features

Background & objectives In gastrointestinal stromal tumour (GIST), not only genetic abnormalities are responsible for adverse clinical events, but epigenetic modifications also play a crucial role. MicroRNA (miRNA) dysregulation plays a significant role in carcinogenesis as miRNAs serve as natural silencer for their targets. Our study aimed to explore the miRNAs expression and its association with molecular and histopathological characteristics of GIST. Methods Fifty GIST samples, including 45 formalin fixed paraffin embedded (FFPE) and fresh tissues were included. Peripheral non-tumour tissues were used as controls. All the cases were confirmed using immunohistochemistry. RNA was extracted using miRNA-specific kit, and the expression was performed using RT-qPCR. The data were evaluated using AriaMx software version 1.5 (Agilent, US). MiRNAs expression was analyzed by using the relative quantification method (ΔΔCT). Results miR-221, miR-222, miR-494 and miR-34a showed significant down-regulation in tumours relative to non-tumour tissues. The expression levels of these miRNAs were significantly down-regulated in c-KIT (proto-oncogene encoding the tyrosine kinase transmembrane receptor)-positive tumours compared to c-KIT-negative. Further analysis revealed that reduced expression was associated with spindle subtypes and gastric localization. However, there was no significant correlation with other histological features. Additionally, miR-221/222, and miR-494 were down-regulated in most of the KIT exon 11 mutant subtypes, while miRNA-34a was associated with platelet derived growth factor receptor alpha (PDGFRA) mutations. Interpretation & conclusions The present study showed that the down-regulation of these miRNAs may help better molecular classification and characterization of GISTs. Our results offer new insight into the association between miRNAs and histological features, enabling a more thorough understanding of GISTs at the molecular level.

A Gastrointestinal Stromal Tumor (GIST) and a Pseudocyst of the Pancreas: A Peculiar Case of Both Co-existing in the Same Patient

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal (GI) tract, typically originating from the interstitial cells of Cajal. The clinical presentations are variable according to their size and shape but rarely present as a palpable abdominal mass. Pancreatic pseudocysts are common complications of chronic pancreatitis characterized by fluid collections surrounded by a non-epithelialized wall of fibrous and granulation tissue. Patients may present with non-specific symptoms like abdominal pain, nausea, and vomiting and they generally have a history of acute pancreatitis. Small pseudocysts often resolve spontaneously, but larger ones often become symptomatic and may lead to complications. It is rare to find both a GIST of the stomach and a pseudocyst of the pancreas in the same patient. We present a unique case of a giant GIST and a pancreatic pseudocyst in a 72-year-old male who was experiencing abdominal pain and distension. Imaging revealed a massive lesion originating from the posterior gastric wall, which resembled a pseudocyst, along with a distinct cystic lesion adjacent to the pancreatic body. During surgical exploration, a complex interplay of both pathologies was discovered, requiring a comprehensive resection approach. The successful outcome highlights the importance of careful evaluation and personalized management in such rare cases.

Postoperative encapsulated hemoperitoneum in a patient with gastric stromal tumor treated by exposed endoscopic full-thickness resection: A case report

BACKGROUND

Gastric stromal tumors, originating from mesenchymal tissues, are one of the most common tumors of the digestive tract. For stromal tumors originating from the muscularis propria, compared with conventional endoscopic submucosal dissection (ESD), endoscopic full-thickness resection (EFTR) can remove deep lesions and digestive tract wall tumors completely. However, this technique has major limitations such as perforation, postoperative bleeding, and post-polypectomy syndrome. Herein, we report a case of postoperative serous surface bleeding which formed an encapsulated hemoperitoneum in a patient with gastric stromal tumor that was treated with exposed EFTR. Feasible treatment options to address this complication are described.

CASE SUMMARY

A 47-year-old male patient had a hemispherical protrusion found during gastric endoscopic ultrasonography, located at the upper gastric curvature adjacent to the stomach fundus, with a smooth surface mucosa and poor mobility. The lesion was 19.3 mm × 16.1 mm in size and originated from the fourth ultrasound layer. Computed tomography (CT) revealed no significant evidence of lymph node enlargement or distant metastasis. Using conventional ESD technology for mucosal pre-resection, exposed EFTR was performed to resect the intact tumor in order to achieve a definitive histopathological diagnosis. Based on its morphology and immunohistochemical expression of CD117 and DOG-1, the lesion was proven to be consistent with a gastric stromal tumor. Six days after exposed EFTR, CT showed a large amount of encapsulated fluid and gas accumulation around the stomach. In addition, gastroscopy suggested intracavitary bleeding and abdominal puncture drainage indicated serosal bleeding. Based on these findings, the patient was diagnosed with serosal bleeding resulting in encapsulated abdominal hemorrhage after exposed EFTR for a gastric stromal tumor. The patient received combined treatments, such as hemostasis under gastroscopy, gastrointestinal decompression, and abdominal drainage. All examinations were normal within six months of follow-up.

CONCLUSION

This patient developed serous surface bleeding in the gastric cavity following exposed EFTR. Serosal bleeding resulting in an encapsulated hemoperitoneum is rare in clinical practice. The combined treatment may replace certain surgical techniques.

Advanced and Metastatic Gastrointestinal Stromal Tumors Presenting With Surgical Emergencies Managed With Surgical Resection: A Case Series

Advanced and metastatic gastrointestinal stromal tumors (GISTs) presenting with surgical emergencies are rare. Neoadjuvant imatinib being the treatment of choice for non-metastatic advanced disease with a proven role in downstaging the disease may not be feasible in patients presenting with bleeding and obstruction. We present a case series with retrospective analysis of a prospectively maintained database of patients with advanced and metastatic GISTs presenting with surgical emergencies. Clinical characteristics, imaging and endoscopic findings, surgical procedures, histological findings, and outcomes in these patients were studied. Four patients were included in this case series, with three males and one female (age range: 24-60 years). Two patients presented with melena; one with hemodynamic instability despite multiple blood transfusions underwent urgent exploratory laparotomy for bleeding gastric GIST, while the other underwent surgical exploration after careful evaluation given the recurrent, metastatic disease with a stable metabolic response on six months of imatinib. One patient with metastatic jejunal GIST who presented with an umbilical nodule and intestinal obstruction was given a trial of non-operative management for 72 hours, but due to non-resolution of obstruction, segmental jejunal en bloc resection with the dome of the urinary bladder with reconstruction and metastasectomy was needed. The patient with advanced gastric GIST who presented with gastric outlet obstruction was resuscitated, and an attempt of endoscopic naso-jejunal tube placement was tried, which failed, and exploration was needed. The mean length of hospital stay was 7.5 days. Histopathological examination confirmed GIST in all four patients with microscopic negative resection margins. All patients were started on imatinib with dose escalation to 800 mg in the patient with recurrent and metastatic disease; however, the patient with bleeding gastric GIST experienced severe adverse effects of imatinib and discontinued the drug shortly. All four patients are disease-free on follow-ups of 15 months, 48 months for the patient with advanced non-metastatic disease, and six and 24 months for the patients with metastatic disease. In the era of tyrosine kinase inhibitor (TKI) therapy for advanced and metastatic disease, upfront surgery is usually reserved for surgical emergencies only. Surgical resection, the cornerstone for the treatment of resectable GIST, may also be clinically relevant in metastatic settings, although it requires a careful and individualized approach.

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.

Surgical outcomes of locally advanced gastrointestinal stromal tumors after multivisceral resection: A retrospective study of 64 patients at a single institution

To analyze the outcome in patients who have undergone multivisceral resection (MVR) for locally advanced gastrointestinal stromal tumors (GISTs), and identify the risk factors for tumor recurrence and postoperative morbidity. Sixty-four patients who operated for locally advanced GISTs with MVR in PPeking University Cancer Hospital Sarcoma Center (PUCHSC) between 2013 and 2021 were identified. Clinicopathologic characteristics, surgical outcomes, recurrence, and 5-year recurrence-free and overall survival were evaluated. The mean age of the patients was 60 years. Mean tumor size was 11.1 cm. Complete resection was achieved in all patients. The estimated 5-year recurrence-free and overall survival were 86.6% and 90.0%, respectively. Independent factor of recurrence following surgery was mitotic count on multivariate analysis. Overall postoperative morbidity was 53.1% (n = 34). Severe morbidity was 21.9% (n = 14). The most common severe complication was clinically relevant pancreatic fistula (n = 12, 18.8%), followed by anastomotic leakage (n = 4, 6.3%) and Intraabdominal abscess (n = 4, 6.3%). Multivariate analysis showed that preoperative imatinib therapy could reduce overall morbidity. Long operation time, combined colectomy and pancreatectomy were independent risk factors for postoperative severe morbidity. Compared to partial pancreatectomy, pancreaticoduodenectomy (PD) was significantly increased the incidence of severe morbidity. In conclusion, compared to systemic therapy alone, the outcome of locally advanced GISTs after MVR was more favorable. Despite the high overall morbidity, the postoperative severe morbidity and mortality of MVR were acceptable. Preoperative imatinib therapy should be recommended whenever possible. Combined pancreatectomy and colectomy are associated with significant postoperative severe morbidities. PD should be thoroughly discussed and be subject to MDT approach before surgery.

A Case of Gastrointestinal Stromal Tumour (GIST) in the Duodenum in a Young Adult

Gastrointestinal stromal tumours (GISTs) are rare gastrointestinal (GI) malignancies, but the most prevalent mesenchymal tumours of the GI tract arise from the interstitial cells of Cajal. They account for 1-3% of all GI malignancies, and only 3-5% of all cases of GIST are located at the duodenal. We present a case of a young adult who presented to the ED with symptoms of GI bleeding.

Efficacy and safety of ripretinib vs. sunitinib in patients with advanced gastrointestinal stromal tumor previously treated with imatinib: A phase 2, multicenter, randomized, open-label study in China

AIM

A bridging study of INTRIGUE study to assess the efficacy and safety of ripretinib versus sunitinib as second-line treatment in Chinese GIST patients.

METHODS

This was a phase 2, multicenter, randomized, open-label study in China. GIST patients previously treated with imatinib were randomized (1:1) to receive ripretinib 150 mg once daily (QD) by continuous dosing in 42-day cycles or sunitinib 50 mg QD in 42-day cycles (four weeks on/two weeks off). Primary endpoint was progression-free survival (PFS) by independent radiological review (IRR).

RESULTS

Between 6 December 2020 and 15 September 2021, 108 patients were randomized to receive ripretinib (n = 54) or sunitinib (n = 54) (all-patient [AP] intention-to-treat [ITT] population). Seventy patients had primary KIT exon 11 mutations (ripretinib, n = 35; sunitinib, n = 35; Ex11 ITT population). By data cut-off (20 July 2022), in AP ITT population, PFS by IRR was comparable between ripretinib and sunitinib arms (HR 0·99, 95 % CI 0·57, 1·69; nominal p = 0·92; median PFS [mPFS] 10·3 vs 8·3 months). In Ex11 ITT population, PFS by IRR was longer for ripretinib than sunitinib (HR 0·46, 95 % CI 0·23, 0·92; nominal p = 0·03; mPFS not reached in ripretinib arm and 4·9 months in sunitinib arm). Fewer patients experienced grade 3/4 treatment-related treatment-emergent adverse events with ripretinib (17%) versus sunitinib (56%).

CONCLUSIONS

Ripretinib demonstrated similar efficacy and a favorable safety profile versus sunitinib as second-line treatment in Chinese GIST patients. Furthermore, ripretinib provided greater clinically meaningful benefit versus sunitinib in patients with KIT exon 11 mutation.

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.

Gastrointestinal Stromal Tumor Complicated by Fistula Formation

Gastrointestinal (GI) stromal tumors are mesenchymal tumors that may arise in any portion of the GI tract. Their clinical presentation and complications may vary but do not often present with fistulization. This case is of clinical interest because of the rarity of GI stromal tumor intestinal fistulas.

Efficacy analysis of endoscopic treatment of giant gastric gastrointestinal stromal tumors (≥5 cm)

OBJECTIVE

To investigate the safety, feasibility and prognosis of endoscopic treatment of giant (≥5 cm) gastric gastrointestinal stromal tumors (gastric GISTs).

METHODS

Data from patients who underwent surgical resection of nonmetastatic gastric GISTs in our hospital from January 2016 to February 2022 were collected. The patients were divided into an endoscopic group and a laparoscopic group according to the surgical method. The clinical data and tumor recurrence information were compared between the two groups.

RESULTS

Eighteen cases were collected in the endoscopic group and sixty-three cases in the laparoscopic group. There were no significant differences in age, gender, tumor diameter, tumor growth site, tumor growth mode, clinical manifestations, risk classification or complication rate between the two groups (P > 0.05). The hospitalization cost, length of postoperative hospital stay and postoperative fasting time of the endoscopic group were less than those of the laparoscopic group, while the operation time was greater than that of the laparoscopic group (P < 0.05). In the endoscopic group, the follow-up was 33.50 ± 19.410 months, and no patients were lost to follow-up. The laparoscopic group was followed up for 59.07 ± 12.964 months, and eleven patients were lost to follow-up. There was no recurrence or metastasis in the two groups during the follow-up.

CONCLUSION

Endoscopic resection of gastric GIST with a diameter ≥5 cm is technically feasible. And it not only achieves a short-term prognosis similar to laparoscopic resection but also has the advantages of rapid postoperative recovery and low cost.

A giant gastric stromal tumor with dizziness as the main complaint: A case report and literature review

INTRODUCTION

Small gastrointestinal stromal tumors (GISTs) are often asymptomatic. However, large tumors can cause symptoms like abdominal pain and GI bleeding. We experienced a unique case where a giant GIST was incidentally found by CT scanning during emergency treatment for dizziness.

PRESENTATION OF CASE

A 61-year-old man presented temporary dizziness after exercising three days ago before his admission. Enhanced CT scan of the abdomen and pelvis revealed a large circular mass in the right upper abdominal cavity, with a maximum cross-sectional size of approximately 132 mm × 155 mm. Biopsy and genetic testing confirmed the diagnosis of GIST. The patient underwent successful radical surgery and was discharged at 12th post-operative day without any complications. The patient now is taking imatinib as an adjuvant targeted therapy.

DISCUSSION

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the digestive tract with diverse clinical presentations according to their sites and sizes. As in this case, the patient's primary complaint was dizziness, which is uncommon for GISTs. Initial workup, including three-dimensional rebuilding of the enhanced CT scanning and biopsy, was given before surgery. Finally, despite the tumor's large size and attachment to adjacent structures, R0 resection was accomplished without intraoperative rupture.

CONCLUSION

This case highlights the importance of healthcare providers vigilant in identifying GISTs with unusual symptoms in emergency situations. A systematic and comprehensive examination can be and should be performed to confirm diagnosis and determine the feasibility of R0 resection. By sharing this unique case, we aim to enhance the understanding of GIST and increase awareness among clinicians about their varied presentations.

Gastrointestinal Stromal Tumor Masquerading As Acute Decompensated Heart Failure: A Challenging Diagnosis

Gastrointestinal stromal tumors (GISTs) are rare lesions of the gastrointestinal tract that have a strong predisposition to the stomach and small intestine. We present a case of an 89-year-old female who initially presented to the emergency room with signs and symptoms of acute decompensated heart failure (HF) and was later discovered to have a 23-centimeter GIST in her abdominal cavity. This case emphasizes the implications of large intraperitoneal neoplasms and the unique constellation of symptoms they may present with.

Jejunal Gastrointestinal Stromal Tumor: A Strange Cause of Massive Gastrointestinal Bleeding

Jejunal gastrointestinal stromal tumors (GIST) are rare mesenchymal tumors of the gastrointestinal (GI) tract and a rare cause of massive GI bleeding. Due to this rarity and non-specific presentation, diagnosis and treatment may be difficult and often delayed. Urgent surgical intervention is crucial for controlling the source of bleeding and total tumor excision. Herein, we present the case of a 40-year-old male who presented to the emergency room (ER) with features of upper GI bleeding. He referred astheny and black stools, and was pale, sweaty, and tachycardic despite normal blood pressure. Rectal examination revealed melena, and laboratory findings revealed decreased hemoglobin (Hb) and elevated blood urea. Upper endoscopy was normal, and the Hb level dropped again to 6.9 g/dL; therefore, blood transfusion was required during ER observation. For further investigation, the patient underwent an angio-computed tomography scan, which revealed a lesion located in a jejunal loop as the probable bleeding source. Emergency exploratory laparotomy revealed a jejunal loop tumor. Segmental enterectomy containing the tumor was performed and the post-operative period was uneventful. The anatomopathological examination was compatible with low-risk GIST, and the multidisciplinary board agreed that surveillance was the best ongoing treatment. Due to the rarity of jejunal GIST as the cause of massive GI bleeding, diagnosis may be challenging, delaying prompt treatment with bleeding source control. In such cases, surgery may be both lifesaving and curative. Therefore, these tumors should not be forgotten when managing patients with occult GI bleeding with an atypical presentation to prevent delays in treatment and severe outcomes.

Giant gastric GIST with fast-growing mass after intra-tumoral bleeding

Only a few instances of giant gastrointestinal stromal tumors and even fewer cases of such tumors with intra-tumoral bleeding have ever been reported. This report represents a case with both giant size and intra-tumoral spontaneous hemorrhage. Here a 42-year-old male patient presented with abdominal pain and abdominal distention of 5-month duration. The distention had fast growth over 1 month before the hospital presentation. Physical examination showed a conjunctival pallor and an ill-defined abdominal mass. A contrast-enhanced computed tomography (CT) scan showed a huge intra-abdominal mass with variable enhancements. Surgical exploration was done and a huge mass measuring 10.5 kg with dimensions of 32 × 30 × 15 cm was excised en-bloc with distal gastrectomy.

Retroperitoneal extra gastrointestinal stromal tumor: A case report

INTRODUCTION

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors. Researchers do not know precisely what leads to GISTs, but genetic mutations play an important role. These mutations have no apparent cause. GISTs are usually asymptomatic tumors, although GI bleeding and weight loss can occur. CT is preferred for investigating potential GISTs.

CASE PRESENTATION

A 36-year-old unmarried Syrian female came to the hospital complaining of recurrent abdominal pain. CT revealed a large mass occupying a significant portion of the left hypochondrium and the lower part of the epigastrium. The tumor exceeded the median line to the right, pressing on the mesenteric vessels and the intestinal loops below. Immunohistochemistry results showed moderate positivity to CD117 and CD34, which were compatible with the diagnosis of GIST. The entire mass was excised. Physicians performed CT follow-ups every three months for 18 months, and no evidence of recurrence was observed.

DISCUSSION

Extragastrointestinal GISTs are a rare subtype of GISTs that occur outside the GI tract. GISTs previously used to be misdiagnosed as leiomyoma, leiomyosarcoma, leiomyoblastoma, and schwannoma. Treatment depends on surgery with adjuvant therapy tyrosine kinase inhibitors. Follow-up is recommended as the risk of recurrence is high.

CONCLUSION

We recommend that GIST, as an extremely rare tumor, should be considered in the differential diagnoses of masses that occur in the extra-intestinal region. Usually, patients need surgery with lymph node resection. However, this was not needed in our case.

Use of a Convolutional Neural Network to Predict the Malignant Potential of Gastrointestinal Stromal Tumors in Transabdominal Ultrasound Images: Visualization of the Focus of the Prediction Model

OBJECTIVE

We established a deep convolutional neural network (CNN) model based on ultrasound images (US-CNN) for predicting the malignant potential of gastrointestinal stromal tumors (GISTs).

METHODS

A total of 980 ultrasound images from 245 pathology-confirmed GIST patients after surgical operation were retrospectively collected and divided into a low (very-low-risk, low-risk) and a high (medium-risk, high-risk) malignant potential group. Eight pre-trained CNN models were used to extract the features. The CNN model with the highest accuracy in the test set was selected. The model's performance was evaluated by calculating accuracy, sensitivity, specificity, positive-predictive value (PPV), negative-predictive value (NPV) and the F1 score. Three radiologists with different experience levels also predicted the malignant potential of GISTs in the same test set. US-CNN and human assessments were compared. Subsequently, gradient-weighted class activation diagrams (Grad-CAMs) were used to visualize the model's final classification decisions.

RESULTS

Among the eight transfer learning-based CNNs, ResNet18 performed best. The accuracy, sensitivity, specificity, PPV, NPV and F1 score were 0.88, 0.86, 0.89, 0.82, 0.92 and 0.90, respectively, which were significantly better than those achieved by radiologists (resident doctor: 0.66, 0.55, 0.79, 0.74, 0.62 and 0.69; attending doctor: 0.68, 0.59, 0.78, 0.70, 0.69 and 0.73; professor: 0.69, 0.63, 0.72, 0.51, 0.80 and 0.76). Model interpretation with Grad-CAMs revealed that the activated areas mainly focused on cystic necrosis and margins.

CONCLUSION

The US-CNN model predicts GIST malignant potential well, which can assist in clinical treatment decision-making.

Diagnosis and management of high risk gastrointestinal stromal tumor in first trimester pregnancy: A case report and review of the literature

Objective

There are less than 20 reported cases of gastrointestinal stromal tumors in pregnancy. Of these reported cases, there are only two that detail GIST in the first trimester. We report our experience with the third known GIST diagnosis in the first trimester of pregnancy. Notably, our case report highlights the earliest known gestational age at time of GIST diagnosis.

Methods

We conducted a literature review of GIST diagnosis in pregnancy via PUBMED, using a combination of the following terms: (pregnancy or gestation) and (GIST). We utilized Epic for chart review of our patient's case report.

Results

A 24 year old G3P1011 presented to the Emergency Department at 4w6d by last menstrual period (LMP) with worsening abdominal cramping, bloating, and associated nausea. Physical exam revealed a large, mobile, nontender mass palpated in the right lower abdomen. Transvagianl ultrasound noted the presence of a large pelvic mass of unknown etiology. Pelvic magnetic resonance imaging (MRI) was obtained for further characterization, revealing a 7.3× 12.4 × 12.2 cm mass with multiple fluid levels, centered in the anterior mesentery. Exploratory laparotomy was performed with en bloc resection of small bowel and pelvic mass, with pathology demonstrating a 12.8 cm spindle cell neoplasm compatible with GIST and notable for a mitotic rate of 40 mitoses/50 high power field (HPF). Next generation sequencing (NGS) was pursued in order to predict tumor responsiveness to Imatinib, which revealed a mutation at KIT exon 11, suggesting a response to tyrosine kinase inhibitor therapy. The patient's multidisciplinary treatment team, consisting of medical oncologists, surgical oncologists, and maternal fetal medicine specialists, made the recommendation for adjuvant Imatinib therapy. The patient was offered termination of pregnancy with immediate initiation of Imatinib, as well as continuation of pregnancy with either immediate or delayed treatment. Interdisciplinary counseling focused on both the maternal and fetal implications of each proposed management plan. She ultimately elected termination of pregnancy, and underwent an uncomplicated dilation and evacuation.

Conclusions

GIST diagnosis in pregnancy is exceedingly rare. Patients with high-grade disease encounter a multitude of decision-making dilemmas, often with competing maternal and fetal interests. As additional cases of GIST in pregnancy are added to the literature, clinicians will be able to implement evidence-based options counseling for their patients. Shared decision-making is contingent upon patient understanding of diagnosis, risk of recurrence, available treatment options, and the treatment-related implications on maternal and fetal outcomes. A multidisciplinary approach is crucial for optimization of patient-centered care.

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.

Diagnostic and Therapeutic Challenges in the Management of Acute Massive Overt Bleeding of Jejunal Gastrointestinal Stromal Tumours: Case Series

INTRODUCTION

Jejunal gastrointestinal stromal tumours (GIST) are rare mesenchymal tumours. Acute massive overt bleeding from jejunal GIST is very rare and poses both diagnostic and therapeutic challenges in emergent conditions.

METHODS

A case series with retrospective analysis of prospectively maintained database of patients presenting with acute massive overt bleeding secondary to histologically proven jejunal GIST was done. Clinical characteristics, endoscopic and imaging diagnostic features, histological findings, surgical procedures and outcomes in these patients were studied.

RESULTS

Three patients were included in this case series. Mean age of presentation was 49.0 years with two male and one female patient. All three patients presented with melena and hemodynamic instability, resuscitated with adequate blood transfusions. Routine endoscopic assessment were inconclusive. Multiphasic Computed Tomographic Angiography (CTA) revealed hypodense hypervascular mass in jejunum in all three patients. One patient was unresponsive to blood transfusion and underwent emergency exploratory laparotomy. One patient underwent laparoscopic resection and reconstruction. Mean length of hospital stay was 5.3 days. Histopathological examination confirmed jejunal GIST in all three patients with microscopically negative resection margins. Two patients were disease free till 18-month follow-up and the one patient lost to follow-up after 1 year.

CONCLUSION

Multiphasic CTA is a single-step diagnostic tool for localisation of bleed and assessment of tumour characteristics in emergent conditions. Surgical resection is the mainstay of treatment for both control of bleed and to provide oncologically clear resection margins.

An Unexpected GIST Causing Life-Threatening Bleeding after an Elective Hernia Repair

Background  Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the alimentary tract. They are usually manifested by GI bleeding. Case Presentation  A 53-year-old male patient was admitted to the hospital for elective inguinal hernia repair. The patient did not have any history of GI symptoms in the past. A day after open inguinal hernia repair, the patient developed recurrent attacks of hematemesis resulting in hemodynamic instability and admission to the intensive care unit. An upper GI endoscopy identified a small bleeding gastric lesion. After multiple failed attempts to control the bleeding endoscopically, an emergency exploratory laparotomy was performed. An unexpected large fungating bleeding gastric mass was detected. The mass measured approximately 40 × 30 cm, and multiple peritoneal deposits were also discovered. A wedge resection of the anterior gastric wall along with the mass was performed. Histopathology revealed a high-grade (G2) GIST. Discussion  GISTs appear in variable sizes and may lead to a variety of complications including abdominal pain, GI obstruction, and bleeding. This case highlights the unexpected presentation and sudden bleeding of a large GIST in a totally asymptomatic patient undergoing elective hernia surgery. It also illustrates that GIST can be asymptomatic and grow to large sizes before developing clinical manifestations. Conclusion  The case report highlights a common complication of GIST with unexpected timing, immediately after routine hernia surgery.

The Application of Virtual Therapeutic Drug Monitoring to Assess the Pharmacokinetics of Imatinib in a Chinese Cancer Population Group

PURPOSE

Imatinib is used in gastrointestinal stromal tumours (GIST) and chronic myeloid leukaemia (CML). Oncology patients demonstrate altered physiology compared to healthy adults, e.g. reduced haematocrit, increased α-1 acid glycoprotein, decreased albumin and reduced glomerular filtration rate (GFR), which may influence imatinib pharmacokinetics. Given that Chinese cancer patients often report raised imatinib plasma concentrations and wider inter-individual variability reported in trough concentration when compared to Caucasian cancer patients, therapeutic drug monitoring (TDM) has been advocated.

METHOD

This study utilised a previously validated a Chinese cancer population and assessed the impact of imatinib virtual-TDM in Chinese and Caucasian cancer populations across a dosing range from 200-800 mg daily.

RESULTS

Staged dose titration to 800 mg daily, resulted in recapitulation to within the target therapeutic range for 50 % (Chinese) and 42.1% (Caucasian) subjects possessing plasma concentration < 550 ng/mL when dosed at 400 mg daily. For subjects with plasma concentrations >1500 ng/mL when dosed at 400 mg daily, a dose reduction to 200 mg once daily was able to recover 67 % (Chinese) and 87.4 % (Caucasian) patients to the target therapeutic range.

CONCLUSION

Virtual TDM highlights the benefit of pharmacokinetic modelling to optimising treatments in challenging oncology population groups.

Gastric volvulus associated with shrinkage of a gastrointestinal stromal tumor by neoadjuvant imatinib: a case report

BACKGROUND

During neoadjuvant chemotherapy for giant gastrointestinal stromal tumors, changes in gastrointestinal stromal tumor size are rarely associated with events such as perforation and bleeding that require emergency surgery. Moreover, it is very rare for gastrointestinal stromal tumors to shrink and become mobile, resulting in gastric volvulus. Herein, we report a case of gastrointestinal stromal tumor shrinkage during neoadjuvant imatinib treatment, resulting in gastric volvulus that required surgery. To the best of our knowledge, this is the first reported occurrence of gastric volvulus during neoadjuvant imatinib treatment for a giant gastrointestinal stromal tumor.

CASE PRESENTATION

A 58-year-old Japanese woman who was diagnosed with a giant gastric gastrointestinal stromal tumor and administered neoadjuvant imatinib presented to our hospital with complaints of abdominal pain and retching. Enhanced computed tomography revealed that the gastrointestinal stromal tumor had shrunk and shifted in position, and the stomach had organoaxially twisted. Accordingly, the patient was diagnosed with gastric volvulus caused by a gastric gastrointestinal stromal tumor. Conservative treatment did not improve the volvulus; hence, laparotomy was performed. The tumor developed from the lesser curvature of the stomach and caused rotation of the gastric body. The local gastric wall was resected. Histopathological examination confirmed the diagnosis of gastrointestinal stromal tumor. The patient received adjuvant imatinib for 3 years and has been alive for 5 years without recurrence.

CONCLUSIONS

Gastric volvulus can be caused by the laxity of the ligaments that hold the stomach and gastric ptosis or esophageal hernia and diaphragmatic hernia; therefore, gastric gastrointestinal stromal tumors rarely cause gastric volvulus. However, a risk of torsion exists if the gastrointestinal stromal tumor develops extramural to lesser curvature and attains a certain size.

Case report: Giant cystic ileal gastrointestinal stromal tumor with an atypical intratumoral abscess

Background

Gastrointestinal stromal tumors (GISTs) are typically solid, sometimes with small cystic areas, but rarely manifest as predominantly cystic neoplasms. In addition, cystic intestinal GISTs with intratumoral abscess formation are rare.

Case presentation

We present the case of a 49-year-old male patient with a history of frequent and urgent urination for 2 weeks. Radiologic studies revealed a large cystic mass in the lower abdomen. The patient underwent abdominal laparotomy, which revealed a large cystic mass arising from the distal ileum invading the sigmoid mesocolon and apex vesicae. Partial resection of the ileum along with the tumor and the adjacent bladder was performed. Macroscopic examination revealed that the cystic mass contained a large amount of foul-smelling pus and a tumor-bowel fistula. The final pathology revealed an abdominal stromal tumor. Postoperative recovery was uneventful, and adjuvant imatinib mesylate 400 mg was administered daily. No tumor recurrence or metastasis was observed during the 9-month follow-up period.

Conclusion

Fingings of a cystic tumor in the abdomen should raise concern for cystic GISTs. This case report reviews a rare presentation of an ileal giant cystic GIST with atypical intratumoral abscess formation. Complete surgical resection and adjuvant imatinib is still the mainstay treatment for GISTs.

Simple Scoring Model Based on Enhanced CT in Preoperative Prediction of Biological Risk of Gastrointestinal Stromal Tumor

Objective: To construct a simple scoring model for predicting the biological risk of gastrointestinal stromal tumors based on enhanced computed tomography (CT) features. Methods: The clinicopathological and imaging data of 149 patients with primary gastrointestinal stromal tumor were retrospectively analyzed in our hospital. According to the risk classification, the patients were divided into low-risk group and high-risk group. The features of enhanced CT were observed and recorded. Univariate and multivariate logistic regression models were used to determine the predictors of high-risk biological behaviors of gastrointestinal stromal tumor, and then a simple scoring model was constructed according to the regression coefficients of each predictor. The receiver operating characteristic curve was used to evaluate the predictive ability of the model. Results: There was no significant difference between the risk classification of gastrointestinal stromal tumor with gender and age (P = .168, .320), while significant difference was found between the tumor size and location (P < .001). Univariate and multivariate logistic regression analyses showed that tumor size, enlarged vessels feeding or draining the mass, peritumoral lymph node enlargement, and venous phase contrast enhancement rate were independent predictors of the biological risk of gastrointestinal stromal tumor (P < .05). The area under the curve value of tumor size, enlarged vessels feeding or draining the mass, peritumoral lymph node enlargement, and venous phase contrast enhancement rate as the high-risk predictor of gastrointestinal stromal tumor were 0.955, 0.729, 0.680, and 0.807, respectively. Receiver operating characteristic curve results showed that the area under the curve of the scoring model constructed based on enhanced CT features was 0.941 (95% confidence interval: 0.891-0.973). When the total score was >1, the sensitivity of the scoring model in diagnosing gastrointestinal stromal tumor was 85.58%, the specificity was 88.89%, the positive predictive value was 88.51%, the negative predictive value was 86.04%, and the accuracy was 86.18%. The results of DeLong test showed that the area under the curve of the scoring model was better than that of the receiver operating characteristic curve of tumor size, enlarged vessels feeding or draining the mass, peritumoral lymph node enlargement, venous phase contrast enhancement rate, and other indicators alone in predicting the high risk of gastrointestinal stromal tumor, and the differences were statistically significant (Z = 26.510, P < .001; Z = 3.992, P < .001; Z = 6.353, P < .001; Z = 4.052, P = .013). Conclusion: The simple scoring model based on enhanced CT features is a simple and practical clinical prediction model, which is helpful to make preoperative individualized treatment plan and improve the prognosis of gastrointestinal stromal tumor patients.

Gastro-intestinal stromal tumor (GIST): Experience from a tertiary care center in a low resource country

Objectives

The aim of this retrospective study was to review the overall survival (OS) and disease-free survival (DFS) of GISTs treated surgically at our center over the past decade.

Material and Methods

We undertook a 12-year retrospective review of our experience in treating this condition with a focus on long-term outcomes of treated patients in a resource-constrained environment. Incomplete follow-up information continues to be a major problem with studies conducted in low resource settings, and in order to overcome this, we undertook telephonic contact with patients or their relatives to get the necessary information about their clinical status.

Results

Fifty-seven patients with GIST underwent surgical resection during this period of time. The stomach was the most common organ involved in the disease, with 74% of the patients. Surgical resection was the main treatment approach, with R0 resection possible in 88%. Nine percent of the patients were given Imatinib as neoadjuvant treatment and 61% were offered the same, as adjuvant therapy. The duration of adjuvant treatment changed from one year to three years over the study period. Pathological risk assessment categorized the patients as Stage I, 33%; Stage II, 19%; Stage III, 39%; and Stage IV, 9%. Of the 40 patients who were at least three years from surgery, 35 were traceable giving an 87.5%, overall three-year survival. Thirty-one patients (77.5%) were confirmed to be disease-free at three years.

Conclusion

This is the first report of mid-long-term outcomes of the multimodality treatment of GIST from Pakistan. Upfront surgery continues to be the main modality. OS & DFS in resource-poor environments can be similar to those seen in a better-structured healthcare setting.

Ruptured gastro-intestinal stromal tumor as a surgical emergency: A case report and literature review

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. GISTs of the small bowel are rare, and often present with an abdominal mass and/or bleeding. Chemotherapy and surgery are the mainstay of therapy. Here, we discuss an unusual case of a ruptured jejunal GIST with hemoperitoneum and recurrence despite surgical excision followed by Imatinib treatment. Forty-five cases of ruptured small intestinal GISTs were identified in the literature. Most cases were in males and were found to be at the site of the jejunum.

Gastrointestinal stromal tumor of the small bowel complicated by torsion: A case report

INTRODUCTION

Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors that originate from the gastrointestinal tract wall. Approximately 20-30 % of GISTs originate from the small intestine. GISTs of the small intestine generally present with a palpable mass, distention, and abdominal pain and may exhibit acute abdomen at the onset. Herein, we describe a rare case of a pedunculated GIST of the small intestine complicated by torsion.

PRESENTATION OF CASE

A 69-year-old woman presented with lower abdominal pain. Abdominal contrast-enhanced computed tomography showed a 73 × 62 × 57-mm³ tumor in the pelvic cavity with enhanced margins and reduced contrast. It was presumed that the tumor had caused hemorrhagic infarction. Emergency laparotomy was performed, and the pedunculated tumor was found to be twisted 360° clockwise at the pedicle with hemorrhage and necrosis due to torsion. We performed partial resection of the small intestine including the tumor. Histopathological examination revealed tightly arranged spindle-shaped cells with hemorrhage, congestion, and inflammatory cell infiltration. Immunohistochemical staining showed positivity for CD34, CD117, and DOG1.

CONCLUSIONS

Torsion of a pedunculated small intestine GIST, although very rare, requires emergency surgery and should be recognized as a cause of acute abdomen in patients with GIST. Immediate surgery is mandatory if torsion of a small intestinal GIST is suspected because the GIST or intestine may become necrotic owing to hemorrhagic infarction.

Prognostic significance of hemoglobin, albumin, lymphocyte, platelet in gastrointestinal stromal tumors: A propensity matched retrospective cohort study

BACKGROUND

The combined index of hemoglobin, albumin, lymphocyte, and platelet (HALP) can reflect systemic inflammation and nutritional status simultaneously, with some evidence revealing its prognostic value for some tumors. However, the effect of HALP on recurrence-free survival (RFS) in patients with gastrointestinal stromal tumors (GISTs) has not been reported.

AIM

To investigate the prognostic value of HALP in GIST patients.

METHODS

Data from 591 untreated patients who underwent R0 resection for primary and localized GISTs at West China Hospital between December 2008 and December 2016 were included. Clinicopathological data, preoperative albumin, blood routine information, postoperative treatment, and recurrence status were recorded. To eliminate baseline inequivalence, the propensity scores matching (PSM) method was introduced. Ultimately, the relationship between RFS and preoperative HALP was investigated.

RESULTS

The optimal cutoff value for HALP was determined to be 31.5 by X-tile analysis. HALP was significantly associated with tumor site, tumor size, mitosis, Ki67, National Institutes of Health (NIH) risk category, and adjuvant therapy (all P < 0.001). Before PSM, GIST patients with an increased HALP had a significantly poor RFS (P < 0.001), and low HALP was an independent risk factor for poor RFS [hazard ratio (HR): 0.506, 95% confidence interval (95%CI): 0.291-0.879, P = 0.016]. In NIH high-risk GIST patients, GIST patients with low HALP had a worse RFS than patients with high HALP (P < 0.05). After PSM, 458 GIST patients were identified; those with an increased HALP still had significantly poor RFS after PSM (P < 0.001) and low HALP was still an independent risk factor for poor RFS (HR: 0.558, 95%CI: 0.319-0.976, P = 0.041).

CONCLUSION

HALP was significantly correlated with postoperative pathology and postoperative treatment. Furthermore, HALP showed a strong ability to predict RFS in GIST patients who underwent radical resection.

Gastrointestinal stromal tumors: a comprehensive radiological review

Gastrointestinal stromal tumors (GISTs) originating from the interstitial cells of Cajal in the muscularis propria are the most common mesenchymal tumor of the gastrointestinal tract. Multiple modalities, including computed tomography (CT), magnetic resonance imaging (MRI), fluorodeoxyglucose positron emission tomography, ultrasonography, digital subtraction angiography, and endoscopy, have been performed to evaluate GISTs. CT is most frequently used for diagnosis, staging, surveillance, and response monitoring during molecularly targeted therapy in clinical practice. The diagnosis of GISTs is sometimes challenging because of the diverse imaging findings, such as anatomical location (esophagus, stomach, duodenum, small bowel, colorectum, appendix, and peritoneum), growth pattern, and enhancement pattern as well as the presence of necrosis, calcification, ulceration, early venous return, and metastasis. Imaging findings of GISTs treated with antineoplastic agents are quite different from those of other neoplasms (e.g. adenocarcinomas) because only subtle changes in size are seen even in responsive lesions. Furthermore, the recurrence pattern of GISTs is different from that of other neoplasms. This review discusses the advantages and disadvantages of each imaging modality, describes imaging findings obtained before and after treatment, presents a few cases of complicated GISTs, and discusses recent investigations performed using CT and MRI to predict histological risk grade, gene mutations, and patient outcomes.

A Huge Malignant Gastric Gastrointestinal Stromal Tumor in a Young Patient

Malignant gastrointestinal stromal tumors (GISTs) are rare neoplasms originating from the gastrointestinal tract that rarely occur in patients below 40 years of age. To our knowledge, there have been no previous reports of satellite and metastatic nodules in GIST. We present a case of a young patient with a huge malignant gastric GIST accompanied by spontaneous bleeding and satellite and metastatic nodules, successfully treated surgically, without preoperative chemotherapy administration. A 28-year-old man was admitted to Haeundae Paik Hospital with melena. A huge bulging gastric mass with ulceration and bleeding was observed on endoscopy. A subepithelial lesion on the stomach body, abutting the pancreatic body and tail, with regional lymph node enlargement was confirmed by EUS and CT. Radical total gastrectomy was performed, the invasion surrounding the pancreatic tail and spleen were surgically dissected, and enlarged lymph nodes around the celiac trunk and the common hepatic artery were removed. The pathology results showed a malignant GIST with two satellite nodules and a metastatic tumor nodule at the left paracardial lymph node site. After complete resection of the malignant GIST, adjuvant chemotherapy with imatinib was initiated. Follow-up CT and endoscopy performed 6 months after surgery confirmed no recurrence of the disease.

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.

Duodenal Gastrointestinal Stromal Tumor: A Rare Disease in a Young Adult Female Patient Presenting with Life-Threatening Hemorrhage

Duodenal gastrointestinal stromal tumors (dGISTs) may be a source of life-threatening hemorrhage that leads to emergency surgical care, precluding tumor staging and the planning of an elective treatment. In this study, we report a case of potentially lethal bleeding dGIST in a young woman successfully treated by an organ-preserving elective surgery after endoscopic and angiographic hemostasis. A 26-year-old female patient was admitted to the Emergency Unit of our hospital with the complaints of hematemesis and melena in the previous 12 h. An upper endoscopy showed a 4-cm submucosal lesion, between the 2nd and 3rd part of the duodenum, in the lateral wall, with massive bleeding arising from central ulceration. Hemostasis was initially achieved endoscopically and then optimized by transarterial embolization. After a contrast-enhanced CT, the patient underwent planning elective surgery. Intraoperatively, a 3-cm lesion was confirmed and resected by excision of the full-thickness duodenum with adequate free margins. Immunohistochemical analysis of the specimen revealed to be a dGIST, with a low mitotic count (<5 mitosis/50 high power field), and tumor necrosis present in <50% of the lesion. The patient had an uneventful course.

A multidisciplinary approach in the diagnostic challenge of GIST

Gastrointestinal stromal tumors (GISTs) are the most common malignant mesenchymal lesions of the gastrointestinal tract. They originate from the interstitial cells of Cajal and are characterized by overexpression of the tyrosine kinase receptor, protein product of c-KIT gene (KIT). In this retrospective study, conducted over a period of 10 years, we retrieved from our database, a total number of 57 patients, admitted and operated in the surgical department of ‘Sf. Pantelimon’ Emergency Clinical Hospital, Bucharest, for digestive tumors, histopathologically confirmed as GISTs. More than half of the cases presented as surgical emergencies and the tumors found during the surgical procedures, which proved to be GISTs, were sometimes difficult to differentiate from other mesenchymal tumors, both for the clinician and the pathologist. The diagnosis of GIST relies mostly on pathology and immunohistochemistry, but also on clinical and imagistic data. The most common emergencies were digestive hemorrhage (associated with gastric location), followed by intestinal obstruction (especially for the ileal localization). The largest dimensions corresponded to gastric location. For selected indications (upper digestive sites), upper digestive endoscopy approaches 100% sensitivity. This study focuses on diagnosis of GISTs sustained by both clinical and imagistic methods, along with histopathology and immunohistochemistry techniques, according to the World Health Organization 2019 criteria. Even though the differential diagnosis of these tumors is challenging, an interdisciplinary cooperation with a multiple approach increases the odds of a correct positive diagnosis.

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

Simple Summary

Gastrointestinal stromal tumors (GISTs) represent about 1–3% of all gastrointestinal malignancies, of which 50–60% are gastric GISTs (GGs). To the date, surgery represents the best therapeutic option, and the robotic gastric surgery could gain an important role, overcoming many laparoscopic drawbacks. The aim of this study is to evaluate safety and effectiveness of minimally invasive surgery (MIS) for GGs, reporting 10-year experience of three different centers. We included a population of 81 patients who underwent MIS approaches (36 laparoscopy vs. 45 robotic surgery). Seventy-two (72) patients were enrolled in a follow-up program to evaluate the long-term oncological outcomes. Furthermore, we discussed some technical notes and also we analyzed the operative and peri-operative outcomes. In conclusion, our results suggest that the robotic approach might be a suitable treatment, especially for GISTs >5 cm, even located in unfavorable places, despite longer operative time and costs than laparoscopic approach.

Abstract

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.