Small intestine gastrointestinal stromal tumors

Unraveling the site-specific features in small intestinal stromal tumors: a retrospective study

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are a rare and less well-characterized disease. There is limited information on the clinical features of small intestinal GISTs at different sites.

AIMS

To enhance the understanding of the clinical characteristics and disease behavior of small intestinal GISTs based on their sites.

METHODS

We conducted a retrospective review of medical records for 317 patients diagnosed with primary small intestinal GISTs confirmed by surgical pathology, comparing their clinical features and tumor characteristics.

RESULTS

According to this cohort's data, duodenal GISTs presented with longer disease durations and higher prevalence of melena (44.6%), while jejunal GISTs manifested as abdominal masses (11.5%) and acute gastrointestinal bleeding (GIB) (13.3%), with the highest rate of emergency surgeries (16.8%). Ileal GISTs were associated with an older age of onset and a higher prevalence of hematochezia (19.6%), with one-third of cases discovered incidentally during gynecological procedures. Notably, the biological behavior of small intestinal GISTs varied significantly by sites. Tumors demonstrated different immunochemical markers and a progressive increase in diameter, mitotic activity, T and M stages, and risk classification from the duodenum to the jejunum and ileum. These findings warrant further validation in prospective multicenter studies.

CONCLUSIONS

Small intestinal GISTs might exhibit distinct clinical presentations and oncological features depending on their sites.

Small Bowel Gastrointestinal Stromal Tumors: The Value of CT Enterography in Assessing Pathological Aggressiveness

OBJECTIVE

This study aimed to characterize the computed tomography (CT) enterography features of the small bowel gastrointestinal stromal tumors (GIST) and to determine the association with pathological aggressiveness.

METHODS

Computed tomography enterography images of 30 patients with the histologically confirmed small bowel GIST were retrospectively enrolled. Tumor size, location, border, growth pattern, enhancement pattern, necrosis, calcification, ulceration, internal air, nodal metastasis, liver metastasis, peritoneal metastasis, and draining vein were evaluated. Relationships between imaging features and pathological aggressiveness were analyzed using χ 2 test or Fisher exact test. Correlations among CT features were analyzed using Spearman correlation analysis.

RESULTS

There were significant differences in tumor size between different risk levels ( F = 8.388, P < 0.001). There were statistically significant differences in the 5 imaging manifestations of necrosis, ulcer, tumor boundary, drainage vein, and intratumoral gas ( P < 0.05). There was a significant negative correlation between tumor size and enhancement type as well as clear tumor boundary. There was a significant positive correlation between tumor size and necrosis, ulcer, drainage vein, intratumoral gas, liver metastasis, and peritoneal metastasis.

CONCLUSIONS

Some CT enterography imaging features might be useful in the determination of the pathological aggressiveness in the patients with small bowel GIST.

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.

The impact of gender on survival outcomes in patients with small intestinal stromal tumors: a comprehensive analysis using the SEER database

BACKGROUND

Small intestinal stromal tumors (SISTs) are a rare type of mesenchymal tumor. Gender is known to influence the incidence and prognosis of various tumors, but its role on the survival of SISTs at the population level remains unclear. Therefore, we aim to explore the relationship between gender and the prognosis of SISTs using the Surveillance, Epidemiology, and End Results (SEER) database.

METHODS

Data on SISTs patients from 2000 to 2019 were derived from the SEER database. Multiple imputation was used to address missing data. Kaplan-Meier analyses and Cox proportional hazard models were applied to evaluate the impact of demographic and clinical characteristics on overall survival (OS) and cancer-specific survival (CSS).

RESULTS

A total of 3513 patients with SISTs were analyzed, including 1921 males and 1592 females. Kaplan-Meier analysis coupled with log-rank testing demonstrated a significantly higher mortality rate among male patients compared to females (P < 0.001). Notably, female patients exhibited superior OS (hazard ratio [HR] 0.808, 95% confidence interval [CI] 0.724-0.902, P < 0.001) and CSS (HR 0.801, 95% CI 0.692-0.927, P = 0.003) compared to male patients. While the mean 1-year CSS rates were comparable between genders (95.3% for males vs. 96.0% for females, P = 0.332), male patients consistently showed lower mean survival rates at 3-, 5-, and 10-year intervals. Surgical intervention significantly boosted 5-year OS and CSS rates in both male and female patients (P < 0.001). Multivariate Cox regression analysis identified age, sex, grade, TNM stage, surgery, and mitotic rate as independent risk factors for OS and CSS in patients with SISTs.

CONCLUSIONS

Our findings suggest that male patients with SISTs have a higher risk of mortality compared to female patients, indicating that gender may serve as a predictive indicator for survival in this patient population.

Hybrid surgical approach excision of gastrointestinal stromal tumor (GIST): A case report of GIST at an unusual location and review of the literature

Gastrointestinal stromal tumors are the most common malignant subepithelial lesions involving the gastrointestinal tract. Surgical techniques have been the mainstay of treatment, however, in recent times hybrid surgeries are being introduced yielding better clinical outcomes.

Gastrointestinal stromal tumors of the small intestine: the challenge of diagnosis and the outcome of management

PURPOSES

Gastrointestinal stromal tumor (GIST) is a rare small intestinal tumor. Most patients usually report long-period complaints due to difficult diagnoses. A high grade of suspicion is required for early diagnosis and initiation of the proper management.

METHODS

A retrospective study of all patients with small intestinal GIST who were operated in the period between January 2008 and May 2021 at Mansoura University Gastrointestinal Surgical Center (GIST).

RESULTS

Thirty-four patients were included in the study with a mean age of 58.15 years (± 12.65) with a male to female ratio of 1.3:1. The mean duration between onset of symptoms and diagnosis was 4.62 years (± 2.34). Diagnosis of a small intestinal lesion was accomplished through abdominal computed tomography (CT) in 19 patients (55.9%). The mean size of the tumor was 8.76 cm (± 7.76) ranging from 1.5 to 35 cm. The lesion was of ileal origin in 20 cases (58.8%) and jejunal in 14 cases (41.2%). During the scheduled follow-up period, tumor recurrence occurred in one patient (2.9%). No mortality was encountered.

CONCLUSION

Diagnosis of a small bowel GISTs requires a high grade of suspicion. Implementing new diagnostic techniques like angiography, capsule endoscopy, and enteroscopy should be encouraged when suspecting these lesions. Surgical resection is always associated with an excellent postoperative recovery profile and very low recurrence rates.

The relationship between Ki-67 expression and imaging signs and pathological features in GISTs

Introduction

To investigate the correlations between the Ki-67 index and plain-scan computerized tomography (CT) signs and pathological features of gastrointestinal stromal tumor (GIST) tissue.

Materials and methods

Data from 186 patients with GIST diagnosed by pathology and immunohistochemistry (IHC) in Peking University First Hospital from May 2016 to May 2022 were analyzed. The patients were divided into two groups: Ki-67 ≤5% and &gt;5%. Correlation analysis, univariate and multivariate Logistic regression analysis were used to explore the correlations between CT signs, pathological features, and Ki-67 expression.

Results

Univariate indicators correlated with the Ki-67 index were mitotic count, pathological grade, tumor hemorrhage, tumor necrosis, tumor size, and tumor density. Multivariate Logistic regression indicated that the mitotic count [odds ratio (OR) 10.222, 95% confidence interval (CI) 4.312–31.039], pathological grade (OR 2.139, 95% CI 1.397–3.350), and tumor size (OR 1.096, 95% CI 1.020–1.190) were independently associated with the Ki-67 expression level. The concordance indexes (C-index) for the pathological features and CT signs models were 0.876 (95% CI 0.822–0.929) and 0.697 (95% CI 0.620–0.774), respectively, with positive predictive values of 93.62% and 58.11% and negative predictive values of 81.29% and 75.89%, respectively. After internal verification by the Bootstrap method, the fitting degree of the pathological features model was found to be better than that of the CT signs model.

Conclusion

Mitotic count, pathological risk grading, and tumor size are independent risk factors correlating with high Ki-67 index. These results indicate that the Ki-67 index reflects tumor malignancy and can predict recurrence and metastasis of GIST.

The analysis of prognostic factors of primary small intestinal gastrointestinal stromal tumors with R0 resection: A single-center retrospective study

OBJECTIVE

We aim to assess factors that affect overall survival in patients with primary small intestinal gastrointestinal stromal tumors (GISTs) who had undergone R0 resection.

METHOD

A retrospective analysis reviewed the data of 82 consecutive confirmed GIST patients at a single medical center in China from January 2012 to June 2020. The survival curve was estimated using the Kaplan-Meier method, and independent prognostic factors were confirmed using the Cox regression model.

RESULTS

A total of 82 patients were included in the study: 42 men and 40 women, the mean age was 59 years old (23-83 years old). Tumors were commonly found in the jejunum (46.3%), ileum (20.7%), and duodenum (32.9%). The median tumor size was 6.0 cm (range: 1.0-15.0 cm). The number of mitoses per one 50 high-power field was used to define the mitotic rates. In our present study, 56 patients presented a mitotic rate ≤5 (68.3%) and 26 patients showed a rate >5 (31.7%) at the time of diagnosis. All patients accepted tumor resection without lymph node resection. The positivity rate was 97.6% for CD117, 96.3% for delay of germination 1, 65.9% for CD34, 6.1% for S-100, and 59.8% for smooth muscle actin using immunohistochemistry. Tumor size, tumor rupture, Ki67 index, mitotic index, and postoperative imatinib were independent prognostic factors for small intestinal GISTs.

CONCLUSIONS

In this study, larger tumor size, high Ki67 index, high mitotic index, the occurrence of tumor rupture, and use of imatinib were independent unfavorable prognostic indicators.

Ki-67 labelling index is related to the risk classification and prognosis of gastrointestinal stromal tumours: a retrospective study

BACKGROUND AND AIMS

Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours of the digestive tract with malignant potential. The current risk classification standard is unable to accurately evaluate the invasiveness and clinical outcomes of GISTs. Ki-67 labelling index (LI) may be an effective indicator in assessing tumour invasiveness and prognosis, however, its exact value in GISTs is still uncertain. The aims of our study were to evaluate the correlation of the Ki-67 LI and clinicopathological features of GISTs and to assess the potential value of the Ki-67 LI in GISTs classification and prognosis.

METHODS

The clinical, pathological and prognostic data were collected and analysed to identify the independent influential factors of GISTs risk stratification and the predictors of GISTs prognosis.

RESULTS

The Ki-67 LI was significantly associated with the clinicopathological features of tumour progression (P<0.05). It was an independent influential factor of GISTs risk classification (odds ratio: 1.322; 95% confidence interval: 1.031-1.696) (P=0.028), and the area under the curve (AUC) value of the Ki-67 LI on the discrimination ability of GISTs risk stratification was 0.906 (P<0.001). The optimal cutoff value of the Ki-67 LI was 6% (sensitivity of 87.5% and specificity of 76.2%), and patients with Ki-67 LI≥6% exhibited significantly poorer progression-free survival (PFS) than those with Ki-67 LI<6% (P<0.001). The AUC value of the Ki-67 LI for predicting PFS in postoperative patients was 0.813 (P=0.03).

CONCLUSIONS

The Ki-67 LI has appreciated value to predict the risk grade and prognosis of GISTs. Patients with Ki-67 LI≥6% are prone to recurrence and metastasis after operation and may need a close follow-up.

Adding trans-abdominal elastography to the diagnostic tool for an ileal gastrointestinal stromal tumor: a case report

Background

Diagnosis of gastrointestinal stromal tumors (GISTs) in the distal small intestine is difficult by endoscopic ultrasound. This is the first reported case of an ileal GIST, which is diagnosed by transabdominal sonography and strain elastography.

Case presentation

A 75 y/o woman presented with tarry stool and dizziness. No definite bleeder could be identified by esophagogastroduodenoscopy and colonoscopy. The transabdominal sonography revealed a large heterogeneous tumor involving the muscular layer of the ileum. Strain elastography showed the strain ratio was 6.51. Strain histogram was skewed to the blue side, and mean color value was 230.5, signifying a stiff tumor. GIST was highly suspected. The patient underwent laparoscope-assisted tumor excision and the histological examination confirmed a malignant GIST. The patient was discharged without postoperative event.

Conclusion

Transabdominal strain elastography could play a role to discriminate small bowel GISTs and other submucosal tumors, especially in the location with difficulty in endoscopic ultrasound.

Perforated gastrointestinal stromal tumor in the small intestine: A rare case of Torricelli-Bernoulli sign

The Torricelli-Bernoulli sign is a computed tomography (CT) finding that occurs when ulceration/necrosis of a submucosal gastrointestinal tumor releases a stream of air bubbles into the intestinal lumen. A 75-year-old man developed acute abdominal pain at night and presented to a local doctor. Acute abdomen was diagnosed and he was referred to the Emergency Department at Tokai University Oiso Hospital. On CT scans, disseminated intestinal tumor-like lesions were seen in the right lower abdomen. The Torricelli-Bernoulli sign and free intraabdominal gas were observed, so perforation of an intestinal tumor was diagnosed and emergency surgery was performed. At operation, there was scanty opaque ascites in the right lower abdomen and an ileal tumor associated with nodules that suggested peritoneal dissemination. Partial resection of the ileum was performed and peritoneal lavage was conducted. The patient was discharged on postoperative day 11. Histopathological examination revealed a high risk gastrointestinal stromal tumor. The abdominal nodules were metastases, indicating that the tumor was Stage IV. The patient is currently on treatment with an oral tyrosine kinase inhibitor (imatinib).

Clinicopathological Features and Prognosis of Gastrointestinal Stromal Tumor Located in the Jejunum and Ileum

BACKGROUND

Data about the clinicopathological features and prognosis of gastrointestinal stromal tumors (GISTs) located in jejunum and ileum are lacking. The present study aims to investigate the features and prognosis of jejunal and ileal GISTs based on the Surveillance, Epidemiology, and End Results (SEER) database.

PATIENTS AND METHODS

Cases of jejunal and ileal GISTs were extracted from SEER database. Clinicopathological characteristics and survival data of patients were recorded. The clinicopathological features and prognosis of patients were analyzed.

RESULTS

There were 399 male (56.8%) and 303 female (43.2%). The median age was 60 years (17-96). Four hundred and seventy-two tumors were located in the jejunum (67.2%) and 230 tumors in the ileum (32.8%). The median tumor size was 7.0 cm (0.5-90). The 5-, 10-, and 20-year disease specific survival (DSS) was 84.4, 71.2, and 54.2% respectively. Clinicopathological features were comparable between tumors located in the jejunum and ileum (all p > 0.05) except gender and tumor size (both p < 0.05). Jejunal GISTs, rather than ileal GISTs (p = 0.043), were commonly found in the males. The tumor size of jejunal GISTs was smaller than that of ileal GISTs (p = 0.010). The DSS of jejunal GISTs was comparable to that of ileal GISTs (p = 0.269).

CONCLUSIONS

Jejunal GISTs were more common than ileal GISTs. The prognosis was comparable between jejunal and ileal GISTs.

Laparoscopic Versus Open Resection of Small Bowel Gastrointestinal Stromal Tumors: Systematic Review and Meta-Analysis

BACKGROUND

Laparoscopic resection (LAP) for small bowel gastrointestinal stromal tumors (GISTs) is not as common as for stomach. This study aimed to evaluate the safety and efficacy of LAP for small bowel GISTs with systematic review and meta-analysis.

METHODS

The Web of Science, Cochrane Library, Embase, and PubMed databases before December 2016 were comprehensively searched to retrieve comparative trials of LAP and conventional open resection (OPEN) for GISTs of small bowel with a relevance of review object. These researches reported intraoperative and postoperative clinical course (operation time, blood loss, time to first flatus and oral intake, hospital stay, morbidity, and mortality), oncologic outcomes, and long-term survival status.

RESULTS

Six studies involving 391 patients were identified. Compared to OPEN, LAP had associated with a shorter operation time (weighted mean difference [WMD] = -27.97 min, 95% confidence interval [CI]: -49.40--6.54, P < 0.01); less intraoperative blood loss (WMD = -0.72 ml; 95% CI: -1.30--0.13, P = 0.02); earlier time to flatus (WMD = -0.83 day; 95% CI: -1.44--0.22, P < 0.01); earlier time to restart oral intake (WMD = -1.95 days; 95% CI: -3.31--0.60, P < 0.01); shorter hospital stay (WMD = -3.00 days; 95% CI: -4.87--1.13, P < 0.01); and a decrease in overall complications (risk ratio = 0.56, 95% CI: 0.33-0.97, P = 0.04). In addition, the tumor recurrence and long-term survival rate showed that there was no significant difference between the two groups of patients.

CONCLUSIONS

LAP for small bowel GISTs is a safe and feasible procedure with shorter operation time, less blood loss, less overall complications, and quicker recovery. Besides, tumor recurrence and the long-term survival rate are similar to open approach. Because of the limitations of this study, methodologically high-quality studies are needed for certain appraisal.

A Diagnostic Surprise For A Right Iliac Fossa Mass - A Perforated Ileal Gastrointestinal Stromal Tumour

Gastrointestinal Stromal Tumours (GISTs) are tumours of the gut found mostly in stomach and small intestine. The complications are Gastrointestinal (GI) bleeding, obstruction, pain and rarely perforation. We are reporting an abnormal presentation of GIST masquerading as an acute abdomen with Right Iliac Fossa (RIF) mass in 60-year-old lady. Contrast Enhanced Computed Tomography (CECT) of abdomen revealed a peripherally enhancing encapsulated abscess in RIF in close contact with base of caecum and adjacent peritonitis suggesting caecal perforation. On laparotomy, a gangrenous perforated ileal GIST was identified along the antimesenteric border of ileum. Pathological examination confirmed the tumour to be a GIST of spindle cell type, further reiterated by immunohistochemistry. Our case report emphasizes, GIST as a rare and unusual differential diagnosis of RIF mass, and to have high degree of clinical suspicion when a similar situation is encountered in an emergency scenario, keeping in mind the poor outcome due to delay in appropriate management of the disease.

Gastrointestinal stromal tumor presenting as a right adnexal mass with histopathologic correlation

The authors report and discuss a rare case of a gastrointestinal stromal tumor (GIST) in a 35-year-old female, which was pre-procedurally characterized as a right ovarian mass by magnetic resonance imaging (MRI) features. This manuscript reviews the imaging and clinical features of GISTs with pathologic correlation, and emphasizes how this entity may present a diagnostic challenge in certain anatomic regions owing in large part to its exophytic nature. This case is unique among similarly reported cases in that there was a "claw sign" with the right ovary, which provided convincing evidence of its point of origin.

Single-incision laparoscopic resection of small bowel tumours: Making it easier for patient and surgeon

BACKGROUND:

Patients with small bowel tumours frequently require surgical intervention. Minimally invasive techniques require advanced skills and may not be offered to many patients. We present a laparoscopic single-incision technique that is minimally invasive without requiring intracorporeal anastomosis.

MATERIALS AND METHODS:

The cases of all patients with laparoscopic small bowel resections performed by one surgeon from 2008 to 2012 were reviewed. A single-port technique was introduced after it became available at our institution in 2009. Before that, conventional laparoscopy (LAP) was performed with extension of the periumbilical incision to allow externalisation of the bowel.

RESULTS:

Totally, 10 patients were identified who underwent laparoscopic resection of small bowel tumours: 9 in the small bowel and 1 in the terminal ileum near the cecum. Three tumours were resected before 2009 using LAP, and 7 were resected using the single-port technique. Median length of stay was 3 days, median follow-up was 16.5 months, and no patients had a recurrence. Operative time, post-operative complications, hospital length of stay, and narcotic utilisation were similar between the single-port and traditional laparoscopic groups.

CONCLUSION:

Laparoscopic removal of small bowel tumours with a small, periumbilical trocar incision is both effective and feasible without advanced technical skill.

Metastatic Gastrointestinal Stromal Tumor to the Skull

BACKGROUND

Gastrointestinal stromal tumors (GISTs) arising from the interstitial cells of Cajal along the gastrointestinal tract rarely metastasize to the central nervous system (CNS) but require aggressive multimodal therapies when they do. We present a case of recurrent GIST metastasis to the skull and review the literature on management, including the role of molecular profiling in determining adjuvant treatment.

CASE

A 64-year-old woman presented with an enlarging palpable mass over her right eye. Magnetic resonance imaging revealed an enhancing T1-hypointense, T2-hyperintense right frontal calvarial lesion with lytic features on computed tomography. Pathology confirmed metastatic GIST to the skull with dural involvement. Molecular profiling revealed a mutation in exon 11 of KIT in her primary tumor, while the skull metastasis harbored an additional mutation in exon 17 associated with acquired drug resistance.

CONCLUSION

We review the epidemiology of GIST metastases and discuss potential reasons for its rare presentation to the CNS. Additionally, we highlight the diagnostic and prognostic value of molecular profiling for metastatic GIST, as well as its influence in arbitrating targeted molecular inhibitor therapy. Evolving molecular signatures, associated with treatment resistance, may play a pivotal role in future integration with multimodality treatment strategies for CNS GIST.

Therapeutic value of endoscopic submucosal dissection for gastric muscularis propria tumors

AIM: To evaluate the safety and efficacy of endoscopic submucosal dissection (ESD) for tumors originating from the gastric muscularis propria.

METHODS: Forty-two patients with tumors originating from the gastric muscularis propria who underwent endoscopic therapy between January 2013 and January 2015 were included. The complications, clinicopathological data, and postoperative follow-up data were analyzed.

RESULTS: Of the 42 patients, 20 were managed by ESD, 15 by endoscopic submucosal excavation (ESE), and 7 by endoscopic full-thickness resection (EFR). Four cases underwent surgery for unsuccessful endoscopic resection, including three cases receiving laparoscopic surgery for difficulties in en bloc removal or perforation, and 1 case receiving open surgery because of uncontrolled bleeding, and the success rate was 90.48%. Delayed hemorrhage occurred in two patients and no delayed perforation occurred. All the complications were successfully managed by endoscopic intervention and conservational therapy. Seven cases of active perforation in the EFR group were all successfully managed by endoscopy. The post-operative follow-up period ranged from 6 to 28 mo. No local recurrence or distant metastasis occurred.

CONCLUSION: ESD is an effective procedure for tumors originating from the gastric muscularis propria, and laparoseopic intervention is necessary for en bloc resection in some cases.

MDCT and clinicopathological features of small bowel gastrointestinal stromal tumours in 102 patients: a single institute experience

OBJECTIVE

Small bowel (SB) is the second most common site of gastrointestinal stromal tumours (GISTs). We evaluated clinical presentation, pathology, imaging features and metastatic pattern of SB GIST.

METHODS

Imaging and clinicopathological data of 102 patients with jejunal/ileal GIST treated at Dana-Farber Cancer Institute and Brigham and Women's Hospital (Boston, MA) between 2002 and 2013 were evaluated. Imaging of treatment-naive primary tumour (41 patients) and follow-up imaging in all patients was reviewed.

RESULTS

90/102 patients were symptomatic at presentation, abdominal pain and lower gastrointestinal blood loss being the most common symptoms. On pathology, 21 GISTs were low risk, 17 were intermediate and 64 were high risk. The mean tumour size was 8.5 cm. On baseline CT (n = 41), tumours were predominantly well circumscribed, exophytic and smooth/mildly lobulated in contour. Of 41 tumours, 16 (39%) were homogeneous, whereas 25 (61%) were heterogeneous. Of the 41 tumours, cystic/necrotic areas (Hounsfield units < 20) were seen in 16 (39%) and calcifications in 9 (22%). CT demonstrated complications in 13/41 (32%) patients in the form of tumour-bowel fistula (TBF) (7/41), bowel obstruction (4/41) and intraperitoneal rupture (2/41). Amongst 102 total patients, metastases developed in 51 (50%) patients (27 at presentation), predominantly involving peritoneum (40/102) and liver (32/102). 7/8 (87%) patients having intraperitoneal rupture at presentation developed metastases. Metastases elsewhere were always associated with hepatic/peritoneal metastases. At last follow-up, 28 patients were deceased (median survival, 65 months).

CONCLUSION

SB GISTs were predominantly large, well-circumscribed, exophytic tumours with or without cystic/necrotic areas. Complications such as TBF, bowel obstruction and intraperitoneal perforation were visualized at presentation, with patients with perforation demonstrating a high risk of metastatic disease. Exophytic eccentric bowel wall involvement and lack of associated adenopathy are useful indicators to help differentiate GISTs from other SB neoplasms.

ADVANCES IN KNOWLEDGE

SB GISTs are predominantly large, well-circumscribed, exophytic tumours, and may present with complications. They often are symptomatic at presentation, are high risk on pathology and metastasize to the peritoneum more commonly than the liver.

Interventional digital subtraction angiography for small bowel gastrointestinal stromal tumors with bleeding

AIM: To retrospectively evaluate the diagnostic efficacy of interventional digital subtraction angiography (DSA) for bleeding small bowel gastrointestinal stromal tumors (GISTs).

METHODS: Between January 2006 and December 2013, small bowel tumors in 25 consecutive patients undergoing emergency interventional DSA were histopathologically confirmed as GIST after surgical resection. The medical records of these patients and the effects of interventional DSA and the presentation and management of the condition were retrospectively reviewed.

RESULTS: Of the 25 patients with an age range from 34- to 70-year-old (mean: 54 ± 12 years), 8 were male and 17 were female. Obscure gastrointestinal bleeding, including tarry or bloody stool and intermittent melena, was observed in all cases, and one case also involved hematemesis. Nineteen patients required acute blood transfusion. There were a total of 28 small bowel tumors detected by DSA. Among these, 20 were located in the jejunum and 8 were located in the ileum. The DSA characteristics of the GISTs included a hypervascular mass of well-defined, homogeneous enhancement and early developed draining veins. One case involved a complication of intussusception of the small intestine that was discovered during surgery. No pseudoaneurysms, arteriovenous malformations or fistulae, or arterial rupture were observed. The completely excised size was approximately 1.20 to 5.50 cm (mean: 3.05 ± 1.25 cm) in maximum diameter based on measurements after the resection. There were ulcerations (n = 8), erosions (n = 10), hyperemia and edema (n = 10) on the intra-luminal side of the tumors. Eight tumors in patients with a large amount of blood loss were treated with transcatheter arterial embolization with gelfoam particles during interventional DSA.

CONCLUSION: Emergency interventional DSA is a useful imaging option for locating and diagnosing small bowel GISTs in patients with bleeding, and is an effective treatment modality.

Endoscopic full-thickness resection and laparoscopic surgery for treatment of gastric stromal tumors

AIM

To assess the effectiveness of endoscopic full-thickness resection (EFR) and laparoscopic surgery in the treatment of gastric stromal tumors arising from the muscularis propria.

METHODS

Out of 62 gastric stromal tumors arising from the muscularis propria, each > 1.5 cm in diameter, 32 were removed by EFR, and 30 were removed by laparoscopic surgery. The tumor expression of CD34, CD117, Dog-1, S-100, and SMA was assessed immunohistochemically. The operative time, complete resection rate, length of hospital stay, incidence of complications, and recurrence rate were compared between the two groups. Continuous data were compared using independent samples t-tests, and categorical data were compared using χ (2) tests.

RESULTS

The 32 gastric stromal tumors treated by EFR and the 30 treated by laparoscopic surgery showed similar operative time [20-155 min (mean, 78.5 ± 30.1 min) vs 50-120 min (mean, 80.9 ± 46.7 min), P > 0.05], complete resection rate (100% vs 93.3%, P > 0.05), and length of hospital stay [4-10 d (mean, 5.9 ± 1.4 d) vs 4-19 d (mean, 8.9 ± 3.2 d), P >0.05]. None of the patients treated by EFR experienced complications, whereas two patients treated by laparoscopy required a conversion to laparotomy, and one patient had postoperative gastroparesis. No recurrences were observed in either group. Immunohistochemical staining showed that of the 62 gastric stromal tumors diagnosed by gastroscopy and endoscopic ultrasound, six were leiomyomas (SMA-positive), one was a schwannoglioma (S-100 positive), and the remaining 55 were stromal tumors.

CONCLUSION

Some gastric stromal tumors arising from the muscularis propria can be completely removed by EFR. EFR could likely replace surgical or laparoscopic procedures for the removal of gastric stromal tumors.

Pfetin as a risk factor of recurrence in gastrointestinal stromal tumors

Background. Despite complete resection of gastrointestinal stromal tumors (GIST), recurrent and/or metastatic disease occurs, often depending on the grade of malignancy. As such, markers are needed that accurately predict patients at high risk for recurrence. Previously our group reported Pfetin as a prognostic biomarker for GIST. In order to create an approach for predicting risk of recurrence, we incorporated Pfetin expression with clinicopathological data to produce a predictive model. Object. Forty-five patients with localized primary GIST were treated with complete gross surgical resection surgically at our institution between 1995 and 2010 were included. The majority of tumors originated in the stomach (38 cases), as well as small intestine (6 cases) and rectum (1 case). Method. (1) We performed retrospective analysis of the connection between Pfetin expression, clinicopathological data, and incidences of recurrence, using bivariate and multivariate analyses. (2) The reactivity of the monoclonal antibody against Pfetin was examined by immunohistochemistry. Pfetin. We have reported Pfetin, identified microarray technology, and compared between statistically different GISTs for good and poor prognoses and for prognostic marker. Results. There were 7 cases of recurrences. (1) By univariate analysis, tumor size, mitoses, exposure to abdominal cavity, and complete tumor removal predicted risk of recurrence. (2) Pfetin-negative cases were significantly related to recurrence (P = 0.002). Conclusions. This analysis demonstrates that lack of Pfetin expression is an additional predictor of recurrence in resected GIST. Further study may determine the role of this variable added to the current predictive model for selection of adjuvant therapy.

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.

Laparoscopic approach to gastrointestinal malignancies: toward the future with caution

After the rapid acceptance of laparoscopy to manage multiple benign diseases arising from gastrointestinal districts, some surgeons started to treat malignancies by the same way. However, if the limits of laparoscopy for benign diseases are mainly represented by technical issues, oncologic outcomes remain the foundation of any procedures to cure malignancies. Cancerous patients represent an important group with peculiar aspects including reduced survival expectancy, worsened quality of life due to surgery itself and adjuvant therapies, and challenging psychological impact. All these issues could, potentially, receive a better management with a laparoscopic surgical approach. In order to confirm such aspects, similarly to testing the newest weapons (surgical or pharmacologic) against cancer, long-term follow-up is always recommendable to assess the real benefits in terms of overall survival, cancer-free survival and quality of life. Furthermore, it seems of crucial importance that surgeons will be correctly trained in specific oncologic principles of surgical oncology as well as in modern miniinvasive technologies. Therefore, laparoscopic treatment of gastrointestinal malignancies requires more caution and deep analysis of published evidences, as compared to those achieved for inflammatory bowel diseases, gastroesophageal reflux disease or diverticular disease. This review tries to examine the evidence available to date for the use of laparoscopy and robotics in malignancies arising from the gastrointestinal district.

Endoscopic full-thickness resection of gastric stromal tumor arising from the muscularis propria

BACKGROUND

Gastric stromal tumors are the most common type of tumor originating from mesenchymal tissue. The traditional method for the treatment of gastric stromal tumor is surgical operation or therapeutic laparoscopy. More recently, endoscopic micro-traumatic surgery has become possible for gastric stromal tumors, with any perforation caused by endoscopic therapy mended endoscopically. We assessed the effectiveness of endoscopic full-thickness resection (EFR) in the treatment of gastric stromal tumors arising from the muscularis propria.

METHODS

Of the 42 gastric stromal tumors, each > 2.0 cm in diameter, arising from the muscularis propria, 22 were removed by EFR and 20 by laparoscopic surgery. Tumor expression of CD34, CD117, Dog-1, S-100, and smooth muscle actin (SMA) was assessed immunohistochemically. Operating time, complete resection rate, length of hospital stay, incidence of complications, and recurrence rates were compared between the two groups. Continuous data were compared by using independent samples t-tests and categorical data by using χ(2) tests.

RESULTS

Comparisons of the 22 gastric stromal tumors treated with EFR and the 20 treated with laparoscopic surgery showed similar operation times (60 - 155 minutes (mean, (90 ± 17) minutes) vs. 50 - 210 minutes (mean, (95 ± 21) minutes), P > 0.05), complete resection rates (100% vs. 95%, P > 0.05), and length of hospital stay (4 - 10 days (mean, (6.0 - 1.8) days) vs. 4 - 12 days (mean, (7.3 - 1.7) days), P > 0.05). None of the patients treated with EFR experienced complications, whereas one patient treated with laparoscopy required a conversion to laparotomy and one experienced postoperative gastroparesis. No recurrences were observed in either group. Immunohistochemical staining showed that of the 42 gastric stromal tumors diagnosed by gastroscopy and endoscopic ultrasound, six were leiomyomas (SMA-positive) and the remaining 36 were stromal tumors.

CONCLUSIONS

Gastric stromal tumors arising from the muscularis propria can be completely removed by EFR. EFR may replace surgical or laparoscopic procedures for the removal of gastric stromal tumors.

Perforated gastrointestinal stromal tumor in the jejunum: A rare cause of acute abdomen

Gastrointestinal stromal tumors (GIST) are highly frequent mesenchymal tumors of the digestive tract, which mainly affect the stomach and small intestine. GISTs frequently exist with unclear symptoms. Their initial clinical presentation as acute abdomen due to their perforation is particularly rare. In the present study we report a case of a 59-year-old male presenting with acute abdomen. The final diagnosis revealed a small bowel perforation due to GIST. In this paper, we report the clinical manifestation as well as computed tomography and histopathological findings helpful for the accurate diagnosis of this rare complication of GIST. Emergency laparotomy and complete resection of tumor are essential. Following surgical resection, adjuvant tyrosine kinase inhibitor therapy should be considered for prevention of early recurrence.

The role of surgery in the multidisciplinary management of patients with localized gastrointestinal stromal tumors

Surgical resection of localized gastrointestinal stromal tumors (GISTs) is associated with recurrence rates of approximately 50% at 5 years of follow-up. The introduction of tyrosine kinase inhibitors, such as imatinib, improved overall survival rates in advanced disease, while in the adjuvant setting, improved recurrence-free survival following resection of high-risk GIST. The demonstration of the clinical benefit of tyrosine kinase inhibitors in both the metastatic and adjuvant settings generated interest in neoadjuvant approaches for patients with operable locally advanced disease, particularly in difficult anatomic locations. The potential impact of tumor downsizing in areas such as the gastroesophageal junction, the duodenum or the rectum, on the extent of surgical resection and morbidity is real. The ongoing research regarding neoadjuvant therapy, the duration of adjuvant therapy and the optimal means by which to risk stratify patients with GIST continues to keep the treatment of this disease at the forefront of personalized cancer care.

Endoscopic therapy for gastric stromal tumors originating from the muscularis propria

AIM

To explore endoscopic therapy methods for gastric stromal tumors originating from the muscularis propria.

METHODS

For 69 cases diagnosed as gastric stromal tumors originating from the muscularis propria, three types of endoscopic therapy were selected, based on the size of the tumor. These methods included endoscopic ligation and resection (ELR), endoscopic submucosal excavation (ESE) and endoscopic full-thickness resection (EFR). The wound surface and the perforation of the gastric wall were closed with metal clips. Immunohistostaining for CD34, CD117, Dog-1, S-100 and smooth muscle actin (SMA) was performed on the resected tumors.

RESULTS

A total of 38 cases in which the tumor size was less than 1.2 cm were treated with ELR; three cases were complicated by perforation, and the perforations were closed with metal clips. Additionally, 18 cases in which the tumor size was more than 1.5 cm were treated with ESE, and no perforation occurred. Finally, 13 cases in which the tumor size was more than 2.0 cm were treated with EFR; all of the cases were complicated by artificial perforation, and all of the perforations were closed with metal clips. All of the 69 cases recovered with medical treatment, and none required surgical operation. Immunohistostaining demonstrated that among all of the 69 gastric stromal tumors diagnosed by gastroscopy, 12 cases were gastric leiomyomas (SMA-positive), and the other 57 cases were gastric stromal tumors.

CONCLUSION

Gastric stromal tumors originating from the muscularis propria can be treated successfully with endoscopic techniques, which could replace certain surgical operations and should be considered for further application.