Differential clinical and pathological characteristics of esophageal stromal tumors and leiomyomata

Exploration of a new method for Photoshop-assisted endoscopic ultrasound to distinguish gastrointestinal stromal tumor and leiomyoma

BACKGROUND

Gastrointestinal stromal tumors (GISTs) and leiomyomas (GILs) are difficult to be distinguished by endoscopic ultrasound (EUS). Photoshop software combined with EUS has limitations in distinguishing GIST and GIL by detecting gray values. Therefore, the research aims to explore the new method by Photoshop in distinguishing the features of GISTs from GILs.

METHODS

Patients who underwent EUS and were confirmed as GIST and GIL pathologically were included. The images of EUS were analyzed by Photoshop software. The mean gray value of tumor (Tmean), muscularis propria (Mmean), submucosa (Smean), water (Wmean) and T_SD that originated from the same image, were calculated one by one. Then the ratio of the mean gray value of tumor to muscularis propria (TMratio), submucosa (TSratio), and water (TWratio) were calculated, respectively.

RESULTS

Four hundred seventy-two patients (239 GILs and 233 GISTs) were enrolled in this study retrospectively. All the tumors were located in the stomach. Tmean and T_SD were significantly higher in GISTs than in the GILs group (63.10 ± 23.29 vs. 57.70 ± 22.67, p = .011; 26.24 ± 8.99 vs. 24.30 ± 8.26, p = .015). TMratio, TSratio, and TWratio were also significantly higher in GISTs group (0.97 ± 0.37 vs. 0.81 ± 0.28, p < .001; 0.42 ± 0.14 vs. 0.38 ± 0.12, p < .001; 2.65 ± 1.36 vs. 2.16 ± 1.02, p < .001). The AUC of Tmean was 0.952 (95% CI 0.897-1.000), which can better distinguish GIST from GIL; the sensitivity was 0.900, the specificity was 0.975, and the Youden Index was 0.875, and the cutoff was 79.64. The AUCs of TMratio, TSratio, and TWratio were 0.917 (95% CI 0.844-0.991), 0.897 (95% CI 0.812-0.981), and 0.929 (95% CI 0.8870-0.987), respectively. The aforementioned data was verified in the clinical cases of known results, including 40 GISTs and 40 GILs. The sensitivity of Tmean, TMratio, TSratio, and TWratio for diagnosis of GIL was 97.5%, 82.5%, 95%, and 97.5%, respectively. And they were 62.5%, 95%, 80%, and 92.5% for GIST.

CONCLUSION

The application of Photoshop combined with EUS to detect the gray value and standard deviation has a specific value in distinguishing GIST from GIL, but with some deviation. Applying the gray value ratio also has great discrimination significance and can avoid the differences in operation from different instrument and equipment personnel. Therefore, it is worthy of clinical promotion in the future.

Patterns of care and clinical outcomes in primary oesophageal gastrointestinal stromal tumours (GIST): A retrospective study of the French Sarcoma Group (FSG)

BACKGROUND

Oesophageal GIST (ESOGIST) are very rare tumours requiring special consideration regarding diagnosis, surgical management, and perioperative treatment.

METHODS

A retrospective study was conducted across 9 centres in the French Sarcoma Group (FSG) to characterize all patients in the years 2000-2014.

RESULTS

Seventeen patients (pts) with primary localized ESOGIST were identified, with median age 69 years (36-81) and 11 females. Eight tumours (T) occurred in the lower third of the oesophagus, five in the oesophageal gastric junction, two in the superior third, and two in the middle third. All pts underwent oesophagoscopy and/or endoscopic ultrasound (EUS) and CT scan. Fifteen had EUS guided biopsy. Nine pts received Imatinib (IM) as initial treatment resulting in six PR, three SD. Tumours were resected in nine pts (53%) (7 upfront, 2 after IM); via enucleation in four (44%) [median size 4 cm], oesophagectomy in five (56%) [median size 10 cm]. Resections were R0 in three pts (33%), R1 in six (66%). Eight pts (47%) had no tumour resection, and one patient was never treated. Six pts received adjuvant IM. With a median follow-up of 24 months (7-101), 11 pts are alive (64.7%), five died (29.4%), one was lost to follow-up. Two pts of 4 pts relapsed following enucleation.

CONCLUSIONS

ESOGIST can be reliably identified pre-operatively by EUS-guided biopsy. Surgery for ESOGIST is either enucleation or oesophagectomy depending on tumour size, location, and patient's individual surgical risk. Preoperative IM therapy could improve resectability and should be considered if surgery is contraindicated or would lead to negative impact on the functional status of the patient.

Progress in research of esophageal granular cell tumors

Esophageal granular cell tumor is a rare benign soft tissue tumor with malignant potential, and its histogenesis remains unclear. Since clinical manifestations lack specificity, the diagnosis depends on endoscopy, endoscopic ultrasonography, pathology and immunohistochemistry. Esophageal granular cell tumors have the potential of malignant transformation and are easily confused with leiomyoma and interstitialoma. At present, the treatment of this disease has not yet reached a consensus. This review aims to elucidate the histogenesis, clinical manifestations, diagnosis, treatment and prognosis of esophageal granular cell tumors.

Ligation-assisted endoscopic enucleation for treatment of esophageal subepithelial lesions originating from the muscularis propria: a preliminary study

An innovative ligation-assisted endoscopic enucleation (EE-L) technique was developed for the diagnosis and treatment of esophageal subepithelial lesions (smaller than 12 mm) originating from muscularis propria by combining endoscopic band ligation and endoscopic enucleation techniques. The aim of the study was to evaluate efficacy and safety of EE-L technique in the treatment of esophageal subepithelial lesions (smaller than 12 mm) originating from muscularis propria. Forty-seven esophageal subepithelial lesions (smaller than 12 mm) originating from the muscularis propria in 44 patients were treated with EE-L between September 2010 and September 2012. The lesion was first aspirated into the transparent cap attached to the tip of endoscope. The elastic band was then released around its base. The purpose of ligation was to force the lesion to assume a polypoid form with a pseudostalk. Endoscopic enucleation was then performed until the tumor was completely enucleated from muscularis propria using a hook knife and forceps. All tumors (median diameter: 8.2 ± 2.3 mm, range: 4-12 mm) were enucleated completely. Histopathology identified 45 tumors (95.7%) as leiomyoma, 2 (4.3%) tumors as gastrointestinal stromal tumor with very low risk. The mean time of the EE-L procedure was 12.5 ± 4.6 minutes (range: 6-23 minutes). Two patients experienced self-limiting, non-life-threatening hemorrhage after EE-L. No perforation and massive hemorrhage requiring further endoscopic or surgical intervention occurred. There were no recurrences during the 6-24 months follow-up period. EE-L offers the option of localized treatment of small esophageal muscularis propria tumors (smaller than 12 mm) with relatively few complications and low mortality, and provides the advantage of allowing a histopathological diagnosis. All the resected lesions in this study had a benign pathology.

Relationship of endothelial area with VEGF-A, COX-2, maspin, c-KIT, and DOG-1 immunoreactivity in liposarcomas versus non-lipomatous soft tissue tumors

Soft tissue tumors are rare tumors that show a heterogeneous structure; thus far, their molecular behavior has not been elucidated. The aim of our study was to define the relationship between microvessel density (MVD), evaluated with CD31, and other immunohistochemical markers, such as vascular endothelial growth factor (VEGF), cyclooxygenase-2 (COX-2), CD34, maspin, DOG-1, and c-KIT. Immunostains were done in 55 cases consisting of benign and malignant tumors, such as liposarcomas, dermatofibrosarcomas, and tumors with histiocytic differentiation. Renal tubes were used as external control for VEGF, maspin, and DOG-1. Although DOG-1 is considered a specific marker for gastrointestinal tumors (GISTs), its positivity, correlated with c-KIT and VEGF immunoexpression, was also shown by dermatofibrosarcomas and tumors with histiocytic and lipomatous differentiation, suggesting its possible pro-angiogenic role. Maspin expression was observed in adipose tissue tumors only. Regarding angiogenesis, 31 of the 55 cases were VEGF-positive, such positivity being directly correlated with COX-2 and CD34 positivity as evaluated in the tumor cells and also with MVD. Although no significant differences in angiogenic activity were found between benign and malignant non-lipomatous tumors, the MVD was directly correlated with the histological type/grade of liposarcomas. Based on these aspects, we conclude that VEGF/COX-2-induced angiogenesis is specific for non-lipomatous tumors, whereas liposarcomas are dependent on the VEGF/maspin angiogenic pathway. The DOG-1/c-KIT/VEGF target may be used for further personalized therapy of soft tissue sarcomas. No data about DOG-1 and maspin positivity in liposarcomas have been published to date.

Telocytes in human oesophagus

Telocytes (TCs), a new type of interstitial cells, were identified in many different organs and tissues of mammalians and humans. In this study, we show the presence, in human oesophagus, of cells having the typical features of TCs in lamina propria of the mucosa, as well as in muscular layers. We used transmission electron microscopy (TEM), immunohistochemistry (IHC) and primary cell culture. Human oesophageal TCs present a small cell body with 2–3 very long Telopodes (Tps). Tps consist of an alternation of thin segments (podomers) and thick segments (podoms) and have a labyrinthine spatial arrangement. Tps establish close contacts (‘stromal synapses’) with other neighbouring cells (e.g. lymphocytes, macrophages). The ELISA testing of the supernatant of primary culture of TCs indicated that the concentrations of VEGF and EGF increased progressively. In conclusion, our study shows the existence of typical TCs at the level of oesophagus (mucosa, submucosa and muscular layer) and suggests their possible role in tissue repair.

Novel diagnosis and treatment of esophageal granular cell tumor: report of 14 cases and review of the literature

BACKGROUND

Granular cell tumors (GCT), especially in the esophagus, are rare neoplasms originating from the nervous system. There is still some controversy regarding the diagnosis and treatment of esophageal GCT.

METHODS

We report 14 cases of esophageal GCT diagnosed and treated from January 2004 to March 2013. Their clinical manifestations, endoscopic image, endoscopic ultrasonography (EUS) appearance, pathology, immunohistochemistry, treatment, and prognosis were reviewed.

RESULTS

The typical images of EUS were hypoechoic, homogenous, and smooth-edged tumors restricted to deep mucosal and submucosal layers. However, there were 2 cases with tumors invading muscular layer. Endoscopic ultrasonography was valuable to assess the tumor size, location, depth of invasion, and nature. According to EUS manifestation, 11 cases with lesions 3 cm or less in diameter without muscular layer invasion underwent endoscopic resection without complication and the other 3 cases underwent surgical resection. A new technique of submucosal tunnel endoscopic resection was performed in 3 submucosal cases with lesions ranging from 2 cm to 3 cm in diameter. All of these cases were benign and histology was necessary for differential diagnosis.

CONCLUSIONS

Endoscopic ultrasonography plays an important guiding role in the diagnosis and treatment of esophageal GCT. Submucosal tunnel endoscopic resection is safe and effective. Further study is needed to determine whether this technique can be expanded into other applications.