Efficacy and Safety of Endoscopic Treatment for Gastrointestinal Stromal Tumors in the Upper Gastrointestinal Tract

Natural History of Asymptomatic Esophageal Subepithelial Tumors of 30 mm or Less in Size

BACKGROUND

No definite guidelines for the management of small esophageal subepithelial tumors (SETs) have been established, because there are limited data and studies on their natural history. We aimed to assess the natural history and propose optimal management strategies for small esophageal SETs.

METHODS

Patients diagnosed as esophageal SETs ≤ 30 mm in size between 2003 and 2017 using endoscopic ultrasound (EUS) with a minimal follow-up of 3 months were enrolled, and their esophagogastroduodenoscopy (EGD) and EUS were retrospectively reviewed.

RESULTS

Of 275 esophageal SETs in 262 patients, the initial size was < 10 mm, 10-20 mm, and 20-30 mm in 104 (37.8%), 105 (38.2%), and 66 (24.0%) lesions, respectively. Only 22 (8.0%) SETs showed significant changes in size and/or echogenicity and/or morphology at a median of 40 months (range, 4-120 months). Tissues of 6 SETs showing interval changes were obtained using EUS-guided fine needle aspiration biopsy; 1 was identified as a gastrointestinal stromal tumor (GIST) and was surgically resected, while the other 5 were leiomyomas and were regularly observed. Eight SETs showing interval changes were resected surgically or endoscopically without pathological confirmation; 1 was a GIST, 2 were granular cell tumors, and the other 5 were leiomyomas.

CONCLUSION

Regular follow-up with EGD or EUS may be necessary for esophageal SETs ≤ 30 mm in size considering that small portion of them has a possibility of malignant potential. When esophageal SETs ≤ 30 mm show significant interval changes, pathological confirmation may precede treatment to avoid unnecessary resection.

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

Background and objectives

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

Method

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

Result

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

Conclusion

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

Comparison of endoscopic full-thickness resection and cap-assisted endoscopic full-thickness resection in the treatment of small (≤1.5 cm) gastric GI stromal tumors

BACKGROUND AND AIMS

With the increasing incidence of small GI stromal tumors (GISTs), endoscopic full-thickness resection (EFTR) and cap-assisted EFTR (EFTR-C) have been suggested as 2 effective resection methods. We aimed to compare the outcomes of EFTR and EFTR-C for the treatment of small (≤1.5 cm) gastric GISTs.

METHODS

This retrospective study included 67 patients who underwent EFTR and 46 patients who underwent EFTR-C at Nanjing Drum Tower Hospital. Clinicopathologic features, adverse events (AEs), and outcomes were compared between the 2 groups. Univariate and multivariate linear and logistic regressions were used to analyze the effects of the procedure on the therapeutic outcomes of patients and adjusted for covariates in the multivariate analysis.

RESULTS

The tumor size in the EFTR group tended to be larger (P = .005). The resection time in the EFTR-C group was shorter than that in the EFTR group (38.3 ± 20.7 minutes vs 15.0 ± 11.8 minutes, P < .001), which retained statistical significance with adjustment for the covariates (adjusted mean difference, 22.2; 95% confidence interval, 15.0-29.4; P < .001). The R0 resection rate of the EFTR group was 94.0% and of the EFTR-C group 97.8% (P = .355). The EFTR-C group was superior to the EFTR group in terms of perioperative therapeutic outcomes, AEs, and postoperative recovery. No recurrence occurred in the EFTR and EFTR-C groups.

CONCLUSIONS

EFTR-C was found to be the preferable technique for small (≤1.5 cm) gastric GISTs with shorter operation times, lower AEs, faster postoperative recovery, and shorter hospitalization times as compared with EFTR.

Retrospective analysis of the outcomes of endoscopic submucosal dissection for the diagnosis and treatment of subepithelial lesions in a center with high expertise

Background

Use of endoscopic submucosal dissection (ESD) for the diagnosis and treatment of subepithelial lesions (SELs) is limited in the West, and the best approach for these lesions is still debated. In this study we describe our experience regarding the usefulness, safety and outcomes of ESD for SELs.

Method

We performed a retrospective analysis of ESD in the diagnosis and treatment of SELs between November 2010 and February 2021.

Results

A total of 634 ESDs were reviewed. Fifty-five (9%) were performed in SELs, 6 in the esophagus, 34 in the stomach, and 15 in the rectum. ESD was technically successful in 53 lesions (96%). Most of them (82%) had previous endoscopic ultrasound evaluation, but only 20% had a histological diagnosis previous to the ESD. Neuroendocrine tumors, gastrointestinal stromal tumors, and granular cell tumors accounted for 38% of the procedures, with a 100% rate of en bloc resection and 65% of R0 resection; the main criterion for non-curative resection was a deep positive margin, and none of the patients treated with complementary surgery had lesions on the gastrointestinal wall. Most of the procedures (62%) were performed in lesions with very low malignant potential, providing the definitive diagnosis of SELs where the previous diagnostic workup was inconclusive. We had a total of 2 delayed bleedings and 1 perforation, all treated endoscopically.

Conclusion

Our real-life experience showed that ESD can be an effective and safe diagnostic tool for undetermined SELs, as well as an effective treatment for neoplastic SELs with malignant potential.

Massive Digestive Hemorrhagia Revealing a Gastro-Intestinal Stromal Tumor of the Jejunum

Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors that originate from Cajal cells located in different sites of the digestive system. They may occur in the entire gastrointestinal tract. They are diagnosed on the basis of the identification of c-kit-positive cells. We report a case of a stromal tumor of the jejunum revealed by a massive digestive hemorrhagia. Surgical resection is the basis of the treatment of GISTs. Imatinib, a tyrosine kinase inhibitor, is a beneficial treatment after surgical resection of high-risk GISTs.

Recent advances in the management of gastrointestinal stromal tumor

Gastrointestinal stromal tumor (GIST) is a rare but an important clinical entity seen in our clinical practice. It is the most common mesenchymal tumor of the gastrointestinal tract and most common malignancy of the small intestine. Although the exact prevalence of GIST is not known, the incidence of GIST has been increasing. GISTs arise from interstitial cells of Cajal. Most of the GISTs occur due to mutation in c-kit gene or platelet derived growth factor receptor alpha gene. 15% of GISTs do not have these mutations and they are called wild-type GISTs. Almost all GISTs express KIT receptor tyrosine kinase. Histologically, GISTs look like spindle cell tumors most of the time but they can be epitheloid or mixed type. The median size of GISTs varies from 2.7 cm to 8.9 cm. Clinically, patients with small GISTs remain asymptomatic but as the GIST size increases, patients present with various symptoms depending on the location of the GIST. Most of GISTs are located in the stomach or small bowel. Diagnosis is suspected on imaging and endoscopic studies, and confirmed by tissue acquisition with immunohistochemical staining. The aggressiveness of GISTs depends on the size, mitotic index and location. Surgical resection is the treatment of choice. But various endoscopic modalities of resection are increasingly being tried. Tyrosine kinase inhibitors are extremely useful in the management of large GISTs, unresectable GISTs and metastatic GISTs. Treatment options for metastatic GISTs also include radiotherapy, chemotherapy, hepatic artery embolization, chemoembolization and radiofrequency ablation.