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Although the incidence of asymptomatic small gastric submucosal tumors increased gradually with routine medical health examination, there was little clinical evidence for management consensus in these small gastric submucosal tumors including endoscopic ultrasound (EUS)-suspected gastric gastrointestinal stromal tumors (GISTs). We investigated the...
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Abstract Background Resistance to conventional dose schemes and radiotoxicity of healthy tissue is a clinical challenge in the radiation therapy of large locally advanced drug-resistant gastrointestinal stromal tumor (LADR-GIST). This study aimed to assess the feasibility of using multi-shell Simultaneous Integrated Boost Intensity-Modulated modali...
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... They suggested that GISTs measuring ≥9.5 mm may be associated with significant pro-gression and recommended more short term EUS follow-up (6-12 months) compared with <9.5 mm GIST (2-3 years) after detection. Fang et al. 12 reported that GIST larger than 1.4 cm with irregular margins were associated with significant progression. Kim et al. 13 reported that the growth rate of subepithelial tumors was 0.14, 0.22, and 0.31 mm/month in those <10 mm, 10-20 mm, and >20-30 mm, respectively, and GIST exhibited significant increases in tumor size compared with other benign tumors. ...
... Some authors insist that early diagnosis and early resection may be required because GISTs <2 cm in size could metastasize. 2 Fang et al. 12 reported that the 2 cm criteria for surgery was inadequate for separating the progressive tumors from the stationary ones. Yang et al. 18 even suggested surgical resection of all small gastric GISTs because small GISTs may have malignant potential. ...
An increase in the volume of endoscopic procedures performed in recent times has led to increasing detection rates of asymptomatic gastrointestinal subepithelial tumors. However, accurate diagnosis and risk assessment of these tumors preoperatively is challenging. A 70-year-old man patient visited the emergency department for evaluation of melena. Emergency endoscopy revealed an ulcerated subepithelial tumor (8 cm in size) in the gastric cardia and fundus. Computed tomography and upper endoscopy performed at another hospital 6 months earlier were reviewed; the mass showed a significant increase in size (from 2 cm to 8 cm). The patient underwent surgical resection of the mass and was diagnosed with a high-risk gastrointestinal stromal tumor (GIST). In this article, we describe a rare case of a rapidly growing GIST at a rate significantly greater than commonly reported rates.
... However, the cutoff size of small GISTs for endoscopic resection remains controversial. Fang et al. investigated the clinical course of small GISTs and demonstrated that a cutoff value of 1.4 cm is appropriate for treatment [19], and Wang et al. proposed that a tumor diameter of 1.45 cm should be the optimal cutoff value for resection, which were consistent with our other retrospective study [20] which identified that a smaller tumor diameter cutoff (1.48 cm) might have better efficacy in differentiating risk grades. Furthermore, a single-institution retrospective study of 69 patients with EUSsuspected GISTs showed that GISTs > 9.5 mm in diameter are associated with significant progression and that 23% of these patients show significant changes in size after more than 3 years of onset [21]. ...
Background and objectives:
Small gastrointestinal stromal tumors (GISTs) are defined as tumors less than 2 cm in diameter, which are often found incidentally during gastroscopy. There is controversy regarding the management of small GISTs, and a certain percentage of small GISTs become malignant during follow-up. Previous studies which used Sanger targeted sequencing have shown that the mutation rate of small GISTs is significantly lower than that of large tumors. The aim of this study was to investigate the overall mutational profile of small GISTs, including those of wild-type tumors, using whole-exome sequencing (WES) and Sanger sequencing.
Methods:
Thirty-six paired small GIST specimens, which were resected by endoscopy, were analyzed by WES. Somatic mutations identified by WES were confirmed by Sanger sequencing. Sanger sequencing was performed in an additional 38 small gastric stromal tumor samples for examining hotspot mutations in KIT, PDGFRA, and BRAF.
Results:
Somatic C-KIT/PDGFRA mutations accounted for 81% of the mutations, including three novel mutation sites in C-KIT at exon 11, across the entire small gastric stromal tumor cohort (n = 74). In addition, 15% of small GISTs harbored previously undescribed BRAF-V600E hotspot mutations. No significant correlation was observed among the genotype, pathological features, and clinical classification.
Conclusions:
Our data revealed a high overall mutation rate (~96%) in small GISTs, indicating that genetic alterations are common events in early GIST generation. We also identified a high frequency of oncogenic BRAF-V600E mutations (15%) in small GISTs, which has not been previously reported.
... Small GISTs are generally considered to have a low malignant potential, and few of them may progress to clinically relevant tumors. However, a population-based study reviewed 378 patients with small GISTs found that approximately 11.4% of small GISTs were accompanied by local progression or even distant metastasis when first diagnosed and claimed that small GISTs might progress and become life-threatening, with a mortality of 12% at 5 years [23]. Additionally, some scholars believe that the conservative observational methods for small GISTs can only evaluate whether the tumor diameter has increased, which will cause psychological burden and risk to patients as clinicians would only passively wait for the tumor size to increase before performing surgical resection [24]. ...
Background:
Gastrointestinal stromal tumors (GISTs) with a diameter of < 2 cm are called small GISTs. Currently, endoscopic ultrasound (EUS) is widely used as a regular follow-up method for GISTs, which can also provide a preliminary basis for judging the malignancy potential of lesions. However, there are no studies on the accuracy of EUS to assess the malignant potential of small GISTs.
Aim:
To evaluate the efficacy of EUS in the diagnosis and risk assessment of small GISTs.
Methods:
We collected data from patients with small GISTs who were admitted to Shengjing Hospital of China Medical University between October 2014 and July 2019. The accurate diagnosis and risk classifications of patients were based on the pathological assessment according to the modified National Institute of Health criteria after endoscopic resection or laparoscopic surgery. Preoperative EUS features (marginal irregularity, cystic changes, homogeneity, ulceration, and strong echogenic foci) were retrospectively analyzed. The assessment results based on EUS features were compared with the pathological features.
Results:
A total of 256 patients (69 men and 187 women) were enrolled. Pathological results included 232, 16, 7, and 1 very low-, low-, intermediate-, and high-risk cases, respectively. The most frequent tumor location was the gastric fundus (78.1%), and mitoses were calculated as > 5/50 high power field in 8 (3.1%) patients. Marginal irregularity, ulceration, strong echo foci, and heterogeneity were detected in 1 (0.4%), 2 (0.8%), 22 (8.6%), and 67 (65.1%) patients, respectively. However, cystic changes were not detected. Tumor size was positively correlated with the mitotic index (P < 0.001). Receiver operating curve analysis identified 1.48 cm as the best cut-off value to predict malignant potential (95% confidence interval: 0.824-0.956). EUS heterogeneity with tumor diameters > 1.48 cm was associated with higher risk classification (P < 0.05).
Conclusion:
Small GISTs (diameters > 1.48 cm) with positive EUS features should receive intensive surveillance or undergo endoscopic surgery. EUS and dissection are efficient diagnostic and therapeutic approaches for small GISTs.
... However, a small GIST size (<20 mm) has also malignancy potential. One study suggested 14 mm as a reasonable cutoff size for small GISTs because of significant tumor progression [18]. In our study, GISTs were highly mitotic when the tumor size was <2 cm (1/14 patients, 7.1%) and annual surveillance alone may be inadequate. ...
Background:
Considering the widespread use of esophagogastroduodenoscopy, the prevalence of upper gastrointestinal (GI) subepithelial tumors (SET) increases. For relatively safer removal of upper GI SETs, endoscopic submucosal dissection (ESD) has been developed as an alternative to surgery. This study aimed to analyze the outcome of endoscopic resection for SETs and develop a prediction model for the need for laparoscopic and endoscopic cooperative surgery (LECS) during the procedure.
Method:
We retrospectively analyzed 123 patients who underwent endoscopic resection for upper GI SETs between January 2012 and December 2020 at our institution. Intraoperatively, they underwent ESD or submucosal tunneling endoscopic resection (STER).
Results:
ESD and STER were performed in 107 and 16 patients, respectively. The median age was 55 years, and the average tumor size was 1.5 cm. En bloc resection was achieved in 114 patients (92.7%). The median follow-up duration was 242 days without recurrence. Perforation occurred in 47 patients (38.2%), and 30 patients (24.4%) underwent LECS. Most perforations occurred in the fundus. Through multivariable analysis, we built a nomogram that can predict LECS requirement according to tumor location, size, patient age, and sex. The prediction model exhibited good discrimination ability, with an area under the curve (AUC) of 0.893.
Conclusions:
Endoscopic resection is a noninvasive procedure for small upper-GI SETs. Most perforations can be successfully managed endoscopically. The prediction model for LECS requirement is useful in treatment planning.
... Considering the malignant potential of GISTs [48,49], the US National Comprehensive Cancer Network and Japanese guidelines recommend either endoscopic or laparoscopic resection for tumors <2 cm if they are symptomatic or have high-risk features with rapid growth, ulceration, irregular margins, or heterogeneous echo patterns [5,6]. Recent retrospective studies found that 1.4 cm was an appropriate cutoff tumor size for small GISTs due to their potential for rapid tumor progression [50]. Endoscopic resection for small GISTs <2 cm is also safe and effective, which could confirm the diagnosis, improve the symptoms, reduce psychological pressure, and achieve complete cure [51]. ...
The aim of this study was to analyze patients who underwent endoscopic resection (ER) for gastric subepithelial tumors (SETs) with a high probability of surgical intervention. Between January 2013 and January 2021, 83 patients underwent ER at the operation theater and 27 patients (32.5%) required backup surgery mainly due to incidental perforation or uncontrolled bleeding despite endoscopic repairing. The tumor was predominantly located in the upper-third stomach (81%) with a size ≤ 2 cm (69.9%) and deep to the muscularis propria (MP) layer (92.8%) but there were no significant differences between two groups except tumor exophytic growth as a risk factor in the surgery group (37% vs. 0%, p < 0.0001). Patients in the ER-only group had shorter durations of procedure times (60 min vs. 185 min, p < 0.0001) and lengths of stay (5 days vs. 7 days, p < 0.0001) but with a higher percentage of overall morbidity graded III (0% vs. 7.1%, p = 0.1571). After ER, five patients (6%) had delayed perforation and two (2.4%) required emergent laparoscopic surgery. Neither recurrence nor gastric stenosis was reported during long-term surveillance. Here, we provide a minimally invasive strategy of endoscopic resection with backup laparoscopic surgery for gastric SETs.
... which is on rising because of the widespread use of endoscopic investigation with incidental discovery [1][2][3]. Although the majority of small SET remains unchanged in size with 3.2-28% enlarging during the follow-ups, the natural course is still poorly understood [1][2][3][4]. Unless tissue acquisition can be achieved by endoscopic ultrasound (EUS)-guided aspiration/biopsy or mucosa unroofing for deep biopsy, the malignant potential of small SET is hard to be predicted [5][6][7]. Therefore, current recommendations determine the have no conflicts of interest or financial ties to disclose. ...
... This study was approved by the Research Ethics Review Committee of Far Eastern Memorial Hospital (FEMH IRB-109047-E). EUS was done in all patients and the indications for POET were those with enlarging (≧ 1.2 times) size during every 6-12 months follow-ups, malignant features under EUS including irregular border and heterogeneous internal echotexture, or by patient's request [4,19]. Demographic, endoscopic and pathological data were analyzed retrospectively. ...
... To facilitate submucosal space entering by endoscope, a 2-cm C-shape transverse incision was done for all gastric lesions (Figs. 1, 2). For those located at esophagus and gastric cardia within 2-cm near esophagogastric junction (EGJ), mucosal entrance was created by a 1.5-2-cm longitudinal mucosal incision at 3-cm and 5-cm proximally to lesions located at esophagus and gastric cardia, respectively (Figs. 3,4). Once the endoscope entered the submucosal space after trimming of mucosal incision, the submucosal tunnel was then created by dissection (spray coagulation E2 50 W) in direction to the SETs until 1-2 cm distal to the lesions. ...
Background
Third space endoscopy technique facilitates therapeutic endoscopy in subepithelial space. This study aimed to investigate peroral endoscopic tumor resection (POET) with preserved mucosa technique for upper gastrointestinal tract subepithelial tumors (UGI-SETs) removal.Methods
Between February 2011 and December 2019, consecutive patients with SETs of esophagus and stomach who underwent POET for enlarging size during follow-up, malignant endoscopic ultrasound features or by patient’s request were enrolled. Demographic, endoscopic and pathological data were analyzed retrospectively.ResultsTotally 18 esophageal (mean ± SD age, 55.23 ± 4.15 year-old, 38.89% female) and 30 gastric (52.65 ± 2.43 year-old, 53.33% female) SETs in 47 patients (one with both esophageal and gastric lesions) were resected. The mean (± SD) endoscopic/pathological tumor size, procedure time, en-bloc/complete resection rate, and hospital stays of esophageal and gastric SET patients were 12.36 (± 7.89)/11.86 (± 5.67) and 12.57 (± 6.25)/12.35 (± 5.73) mm, 14.86 (± 6.15) and 38.21 (± 15.29) minutes, 88.89%/94.44% and 86.77%/93.30%, and 4.14 (± 0.21) and 4.17 (± 0.20) days, respectively. The overall complication rate was 18.75%, including 6 self-limited fever and 3 pneumoperitoneum relieved by needle puncture. There was no mortality or recurrence reported with mean follow-up period of 23.74 (± 4.12) months.ConclusionsPOET is a safe and efficient third space endoscopic resection technique for removal of UGI-SETs less than 20 mm. Long term data are warranted to validate these results.
... This is the first study to suggest that imaging underestimates Additionally, Gao et al. 47 and Fang et al. 48 determined that GISTs < 2 cm on imaging have a notable risk of progression on follow-up. While these findings seem contradictory to data from pathologic studies suggesting a low risk of progression for small GISTs, 4,5,7-9 we suggest they are not. ...
Background:
How well imaging size agrees with pathologic size of gastric gastrointestinal stromal tumors (GISTs) is unknown. GIST risk stratification is based on pathologic size, location, and mitotic rate. To inform decision making, the size discrepancy between imaging and pathology for gastric GISTs was investigated.
Methods:
Imaging and pathology reports were reviewed for 113 patients. Bland-Altman analyses and intraclass correlation (ICC) assessed agreement of imaging and pathology. Changes in clinical risk category due to size discrepancy were identified.
Results:
Computed tomography (CT) (n = 110) and endoscopic ultrasound (EUS) (n = 50) underestimated pathologic size for gastric GISTs by 0.42 cm, 95% confidence interval (CI): (0.11, 0.73), p = 0.008 and 0.54 cm, 95% CI: (0.25, 0.82), p < 0.001, respectively. ICCs were 0.94 and 0.88 for CT and EUS, respectively. For GISTs ≤ 3 cm, size underestimation was 0.24 cm for CT (n = 28), 95% CI: (0.01, 0.47), p = 0.039 and 0.56 cm for EUS (n = 26), 95% CI: (0.27, 0.84), p < 0.0001. ICCs were 0.72 and 0.55 for CT and EUS, respectively. Spearman's correlation was ≥0.84 for all groups. For GISTs ≤ 3 cm, 6/28 (21.4% p = 0.01) on CT and 7/26 (26.9% p = 0.005) on EUS upgraded risk category using pathologic size versus imaging size. No GISTs ≤ 3 cm downgraded risk categories. Size underestimation persisted for GISTs ≤ 2 cm on EUS (0.39 cm, 95% CI: [0.06, 0.72], p = 0.02, post hoc analysis).
Conclusion:
Imaging, particularly EUS, underestimates gastric GIST size. Caution should be exercised using imaging alone to risk-stratify gastric GISTs, and to decide between surveillance versus surgery.
... But recent literature reported that the rate of invasion and metastasis reached 11.4% in 378 cases of small gastrointestinal stromal tumor (GIST) when they were diagnosed at the first time [22]. It is suggested to observe closely by some scholars, but doctors can only observe the size of tumors and then produce a procedure passively when they become lager [23,24]. So it is important to assess the invasion and metastasis risk of small GIST. ...
Objectives:
To evaluate the methodology, feasibility, safety, and efficacy of a novel method called over-the-scope clip- (OTSC-) associated endoscopic muscular dissection for small GSMT.
Methods:
A pilot study on small GSMT diameter ≤ 1 cm was performed. OTSC-associated endoscopic muscular dissection was based on the requirement of OTSC apparatus and ESD technique; after ligaturing the bottom of small GSMT by OTSC, ESD was performed to resect the tumors, and the wounds of ESD were closed by clips finally. All the patients were followed up for more than 3 months, and the complications during and after OTSC-associated endoscopic muscular dissection were recorded.
Results:
A total of 7 consecutive patients with small GSMT were included. All tumors were completely dissected without any perforation or infection during and after the procedure in all cases, while three patients had mild abdominal pain, and one experienced postoperative bleeding after the procedure which was treated by the endoscopy with titanium clips. All the patients were followed by endoscopy three months later, all the wounds healed well, and all the OTSCs were still in the gastric wall.
Conclusions:
OTSC-associated endoscopic muscular dissection as a novel endoscopic interventional therapy should be a convenient, safe, and effective therapy for small GSMT. The short-time outcome is excellent, whereas long-term effect is unclear, and the further follow-up is needed to schedule.
... However, studies found that some GGs < 2 cm would enlarge after years of follow-up. 26,27 Some medicines, such as PPIs and NSAIDs, and diseases (gastric ulcer, non-AG, Hp. infection) would increase the PG level. To minimize the drug impact on PG level, we excluded patients who received PPIs, NSAIDs, Hp. eradication therapy or TCM. ...
Background
No biomarker was identified for gastric GISTs(GG) detection. We first observed that glands surrounding GG are regionally atrophic. We hypothesize that this local atrophy may mildly reduce pepsinogen Ⅰ(PGⅠ) but the PGⅠ/PGII ratio remains normal. To test our hypothesis, a retrospective analysis was conducted to evaluate the diagnostic efficiency of PG in GG detection.
Methods
We retrospectively analyzed a cohort of consecutive GG and gastric cancer(GC) patients at our center. Pathologic confirmed GG patients and GC patients with tested PG levels before medical intervention were included. Three criteria were assessed: 1.Serum PGI≤70ng/ml; 2.Positive-Gastric-GIST-PG(PGⅠ≤70 ng/ml and PGI/PGII ratio>3.0); and 3.Positive-Gastric-GIST-PG-CEA(Positive-Gastric-GIST-PG plus normal CEA). Sensitivity, specificity, positive predictive value(PPV), negative predictive value(NPV) and overall accuracy(OA) were calculated. A Chi-square test was applied to detect the differences.
Results
After screened 562 GG and 1090 GC, 100 GG and 174 GC samples were included. For PGI≤70ng/ml, the Positive-Gastric-GIST-PG and the Positive-Gastric-GIST-PG-CEA criteria discriminating GG from GC, the sensitivities were 75%(95%CI 66-82),70%(60-78) and 68%(58-76), respectively; the specificities were 50%(43-57), 70%(62-76), and 78%(71-83), respectively; the PPV were 46%(39-54), 57%(48-65), and 64%(55-73), respectively; the NPV were 78%(69-84), 80%(73-86), 81%(74-86), respectively; and the OA were 59%(53-65), 70%(64-75), and 74%(69-79), respectively. There was statistic difference in sensitivities between GG and GC for Positive-Gastric-GIST-PG-CEA criterion(68% for GG vs. 22% for GC, P<0.0001).
Conclusion
Serum PGs are useful for both detecting GG and distinguishing GG from GC. Integrating our criteria into current PG test scheme of gastric precancerous screening will be helpful for early GG detection without additional economic expense.
... aged 40-60 years with a peak incidence in the fifth decade and bears no gender predilection [1].The majority of such lesions are generally slow growing and asymptomatic, and are incidentally found during routine endoscopic examination, at autopsy or during abdominal surgical exploration for other reasons [2]. However, when symptomatic, GLM manifests with upper gastrointestinal bleeding, atypical epigastric pain or non-specific dyspepsia, generally due to mucosal ulceration [1,3]. ...
Objectives
To investigate CT findings and develop a diagnostic score model to differentiate GLMs from GISTs.
Methods
This retrospective study included 109 patients with pathologically confirmed GLMs (n = 46) and GISTs (n = 63) from January 2013 to August 2018 who received CE-CT before surgery. Demographic and radiological features was collected, including lesion location, contour, presence or absence of intralesional necrosis and ulceration, growth pattern, whether the tumor involved EGJ, the long diameter (LD) /the short diameter (SD) ratio, pattern and degree of lesion enhancement. Univariate analyses and multivariate logistic regression analyses were performed to identify independent predictors and establish a predictive model. Independent predictors for GLMs were weighted with scores based on regression coefficients. A receiver operating characteristic (ROC) curve was created to determine the diagnostic ability of the model. Overall score distribution was divided into four groups to show differentiating probability of GLMs from GISTs.
Results
Five CT features were the independent predictors for GLMs diagnosis in multivariate logistic regression analysis, including esophagogastric junction (EGJ) involvement (OR, 367.9; 95% CI, 5.8-23302.8; P = 0.005), absence of necrosis (OR, 11.9; 95% CI, 1.0-138. 1; P = 0.048) and ulceration (OR, 151.9; 95% CI, 1.4-16899.6; P = 0.037), degree of enhancement (OR, 9.3; 95% CI, 3.2-27.4; P < 0.001), and long diameter/ short diameter (LD/SD) ratio (OR,170.9; 95% CI, 8.4-3493.4; P = 0.001). At a cutoff of 9 points, AUC for this score model was 0.95, with 95.65% sensitivity, 79.37% specificity, 77.19% PPV, 96.15% NPV and 86.24% diagnostic accuracy. An increasing trend was showed in diagnostic probability of GLMs among four groups based on the score (P < 0.001).
Conclusions
The newly designed scoring system is reliable and easy-to-use for GLMs diagnosis by distinguishing from GISTs, including EGJ involvement, absence of ulceration and necrosis, mild enhancement and high LD/SD ratio. The overall score of model ranged from 1 to 17 points, which was divided into 4 groups: 1-7 points, 7-10 points, 10-13 points and 13-17 points, with a diagnostic probability of GLMs 0%, 45%, 83% and 100%, respectively.
