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.

Efficacy and safety of endoscopic resection in treatment of small gastric stromal tumors: A state-of-the-art review

Gastrointestinal stromal tumors can occur in any part of the gastrointestinal tract,but gastric stromal tumors(GSTs)are the most common.All GSTs have the potential to become malignant,and these can be divided into four different grades by risk from low to high:Very low risk,low risk,medium risk,and high risk.Current guidelines all recommend early complete excision of GSTs larger than 2 cm in diameter.However,it is not clear whether small GSTs(sGSTs,i.e.,those smaller than 2 cm in diameter)should be treated as early as possible.The National Comprehensive Cancer Network recommends that endoscopic ultrasonographyguided(EUS-guided)fine-needle aspiration biopsy and imaging(computed tomography or magnetic-resonance imaging)be used to assess cancer risk for sGSTs detected by gastroscopy to determine treatment.When EUS indicates a higher risk of tumor,surgical resection is recommended.There are some questions on whether sGSTs also require early treatment.Many studies have shown that endoscopic treatment of GSTs with diameters of 2-5 cm is very effective.We here address whether endoscopic therapy is also suitable for sGSTs.In this paper,we try to explain three questions:(1)Does sGST require treatment?(2)Is digestive endoscopy a safe and effective means of treating sGST?and(3)When sGSTs are at different sites and depths,which endoscopic treatment method is more suitable?

Multi-slice spiral computed tomography in differential diagnosis of gastric stromal tumors and benign gastric polyps,and gastric stromal tumor risk stratification assessment

BACKGROUND The biological characteristics of gastric stromal tumors are complex,and their incidence has increased in recent years.Gastric stromal tumors(GST)have potential malignant tendencies,and the probability of transformation into malignant tumors is as high as 20%-30%.AIM To investigate the value of multi-slice spiral computed tomography(MSCT)in the differential diagnosis of GST and benign gastric polyps,and GST risk stratification assessment.METHODS We included 64 patients with GST(GST group)and 60 with benign gastric polyps(control group),confirmed by pathological examination after surgery in PLA General Hospital,from January 2016 to June 2021.The differences in the MSCT imaging characteristic parameters and enhanced CT values between the two groups before surgery were compared.According to the National Institutes of Health’s standard,GST is divided into low-and high-risk groups for MSCT imaging characteristic parameters and enhanced CT values.RESULTS The incidences of extraluminal growth,blurred boundaries,and ulceration in the GST group were significantly higher than those in the control group(P<0.05).The CT values and enhanced peak CT values in the arterial phase in the CST group were higher than those in the control group(P<0.05).The MSCT differential diagnosis of GST and gastric polyp sensitivity,specificity,misdiagnosis rate,missed diagnosis rate,and areas under the curve(AUCs)were 73.44%,83.33%,26.56%,16.67%,0.784,respectively.The receiver operating characteristic curves were plotted with the arterial CT value and enhanced peak CT value,with a statistical difference.The results showed that the sensitivity,specificity,misdiagnosis rate,missed diagnosis rate,and AUC value of arterial CT in the differential diagnosis of GST and gastric polyps were 80.18%,62.20%,19.82%,37.80%,and 0.710,respectively.The sensitivity,specificity,misdiagnosis rate,missed diagnosis rate,and AUC value of the enhanced peak CT value in the differential diagnosis of GST and gastric polyps were 67.63%,60.40%,32.37%,39.60%,and 0.710,respectively.The incidence of blurred lesion boundaries and ulceration in the high-risk group was significantly higher than that in the low-risk group(P<0.05).The arterial phase and enhanced peak CT values in the high-risk group were significantly higher than those in the low-risk group(P<0.05).CONCLUSION Presurgical MSCT examination has important value in the differential diagnosis of GST and gastric benign polyps and can effectively evaluate the risk grade of GST patients.

Effect of gastroscopy combined with laparoscopy on gastric stromal tumors

Objective:To analyze the clinical effect of gastroscopy combined with laparoscopy in the treatment of gastric stromal tumors.Methods:From January 2015 to December 2017,53 patients with gastric interstitial tumors were screened from the patients who were examined or admitted to our hospital.The patients who were not suitable for surgical treatment with gastroscopy and laparoscopy will be selected.As a control group,a total of 21 patients were treated with open surgery;the remaining 32 patients were treated as a study group with gastroscopy combined with laparoscopy.After treatment,analyze intraoperative or postoperative indicators,pathological results,risk of tumor recurrence,and incidence of complications.Results:The operation time in the study group was significantly longer than that in the control group.The blood loss,abdominal drainage volume,exhaust time,analgesic use time,and hospital stay in the study group were significantly shorter than those in the control group,P<0.05,and the differences were statistically significant.There was no difference between the immunohistochemical results and the benign and malignant tumor results in the group,P>0.05,which was not statistically significant;the difference in recurrence risk between the study group and the control group was not significant,P>0.05;the incidence of complications was significantly lower in the study group.In the control group,the difference was significant,P<0.05.Conclusion:Gastroscopy combined with laparoscopy for gastric stromal tumors has a significant effect,is safe and reliable,and is worthy of clinical promotion.

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.

Comparison of short-and long-term outcomes of laparoscopic vs open resection for gastric gastrointestinal stromal tumors

AIM To compare the short-and long-term outcomes of laparoscopic(LR) vs open resection(OR) for gastric gastrointestinal stromal tumors(g GISTs).METHODS In total, 301 consecutive patients undergoing LR or OR for pathologically confirmed g GISTs from 2005 to 2014 were enrolled in this retrospective study. After exclusion of 77 patients, 224 eligible patients were enrolled(122 undergoing LR and 102 undergoing OR). The demographic, clinicopathologic, and survival data of all patients were collected. The intraoperative, postoperative, and long-term oncologic outcomes were compared between the LR and OR groups following the propensity score matching to balance the measured covariates between the two groups.RESULTS After 1:1 propensity score matching for the set of covariates including age, sex, body mass index, American Society of Anesthesiology score, tumor location, tumor size, surgical procedures, mitotic count, and risk stratification, 80 patients in each group were included in the final analysis. The baseline parameters of the two groups were comparable after matching. TheLR group was significantly superior to the OR group with respect to the operative time, intraoperative blood loss, postoperative first flatus, time to oral intake, and postoperative hospital stay(P < 0.05). No differences in perioperative blood transfusion or the incidence of postoperative complications were observed between the two groups(P > 0.05). No significant difference was found in postoperative adjuvant therapy(P = 0.587). The mean follow-up time was 35.30 ± 26.02(range, 4-102) mo in the LR group and 40.99 ± 25.07(range, 4-122) mo in the OR group with no significant difference(P = 0.161). Survival analysis showed no significant difference in the disease-free survival time or overall survival time between the two groups(P > 0.05).CONCLUSION Laparoscopic surgery for g GISTs is superior to open surgery with respect to intraoperative parameters and postoperative outcomes without compromising longterm oncological outcomes.

Clinical presentations of gastric small gastrointestinal stromal tumors mimics functional dyspepsia symptoms

AIM: To explore whether clinical presentations of gastric small gastrointestinal tumors (GISTs) mimics gastrointestinal dyspepsia symptoms.

Preoperative prediction of malignant potential of 2-5 cm gastric gastrointestinal stromal tumors by computerized tomography-based radiomics

BACKGROUND The use of endoscopic surgery for treating gastrointestinal stromal tumors(GISTs)between 2 and 5 cm remains controversial considering the potential risk of metastasis and recurrence.Also,surgeons are facing great difficulties and challenges in assessing the malignant potential of 2-5 cm gastric GISTs.AIM To develop and evaluate computerized tomography(CT)-based radiomics for predicting the malignant potential of primary 2-5 cm gastric GISTs.METHODS A total of 103 patients with pathologically confirmed gastric GISTs between 2 and 5 cm were enrolled.The malignant potential was categorized into low grade and high grade according to postoperative pathology results.Preoperative CT images were reviewed by two radiologists.A radiological model was constructed by CT findings and clinical characteristics using logistic regression.Radiomic features were extracted from preoperative contrast-enhanced CT images in the arterial phase.The XGboost method was used to construct a radiomics model for the prediction of malignant potential.Nomogram was established by combing the radiomics score with CT findings.All of the models were developed in a training group(n=69)and evaluated in a test group(n=34).RESULTS The area under the curve(AUC)value of the radiological,radiomics,and nomogram models was 0.753(95%confidence interval[CI]:0.597-0.909),0.919(95%CI:0.828-1.000),and 0.916(95%CI:0.801-1.000)in the training group vs 0.642(95%CI:0.379-0.870),0.881(95%CI:0.772-0.990),and 0.894(95%CI:0.773-1.000)in the test group,respectively.The AUC of the nomogram model was significantly larger than that of the radiological model in both the training group(Z=2.795,P=0.0052)and test group(Z=2.785,P=0.0054).The decision curve of analysis showed that the nomogram model produced increased benefit across the entire risk threshold range.CONCLUSION Radiomics may be an effective tool to predict the malignant potential of 2-5 cm gastric GISTs and assist preoperative clinical decision making.

Altered Expression Profile of Micro RNAs in Gastric Stromal Tumor

Summary： MicroRNAs （miRNAs） play important roles in carcinogenesis, but the global miRNA ex- pression profile in gastric stromal tumor tissues remains unclear. This study was to examine the miRNA expression profile in gastric stromal tumor tissues and explore the function of dysregulated miRNAs by performing gene ontology （GO） and pathway enrichment analysis. Total RNA was extracted and puri- fied from 3 pairs of frozen gastric stromal tumor tissues and the adjacent non-tumor tissues by using mirVanaTM miRNA isolation kit. The miRNA expression was analyzed with Affymetrix microarrays （version 4.0） containing 2578 human mature microRNA probes. The dysregulated microRNAs were validated by quantitative RT-PCR in 30 pairs of gastric stromal tumor tissues. The target gene of the dysregulated microRNAs was predicted by miRanda, TargetScan and PicTar. GO and pathway enrich- ment analysis was conducted to examine the potential function of miR-3178 and miR-193a-5p. The re- suits showed that there were 12 differently expressed microRNAs in gastric stromal tumor tissues, among which 10 miRNAs were down-regulated, and 2 were up-regulated （P〈0.05）. The validation re- sults by RT-PCR were in accordance with those by microRNA microarry. GO analysis found that the target genes of miR-3178 were involved in 5 GO terms and those of miR-193a-5p in 7 GO terms in level 2. Pathway enrichment analysis suggested that miR-3178 and miR-193a-5p were related to 57 and 122 signaling pathways, respectively. It was concluded that gastric stromal tumor displays a unique miRNA signature. This specific expression may become a new diagnostic and prognostic biomarker for gastric stromal ~xnor. miR-3178 and miR-193a-5p function as suppressive microRNAs, and they may also become diagnosis and treatment targets for gastric stromal tumor.

Splenosis masquerading as gastric stromal tumor: A case report

BACKGROUND Splenosis is a rare benign disease that often disguises itself as a malignant tumor.There are few articles providing a comprehensive description of splenosis,especially cases located in the stomach being treated by laparoscopic surgery.CASE SUMMARY A 44-year-old man presented with recurrent upper abdominal pain for more than half a year.The patient had splenic rupture caused by trauma more than 10 years ago and underwent splenectomy.An abdominal contrast-enhanced computed tomography scan revealed an irregular soft tissue density.Gastroscopy revealed an approximately 3.0 cm×3.0 cm mucosal eminence at the posterior wall of the upper segment of the gastric body.Biopsy was not performed since the lesion was found under the mucosa and the gastric mucosa appeared normal.According to these findings,a diagnosis of gastric stromal tumor was made,although a definitive differential diagnosis was not known before surgery.When laparoscopic resection of the gastric stromal tumor was performed,an astonishing finding was made when postoperative pathology showed that the lesion comprised typical spleen tissue.CONCLUSION This case highlights the strong similarities between splenosis and malignant tumors.A detailed medical history combined with various effective auxiliary examinations can help improve differential diagnosis.

Spontaneous rupture of the giant gastric stromal tumor(> 35 cm) as a rare cause of acute abdomen: a case report

A case of spontaneous rupture of giant gastrointestinal stromal tumor(GIST) of stomach causing acute abdomen is described below. A male patient with abdominal mass presented with symptoms and signs of acute abdomen after admitting for 1 day. After preoperative management and evaluation, an exploratory laparotomy was performed, where rupture of a huge tumor in the stomach was found. A subtotal gastrectomy including the mass was performed and the final immunohistochemical examination verified that the neoplasm was a high risk GIST. The postoperative period was uneventful and the patient received treatment with imatinib mesylate, and regular follow-up without recurrence.

Relationship between Ki-67 and CD44 expression and microvascular formation in gastric stromal tumor tissues

BACKGROUND A gastric stromal tumor(GST)is a mesenchymal tumor that occurs in the gastrointestinal tract;its biological characteristics are highly complex.Clinically,the severity of a GST is often evaluated by factors such as risk classification,tumor size,and mitotic figures.However,these indicators are not very accurate.Even patients classified as low risk are also at risk of metastasis and recurrence.Therefore,more accurate and objective clinical biological behavior evaluations are urgently needed.AIM To determine the relationship between Ki-67 and CD44 expression in GSTs and microvessel formation and prognosis.METHODS Eighty-six GST tissue specimens from our hospital were selected for this study.The immunohistochemical staining technique was used to detect Ki-67,CD44,and microvessel density(MVD)in the collected samples to analyze the different risk grades and mitotic figures.In addition,this approach was used to determine the differences in the expression of Ki-67 and CD44 in GST tissues with varying lesion diameters.RESULTS In GSTs with positive expression of the Ki-67 protein,the proportions of patients with medium-to-high risk and more than five mitotic counts were 24.07%and 38.89%,respectively.In GSTs with positive expression of the CD44 protein,the proportions of patients with medium-to-high risk and more than five mitotic counts were 23.73%and 38.98%,respectively.In GSTs with negative expression of the Ki-67 protein,these values were relatively high(3.70%and 11.11%,respectively).The MVD in GSTs with positive and negative expression of the CD44 protein was 15.92±2.94 and 13.86±2.98/Hp,respectively;the difference between the two groups was significant(P<0.05).CONCLUSION Ki-67 and CD44 expression in GSTs is correlated with the grade of tumor risk and mitotic figures.CD44 expression is correlated with microvessel formation in tumor tissues.

Gastroduodenal intussusception caused by gastric gastrointestinal stromal tumor:A case report and review of the literature

BACKGROUND Gastric gastrointestinal stromal tumor(GIST)is the most common etiology of gastroduodenal intussusception.Although gastroduodenal intussusception caused by gastric GIST is mostly treated by surgical resection,the first case of gastroduodenal intussusception caused by gastric GIST was treated by endoscopic submucosal dissection(ESD)in Japan in 2017.CASE SUMMARY An 84-year-old woman presented with symptoms of postprandial fullness with nausea and occasional vomiting for a month.Initially,she visited a local clinic for help,where abdominal sonography revealed a space-occupying lesion around the liver,so she was referred to our hospital for further confirmation.Abdominal sonography was repeated,which revealed a mass with an alternating concentric echogenic lesion.Esophagogastroduodenoscopy(EGD)was performed under the initial impression of gastric cancer with central necrosis and showed a tortuous distortion of gastric folds down from the lesser curvature side to the duodenal bulb with stenosis of the gastric outlet.EGD was barely passed through to the 2nd portion of the duodenum and a friable ulcerated mass was found.Several differential diagnoses were suspected,including gastroduodenal intussusception,gastric cancer invasion to the duodenum,or pancreatic cancer with adherence to the gastric antrum and duodenum.Abdominal computed tomography for further evaluation was arranged and showed gastroduodenal intussusception with a long stalk polypoid mass 5.9 cm in the duodenal bulb.Under the impression of gastroduodenal intussusception,ESD was performed at the base of the gastroduodenal intussusception;unfortunately,a gastric perforation was found after complete resection was accomplished,so gastrorrhaphy was performed for the perforation and retrieval of the huge polypoid lesion.The gastric tumor was pathologically proved to be a GIST.After the operation,there was no digestive disturbance and the patient was discharged uneventfully on the 10th day following the operation.CONCLUSION We present the second case of gastroduodenal intussusception caused by GIST treated by ESD.It is also the first case report of gastroduodenal intussusception by GIST in Taiwan,and endoscopic reduction or resection is an alternative treatment for elderly patients who are not candidates for surgery.

Endoscopic“calabash”ligation and resection for small gastric mesenchymal tumors

BACKGROUND Gastric mesenchymal tumors(GMT)are identified as soft tissue neoplasms that arise from mesenchymal stem cells within the gastrointestinal tract.GMT pri-marily encompass gastric stromal tumors(GST),gastric leiomyomas,and gastric schwannomas.Although most GMT are benign,there are still potential malignant changes,especially GST.Thus,early surgical intervention is the primary treat-ment for GMT.We have designed a simple endoscopic“calabash”ligation and resection(ECLR)procedure to treat GMT.Its efficacy and safety need to be com-pared with those of traditional endoscopic techniques,such as endoscopic sub-mucosal excavation(ESE).AIM To assess the safety and effectiveness of ECLR in managing small GMT(sGMT)with a maximum diameter≤20 mm by comparing to ESE.METHODS This retrospective analysis involved patients who were hospitalized in our institution between November 2021 and March 2023,underwent endoscopic resection,and received a pathological diagnosis of GMT.Cases with a tumor diameter≤20 mm were chosen and categorized into two cohorts:Study and control groups.The study group was composed of patients treated with ECLR,whereas the control group was composed of those treated with ESE.Data on general clinical characteristics(gender,age,tumor diameter,tumor growth direction,tumor pathological type,and risk grade),surgery-related information(complete tumor resection rate,operation duration,hospitalization duration,hospitalization cost,and surgical complications),and postoperative follow-up were collected for both groups.The aforementioned data were subsequently analyzed and compared.RESULTS Five hundred and eighty-nine individuals were included,with 297 cases in the control group and 292 in the study group.After propensity score matching,the final analysis incorporated 260 subjects in each cohort.The findings indicated that the study group exhibited shorter operation duration and lowered medical expenses relative to the control group.Furthermore,the study group reported less postoperative abdominal pain and had a lower incidence of intraoperative perforation and postoperative electrocoagulation syndrome than the control group.There were no substantial variations observed in other parameters among the two cohorts.CONCLUSION ECLR is a viable and effective approach for managing sGMT.

Hepatic Metastatic GIST:Diagnostic and Therapeutic Difficulties in Souro Sanou Teaching Hospital in Bobo Dioulasso,Burkina Faso

Introduction: Gastrointestinal stromal tumor (GIST) is the most common non-epithelial, mesenchymal tumor of the digestive tract. Targeted therapy has improved the prognosis but the diagnosis must be accurate before using the existing drugs. Aim: To report the diagnostic difficulty in our context through the clinical polymorphism and define the position of targeted therapy in the management of GIST metastatic stomach. Casuistry: We report 3 cases of gastric GIST with liver metastasis in different circumstances of discovery. Patients were 21, 45, and 73 years old. Discovery circumstances were respectively digestive hemorrhage, severe clinical anemia, abdominal tumor and gastric tumor. There was hepatic metastasis in the three cases. The three patients received Imatinib treatment, adjuvant treatment for the first two cases, and neo-adjuvant treatment for the third case, with a very good clinical response and CT response on metastases. Conclusion: Because of their rarity, GISTs are often difficult to diagnose, and necessarily require immunohistochemistry which is not available in our work context. The effectiveness of targeted therapy even on metastasis needs a rigorous diagnostic approach to improve patient survival.

Clinical Control Study of Endoscopic Full-thickness Resection and Laparoscopic Surgery in the Treatment of Gastric Tumors Arising from the Muscularis Propria

Background： Gastric stromal tumors arising from the muscularis propria are located in deeper layers. Endoscopic resection may be contraindicated due to the possibility of perforation. These tumors are therefore usually removed by surgical or laparoscopic procedures. This study evaluated the curative effects, safety and feasibility of endoscopic full-thickness resection （EFR） of gastric stromal tumors originating from the muscularis propria. Methods： This study enrolled 92 patients with gastric stromal tumors 〉2.5 cm originating from the muscularis propria. Fifty patients underwent EFR, and 42 underwent laparoscopic intragastric surgery. Operation time, complete resection rate, length of hospital stay, incidence of complications, and recurrence rates were compared in these two groups. Results： EFR resulted in complete resection of all 50 gastric stromal tumors, with a mean procedure time of 85± 20 min, a mean hospitalization time of 7.0± 1.5 days and no complications. Laparoscopic intragastric surgery also resulted in a 100% complete resection rate, with a mean operation time of 88 ± 12 min and a mean hospitalization period of 7.5 ± 1.6 days. The two groups did not differ significantly in operation time, complete resection rates, hospital stay or incidence of complications （P 〉 0.05）. No patient in either group experienced tumor recurrence. Conclusions： EFR technique is effective and safe for the resection of gastric stromal tumors arising from the muscularis propria.

Screening for Differentially Expressed Genes of Gastric Stromal Tumor Originating from Muscularis Propria

INTRODUCTION Gastric stromal tumor （GST） is a set of gastrointestinal mesenchymal tumors those originate from interstitial cells of Cajal. Its early diagnosis and treatment are critical to prognosis. The occurrence of GST remains obscure; this study used Affymetrix expression spectrum chip to detect the gene expression spectrum of GST and explore new molecular target that is used in the treatment and prognosis of GST.

Coexistence of esophageal blue nevus, hair follicles and basaloid sqamous carcinoma:A case report

We present the case of a 57-year-old man who underwent esophagectomy for esophageal carcinoma found at barium meal and gastroscopic examination. He was diagnosed as esophageal basaloid squamous carcinoma （BSC） and gastric stromal tumor, which were associated with focal proliferation of melanocytes/ pigmentophages and hair follicles in esophageal mucosa. Melanocytic hyperplasia （melanocytosis） has previously been recognized as an occasional reactive lesion, which can accompany esophageal inflammation and invasive squamous carcinoma. The present case is unusual because of its hyperplasia of not only melanocytes but also hair follicles. To our knowledge, this is the first report of esophageal blue nevus and hair follicle coexisting with BSC.