Impact of tumour rupture risk on the oncological rationale for the surgical treatment choice of gastrointestinal stromal tumours

Tumour rupture of gastrointestinal stromal tumours(GISTs)has been considered to be a remarkable risk factor because of its unfavourable impact on the oncological outcome.Although tumour rupture has not yet been included in the current tumor-node-metastasis classification of GISTs as a prognostic factor,it may change the natural history of a low-risk GIST to a high-risk GIST.Originally,tumour rupture was defined as the spillage or fracture of a tumour into a body cavity,but recently,new definitions have been proposed.These definitions distinguished from the prognostic point of view between the major defects of tumour integrity,which are considered tumour rupture,and the minor defects of tumour integrity,which are not considered tumour rupture.Moreover,it has been demonstrated that the risk of disease recurrence in R1 patients is largely modulated by the presence of tumour rupture.Therefore,after excluding tumour rupture,R1 may not be an unfavourable prognostic factor for GISTs.Additionally,after the standard adjuvant treatment of imatinib for GIST with rupture,a high recurrence rate persists.This review highlights the prognostic value of tumour rupture in GISTs and emphasizes the need to carefully take into account and minimize the risk of tumour rupture when choosing surgical strategies for GISTs.

Imaged guided surgery during arteriovenous malformation of gastrointestinal stromal tumor using hyperspectral and indocyanine green visualization techniques:A case report

BACKGROUND This case report demonstrates the simultaneous development of a gastrointestinal stromal tumour(GIST)with arteriovenous malformations(AVMs)within the jejunal mesentery.A 74-year-old male presented to the department of surgery at our institution with a one-month history of abdominal pain.Contrast-enhanced computed tomography revealed an AVM.During exploratory laparotomy,hyperspectral imaging(HSI)and indocyanine green(ICG)fluorescence were used to evaluate the extent of the tumour and determine the resection margins.Intraoperative imaging confirmed AVM,while histopathological evaluation showed an epithelioid,partially spindle cell GIST.CASE SUMMARY This is the first case reporting the use of HSI and ICG to image GIST intermingled with an AVM.The resection margins were planned using intraoperative analysis of additional optical data.Image-guided surgery enhances the clinician’s knowledge of tissue composition and facilitates tissue differentiation.CONCLUSION Since image-guided surgery is safe,this procedure should increase in popularity among the next generation of surgeons as it is associated with better postoperative outcomes.

Tunneled biopsy is an underutilised,simple,safe and efficient method for tissue acquisition from subepithelial tumours

BACKGROUND Tissue acquisition from subepithelial lesions is often attempted by endoscopic ultrasound(EUS)-sampling as conventional endoscopic biopsy usually fails to reach deeper layers of the gastrointestinal wall.AIM To investigate the utilisation,safety and diagnostic yield of an intensified“biteon-bite”tunnel biopsy technique.METHODS In this retrospective cohort study,all patients presenting with subepithelial masses in the upper gastrointestinal tract from March 2013 to July 2019 were included.Data were analysed for size and location of the subepithelial mass,use of intensified tunnel biopsy protocol(more than 10 double bite-on-bite biopsies)or superficial conventional biopsies,histology and imaging results,occurrence of readmission and adverse events after endoscopy.RESULTS Two hundred and twenty-nine patients with subepithelial lesions were included.Superficial conventional biopsies were taken in 117 patients and were diagnostic only in one lipoma(0.9%).Tunnel biopsies taken in 112/229(48.9%)patients were significantly more likely to provide histological diagnosis(53.6%;P<0.001).For lesions≥10mm the diagnostic yield of tunnel biopsies further increased to 41/67(61.2%).No immediate or delayed complications were reported.Only 8 of the 51 endoscopists(15.7%)regularly attempted tunnel biopsies.CONCLUSION Tunnel biopsy is a simple,safe and efficient but underutilised diagnostic modality for tissue acquisition in subepithelial masses.It should be routinely attempted at the initial endoscopy.

Histopathological landscape of rare oesophageal neoplasms

The landscape of neoplastic pathology of the oesophagus is dominated by malignancies of epithelial origin,in particular by oesophageal adenocarcinoma and oesophageal squamous cell carcinoma.However,several other histopathological variants can be distinguished,some associated with peculiar histopathological profiles and prognostic behaviours and frequently underrecognized in clinical practice.The aim of this review is to provide a comprehensive characterization of the main morphological and clinical features of these rare variants of oesophageal neoplastic lesions.

A ruptured recurrent small bowel gastrointestinal stromal tumour causing hemoperitoneum

Hemoperitoneum is a rare and potentially life-threatening complication of GIST. We reported a 54- year-old man who developed disseminated intra-abdominal recurrence from a previously resected gastrointestinal stromal tumour （GIST） of the small bowel, and the patient presented with hemoperitoneum. Emergent debulking surgery was performed. A high dose imatinib was prescribed. Despite the presence of residual disease, the patient was well clinically 8 months after the operation. Even though, there is no evidence to support the routine use of debulking surgery in the management of GIST. In our patient, disease progression after second line targeted therapy and the absence of alternative treatment options for spontaneous rupture and hemoperitoneum prompted us to treat the patient aggressively. Resection of the ruptured GIST was carried out for control of bleeding and to prevent recurrent bleeding in this patient with good surgical risks. During the treatment decision-making, the patient＇s general condition, the risk of surgery and the extent of dissemination were taken into consideration. In this patient who presented with spontaneous rupture of a small intestinal GIST, the novel use of targeted therapy and aggressive surgical treatment produced reasonably good survival outcome.

Genetic characteristics of a patient with multiple primary cancers:A case report

BACKGROUND Two or multiple primary malignant neoplasms(MPMNs)rarely occur in the same patient.It has been reported that MPMNs are easily misdiagnosed as the recurrence or metastasis of malignancies in clinical practice,affecting the choice of treatment for the patients,thereby resulting in the delay of optimal diagnosis.Next generation sequencing(NGS)can be used to distinguish between multiple primary lung cancers and intrapulmonary metastasis,and may distinguish the origin of tumours in different sites of the body.CASE SUMMARY We report the case of 66-year-old woman who suffered from different malignant neoplasms in the rectum and esophageal and gastrointestinal tract.The first neoplasm rectal adenocarcinoma was diagnosed and removed in 2016.The second and third lesions were diagnosed with esophageal squamous-cell carcinoma(ESCC)and gastrointestinal stromal tumour(GIST),respectively,in 2019.Nextgeneration whole exome sequencing was performed on the tissue specimens of rectal carcinoma,esophageal cancer,GIST,and white blood cells to investigate the relationship between malignancies at different timeframe and determine whether the ESCC and GIST evolved from the rectal adenocarcinoma.Mutations including v-Ki-ras2-Kirsten rat sarcoma viral oncogene homolog,adenomatosis polyposis coli,and mothers against decapentaplegic homolog 4 were detected in rectal adenocarcinoma sample,mast/stem cell growth factor receptor was detected in GIST tissue,and lysine methyltransferase 2D was detected in ESCC specimen.Overall,ESCC and GIST were not genetically evolved from rectal adenocarcinoma,and this patient did not have a trunk driven clone.CONCLUSION NGS is an effective tool to study clonal evolution of tumours and distinguish between MPMNs and intrapulmonary metastasis.

Excitation-emission matrices （EEMs） of colorectal tumors- tool for spectroscopic diagnostics of gastrointestinal neoplasia

The autofluorescence spectroscopy of biologi- cal tissues is a powerful tool for non-invasive detection of tissue pathologies and evaluation of any biochemical and morphological changes arising during the lesions＇ growth. To obtain a full picture of the whole set of endogenous fluorophores appearing in the gastrointestinal （GI） tumors investigated, the technique of excitation-emission matrix （EEM） development was applied in a broad spectral region, covering the ultraviolet and visible spectral ranges. We could thus address a set of diagnostically-important chromophores and their alterations during tumor develop- ment, namely, collagen, elastin, nicotinamide adenine dinucleotide （NADH）, flavins, porphyrins, while hemo- globin＇s absorption influence on the spectra obtained could be evaluated as well. Comparisons are presented between EEM data of normal mucosae, benign polyps and malignant carcinoma, and the origins are determined of the fluorescence signals forming these matrices.