Gastric Cancer

, Volume 22, Issue 5, pp 980–987 | Cite as

Digital image analysis-based scoring system for endoscopic ultrasonography is useful in predicting gastrointestinal stromal tumors

  • Moon Won Lee
  • Gwang Ha KimEmail author
  • Kwang Baek Kim
  • Yoon Ho Kim
  • Do Youn Park
  • Chang In Choi
  • Dae Hwan Kim
  • Tae Yong Jeon
Original Article



When gastric mesenchymal tumors (GMTs) measuring 2–5 cm in size are found, whether to undergo further treatment or not is controversial. Endoscopic ultrasonography (EUS) is useful for the evaluation of malignant potential of GMTs, but has limitations, such as subjective interpretation of EUS images. Therefore, we aimed to develop a scoring system based on the digital image analysis of EUS images to predict gastrointestinal stromal tumors (GISTs).


We included 103 patients with histopathologically proven GIST, leiomyoma or schwannoma on surgically resected specimen who underwent EUS examination between January 2007 and June 2018. After standardization of the EUS images, brightness values, including the mean (Tmean), indicative of echogenicity, and the standard deviation (TSD), indicative of heterogeneity, in the tumors were analyzed.


Age, Tmean, and TSD were significantly higher in GISTs than in non-GISTs. The sensitivity and specificity were almost optimized for differentiating GISTs from non-GISTs when the critical values of age, Tmean, and TSD were 57.5 years, 67.0, and 25.6, respectively. A GIST-predicting scoring system was created by assigning 3 points for Tmean ≥ 67, 2 points for age ≥ 58 years, and 1 point for TSD ≥ 26. When GMTs with 3 points or more were diagnosed as GISTs, the sensitivity, specificity, and accuracy of the scoring system were 86.5%, 75.9%, and 83.5%, respectively.


The scoring system based on the information of digital image analysis is useful in predicting GISTs in case of GMTs that are 2–5 cm in size.


Stomach Endoscopic ultrasonography Gastrointestinal stromal tumor Mesenchymal tumor Image analysis 



This study was supported by Biomedical Research Institute Grant (2018B015), Pusan National University Hospital and a Busan Cancer Center Research Grant (2018), Pusan National University Hospital.

Author contributions

GHK and KBK jointly conceived the study. MWL, GHK and YHK performed the data analysis. MWL, GHK, DYP, CIC, DHK, and TYJ were responsible for the data collection and contributed to the data analysis and writing of the manuscript. MWL and GHK contributed to the interpretation of the results, and reviewed the manuscript. All authors critically revised each stage of the manuscript and all authors approved the final draft for submission.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interests.

Human rights statement

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Declaration of Helsinki of 1964 and later versions.

Informed consent

Informed consent or a substitute for it was obtained from all patients before they were included in the study.

Supplementary material

10120_2019_928_MOESM1_ESM.docx (15 kb)
Supplementary material 1 (DOCX 15 KB)
10120_2019_928_MOESM2_ESM.eps (966 kb)
Supplementary material 2 (EPS 966 KB)
10120_2019_928_MOESM3_ESM.eps (957 kb)
Supplementary material 3 (EPS 956 KB)
10120_2019_928_MOESM4_ESM.eps (953 kb)
Supplementary material 4 (EPS 952 KB)


  1. 1.
    Pidhorecky I, Cheney RT, Kraybill WG, Gibbs JF. Gastrointestinal stromal tumors: current diagnosis, biologic behavior, and management. Ann Surg Oncol. 2000;7:705–12.CrossRefGoogle Scholar
  2. 2.
    Sarlomo-Rikala M, Kovatich AJ, Barusevicius A, Miettinen M. CD117: a sensitive marker for gastrointestinal stromal tumors that is more specific than CD34. Mod Pathol. 1998;11:728–34.PubMedGoogle Scholar
  3. 3.
    Miettinen M, Sobin LH, Sarlomo-Rikala M. Immunohistochemical spectrum of GISTs at different sites and their differential diagnosis with a reference to CD117 (KIT). Mod Pathol. 2000;13:1134–42.CrossRefPubMedGoogle Scholar
  4. 4.
    Blay JY, Bonvalot S, Casali P, Choi H, Debiec-Richter M, Dei Tos AP, et al. Consensus meeting for the management of gastrointestinal stromal tumors. Report of the GIST Consensus Conference of 20–21 March 2004, under the auspices of ESMO. Ann Oncol. 2005;16:566–78.CrossRefGoogle Scholar
  5. 5.
    Miettinen M, Sobin LH, Lasota J. Gastrointestinal stromal tumors of the stomach: a clinicopathologic, immunohistochemical, and molecular genetic study of 1765 cases with long-term follow-up. Am J Surg Pathol. 2005;29:52–68.CrossRefGoogle Scholar
  6. 6.
    Fletcher CD, Berman JJ, Corless C, Gorstein F, Lasota J, Longley BJ, et al. Diagnosis of gastrointestinal stromal tumors: a consensus approach. Hum Pathol. 2002;33:459–65.CrossRefGoogle Scholar
  7. 7.
    Demetri GD, von Mehren M, Antonescu CR, DeMatteo RP, Ganjoo KN, Maki RG, et al. NCCN Task Force report: update on the management of patients with gastrointestinal stromal tumors. J Natl Compr Canc Netw. 2010;8(Suppl 2):1–41 (quiz S2–4).CrossRefGoogle Scholar
  8. 8.
    Chak A, Canto MI, Rosch T, Dittler HJ, Hawes RH, Tio TL, et al. Endosonographic differentiation of benign and malignant stromal cell tumors. Gastrointest Endosc. 1997;45:468–73.CrossRefPubMedGoogle Scholar
  9. 9.
    Palazzo L, Landi B, Cellier C, Cuillerier E, Roseau G, Barbier JP. Endosonographic features predictive of benign and malignant gastrointestinal stromal cell tumours. Gut. 2000;46:88–92.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Kim GH, Park do Y, Kim S, Kim DH, Choi CW, Heo J, et al. Is it possible to differentiate gastric GISTs from gastric leiomyomas by EUS? World J Gastroenterol. 2009;15:3376–81.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Okai T, Minamoto T, Ohtsubo K, Minato H, Kurumaya H, Oda Y, et al. Endosonographic evaluation of c-kit-positive gastrointestinal stromal tumor. Abdom Imaging. 2003;28:301–7.CrossRefPubMedGoogle Scholar
  12. 12.
    Catalano MF, Sivak MV Jr, Bedford RA, Falk GW, van Stolk R, Presa F, et al. Observer variation and reproducibility of endoscopic ultrasonography. Gastrointest Endosc. 1995;41:115–20.CrossRefPubMedGoogle Scholar
  13. 13.
    Gress F, Schmitt C, Savides T, Faigel DO, Catalano M, Wassef W, et al. Interobserver agreement for EUS in the evaluation and diagnosis of submucosal masses. Gastrointest Endosc. 2001;53:71–6.CrossRefPubMedGoogle Scholar
  14. 14.
    Nishida T, Blay JY, Hirota S, Kitagawa Y, Kang YK. The standard diagnosis, treatment, and follow-up of gastrointestinal stromal tumors based on guidelines. Gastric Cancer. 2016;19:3–14.CrossRefPubMedGoogle Scholar
  15. 15.
    Nishida T, Kawai N, Yamaguchi S, Nishida Y. Submucosal tumors: comprehensive guide for the diagnosis and therapy of gastrointestinal submucosal tumors. Dig Endosc. 2013;25:479–89.CrossRefPubMedGoogle Scholar
  16. 16.
    Hwang JH, Rulyak SD, Kimmey MB; American Gastroenterological Association Institute. American Gastroenterological Association Institute technical review on the management of gastric subepithelial masses. Gastroenterology. 2006;130:2217–28.CrossRefGoogle Scholar
  17. 17.
    Lee HL. Advances in the management of upper gastrointestinal subepithelial tumor: pathologic diagnosis using endoscopy without endoscopic ultrasound-guided biopsy. Clin Endosc. 2016;49:216–9.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Kim GH, Kim KB, Lee SH, Jeon HK, Park DY, Jeon TY, et al. Digital image analysis of endoscopic ultrasonography is helpful in diagnosing gastric mesenchymal tumors. BMC Gastroenterol. 2014;14:7.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Park CH, Kim GH, Lee BE, Song GA, Park DY, Choi KU, et al. Two staging systems for gastrointestinal stromal tumors in the stomach: which is better? BMC Gastroenterol. 2017;17:141.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Yoon JM, Kim GH, Park DY, Shin NR, Ahn S, Park CH, et al. Endosonographic features of gastric schwannoma: a single center experience. Clin Endosc. 2016;49:548–54.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Williams DB, Sahai AV, Aabakken L, Penman ID, van Velse A, Webb J, et al. Endoscopic ultrasound guided fine needle aspiration biopsy: a large single centre experience. Gut. 1999;44:720–6.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Hu J, Liu X, Ge N, Wang S, Guo J, Wang G, et al. Role of endoscopic ultrasound and endoscopic resection for the treatment of gastric schwannoma. Medicine (Baltimore). 2017;96:e7175.CrossRefGoogle Scholar
  23. 23.
    Yeh CN, Hwang TL, Huang CS, Lee PH, Wu CW, Chen-Guo K, et al. Clinical practice guidelines for patients with gastrointestinal stromal tumor in Taiwan. World J Surg Oncol. 2012;10:246.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Kim GH, Cho YK, Kim EY, Kim HK, Cho JW, Lee TH, et al. Comparison of 22-gauge aspiration needle with 22-gauge biopsy needle in endoscopic ultrasonography-guided subepithelial tumor sampling. Scand J Gastroenterol. 2014;49:347–54.CrossRefGoogle Scholar
  25. 25.
    Han JP, Lee TH, Hong SJ, Kim HK, Noh HM, Lee YN, et al. EUS-guided FNA and FNB after on-site cytological evaluation in gastric subepithelial tumors. J Dig Dis. 2016;17:582–7.CrossRefPubMedGoogle Scholar
  26. 26.
    Zhang XC, Li QL, Yu YF, Yao LQ, Xu MD, Zhang YQ, et al. Diagnostic efficacy of endoscopic ultrasound-guided needle sampling for upper gastrointestinal subepithelial lesions: a meta-analysis. Surg Endosc. 2016;30:2431–41.CrossRefPubMedGoogle Scholar

Copyright information

© The International Gastric Cancer Association and The Japanese Gastric Cancer Association 2019

Authors and Affiliations

  • Moon Won Lee
    • 1
  • Gwang Ha Kim
    • 1
    Email author
  • Kwang Baek Kim
    • 2
  • Yoon Ho Kim
    • 1
  • Do Youn Park
    • 3
  • Chang In Choi
    • 4
  • Dae Hwan Kim
    • 4
  • Tae Yong Jeon
    • 4
  1. 1.Department of Internal MedicinePusan National University School of Medicine and Biomedical Research Institute, Pusan National University HospitalBusanSouth Korea
  2. 2.Division of Computer EngineeringSilla UniversityBusanSouth Korea
  3. 3.Department of PathologyPusan National University School of MedicineBusanSouth Korea
  4. 4.Department of SurgeryPusan National University School of MedicineBusanSouth Korea

Personalised recommendations