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Endoscopic Management of Gastrointestinal Stromal Tumors

  • Stomach and Duodenum (Joseph R. Pisegna, Section Editor)
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Abstract

Subepithelial lesions are increasingly being identified with improved endoscopic imaging technologies. Many of these lesions are now recognized as gastrointestinal stromal tumors (GISTs). Recent advances in immunohistochemistry have allowed for reliable differentiation of GISTs from other subepithelial tumors, thereby significantly improving our understanding of these lesions. The wealth of recent information and continual evolution in our understanding of GISTs has exposed some knowledge gaps pertaining to the optimal management of these lesions. In this article, we review the endoscopic management of GISTs as it relates to the identification, diagnosis and management of these lesions based on the best available literature and our own clinical experience to date.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Hirota S, Isozaki K, Moriyama Y, et al. Gain-of-function mutations of c-kit in human gastrointestinal stromal tumors. Science. 1998;279:577–80.

    Article  PubMed  CAS  Google Scholar 

  2. Miettinen M, Lasota J. Gastrointestinal stromal tumors: pathology and prognosis at different sites. Semin Diagn Pathol. 2006;23:70–83.

    Article  PubMed  Google Scholar 

  3. Heinrich MC, Corless CL, Duensing A, et al. PDGFRA activating mutations in gastrointestinal stromal tumors. Science. 2003;299:708–10.

    Article  PubMed  CAS  Google Scholar 

  4. Lee CH, Liang CW, Espinosa I. The utility of discovered on gastrointestinal stromal tumor 1 (DOG1) antibody in surgical pathology-the GIST of it. Adv Anat Pathol. 2010;17:222–32.

    Article  PubMed  CAS  Google Scholar 

  5. Novelli M, Rossi S, Rodriguez-Justo M, et al. DOG1 and CD117 are the antibodies of choice in the diagnosis of gastrointestinal stromal tumours. Histopathology. 2010;57:259–70.

    Article  PubMed  Google Scholar 

  6. Ho MY, Blanke CD. Gastrointestinal stromal tumors: disease and treatment update. Gastroenterology. 2011;140:1372–6.

    Article  PubMed  Google Scholar 

  7. Nilsson B, Bumming P, Meis-Kindblom JM, et al. Gastrointestinal stromal tumors: the incidence, prevalence, clinical course, and prognostication in the preimatinib mesylate era–a population-based study in western Sweden. Cancer. 2005;103:821–9.

    Article  PubMed  Google Scholar 

  8. Tryggvason G, Gislason HG, Magnusson MK, et al. Gastrointestinal stromal tumors in Iceland, 1990–2003: the icelandic GIST study, a population-based incidence and pathologic risk stratification study. Int J Cancer. 2005;117:289–93.

    Article  PubMed  CAS  Google Scholar 

  9. Tryggvason G, Kristmundsson T, Orvar K, et al. Clinical study on gastrointestinal stromal tumors (GIST) in Iceland, 1990–2003. Dig Dis Sci. 2007;52:2249–53.

    Article  PubMed  Google Scholar 

  10. Agaimy A, Wunsch PH, Hofstaedter F, et al. Minute gastric sclerosing stromal tumors (GIST tumorlets) are common in adults and frequently show c-KIT mutations. Am J Surg Pathol. 2007;31:113–20.

    Article  PubMed  Google Scholar 

  11. Chetty R. Small and microscopically detected gastrointestinal stromal tumours: an overview. Pathology. 2008;40:9–12.

    Article  PubMed  Google Scholar 

  12. Hwang JH, Rulyak SD, Kimmey MB, et al. American Gastroenterological Association Institute technical review on the management of gastric subepithelial masses. Gastroenterology. 2006;130:2217–28.

    Article  PubMed  Google Scholar 

  13. Hunt GC, Smith PP, Faigel DO. Yield of tissue sampling for submucosal lesions evaluated by EUS. Gastrointest Endosc. 2003;57:68–72.

    Article  PubMed  Google Scholar 

  14. Cantor MJ, Davila RE, Faigel DO. Yield of tissue sampling for subepithelial lesions evaluated by EUS: a comparison between forceps biopsies and endoscopic submucosal resection. Gastrointest Endosc. 2006;64:29–34.

    Article  PubMed  Google Scholar 

  15. Hwang JH, Saunders MD, Rulyak SJ, et al. A prospective study comparing endoscopy and EUS in the evaluation of GI subepithelial masses. Gastrointest Endosc. 2005;62:202–8.

    Article  PubMed  Google Scholar 

  16. Hunt GC, Rader AE, Faigel DO. A comparison of EUS features between CD-117 positive GI stromal tumors and CD-117 negative GI spindle cell tumors. Gastrointest Endosc. 2003;57:469–74.

    Article  PubMed  Google Scholar 

  17. Brand B, Oesterhelweg L, Binmoeller KF, et al. Impact of endoscopic ultrasound for evaluation of submucosal lesions in gastrointestinal tract. Dig Liver Dis. 2002;34:290–7.

    Article  PubMed  CAS  Google Scholar 

  18. Gress F, Schmitt C, Savides T, et al. Interobserver agreement for EUS in the evaluation and diagnosis of submucosal masses. Gastrointest Endosc. 2001;53:71–6.

    Article  PubMed  CAS  Google Scholar 

  19. Chak A, Canto MI, Rosch T, et al. Endosonographic differentiation of benign and malignant stromal cell tumors. Gastrointest Endosc. 1997;45:468–73.

    Article  PubMed  CAS  Google Scholar 

  20. Jeon SW, Park YD, Chung YJ, et al. Gastrointestinal stromal tumors of the stomach: endosonographic differentiation in relation to histological risk. J Gastroenterol Hepatol. 2007;22:2069–75.

    Article  PubMed  Google Scholar 

  21. Shah P, Gao F, Edmundowicz SA, et al. Predicting malignant potential of gastrointestinal stromal tumors using endoscopic ultrasound. Dig Dis Sci. 2009;54:1265–9.

    Article  PubMed  Google Scholar 

  22. Nickl N, Gress F, McClave S, et al. Hypoechoic intramural tumor study: final report [Abstract]. Gastrointest Endosc. 2002;55:AB98.

    Google Scholar 

  23. Demetri GD, Benjamin RS, Blanke CD, et al. NCCN Task Force report: management of patients with gastrointestinal stromal tumor (GIST)–update of the NCCN clinical practice guidelines. J Natl Compr Canc Netw. 2007;5 Suppl 2:S1–S29.

    PubMed  Google Scholar 

  24. Klapman JB, Logrono R, Dye CE, et al. Clinical impact of on-site cytopathology interpretation on endoscopic ultrasound-guided fine needle aspiration. Am J Gastroenterol. 2003;98:1289–94.

    Article  PubMed  Google Scholar 

  25. Ando N, Goto H, Niwa Y, et al. The diagnosis of GI stromal tumors with EUS-guided fine needle aspiration with immunohistochemical analysis. Gastrointest Endosc. 2002;55:37–43.

    Article  PubMed  Google Scholar 

  26. Akahoshi K, Sumida Y, Matsui N, et al. Preoperative diagnosis of gastrointestinal stromal tumor by endoscopic ultrasound-guided fine needle aspiration. World J Gastroenterol. 2007;13:2077–82.

    PubMed  Google Scholar 

  27. Hoda KM, Rodriguez SA, Faigel DO. EUS-guided sampling of suspected GI stromal tumors. Gastrointest Endosc. 2009;69:1218–23.

    Article  PubMed  Google Scholar 

  28. • Sepe PS, Moparty B, Pitman MB, et al.: EUS-guided FNA for the diagnosis of GI stromal cell tumors: sensitivity and cytologic yield. Gastrointest Endosc 2009, 70:254–61. This study evaluated the diagnostic yield and sensitivity of EUS-FNA for patients with histologically confirmed c-kit-positive GISTs. Sensitivity of EUS-FNA for GISTs was 78.4%.

  29. Mekky MA, Yamao K, Sawaki A, et al. Diagnostic utility of EUS-guided FNA in patients with gastric submucosal tumors. Gastrointest Endosc. 2010;71:913–9.

    Article  PubMed  Google Scholar 

  30. Rodriguez SA, Faigel DO. Endoscopic diagnosis of gastrointestinal stromal cell tumors. Curr Opin Gastroenterol. 2007;23:539–43.

    Article  PubMed  Google Scholar 

  31. Philipper M, Hollerbach S, Gabbert HE, et al. Prospective comparison of endoscopic ultrasound-guided fine-needle aspiration and surgical histology in upper gastrointestinal submucosal tumors. Endoscopy. 2010;42:300–5.

    Article  PubMed  CAS  Google Scholar 

  32. Watson RR, Binmoeller KF, Hamerski CM, et al. Yield and performance characteristics of endoscopic ultrasound-guided fine needle aspiration for diagnosing upper GI tract stromal tumors. Dig Dis Sci. 2011;56:1757–62.

    Article  PubMed  Google Scholar 

  33. • Ha CY, Shah R, Chen J, et al.: Diagnosis and management of GI stromal tumors by EUS-FNA: a survey of opinions and practices of endosonographers. Gastrointest Endosc 2009, 69:1039–44. This article demonstrates the substantial practice variations in diagnosing and management of GISTs and underscores the need for a standardized approach to these lesions.

  34. Fletcher CD, Berman JJ, Corless C, et al. Diagnosis of gastrointestinal stromal tumors: a consensus approach. Int J Surg Pathol. 2002;10:81–9.

    Article  PubMed  Google Scholar 

  35. • Fernandez-Esparrach G, Sendino O, Sole M, et al.: Endoscopic ultrasound-guided fine-needle aspiration and trucut biopsy in the diagnosis of gastric stromal tumors: a randomized crossover study. Endoscopy 2010, 42:292–9. This prospective randomized crossover study demonstrated that the diagnostic accuracy for gastric subepithelial tumors was not superior with EUS-trucut biopsy (55%) compared to EUS-FNA (52%). The main limitation of EUS-TCB was the high rate of technical failure; however, when an adequate sample was obtained with TCB, immunohistochemica phenotyping was almost always possible.

  36. Gines A, Wiersema MJ, Clain JE, et al. Prospective study of a Trucut needle for performing EUS-guided biopsy with EUS-guided FNA rescue. Gastrointest Endosc. 2005;62:597–601.

    Article  PubMed  Google Scholar 

  37. Levy MJ, Jondal ML, Clain J, et al. Preliminary experience with an EUS-guided trucut biopsy needle compared with EUS-guided FNA. Gastrointest Endosc. 2003;57:101–6.

    Article  PubMed  Google Scholar 

  38. Varadarajulu S, Fraig M, Schmulewitz N, et al. Comparison of EUS-guided 19-gauge Trucut needle biopsy with EUS-guided fine-needle aspiration. Endoscopy. 2004;36:397–401.

    Article  PubMed  CAS  Google Scholar 

  39. Polkowski M, Gerke W, Jarosz D, et al. Diagnostic yield and safety of endoscopic ultrasound-guided trucut biopsy in patients with gastric submucosal tumors: a prospective study. Endoscopy. 2009;41:329–34.

    Article  PubMed  CAS  Google Scholar 

  40. Levy MJ, Wiersema MJ. EUS-guided Trucut biopsy. Gastrointest Endosc. 2005;62:417–26.

    Article  PubMed  Google Scholar 

  41. Demetri GD, von Mehren M, Blanke CD, et al. Efficacy and safety of imatinib mesylate in advanced gastrointestinal stromal tumors. N Engl J Med. 2002;347:472–80.

    Article  PubMed  CAS  Google Scholar 

  42. Buchdunger E, Cioffi CL, Law N, et al. Abl protein-tyrosine kinase inhibitor STI571 inhibits in vitro signal transduction mediated by c-kit and platelet-derived growth factor receptors. J Pharmacol Exp Ther. 2000;295:139–45.

    PubMed  CAS  Google Scholar 

  43. Casali PG, Jost L, Reichardt P, et al. Gastrointestinal stromal tumors: ESMO clinical recommendations for diagnosis, treatment and follow-up. Ann Oncol. 2008;19 Suppl 2:35–8.

    Google Scholar 

  44. Demetri GD, van Oosterom AT, Garrett CR, et al. Efficacy and safety of sunitinib in patients with advanced gastrointestinal stromal tumour after failure of imatinib: a randomised controlled trial. Lancet. 2006;368:1329–38.

    Article  PubMed  CAS  Google Scholar 

  45. Melzer E, Fidder H. The natural course of upper gastrointestinal submucosal tumors: an endoscopic ultrasound survey. Isr Med Assoc J. 2000;2:430–2.

    PubMed  CAS  Google Scholar 

  46. Lok KH, Lai L, Yiu HL, et al. Endosonographic surveillance of small gastrointestinal tumors originating from muscularis propria. J Gastrointestin Liver Dis. 2009;18:177–80.

    PubMed  Google Scholar 

  47. Huang WH, Feng CL, Lai HC, et al. Endoscopic ligation and resection for the treatment of small EUS-suspected gastric GI stromal tumors. Gastrointest Endosc. 2010;71:1076–81.

    Article  PubMed  Google Scholar 

  48. Lee IL, Lin PY, Tung SY, et al. Endoscopic submucosal dissection for the treatment of intraluminal gastric subepithelial tumors originating from the muscularis propria layer. Endoscopy. 2006;38:1024–8.

    Article  PubMed  Google Scholar 

  49. Park YS, Park SW, Kim TI, et al. Endoscopic enucleation of upper-GI submucosal tumors by using an insulated-tip electrosurgical knife. Gastrointest Endosc. 2004;59:409–15.

    Article  PubMed  Google Scholar 

  50. Zhou PH, Yao LQ, Qin XY, et al.: Endoscopic full-thickness resection without laparoscopic assistance for gastric submucosal tumors originated from the muscularis propria. Surg Endosc 2011 Mar 18. [Epub ahead of print].

  51. Sun S, Ge N, Wang C, et al. Endoscopic band ligation of small gastric stromal tumors and follow-up by endoscopic ultrasonography. Surg Endosc. 2007;21:574–8.

    Article  PubMed  Google Scholar 

  52. Ledo-Rodriguez A, Ulla-Rocha JL, Baltar-Arias R, et al. Endoscopic resection of rectal gastrointestinal stromal tumor (GIST) using band ligation. Rev Esp Enferm Dig. 2009;101:870–1.

    Article  PubMed  CAS  Google Scholar 

  53. Katoh T, Itoh Y, Mohri T, et al. Endoscopic enucleation of gastrointestinal stromal tumors of the stomach: report of five cases. World J Gastroenterol. 2008;14:2609–11.

    Article  PubMed  Google Scholar 

  54. Sasaki A, Koeda K, Obuchi T, et al. Tailored laparoscopic resection for suspected gastric gastrointestinal stromal tumors. Surgery. 2010;147:516–20.

    Article  PubMed  Google Scholar 

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Correspondence to Vinay Chandrasekhara.

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Chandrasekhara, V., Ginsberg, G.G. Endoscopic Management of Gastrointestinal Stromal Tumors. Curr Gastroenterol Rep 13, 532–539 (2011). https://doi.org/10.1007/s11894-011-0224-6

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