Long-Term Outcomes after Endoscopic Treatment of Gastric Gastrointestinal Stromal Tumor

Jong-Jae Park

doi:10.5946/ce.2016.052

Articles

Page Path: HOME > Clin Endosc > Volume 49(3); 2016 > Article

Focused Review Series: Advances in the management of upper GI SET Long-Term Outcomes after Endoscopic Treatment of Gastric Gastrointestinal Stromal Tumor: Jong-Jae Park; Clinical Endoscopy 2016;49(3):232-234.
DOI: https://doi.org/10.5946/ce.2016.052
Published online: May 19, 2016

Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea

Correspondence: Jong-Jae Park, Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul 08308, Korea Tel: +82-2-2626-1027, Fax: +82-2-2626-1038, E-mail: gi7pjj@korea.ac.kr

• Received: March 17, 2016 • Accepted: April 18, 2016

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

8,168 Views
153 Download
20 Web of Science
21 Crossref
21 Scopus

prev next

Full Article

Download PDF

Abstract
INTRODUCTION
CONSIDERATIONS FOR ENDOSCOPIC RESECTION OF GASTRIC SETs
LONG-TERM CLINICAL OUTCOMES OF ENDOSCOPIC TREATMENT OF GASTRIC GIST
CONCLUSIONS
NOTES
REFERENCES

Abstract

Endoscopic resection of gastric subepithelial tumors (SETs) has several advantages over biopsy techniques, such as superior diagnostic yield and definite diagnosis. Removal of gastric SETs and histopathologic confirmation should be considered whenever gastric SETs are highly suspected to have malignant potential such as gastrointestinal stromal tumor (GIST) or neuroendocrine tumor. According to our clinical experience, we suggest that endoscopic resection of gastric SETs is feasible for GISTs less than 3.0 cm without positive endoscopic ultrasonography findings or for hypoechoic SETs less than 3.0 cm. However, serious complications such as macroperforation may occur during endoscopic resection, and this procedure is highly dependent on endoscopists’ skills. We recently reported the long-term clinical outcomes of endoscopic resection of gastric GIST, which showed a relatively low recurrence rate (2.2%) during long-term follow-up (46.0±28.5 months) despite the low R0 resection rate (25.0%). We suggest that endoscopic surveillance might be possible without additional surgical resection in completely resected GISTs without residual tumor confirmed to be lower risk, even if they show an R1 resection margin.
Keywords: Subepithelial tumor; Gastrointestinal stromal tumors; Endoscopy

INTRODUCTION

Subepithelial tumors (SETs) in the stomach are usually found incidentally during endoscopic examinations [1]. Most gastric SETs do not cause symptoms and were formerly considered to have a benign nature, such as lipomas, inflammatory fibroid polyps, or several neural origin tumors (i.e., schwannomas) [2]. However, several gastric SETs have malignant potential, especially when they originate from the muscularis propria (MP) layer, such as gastrointestinal stromal tumors (GISTs), neuroendocrine tumors (NETs), glomus tumors, and even metastastic tumors [3]. Thus, removal of gastric SETs and histopathologic confirmation are required when GIST or NET is highly suspected.

In this review, we summarize the critical points when planning endoscopic resection of gastric SETs as well as the long-term clinical outcomes of endoscopic resection of gastric GIST.

CONSIDERATIONS FOR ENDOSCOPIC RESECTION OF GASTRIC SETs

Endoscopic resection of gastric SETs has several advantages over biopsy techniques. First, diagnostic yield can be improved by obtaining whole SET tissue; thus, endoscopists can avoid frequent re-examination. Second, physicians are able to confidently provide a therapeutic plan to patients according to definite diagnosis; thus, reassuring patients and reducing their anxiety. Third, insurance-related conflicts can be avoided. Unfortunately, neither strict guidelines nor widespread acceptance for endoscopic resection as the treatment for gastric SETs have yet been established. We cautiously suggest indications for endoscopic resection based on our clinical experiences as follows: GISTs less than 3.0 cm without positive endoscopic ultrasonography (EUS) findings (i.e., irregular borders, cystic space, ulceration, echogenic foci, and heterogeneity) or hypoechoic SETs less than 3.0 cm. However, there are several limitations in applying these indications. First, the tumor should be smaller than 3.0 to 4.0 cm, even though the exact cut-off limit remains controversial. If the tumor is larger than this limit, endoscopic resection might be technically unavailable or cause serious complications including macroperforation. Second, the endoscopic procedure is operator-dependent, because the techniques mentioned above require highly advanced skills and sufficient clinical experience. Third, only limited studies including small numbers of patients and short-term follow-up periods have been published and are thus subject to selection biases. Table 1 summarizes procedure-related outcomes of endoscopic resection of SETs in the upper gastrointestinal tract (UGIT).

Another important issue concerning endoscopic resection is post-procedural use of imatinib. Recent guidelines from the National Comprehensive Cancer Network state that if GISTs are completely resected (including R1 resection), adjuvant therapy with imatinib can be considered, especially for patients with a significant high risk of recurrence (intermediate or high risk by recent World Health Organization classifications) [4]. However, imatinib therapy followed by endoscopic resection is neither approved nor covered by the national health insurance system in Korea, and guidelines from the Korean GIST Study Group suggest that complete en bloc resection with negative margins should be performed regardless of tumor size; therefore, even if the tumor is small, endoscopic shell-out procedure or enucleation should be avoided if GIST is suspected [5]. Further discussion and opinions should be based on clinical outcomes and long-term follow-up data of endoscopic procedures.

LONG-TERM CLINICAL OUTCOMES OF ENDOSCOPIC TREATMENT OF GASTRIC GIST

As technical skills have advanced and novel endoscopic procedures have been developed, complete en bloc endoscopic resection of gastric SETs has been reported [6-17]. However, they included only a small number of gastric GISTs, and their long-term follow-up results have not yet been reported. Recent studies have reported no recurrence of gastric GISTs resected by endoscopic procedure; however, their follow-up periods were relatively short, ranging from 1 to 2 years [16,17]. Here, we show our clinical outcomes of endoscopic resection for gastric GISTs [18]. A total of 249 patients with SET in the UGIT underwent endoscopic resection in our hospital; among them, 89 cases were confirmed as gastric GIST by histopathologic examination. The most common site of the gastric GISTs was the gastric body (43.3%), followed by the cardia (22.2%) and fundus (21.1%). The mean tumor size was 2.3±1.2 cm, and most were considered to have originated from the MP layer (64.4%) based on pre-procedural EUS findings. Most of the tumors were resected by endoscopic submucosal dissection (80.0%), followed by submucosal tunneling endoscopic resection (8.9%), and two cases (2.2%) by endoscopic full-thickness resection. The complication rate was 14.4%, including micro- and macroperforation (5.6%/4.4%, respectively) and major bleeding (2.2%). The recurrence rate was relatively low (2.2%) during the long-term follow-up period (46.0±28.5 months) despite the low R0 resection rate (25.0%) and did not differ significantly from that of surgically resected gastric GIST (5.0%). This comparable recurrence rate may be explained by the fact that most of the gastric GISTs in the endoscopic resection group had smaller sizes and low mitotic index counts (<5/high power field, 84.4%), which consequently corresponded to very low (50.0%) and low (31.1%) risk. Indeed, if a GIST is completely resected without residual tumor in an endoscopic view and is classified as lower risk by histopathological evaluation, the endoscopic procedure may be an alternative choice for optimal treatment of GIST in the UGIT, even with R1 resection margins. Further evaluation with large-scale prospective studies is needed to clarify this issue.

CONCLUSIONS

Endoscopic resection of gastric GIST is increasingly used for tissue diagnosis and treatment, and is expected to be a substitute for surgical resection in selected cases. Endoscopic resection is a feasible and effective alternative therapeutic modality for lower risk gastric GIST with acceptable long-term follow-up results.

Conflicts of Interest: The author has no financial conflicts of interest.

Table 1.

Results of Endoscopic Treatment of Subepithelial Tumor in the Upper Gastrointestinal Tract

Study	Method	No. of case, total (E/S/D)	Layer of origin, mm/sm/mp	Dx., GIST/other	Complete resection, n (%)	Perforation, n (%)
Li et al. (2013) [6]	ESD	11 (0/11/0)	0/0/11	8/3	10/11 (91)	3/11 (27)
Chun et al. (2013) [7]	ESD	35 (0/35/0)	0/0/35	10/25	26/35 (74)	2/35 (5.7)
Lee et al. (2006) [8]	ESD/EMD	12 (0/12/0)	0/0/12	8/4	9/12 (75)	0/12 (0)
Park et al. (2004) [9]	EE-I	15 (5/10/0)	1-2-11	4/11	14/15 (93)	1/15 (7)
Goessl et al. (2007) [10]	EE-I	3 (0/3/0)	0/0/3	3/0	3/3 (100)	0/3 (0)
Sun et al. (2004) [11]	Band ligation	64 (50/12/2)	0/0/64	0/64	61/64 (95)	0/64 (0)
Hoteya et al. (2009) [12]	ESD	9 (0/9/0)	mm or sm only	1/8	9/9 (100)	0/9 (0)
Białek et al. (2012) [13]	ESD	37 (0/37/0)	0/15/22	17/20	30/37 (81)	2/37 (5.4)
Catalano et al. (2013) [14]	ESD	20 (0/20/0)	0/17/3	10/10	18/20 (90)	3/20 (15.0)
He et al. (2013) [16]	ESD	144 (0/144/0)	0/0/144	89/55	134/144 (92)	21/144 (14)
Zhang et al. (2013) [17]	ESD	18 (0/18/0)	0/0/18	13/5	17/18 (94)	2/18 (11)

E/S/D, esophagus/stomach/duodenum; mm/sm/mp, muscularis mucosa/submucosa/muscularis propria; Dx., diagnosis; GIST, gastrointestinal stromal tumor; ESD, endoscopic submucosal dissection; EMD, endoscopic muscular dissection; EE-I, en bloc enucleation with ITknife.

REFERENCES

1. Hedenbro JL, Ekelund M, Wetterberg P. Endoscopic diagnosis of submucosal gastric lesions. The results after routine endoscopy. Surg Endosc 1991;5:20–23.Article PubMed
2. Jeong ID, Jung SW, Bang SJ, Shin JW, Park NH, Kim do H. Endoscopic enucleation for gastric subepithelial tumors originating in the muscularis propria layer. Surg Endosc 2011;25:468–474.Article PubMed
3. 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;130:2217–2228.Article PubMed
4. von Mehren M, Randall RL, Benjamin RS, et al. Gastrointestinal stromal tumors, version 2.2014. J Natl Compr Canc Netw 2014;12:853–862.Article PubMed
5. Kang YK, Kim KM, Sohn T, et al. Clinical practice guideline for accurate diagnosis and effective treatment of gastrointestinal stromal tumor in Korea. J Korean Med Sci 2010;25:1543–1552.Article PubMed PMC
6. Li L, Wang F, Wu B, Wang Q, Wang C, Liu J. Endoscopic submucosal dissection of gastric fundus subepithelial tumors originating from the muscularis propria. Exp Ther Med 2013;6:391–395.Article PubMed PMC
7. Chun SY, Kim KO, Park DS, et al. Endoscopic submucosal dissection as a treatment for gastric subepithelial tumors that originate from the muscularis propria layer: a preliminary analysis of appropriate indications. Surg Endosc 2013;27:3271–3279.Article PubMed PMC
8. Lee IL, Lin PY, Tung SY, Shen CH, Wei KL, Wu CS. Endoscopic submucosal dissection for the treatment of intraluminal gastric subepithelial tumors originating from the muscularis propria layer. Endoscopy 2006;38:1024–1028.Article PubMed
9. 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;59:409–415.Article PubMed
10. Goessl C, Hempfling W, Hoppe B, Stolte M, Frank N. Endoscopic enucleation of small gastrointestinal stromal tumors from the stomach. Endoscopy 2007;39 Suppl 1:E308.Article PDF
11. Sun S, Jin Y, Chang G, Wang C, Li X, Wang Z. Endoscopic band ligation without electrosurgery: a new technique for excision of small upper-GI leiomyoma. Gastrointest Endosc 2004;60:218–222.Article PubMed
12. Hoteya S, Iizuka T, Kikuchi D, Yahagi N. Endoscopic submucosal dissection for gastric submucosal tumor, endoscopic sub-tumoral dissection. Dig Endosc 2009;21:266–269.Article PubMed
13. Białek A, Wiechowska-Kozłowska A, Pertkiewicz J, et al. Endoscopic submucosal dissection for treatment of gastric subepithelial tumors (with video). Gastrointest Endosc 2012;75:276–286.Article PubMed
14. Catalano F, Rodella L, Lombardo F, et al. Endoscopic submucosal dissection in the treatment of gastric submucosal tumors: results from a retrospective cohort study. Gastric Cancer 2013;16:563–570.Article PubMed
15. Kobara H, Mori H, Rafiq K, et al. Indications of endoscopic submucosal dissection for symptomatic benign gastrointestinal subepithelial or carcinoid tumors originating in the submucosa. Mol Clin Oncol 2013;1:1002–1008.Article PubMed PMC
16. He Z, Sun C, Wang J, et al. Efficacy and safety of endoscopic submucosal dissection in treating gastric subepithelial tumors originating in the muscularis propria layer: a single-center study of 144 cases. Scand J Gastroenterol 2013;48:1466–1473.Article PubMed
17. Zhang S, Chao GQ, Li M, Ni GB, Lv B. Endoscopic submucosal dissection for treatment of gastric submucosal tumors originating from the muscularis propria layer. Dig Dis Sci 2013;58:1710–1716.Article PubMed
18. Joo MK, Park JJ, Kim H, et al. Endoscopic versus surgical resection of GI stromal tumors in the upper GI tract. Gastrointest Endosc 2016;83:318–326.Article PubMed

Figure & Data

REFERENCES

Citations

Citations to this article as recorded by

Efficacy and Safety of Endoscopic Resection for Gastric Gastrointestinal Stromal Tumors Originating from the Muscularis Propria
Ji Li, Dong Xu, Wei-Feng Huang, Shao-Kun Hong, Jin-Yan Zhang
Digestive Diseases and Sciences.2024; 69(6): 2184. CrossRef
Clinical outcomes of endoscopic resection for the treatment of intermediate- or high-risk gastric small gastrointestinal stromal tumors: a multicenter retrospective study
Enpan Xu, Qiang Shi, Zhipeng Qi, Bing Li, Huihui Sun, Zhong Ren, Shilun Cai, Dongli He, Zhengtao Lv, Zhanghan Chen, Liang Zhong, Leiming Xu, Xiaobo Li, Shuchang Xu, Pinghong Zhou, Yunshi Zhong
Surgical Endoscopy.2024; 38(6): 3353. CrossRef
Endoscopic resection of extra-luminal gastric gastrointestinal stromal tumors using a snare assisted external traction technique (with video)
Jing-wen Zhang, Chang-qing Guo, Shan-shan Zhu, Nan Dai, Ping Liu, Fang-bin Zhang, Hai-ning Zhou, Jian-feng Wang, Si-su Zhou, Xin-Guang Cao
Digestive and Liver Disease.2024; 56(11): 1914. CrossRef
Endoscopic resection penetrating the muscularis propria for gastric gastrointestinal stromal tumors: advances and challenges
Jin Woong Cho
Clinical Endoscopy.2024; 57(3): 329. CrossRef
Follow-up analysis and research of very low-risk and low-risk gastrointestinal stromal tumors after endoscopic resection
Jiaxin Gao, Zide Liu, Xingxing Liu, Xu Shu, Yin Zhu, Youxiang Chen, Chunyan Zeng
Scientific Reports.2024;[Epub] CrossRef
Gastric Inverted Hyperplastic Polyp Removed Using Endoscopic Submucosal Dissection
Jee Won Boo, Joon Sung Kim, Byung-Wook Kim
The Korean Journal of Helicobacter and Upper Gastrointestinal Research.2023; 23(1): 63. CrossRef
Clinical Efficacy and Safety of Endoscopic Treatment of Gastrointestinal Stromal Tumors in the Stomach
Moon Kyung Joo, Jong-Jae Park, Yeon Ho Lee, Beom Jae Lee, Seong Min Kim, Won Shik Kim, Ah Young Yoo, Hoon Jai Chun, Sang Woo Lee
Gut and Liver.2023; 17(2): 217. CrossRef
Predictors of the difficulty for endoscopic resection of gastric gastrointestinal stromal tumor and follow‐up data
Wei Su, Min Wang, Danfeng Zhang, Yan Zhu, Minzhi Lv, Liang Zhu, Jie He, Hao Hu, Pinghong Zhou
Journal of Gastroenterology and Hepatology.2022; 37(1): 48. CrossRef
Comparison of endoscopic full-thickness resection and cap-assisted endoscopic full-thickness resection in the treatment of small (≤1.5 cm) gastric GI stromal tumors
Jinping Yang, Muhan Ni, Jingwei Jiang, Ximei Ren, Tingting Zhu, Shouli Cao, Shahzeb Hassan, Ying Lv, Xiaoqi Zhang, Yongyue Wei, Lei Wang, Guifang Xu
Gastrointestinal Endoscopy.2022; 95(4): 660. CrossRef
Endoscopic subserosal dissection for gastric tumors: 18 cases in a single center
Jihyun Han, Jinwoong Cho, Jaesun Song, Mina Yang, Youngjae Lee, Myoungjin Ju
Surgical Endoscopy.2022; 36(11): 8039. CrossRef
Endoscopic Management of Gastric Subepithelial Tumor
Hyunchul Lim
Journal of Digestive Cancer Research.2022; 10(1): 16. CrossRef
Predictors of difficult endoscopic resection of submucosal tumors originating from the muscularis propria layer at the esophagogastric junction
Yu-Ping Wang, Hong Xu, Jia-Xin Shen, Wen-Ming Liu, Yuan Chu, Ben-Song Duan, Jing-Jing Lian, Hai-Bin Zhang, Li Zhang, Mei-Dong Xu, Jia Cao
World Journal of Gastrointestinal Surgery.2022; 14(9): 918. CrossRef
Usefulness of tumor traction with a snare and endoclips in gastric submucosal tumor resection: a propensity-score-matching analysis
Qiang Zhang, Jian-Qun Cai, Zhen Wang
Gastroenterology Report.2021; 9(2): 125. CrossRef
Endoscopic Resection of Gastrointestinal Stromal Tumor: Is It Safe?
Moon Kyung Joo
The Korean Journal of Helicobacter and Upper Gastrointestinal Research.2021; 21(3): 180. CrossRef
Microscopic positive tumor margin does not increase the rate of recurrence in endoscopic resected gastric mesenchymal tumors compared to negative tumor margin
Yan Zhu, Mei-Dong Xu, Chen Xu, Xiao-Cen Zhang, Shi-Yao Chen, Yun-Shi Zhong, Yi-Qun Zhang, Wei-Feng Chen, Tian-Yin Chen, Jia-Xin Xu, Li-Qing Yao, Quan-Lin Li, Ping-Hong Zhou
Surgical Endoscopy.2020; 34(1): 159. CrossRef
Mucosectomy device‐assisted endoscopic resection of gastric subepithelial lesions
Lian Yong Li, Bai Wen Li, Parit Mekaroonkamol, Hui Min Chen, Shan Shan Shen, Hui Luo, Sunil Dacha, Yue Xue, Sarah Cristofaro, Steven Keilin, Field Willingham, Qiang Cai
Journal of Digestive Diseases.2020; 21(4): 215. CrossRef
Submucosal Tunnel Endoscopic Resection for Esophageal Submucosal Tumors: A Multicenter Study
Sufang Tu, Silin Huang, Guohua Li, Xiaowei Tang, Haitao Qing, Qiaoping Gao, Jingwen Fu, Guoping Du, Wei Gong
Gastroenterology Research and Practice.2018; 2018: 1. CrossRef
Comparison between submucosal tunneling endoscopic resection and endoscopic full-thickness resection for gastric stromal tumors originating from the muscularis propria layer
Yuyong Tan, Xiaoyu Tang, Ting Guo, Dongzi Peng, Yao Tang, Tianying Duan, Xuehong Wang, Liang Lv, Jirong Huo, Deliang Liu
Surgical Endoscopy.2017; 31(8): 3376. CrossRef
Subepithelial rectal gastrointestinal stromal tumor – the use of endoscopic ultrasound-guided fine needle aspiration to establish a definitive cytological diagnosis: a case report
Vitor Ottoboni Brunaldi, Martin Coronel, Danielle Azevedo Chacon, Eduardo Turiani Hourneaux De Moura, Sérgio E. Matuguma, Eduardo Guimarães Hourneaux De Moura, Diogo Turiani Hourneaux De Moura
Journal of Medical Case Reports.2017;[Epub] CrossRef
Management of Gastrointestinal Stromal Tumors
Emily Z. Keung, Chandrajit P. Raut
Surgical Clinics of North America.2017; 97(2): 437. CrossRef
Gastroduodenal Intussusception with a Gastric Gastrointestinal Stromal Tumor Treated by Endoscopic Submucosal Dissection
Kenji Yamauchi, Masaya Iwamuro, Eiji Ishii, Makoto Narita, Nobuto Hirata, Hiroyuki Okada
Internal Medicine.2017; 56(12): 1515. CrossRef

PubReader
ePub Link

Cite

CITE: export Copy Download Format; Close

Download Citation

Download a citation file in RIS format that can be imported by all major citation management software, including EndNote, ProCite, RefWorks, and Reference Manager.

Format:

RIS — For EndNote, ProCite, RefWorks, and most other reference management software
BibTeX — For JabRef, BibDesk, and other BibTeX-specific software

Include:

Citation for the content below
Citation and abstract for the content below

Long-Term Outcomes after Endoscopic Treatment of Gastric Gastrointestinal Stromal Tumor

Clin Endosc. 2016;49(3):232-234. Published online May 19, 2016

DOI: https://doi.org/10.5946/ce.2016.052

XML Download

Related articles

Long-Term Outcomes after Endoscopic Treatment of Gastric Gastrointestinal Stromal Tumor

Study	Method	No. of case, total (E/S/D)	Layer of origin, mm/sm/mp	Dx., GIST/other	Complete resection, n (%)	Perforation, n (%)
Li et al. (2013) [6]	ESD	11 (0/11/0)	0/0/11	8/3	10/11 (91)	3/11 (27)
Chun et al. (2013) [7]	ESD	35 (0/35/0)	0/0/35	10/25	26/35 (74)	2/35 (5.7)
Lee et al. (2006) [8]	ESD/EMD	12 (0/12/0)	0/0/12	8/4	9/12 (75)	0/12 (0)
Park et al. (2004) [9]	EE-I	15 (5/10/0)	1-2-11	4/11	14/15 (93)	1/15 (7)
Goessl et al. (2007) [10]	EE-I	3 (0/3/0)	0/0/3	3/0	3/3 (100)	0/3 (0)
Sun et al. (2004) [11]	Band ligation	64 (50/12/2)	0/0/64	0/64	61/64 (95)	0/64 (0)
Hoteya et al. (2009) [12]	ESD	9 (0/9/0)	mm or sm only	1/8	9/9 (100)	0/9 (0)
Białek et al. (2012) [13]	ESD	37 (0/37/0)	0/15/22	17/20	30/37 (81)	2/37 (5.4)
Catalano et al. (2013) [14]	ESD	20 (0/20/0)	0/17/3	10/10	18/20 (90)	3/20 (15.0)
He et al. (2013) [16]	ESD	144 (0/144/0)	0/0/144	89/55	134/144 (92)	21/144 (14)
Zhang et al. (2013) [17]	ESD	18 (0/18/0)	0/0/18	13/5	17/18 (94)	2/18 (11)

Table 1. Results of Endoscopic Treatment of Subepithelial Tumor in the Upper Gastrointestinal Tract