Necessity For Surgical Intervention Of Small Gastric Gastrointestinal Stromal Tumors And The Efficacy Of Endoscopic Therapy

Object: The incidence of small-size gastric gastrointestinal stromal tumors is increasing,due to the enhanced health consciousness and popularized endoscopic examination.But there is still controversial in the biological behavior and clinical treatment of GIST.In this paper,we discussed the necessity for surgical intervention of small gastric GIST,and evaluated the efficacy and safety of endoscopic therapy for small gastric GIST patients.Methods: Collect the medical records and follow-up datas of 18 patients with gastric GIST undergoing endoscopic therapy in the Second Hospital of Dalian Medical University from January 1,2013 to December 31,2015,and 27 patients who underwent the laparoscopic resection in the same period.The clinicalpathological features of small gastric GIST were analyzed,and the association between mitotic index and tumor size was used to investigate the biological behaviors of small gastric GIST.The factors that affecting prognosis of GIST were analysed to evaluate the necessity for surgical intervention of small gastric GIST.Compared the operation time,time to defecation,time to diet,postoperative hospital stays,postoperative complications between the patients with small gastric GIST who underwent endoscopic resection and laparoscopic resection.Result: 1.General informations and Clinical manifestations: There were 11 males and34 females,with a median age 62.3±8.73 years.Non-specific symptoms(29cases,64.4%),like upper abdominal distention,were the most common chief complaints.Health screening(12cases,26.7%)was also the common reason leading to diagnosis.Other reasons,including upper gastrointestinal hemorrhage(3cases,6.7%),symptomatic upper abdominal masses(1cases,2.2%).The symptoms of all small GIST patients were mild.2.Prognostic analysis: The follow-up of 41 cases was 40-1015 days,the median follow-up was 241 days.One case(gastric body GIST,6cm)presented recurrence 9 months after operation.And another case(gastric fundus,4.5cm)also presented recurrence 17 months after operation.Both the two cases’ s mitotic index exceeded 5/50 HPFs.No recurrence or metastasis was found in small gastric GIST Patients.The factors that affecting prognosis of gastric GIST were analysed.the result shows the mitotic index is a risk factor for recurrence(P<0.05).3.Analysis of the association between mitotic index and tumor size of small gastric GIST :There were 31 small gastric GIST lesions enrolled in this study.Mitosis was not found in 15 lesions(48.4%).While,those with 1-2 mitoses per 50 high-power field(50HPFs)were 7 lesions(22.6%),and those with 3-5 mitoses per 50 HPFs were 8lesions(25.8%).And 1 lesion(3.2%)possessed more than 5 mitoses per 50 HPFs.Tumors were classified according to the NIH and AFIP criteria,30 tumors belong to very-low risk GIST,1 tumor belongs to uncertain malignant potential GIST.According to the size,dividing the small gastric GIST into four groups,the result reveals the bigger tumor size,the more mitoses.Especially the small gastric GIST with 1.0cm or more,possessed the more mitotic index.4.Comparison of endoscopic and laparoscopic resection for small gastric GIST: Within 18 cases undergoing endoscopic resection,16 cases were successed,the success rate was 88.9%.Except for patient lost to follow-up,there were 15 small GIST patients who only underwent endoscopic resection,with a median tumors size0.8(0.5-1.5)cm,including 11 cases with Endoscopic submucosal excavation and 4 cases with Endoscopic full-thickness resection.While,there were 8 small GIST patients who underwent laparoscopic resection,with a median tumors size 1.4(0.775-1.5)cm.In the endoscopic resection group.,the operation time【84.67±49.30 min VS 161.25±61.98 min,P<0.01】,time to diet【1(1-3)days VS 3.5(3-4)days,P<0.01】,postoperative hospital stay【5(4-6)days VS 7(6-8)days,P<0.01】was shorter.But there was no statistical difference in postoperative complications,time to defecation and prognosis..Conclusions: 1.The mitotic index is the influencing factor for recurrence of gastric GIST.And the bigger tumor size,the more mitoses.For prevention of recurrence or metastasis in such patients,it is necessary for resection while the tumor is less than 2cm.2.The endoscopic therapy for small GIST is efficacy and safety.