| ObjectiveGastrointestinal stromal tumors(GISTs)are the most common mesenchymal neoplasms of the gastrointestinal tract.GISTs are common in the stomach(60%)and are called gastric stromal tumors(GSTs)when they occur in the stomach.Those smaller than2 cm are called small GSTs.Most primary GSTs potentially become malignancies.The standard treatment for GSTs is surgical removal of the neoplasm.Recent advances in endoscopy have facilitated innovative surgical treatment of GSTs.This article aims to analyze the clinicopathological characteristics of gastric GSTs,assess the feasibility,clinical efficacy and safety of the endoscopic removal of gastric GSTs.MethodsEndoscopic removal of GSTs was performed in 120 patients at the Affiliated Hospital of Qingdao University from January 2014 to December 2018.The clinical features,EUS characteristics,surgical outcomes,complications,pathological diagnosis,and risk classification were evaluated retrospectively.Single-factor ANOVA was used to analyze the correlation between EUS characteristics of GSTs and risk classification.T-test and Chi-square analysis are used for the comparison of the incidence of complications,the postoperative hospital stay et al in different surgical methods and different sizes.Results(1)Among the 120 patients with gastric GSTs undergone endoscopic removal,The ratio of males to females was about 1:1.3.The average age was(60.07 ± 9.69)years old.The average tumor size was(1.59 ± 0.98)cm(range:0.3-6.0cm),and 94 of them were small tumors(78.3%,range:0.3-2cm)while 26 of them were non-small tumors(21.7%,range: 2.1-6.0cm).Of the 120 GSTs,GSTs were located at the gastric fundus in 64 cases,at the corpus in 45,at the antrum in 8,and at the cardia in 3.GSTs were asymptomatic in22 patients,and abdominal pain(38.3%)and abdominal distension(20.0%)were the most common symptoms.Only one patient manifested hematemesis.According to the NIH risk classification,92 cases(76.7%)were of a very low risk,19 cases(15.8%)of a low risk,8 cases(6.7%)of a moderate risk and a high risk.Among them,there 2 small GSTs with moderate and high risk.(2)According to the EUS,all GSTs were originated from the muscularis propria layer.Mostly manifested as regular clear boundary with homogeneous or uneven hypoechoic and the proportion of uneven hypoechoic and calcification in small GSTswas lower than the whole.By performing a single factor analysis of different kinds of echo manifestations with different risk classification,it can be concluded that echo heterogeneity(P=0.015)and calcification(P=0.021)are related to risk classification while the tumor boundary(P=0.200)and cystic degeneration(P=0.839)are not related to risk classification.(3)119 cases have achieved complete resection among the 120 tumors,including by ESD in 39 cases,by ESE in 32 cases,by EFTR in 45 cases,and by STER in 3 cases.26 cases were non-small GSTs(2.1-6.0cm)while 94 were small GSTs(0.3-2cm).One case was converted to laparoscopy surgery due to the tight and wide adherence of the lesion with adjacent muscle fibers and difficulty in manipulating the endoscope.Perforation in 54 cases(45.0%),including intentional perforation(or full-thickness resection)in 45 cases(37.5%)and accidental perforation in 9 cases(7.5%).All the perforations were sealed under the endoscope.There was minor bleeding in almost every case with the average blood loss of less than 20 ml,which was well managed by endoscopic hemostasis.There was no postoperative perforation or tumor rupture during the surgery.Pneumoperitoneum occurred in one case after the procedure,and this case recovered after conservative treatment.3 patients had fever after the operation,and their temperature returned to normal after antibiotic treatment.The average length of hospital stay is(5.78 ± 1.75)days.(4)The outcomes after the operations were compared among the four treatment methods.The perforation rate and average length of hospital stay were statistically significant with both P values under 0.001.The perforation rate is higher in ESE(18.7%)and EFTR(100%)than in ESD(2.5%)and STER(0).(5)According to the tumor size,GSTs were divided into small GSTs and non-small GSTs groups.Small GSTs are mostly distributed in the gastric fundus(58.5%),while non-small GSTs are mostly distributed in the gastric corpus(53.8%).There are no significant differences between the two groups in age,gender,perforation rate,and length of hospital stay.The P values were 0.592,0.499,0.108,0.354,0.615 respectively.(6)119 cases(99.2%)were spindle cell type,while one was epithelioid cell type.The mitotic index in 8 cases was over 5/50 HPF,2 of them were small GSTs.Small GSTSs had lower mitotic index than non-small GSTs.Ki67 in 8 cases was over 5%,and5 cases among them were small GSTs.The results of immunohistochemistry indicated that CD117 was positive in 119 patients(99.2%),CD34 was positive in 119 patients(99.2%)and DOG1 was positive in 115 patients(95.8%).SMA was positive in 9 cases while S-100 and SOX10 were negative in all cases.(7)There was no recurrence and metastasis case during the mean follow-up of(28±8)months(range:6-48 months).Conclusion1.GSTs most commonly located in the gastric fundus and corpus.The ratio of males to females was about 1:1.3.Small GSTs are more likely to distributed in the gastric fundus,while non-small GSTs are mostly distributed in the gastric corpus.2.In the EUS,GSTs with heterogeneous echo,calcification are relevant to risk classification.3.Small GSTSs usually have lower mitotic index and with less risk classification than non-small GSTs.4.The endoscopic treatment is feasible,effective,and safe for small GSTs and with low recurrence rate.Tumor size is not an absolute contraindication to endoscopic resection.Perforation is the most common complication.ESE and EFTR have a higher perforation rate than ESD and STER. |
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