Efficacy of different laparoscopic surgeries for gastrointestinal stromal tumors of gastric cardia and fundus: a multicenter study / 中华消化外科杂志

Objective:To investigate the efficacy of different laparoscopic surgeries for gastrointestinal stromal tumors (GIST) of gastric cardia and fundus.Methods:The retrospective cohort study was conducted. The clinicopathological data of 251 patients with GIST of gastric cardia and fundus who underwent laparoscopic radical resection in 14 medical centers, including Guangdong Provincial People′s Hospital et al, from December 2007 to December 2021 were collected. There were 123 males and 128 females, aged 58(24,87)years. Observation indicators: (1) treatment; (2) clinicopathological data of patients undergoing different laparoscopic surgeries; (3) subgroup analysis for special laparoscopic techniques. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the t test or ANOVA. Measure-ment data with skewed distribution were represented as M( Q1, Q3), and comparison between groups was conducted using the Mann-Whitney U test or Kruskal-Wallis H test. Count data were described as absolute numbers or percentages. Comparison of ordinal data was conducted using the rank sum test. Results:(1) Treatment. Of the 251 patients,202 cases underwent gastric wedge resection, 26 cases underwent special laparoscopic techniques including 10 cases with serotomy and dissection and 16 cases with transluminal gastrectomy, 23 cases underwent structural gastrectomy including 6 cases with total gastrectomy and 17 cases with proximal partial gastrectomy. There were 24 patients had postoperative complications after surgery. (2) Clinicopathological data of patients undergoing different laparoscopic surgeries. The gender (male, female), age, tumor diameter, operation time, volume of intraoperative blood loss, length of incision, time to postoperative initial whole liquid food intake, time to postoperative initial semi-liquid food intake, duration of postoperative hospital stay, cases with perioperative complications, cases with mitotic count as ≤5/50 high power field, 6?10/50 high power field, >10/50 high power field, cases be classified as very low risk, low risk, medium risk, high risk according to the National Institutes of Health risk classification, cases with tumor located at fundus and gastric cardia were 93, 109, (59±11)years, 3.50(0.40,10.00)cm, 88.00(25.00,290.00)minutes,20.00(25.00,290.00)mL, 4.00(2.00,12.00)cm, 3.00(1.00,9.00)days, 4.00(1.00,16.00)days, 5.00(1.00,18.00)days, 14, 164, 31, 7, 47, 83, 50, 22, 30, 172 in patients undergoing gastric wedge resection, respectively. The above indicators were 19, 7, (49±14)years, 2.55(0.20,5.00)cm, 101.00(59.00,330.00)minutes, 27.50(2.00,300.00)mL, 4.50(0,6.00)cm, 2.50(1.00,10.00)days, 4.00(1.00,16.00)days, 6.00(1.00,18.00)days, 3, 20, 5, 1, 15, 5, 2, 4, 24, 2 in patients undergoing special laparos-copic techniques, and 11, 12, (52±10)years, 5.00(0.80,10.00)cm, 187.00(80.00,325.00)minutes, 50.00(10.00,300.00)mL, 6.00(4.00,12.00)cm, 4.00(2.00,8.00)days, 6.00(3.00,14.00)days, 8.00(2.00,18.00)days, 7, 11, 5, 7, 2, 6, 6, 9, 13, 10 in patients undergoing structural gastrectomy. There were significant differences in the above indicators among the three groups of patients ( χ2=6.75, F=10.19, H=17.71, 37.50, 35.54, 24.68, 16.09,20.20, 13.76, χ2=13.32, Z=28.98, 32.17, χ2=82.14, P<0.05). (3) Subgroup analysis for special laparoscopic techniques. The time to postoperative initial whole liquid food intake, time to postoperative initial semi-liquid food intake, classification of tumor location (endophytic type, exophytic type, parietal type) were 4.50(1.00,10.00)days, 8.00(3.00,12.00)days, 0, 8, 2 in patients undergoing serotomy and dissection, versus 2.00(1.00,4.00)days, 3.00(1.00,6.00)days, 16, 0, 0 in patients undergoing transluminal gastrectomy. There were significant differences in time to postoperative initial whole liquid food intake, time to postoperative initial semi-liquid food intake between them ( Z=-2.65, -3.16, P<0.05); and there was a significant difference in classification of tumor location between them ( P<0.05). Conclusions:Gastric wedge resection is the most commonly used laparoscopic technique for GIST of gastric cardia and fundus. The application of special laparoscopic techniques is focused on the GIST of cardia to preserve the function of the cardia.

Application of laparoscopic surgery for gastric stromal tumor in unfavorable sites / 国际外科学杂志

Gastrointestinal stromal tumor (GIST) is a kind of mesenchymal tumor, most commonly found in the stomach, with unique immunophenotype and molecular genetic characteristics. Gastric GIST mostly originates from the musculi propria of the stomach wall. It often grows expansively with clear boundaries and is relatively easy to separate. Surgery is still the preferred treatment for gastric GIST. With the rapid development of laparoscopic technique, laparoscopic surgical treatment for gastric GIST has been gradually recognized. However, it still remains unclear whether laparoscopic surgery can be applied in gastric gastrointestinal stromal tumors located in unfavorable sites. Here, this paper will combine author center′s exploration and clinical application on laparoscopic surgery for gastric GIST located in unfavorable sites and make a brief summary in order to choose a better way for treatment of gastric GIST located in unfavorable sites.

Condroma pulmonar y paraganglioma carotídeo como manifestaciones de la tríada de Carney: reporte de un caso / Pulmonary chondroma and carotid paraganglioma as expressions of Carney's triad: report of a case

Resumen Objetivos: Presentar caso clínico y revisión de la literatura sobre asociación de tumores poco frecuentes compatibles con diagnóstico de tríada de Carney. Paciente y Métodos: Revisión de ficha clínica de paciente de sexo femenino de 39 años de edad con antecedentes de asma, quien acude a servicio de urgencias por síntomas respiratorios. En estudio con imágenes se evidencia masa pulmonar en lóbulo superior derecho probablemente hamartoma y masa en la bifurcación carotídea izquierda compatible con posible paraganglioma. Se completó el estudio con endoscopia digestiva alta sin evidencia de tumor gástrico y PET-CT (tomografía de emisión de positrones-tomografía computarizada) que descartó otras lesiones. Resultados: La paciente fue sometida a resección quirúrgica de ambos tumores (pulmonar y carotídeo). En estudio histopatológico diferido, se plantean los diagnósticos de paraganglioma carotideo y hamartoma pulmonar, el cual, luego de una segunda revisión histopatológica, es corregido a condroma pulmonar. Discusión: La tríada de Carney se compone por la asociación de al menos 2 de 3 tumores: tumor estromal gastrointestinal (GIST), paraganglioma extra-adrenal y condroma pulmonar. Su expresión es variable, coexistiendo en forma completa en solo el 22% de los casos. Conclusión: Los pacientes con sospecha de tríada de Carney deben recibir evaluación multidisciplinaria, estudio completo en búsqueda de tumores asociados y seguimiento a largo plazo por posibles recurrencias o metástasis.

Objective: To present a clinical case and review of the literature on the infrequent association of pulmonary and extra thoracic tumors compatible with Carney's triad. Patient and Methods: Review of clinical records of a 39 years-old female patient with history of asthma who presented in the emergency department with respiratory symptoms. An imaging study showed a pulmonary mass in the right upper lobe with the aspect of hamartoma and a mass in the left carotid artery bifurcation compatible with a possible paraganglioma. Upper gastrointestinal endoscopy showed no evidence of gastric tumor and a PET-CT (Positron Emission Tomography - Computed Tomography) excluded other lesions. Results: Patient underwent surgical resection of both tumors (pulmonary and carotid). Diagnosis of carotid paraganglioma and pulmonary hamartoma were stated by histopathology. However, lung tumor after a second pathological analysis was confirmed to be a pulmonary chondroma. Discussion: Carney's triad is defined by the association of at least 2 of 3 tumors: Gastrointestinal Stromal Tumor (GIST), extraadrenal paraganglioma and pulmonary chondroma. Its expression is variable, coexisting completely in only 22% of cases. Conclusion: Patients with suspected Carney's triad should receive a multidisciplinary assessment, a complete study searching associated tumors and long-term follow-up for recurrences or metastases.

Jejunal GIST — An Obscure Cause of Melaena

Gastrointestinal Stromal Tumours (GISTs) are one of the rare causes of Alimentary Tract Neoplasm. They arise from the Interstitial Cells of Cajal (ICC) with overexpression of proto-oncogenes like KIT, PDGFRA and BRAF-Kinase, etc1. The typical location of these tumors is the stomach with Jejunal GIST being the rarest variant. The maximal incidence of the disease is reported in the sixth decade of life. GISTs are often asymptomatic and clinicians are misdirected towards a different diagnosis because of its variable nature of presentation. The clinical feature typically ranges from non-specific abdominal symptoms like nausea, vomiting, bloating, etc, to abdominal emergencies like hemorrhage, anemia, or obstruction. Although mostly benign, there is a high probability of progression to malignancy2. Thus, in patients with no appreciable cause of gastrointestinal bleed or chronic abdominal discomfort, GIST should have high suspicion index. This can help to limit the progression and thereby prevent further complications. Due to its location, it is difficult to identify by Endoscopy or Colonoscopy. Single Balloon Enteroscopy (SBE) and CT Scan of Abdomen are the primary investigational modalities. The treatment aims at resection of the mass with continued Postsurgical surveillance and targeted molecular therapy in some cases. Herein, we report a 14-year-old boy with chronic paleness and gradual onset repeat episodes of Melaena. Despite repeated blood transfusions, the patient had a Hemoglobin

Comparative analysis of endoscopic resection and laparoscopic surgery in the treatment of gastric gastrointestinal stromal tumor with a maximum diameter of 2 to 5 cm / 中华消化杂志

Objective:To compare the clinical efficacy of endoscopic resection and laparoscopic surgery in the treatment of gastric gastrointestinal stromal tumor (GIST) with a maximum diameter of 2 to 5 cm, and to analyze the influence of factors such as tumor surface, growth pattern and lesion origin on the choice of resection method, so as to provide a safer and more effective treatment for patients with gastric GIST.Methods:From January 2012 to November 2019, at the First Affiliated Hospital of Zhengzhou University, the clinical data of 301 patients with gastric GIST who underwent endoscopic resection (137 cases in the endoscopic resection group) or laparoscopic surgery (164 cases in the laparoscopic surgery group) were retrospectively analyzed, including age, gender, whether there was depression on the tumor surface (the local subsidence depth of the mucosa on the tumor surface was >5 mm), whether the tumor surface was irregular (non-hemispherical or non-elliptical tumor surface), whether there was combined ulcer, location, shape, origin of the lesion, growth pattern (intralumina growth or combined intraluminal and extraluminal growth), risk classification (very low risk, low risk, medium risk, high risk), whether the tumor was en bloc resection, operation time, whether bleeding or not, fasting time, indwelling time of gastric tube, time of hospitalization, time of postoperative hospital stay, postoperative complications and follow-up. Independent sample t test, chi-square test or Fisher′s exact test and Wilcoxon rank sum test were used for statistical analysis. Results:Among the 137 patients with gastric GIST in the endoscopic resection group, 85 cases (62.0%) underwent endoscopic submucosal dissection, 9 cases (6.6%) underwent endoscopic submucosal excavation, 42 cases (30.7%) underwent endoscopic full-thickness resection, and 1 case (0.7%) underwent submucosal tunnel endoscopic resection. There were no significant differences in gender, age, lesion location, tumor size, and risk classification between the endoscopic resection group and the laparoscopic surgery group (all P>0.05). The tumor surface was depressed, with ulcer or irregular in 1, 49, 26, and 2 cases of patients with gastric GIST of very low risk, low risk, medium risk and high risk, respectively. There was statistically significant difference in the proportion of depression, irregularity and ulcer on the tumor surface at different risk levels ( Z=-2.55, P=0.011). The complete tumor resection rate of the endoscopic resection group was lower than that of the laparoscopic surgery group (86.1%, 118/137 vs. 100.0%, 164/164), and the difference was statistically significant ( χ2=24.28, P<0.001). However the operation time, fasting time, the indwelling time of gastric tube, time of hospitalization, and the time of postoperative hospital stay of the endoscopic resection group were shorter than those of the laparoscopic surgery group, and the total hospitalization cost was lower than that of the laparoscopic surgery group (90.0 min (62.5 min, 150.0 min) vs. 119.5 min, (80.0 min, 154.2 min); 3 d (3 d, 4 d) vs. 5 d (4 d, 7 d); 3 d (2 d, 4 d) vs. 4 d (2 d, 6 d); 11 d (10 d, 14 d) vs. 16 d (12 d, 20 d); 7 d (6 d, 9 d) vs. 9 d (7 d, 11 d); (38 211.6±10 221.0) yuan vs. (59 926.1±17 786.1) yuan), and the differences were statistically significant ( Z=-2.46, -7.12, -4.44, -6.89 and -5.92, t=-13.24; all P<0.05). The incidence of postoperative abdominal pain and other severe postoperative complications (including shock, respiratory failure, pulmonary embolism, gastroparesis, etc.) of the endoscopic resection group were all lower than those of the laparoscopic surgery group (16.8%, 23/137 vs. 27.4%, 45/164; 0.7%, 1/137 vs. 4.9%, 8/164), and the differences were statistically significant ( χ2=4.84, Fisher′s exact test, P=0.028 and 0.043). There were no significant differences in the incidence of intraoperative bleeding, postoperative bleeding, fever and perforation between the two groups (all P>0.05). The incidence of operation-related complications of lesions with intraluminal growth and originating from muscularis propria in the endoscopic resection group were lower than those of the laparoscopic surgery group (19.5%, 25/128 vs. 32.6%, 45/138; 12.6%, 12/95 vs. 31.4%, 37/118), and the differences were statistically significant ( χ2=5.86 and 10.42, P=0.016 and 0.001). There was no significant difference in the postoperative tumor recurrent rate between the endoscopic resection group and the laparoscopic surgery group (0, 0/137 vs. 2.4%, 4/164; Fisher’s exact test, P=0.129). Conclusions:Endoscopic treatment is safe and effective for gastric GIST with a maximum diameter of 2 to 5 cm, which is superior to laparoscopic surgery. However, laparoscopic surgery is recommended for tumor with depressed, ulcerative, or irregular surface and combined intraluminal and extraluminal growth.

Application value of laparoscopic intra-gastric surgery in the treatment of gastrointestinal stromal tumors around the cardia / 中华消化外科杂志

Objective:To investigate the application value of laparoscopic intra-gastric surgery (LIGS) in the treatment of gastrointestinal stromal tumors (GIST) around the cardia.Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 5 patients who underwent LIGS for GIST around the cardia in the Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine from January 2019 to December 2021 were collected. There were 3 males and 2 females, aged 52(range, 35?69)years. All patients underwent LIGS. Observation indicators: (1) intraoperative and postoperative conditions; (2) follow-up. Follow-up was conducted using tele-phone interview or outpatient examination. Patients were followed up once every 3 months to detect long-term complications and tumor recurrence up to April 1st, 2022. Measurement data with skewed distribution were represented as M(range) and count data were described as absolute numbers. Results:(1) Intraoperative and postoperative conditions. All 5 patients underwent LIGS successfully, without conversion to laparotomy or changes in surgical methods. Intraoperative tumor exploration showed that the tumor was located on the lesser curvature of the cardia in 3 patients and on the posterior wall of the gastric fundus in 2 patients. The distance between the tumor and the dentate line of the cardia was 1.5(range, 1.0?3.0)cm. Of the 5 patients, 3 cases with tumor patholo-gically evaluable margins as 0.3, 0.8, and 1.5 cm and 2 cases without tumor pathologically evaluable margins but the tumor had an intact capsule. The operation time, volume of intraoperative blood loss, time to postoperative first anal exsufflation, time to postoperative initial fluid diet intake, time to extubation and duration of postoperative hospital stay were 75(range, 65?112)minutes, 25(range, 15?70)mL, 2(range, 1?3)days, 3(range, 2?4)days, 4(range, 3?5)days and 6(range, 5?8)days in the 5 patients. There was no short-term postoperative complication such as bleeding, anastomotic leakage, and gastroparesis in the 5 patients and results of postoperative histopathological examina-tion showed GIST in all 5 patients, with tumor diameter as 3.0(range, 1.8?5.5)cm. There were 2 patients with tumor diameter ≤2.0 cm and 3 patients with tumor diameter ≥3.0 cm. The 5 patients were classified as very low risk in 2 cases, low risk in 2 cases, and intermediate risk in 1 case. (2) Follow-up. All 5 patients were followed up after operation, with the follow-up time of 9(range, 3?15)months. During the follow-up, there was no long-term complication such as dysphagia and gastroesophageal reflux, and no recurrence or metastasis of tumor occurred in patients by computed tomography examinations.Conclusion:LIGS can be used for the treatment of GIST around the cardia.

Clinicopathological features and prognosis analysis of patients with gastric gastrointestinal stromal tumor combined with digestive tract cancer / 中华消化外科杂志

Objective:To investigate the clinicopathological features and prognosis of patients with gastric gastrointestinal stromal tumor (GIST) combined with digestive tract cancer.Methods:The retrospective cohort study was conducted. The clinicopathological data of 1 163 patients with gastric GIST who were admitted to the Union Hospital admitted to Tongji Medical College of Huazhong University of Science and Technology from January 2002 to December 2021 were collected. There were 606 males and 557 females, aged 59(range,20?94)years. Of the 1 163 patients, 129 cases with gastric GIST combined with other digestive tract cancer were divided into the combined group, and 1 034 cases with only gastric GIST were divided into the non-combined group. Observation indicators: (1) clinicopathological features of patients; (2) surgical situations and postoperative complications; (3) follow-up and survival of patients; (4) analysis of prognosis associated affecting factors. Follow-up was conducted using outpatient examination, telephone and online interview to detect survival of patients up to January 2022. The overall survival time was defined as the time from surgery to the last tine of follow-up or the outcome events, such as death of patient, loss of follow-up, etc. Measurement data with normal distribution were represented as Mean± SD, and measure-ment data with skewed distribution were represented as M(range). Count data were described as absolute numbers, and comparison between groups was conducted using the chi-square test. Com-parison of ordinal data was conducted using the non-parameter Mann-Whitney U test. Kaplan-Meier method was used to draw survival curves and calculate survival rates, and Log-Rank test was used to conduct survival analysis. The COX proportional hazard model was used for univariate and multivariate analyses. Results:(1) Clinicopathological features of patients. Of the 129 patients in the combined group, there were 81 cases combined with gastric cancer, 39 cases combined with esophageal cancer, 8 cases combined with colon cancer and 1 case combined with rectal cancer. Gender (male, female), cases with age ≤60 years or>60 years, cases without or with clinical symp-toms before surgery, cases with tumor diameter of gastric GIST as<2 cm, 2?5 cm, 5?10 cm,>10 cm, cases with mitotic index as <5/50× high power field, 5?10/50× high power field, >10/50× high power field, cases with cell proliferation index of Ki-67 as ≤5% or >5%, cases classified as extremely low risk, low risk, medium risk and high risk of the modified national institutes of health (NIH) risk classification, cases with or without tumor necrosis of the gastric GIST, cases without or with adjuvant imatinib therapy, cases with the expression of DOG-1 detected by immunohistochemical staining as positive or negative, cases with the expression of CD34 as positive or negative were 92, 37, 30, 99, 9, 120, 114, 10, 3, 2, 126, 1, 2, 122, 2, 112, 8, 5, 4, 129, 0, 121, 8, 118, 3, 117, 12 in the combined group, versus 514, 520, 585, 449, 194, 840, 383, 360,201, 90, 799, 155, 80, 851, 143, 337, 308, 192, 197, 960, 74, 769, 265, 850, 80, 990, 44 in the non-combined group, showing significant differences in the above indicators between the two groups ( χ2=21.46, 51.11, 11.06, Z=?10.27, ?5.34, χ2=15.94, Z=?10.61, χ2=9.86, 24.10, 5.52, 6.37, P<0.05). Of the 1 163 patients, there were 12 cases of the combined group suspected diagnosed as gastric GIST before surgery and 1 case of the combined group dia-gnosed as gastric GIST by gastroscopy and pathological examination before surgery. The rest of 1 150 patients were diagnosed as gastric GIST by intraoperative exploration or postoperative pathological examination. (2) Surgical situations and postoperative complications. Of the 129 patients in the combined group, 72 cases underwent open surgery and 57 cases underwent laparoscopic or thoracoscopic surgery including 3 cases converted to open surgery. Of the 1 034 patients in the non-combined group,207 cases underwent endoscopic surgery, 371 cases underwent open surgery, and 456 cases underwent laparoscopic or thoracoscopic surgery including 8 cases converted to open surgery. Incidence of postoperative complications was 10.078%(13/129) in the combined group, versus 2.321%(24/1 034) in the non-combined group, showing a significant difference between the two groups ( χ2=22.40, P<0.05). (3) Follow-up and survival of patients. Of the 1 163 patients, 1 046 cases were followed up for 44(range, 1?220)months, with the postoperative 5-year overall survival rate as 87.2%. The postoperative 5-year overall survival rate was 51.2% in the combined group, versus 91.4% in the non-combined group, showing a significant difference between the two groups ( χ2=169.07, P<0.05). (4) Analysis of prognosis associated affecting factors. Results of univariate analysis showed that gender, age, tumor diameter of gastric GIST as 2?5 cm, 5?10 cm and >10 cm, combined with other digestive tract cancer, mitotic index as >10/50× high power field and tumor necrosis of the gastric GIST were related factors affecting the postoperative 5-year overall survival rate of patients with gastric GIST ( hazard ratio=2.16, 2.27, 0.46, 0.57, 1.75, 7.58, 2.70, 1.80, 95% confidence intervals as 1.52?3.07, 1.60?3.22, 0.29?0.71, 0.34?0.94, 1.11?2.77, 5.29?10.85, 1.67?4.38, 1.08?2.98, P<0.05). Results of multivariate analysis showed that gender, age, tumor diameter of gastric GIST, combined with other digestive tract cancer and mitotic index were independent factors affecting the post-operative 5-year overall survival rate of patients with gastric GIST ( hazard ratio=1.91, 1.82, 2.10, 7.11, 2.75, 95% confidence intervals as 1.33?2.75, 1.27?2.62, 1.14?3.87, 4.58?11.04, 1.50?5.03, P<0.05). Conclusions:The tumor diameter of gastric GIST is short in patients combined with other digestive tract cancer, and the risk grade of modified NIH risk classification is lower. Gender, age, tumor diameter of gastric GIST, combined with other digestive tract cancer and mitotic index are independent factors affecting the postoperative 5-year overall survival rate of patients with gastric GIST.

Clinical efficacy and prognostic influencing factors of radical surgery for duodenal gastro-intestinal stromal tumor: a multicenter retrospective study / 中华消化外科杂志

Objective:To investigate the clinical efficacy and prognostic influencing factors of radical surgery for duodenal gastrointestinal stromal tumor (GIST).Methods:The retrospective cohort study was conducted. The clinicopathological data of 741 duodenal GIST patients who under-went radical surgery in 17 medical centers, including 121 cases in Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine, 121 cases in Chinese PLA General Hospital, 116 cases in Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 77 cases in Fudan University Shanghai Cancer Center, 77 cases in West China Hospital, Sichuan University, 31 cases in Guangdong Provincial People′s Hospital, 24 cases in Fujian Cancer Hospital, 22 cases in Fujian Medical University Union Hospital, 25 cases in Shengjing Hospital of China Medical University, 19 cases in Xiangya Hospital, Central South University, 23 cases in Zhejiang Cancer Hospital, 17 cases in Liaoning Cancer Hospital＆Institute, 17 cases in the First Affiliated Hospital of Xiamen University, 15 cases in Sun Yat-sen University Cancer Center, 14 cases in the First Affiliated Hospital of Nanjing Medical University, 14 cases in Zhongshan Hospital Affiliated to Xiamen University and 8 cases in General Hospital of Chinese People′s Liberation Army Air Force, from January 2010 to April 2020 were collected. There were 346 males and 395 females, aged 55(range, 17?86)years. Observation indicators: (1) neoadjuvant treatment; (2) surgical and postoperative situations; (3) follow-up; (4) stratified analysis. Follow-up was conducted using outpatient examination or telephone interview. Patients were followed up once every 3?6 months during neoadjuvant therapy and once every 6?12 months after radical surgery to detect tumor recurrence and survival of patient up to April 2022. Measurement data with normal distribution were represented as Mean± SD. Measurement data with skewed distribution were represented as M(range), and comparison between groups was conducted using the Mann-Whitney U test. Count data were described as absolute numbers or percentages, and comparison between groups was conducted using chi-square test or Fisher exact probability. The Kaplan-Meier method was used to draw survival curves and calculate survival rates. Log-rank test was used for survival analysis. The COX regression model was used for univariate and multivariate analyses. Propensity score matching was done by the 1∶1 nearest neighbor matching method, and the matching tolerance was 0.02. Results:(1) Neoadjuvant therapy. Of the 741 patients, 34 cases received neoadjuvant therapy for 8(range, 3?44)months. Cases assessed as partial response, stable disease and progressive disease before the radical surgery of the 34 cases were 21, 9, 4, respectively. The tumor diameter of the 34 patients before the neoadjuvant therapy and before the radical surgery were 8.0(range, 3.0?26.0)cm and 5.3(range, 3.0?18.0)cm, with the regression rate as 31.9%(range, ?166.7% to 58.3%). (2) Surgical and postoperative situations. Of the 741 patients, 34 cases underwent radical surgery after receiving neoadjuvant therapy, and 707 cases underwent radical surgery directly. All the 741 patients underwent radical surgery successfully, in which 633, 102 and 6 cases received open surgery, laparoscopic surgery and endoscopic treatment, respectively. Of the 633 cases receiving open surgery and the 102 cases receiving laparoscopic surgery, cases with surgical resection range as pancreatoduodenectomy (PD) was 238, and cases with surgical resection range as duodenal limited resection, including duodenal wedge resection, distal gastrectomy, segmental duodenal resection, local resection of duodenal tumor or segmental duodenum combined with subtotal gastrectomy, was 497, 226, 55, 204, 12. Of the 741 patients, 131 cases had post-operative complications including 113 cases with grade Ⅰ?Ⅱ complications and 18 cases with ≥ grade Ⅲ complications of the Clavien-Dindo classification. The duration of postoperative hospital stay of the 741 patients was 13(range, 4?120)days. Of the 707 patients receiving direct radical surgery, 371 cases were evaluated as extremely low risk, low risk, medium risk of the modified National Institutes of Health (NIH) risk classification after surgery, and 336 cases were evaluated as high risk in which 205 cases receive postoperative adjuvant imatinib therapy with the treatment time as 24(range, 6?110)months. (3) Follow-up. All the 741 patients were followed up for 58(range, 7?150)months. During the follow-up, 110 patients had tumor recurrence and metastasis. The 1-, 3-, 5-year overall survival rates and 1-, 3-, 5-year disease-free survival rates of the 741 patients were 100.0%, 98.6%, 94.5% and 98.4%, 90.9%, 84.9%, respectively. The 1-, 3-, 5-year overall survival rates and 1-, 3-, 5-year disease-free survival rates of the 707 patients receiving direct radical surgery were 100.0%, 98.5%, 94.3% and 98.4%, 91.1%, 85.4%, respectively. (4) Stratified analysis. ① Analysis of prognostic factors in patients undergoing radical surgery directly. Results of univariate analysis showed that primary tumor location, tumor diameter, mitotic count, modified NIH risk classification and tumor gene information were related factors affecting the overall survival of 707 patients with primary duodenal GIST who underwent direct radical surgery ( hazard ratio=0.43, 0.18, 0.22, 0.06, 0.29, 95% confidence intervals as 0.20?0.93, 0.09?0.35, 0.10?0.50, 0.03?0.12, 0.09?0.95, P<0.05). The primary tumor location, tumor diameter, mitotic count, modified NIH risk classification were related factors affecting the disease-free survival of 707 patients with primary duodenal GIST who underwent direct radical surgery ( hazard ratio=0.65, 0.25, 0.25, 0.10, 95% confidence intervals as 0.41?1.03, 0.17?0.37, 0.15?0.42, 0.07?0.15, P<0.05). Results of multivariate analysis showed that primary tumor located at the horizontal segment of duodenum, mitotic count >5/50 high power field, tumor gene KIT exon 9 mutation were independent risk factors affecting the overall survival of 365 patients with primary duodenal GIST after removing 342 patients without tumor gene information who underwent direct radical surgery ( hazard ratio=2.85, 2.73, 3.13, 95% confidence intervals as 1.12?7.20, 1.07?6.94, 1.23?7.93, P<0.05). Tumor diameter >5 cm and mitotic count >5/50 high power field were independent risk factors affecting the disease-free survival of 707 patients with primary duodenal GIST who underwent direct radical surgery ( hazard ratio=3.19, 2.98, 95% confidence intervals as 2.05?4.97, 1.99?4.45, P<0.05). ② Effect of postoperative adjuvant therapy on prognosis of high-risk patients of modified NIH risk classification. Of the 336 patients evaluated as high risk of the modified NIH risk classification, the 5-year overall survival rate and 5-year disease-free survival rate were 94.6% and 77.3% in the 205 cases with postoperative adjuvant therapy, versus 83.2% and 64.4% in the 131 cases without postoperative adjuvant therapy, showing significant differences between them ( χ2=8.39, 4.44, P<0.05). Of the 205 patients evaluated as high risk of the modified NIH risk classification who received postoperative adjuvant therapy, there were 106 cases receiving postoperative adjuvant therapy <36 months, with the 5-year overall survival rate and 5-year disease-free survival rate were 87.1% and 58.7%, and there were 99 cases receiving post-operative adjuvant therapy ≥36 months, with the 5-year overall survival rate and 5-year disease-free survival rate were 100.0% and 91.5%. There were significant differences in the 5-year overall survival rate and 5-year disease-free survival rate between the 106 patients and the 99 patients ( χ2=13.92, 29.61, P<0.05). ③ Comparison of clinical efficacy of patients with different surgical methods. Before propensity score matching, cases with primary tumor located at bulb, descending, horizontal, ascending segment of duodenum, cases with tumor diameter ≤5 cm and >5 cm were 95, 307, 147, 34, 331, 252, in the 583 patients receiving open surgery with complete clinical data, versus 15, 46, 17, 5, 67, 16 in the 83 patients receiving laparoscopic surgery with complete clinical data, showing no significant difference in the primary tumor location ( χ2=0.94, P>0.05), and a significant difference in the tumor diameter ( χ2=17.33, P<0.05) between them. After propensity score matching, the above indicator were 16, 39, 20, 8, 67, 16 in the 83 patients receiving open surgery, versus 15, 46, 17, 5, 67, 16 in the 83 patients receiving laparoscopic surgery, showing no significant difference between them ( χ2=1.54, 0.00, P>0.05). Cases with postoperative complications, cases with grade Ⅰ?Ⅱ complica-tions and ≥grade Ⅲ complications of the Clavien-Dindo classification, duration of postoperative hospital stay, the 5-year overall survival rate and 5-year disease-free survival rate were 17, 12, 5, 11(range, 5?120)days, 92.0%, 100.0% in the 83 patients receiving open surgery, versus 9, 7, 2, 11(range, 5?41)days, 91.6%, 97.3% in the 83 patients receiving laparoscopic surgery, showing no signi-ficant difference in postoperative complications, duration of postoperative hospital stay, the 5-year overall survival rate and 5-year disease-free survival rate ( χ2=2.91, Z=3 365.50, χ2=3.02, 1.49, P>0.05) between them. There was no significant difference in complications of the Clavien-Dindo classification between them ( P>0.05). ④ Comparison of clinical efficacy of patients with primary tumor located at the descending segment of duodenum who underwent surgery with different surgical resection scopes. Before propensity score matching, cases with tumor diameter ≤5 cm and >5 cm, cases with tumor located at opposite side of mesangium and mesangium were 71, 85, 28, 128 in the 156 patients with primary tumor located at the descending segment of duodenum who underwent PD with complete clinical data, versus 92, 41, 120, 13 in the 133 patients with primary tumor located at the descending segment of duodenum who underwent duodenal limited resection with complete clinical data, showing significant differences between them ( χ2=16.34, 150.10, P<0.05). After propensity score matching, the above indicator were 28, 13, 16, 25 in the 41 patients with primary tumor located at the descending segment of duodenum who underwent PD with complete clinical data, versus 28, 13, 16, 25 in the 41 patients with primary tumor located at the descending segment of duodenum who underwent duodenal limited resection with complete clinical data, showing no significant difference between them ( χ2=0.00, 0.00, P>0.05). Cases with postopera-tive complications, cases with grade Ⅰ?Ⅱ complications and ≥grade Ⅲ compli-cations of the Clavien-Dindo classification, duration of postoperative hospital stay, the 5-year overall survival rate and 5-year disease-free survival rate were 13, 11, 2, 15(range, 9?62)days, 94.2%, 64.3% in the 41 patients with primary tumor located at the descending segment of duodenum who underwent PD with complete clinical data, versus 9, 8, 0, 15(range, 7?40)days, 100.0%, 78.8% in the 41 patients with primary tumor located at the descending segment of duodenum who underwent duodenal limited resection with complete clinical data, showing no significant difference in post-operative complica-tions, the 5-year overall survival rate and 5-year disease-free survival rate ( χ2=0.99, 0.34, 1.86, P>0.05) between them. There was no significant difference in complications of the Clavien-Dindo classification ( P>0.05) and there was a significant difference in duration of postopera-tive hospital stay ( Z=614.50, P<0.05) between them. Conclusions:The clinical efficacy of radical surgery for duodenal GIST are ideal. Primary tumor located at the horizontal segment of duodenum, mitotic count >5/50 high power field, tumor gene KIT exon 9 mutation are independent risk factors affec-ting the overall survival of patients undergoing direct radical surgery and tumor diameter >5 cm and mitotic count >5/50 high power field are independent risk factors affecting the disease-free survival of patients. There is no significant difference in the short-term efficacy and long-term prognosis between patients undergoing open surgery and laparoscopic surgery. For patients with primary tumor located at the descending segment of duodenum, the duration of postoperative hospital stay is longer in patients undergoing PD compared with patients undergoing duodenal limited resection. For patients evaluated as high risk of the modified NIH risk classification, posto-perative adjuvant therapy and treatment time ≥36 months are conducive to improving the prognosis of patients.

Review and reflection on the clinical diagnosis, treatment and research of gastrointestinal stromal tumor in China for 20 years: theory, practice, exploration and innovation / 中华消化外科杂志

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the gastrointestinal tract. Twenty years ago, tyrosine kinase inhibitors targeting KIT/platelet-derived growth factor receptor α were applied to GIST treatment and achieved great success. Therefore, this rare tumor has attracted great attention of clinicians and researchers. After 20 years of exploration and practice, great progress has been made in the clinical diagnosis and research level of GIST in China. In terms of clinical diagnosis and treatment, the pathological diagnosis system has been established and deepened, and the surgical treatment has gradually tended to be standardized, minimally invasive and integrated. More and more targeted drugs continue to challenge the survival limit of GIST patients, and the standardized diagnosis and treatment model has been initially formed and continuously developed. In terms of GIST related researches, drug clinical research from China has experienced the exploration from imitation to innovation, the clinical research related to surgical treatment is undergoing preliminary exploration. The research related to endoscopic treatment has formed a distinctive style with unique Chinese characteristics, and the translational research has also helped solving the clinical problems. In the future, the clinical diagnosis and treatment of GIST in China will be more standardized, minimally invasive, precise, comprehensive and whole process. The research direction in the field of GIST will be to carry out high-quality multi-center clinical research and targeted laboratory researches for clinical focus issues.

Tumor de estroma gastrointestinal extraintestinal gigante: reporte de un caso y revisión de bibliografía / Giant extraintestinal gastrointestinal stromal tumor: Case report and bibliography review

Resumen Los tumores del estroma gastrointestinal (GIST) son tumores infrecuentes del tracto digestivo. Sus localizaciones más frecuentes son el estómago, intestino delgado, colon y recto; su aparición en otros lugares fuera del trato gastrointestinal como el mesenterio, epiplón o retroperitoneo es infrecuente. La tomografía axial computarizada (TAC) y la resonancia magnética (RM) son los estudios de imágenes de primera elección. La recesión quirúrgica es el estándar de oro para los tumores localizados y en los tumores avanzados o metastásicos son tratados con imatinib. A continuación, se presenta el caso de un paciente masculino de 53 años de edad sin antecedentes de patologías previos con cuadro clínico de dolor abdominal generalizado, pérdida de peso de 20 kg aproximadamente, distención abdominal, melena, hematemesis y astenia; en el examen físico presentó abdomen distendido y en la palpación se encontró endurecimiento epigástrico y mesogástrico, y marco colónico izquierdo. En la tomografía de abdomen se observó una masa tumoral de aspecto infiltrativo de aparente origen gástrico, con crecimiento extragástrico e infiltración del bazo, páncreas, raíz mesentérica, epiplón mayor, colon transverso, asas intestinales delgadas e infiltración en el hilio hepático, y metástasis hepática. Además, el cuadro se asoció con enfermedad respiratoria por coronavirus del síndrome respiratorio agudo grave de tipo 2 (SARS-CoV-2; neumonía por coronavirus de 2019 [COVID-19]). Se realizó una biopsia percutánea ecodirigida en el hipocondrio izquierdo y la histología reportó un GIST. En este artículo se revisa la clínica, diagnóstico y tratamiento del GIST gigante extradigestivo.

Abstract Giant extraintestinal gastrointestinal stromal tumors (GIST) are rare tumors of the digestive tract. Its most frequent locations are the stomach, small intestine, colon, and rectum. Its appearance in other places outside the gastrointestinal tract such as the mesentery, omentum, or retroperitoneum is infrequent. Computerized axial tomography (CT) and magnetic resonance imaging (MRI) are the imaging studies of the first choice. Surgical recession is the gold standard for localized tumors and advanced or metastatic tumors are treated with imatinib. This study presents the case of a male patient of 53 years with no history of previous pathologies. The patient was admitted with a clinical condition of generalized abdominal pain, weight loss of approximately 20 kg, abdominal distention, melena, hematemesis, and asthenia. Physical examination revealed a distended abdomen and palpation revealed epigastric and mesogastric hardening and left colonic frame. The abdominal tomography revealed a tumor mass with an infiltrative appearance of apparent gastric origin, with extragastric growth and infiltration of the spleen, pancreas, mesenteric root, greater omentum, transverse colon, thin intestinal loops, and infiltration in the hepatic hilum, and liver metastases. Moreover, the condition was related to the severe acute respiratory syndrome type 2 coronavirus (SARS-CoV-2). An ultrasound-guided percutaneous biopsy was performed in the left upper quadrant and histology reported a GIST. In this article medical condition, diagnosis, and treatment of the Giant extraintestinal gastrointestinal stromal, is reviewed.

Tumor del estroma gastrointestinal / Gastrointestinal stromal tumor

Introducción: El tumor del estroma gastrointestinal, es el tumor mesenquimal más frecuente en el tracto digestivo, que causa sangrado y obstrucción, con una incidencia de 10 a 20 casos por millón de habitantes. La prevalencia es mayor, debido el curso clínico largo de la enfermedad. Objetivo: Presentar un caso inusual de cirugía electiva, con tumor del estroma gastrointestinal digestivo, operado en el servicio de cirugía general. Caso clínico: Paciente masculino de 57 años de edad, que consulta por dolor abdominal en mesogastrio, acompañado de vómitos postprandiales tardíos, pérdida de peso y episodios recurrentes de sangrado digestivo bicolor, se ingresa de forma electiva y se estudia. Se interviene quirúrgicamente con el diagnóstico presuntivo de tumor abdominal. Se encuentra durante la laparotomía tumor de 14 por 20 centímetros que compromete la luz del intestino delgado, se decide realizar extracción del tumor y anastomosis término terminal convencional. El paciente fue egresado a los ocho días con evolución favorable y pendiente de resultado anatomopatológico, el cual informó tumor del estroma gastrointestinal. Conclusiones: Los tumores del estroma gastrointestinal son poco frecuentes como causa de cirugía electiva en los servicios de cirugía general(AU)

Introduction: Gastrointestinal stromal tumor is the most frequent mesenchymal tumor in the digestive tract, causing bleeding and obstruction, with an incidence of 10 to 20 cases per million inhabitants. The prevalence is higher, due to the long clinical course of the disease. Objective: To present an unusual case of elective surgery, with a gastrointestinal digestive stromal tumor, operated on in the general surgery service. Clinical case: A 57-year-old male patient who consulted for abdominal pain in the mesogastrium, accompanied by late postprandial vomiting, weight loss and recurrent episodes of bicolor digestive bleeding, was admitted electively and studied. Surgery was performed with the presumptive diagnosis of abdominal tumor. During the laparotomy, a 14 by 20-centimeter tumor that compromises the lumen of the small intestine is found; it is decided to perform extraction of the tumor and a conventional end-to-end anastomosis. The patient was discharged after eight days with a favorable evolution and pending histopathological result, which reported a gastrointestinal stromal tumor. Conclusions: Gastrointestinal stromal tumors are rare as a cause of elective surgery in general surgery services(AU)

Tumores estromales gastrointestinales (GIST) gástricos, serie de casos / Gastrointestinal stromal tumors (GIST). Case series

Resumen Introducción: Los tumores estromales gastrointestinales (GIST) representan hasta el 2 % de las neoplasias gastrointestinales, estos aparecen en cualquier parte del tracto gastrointestinal y son encontrados más frecuentemente en el estómago (60 %). El diagnóstico se realiza por la expresión de un receptor de factor de crecimiento de tirosina-cinasa, antígeno de diferenciación (CD) 117, lo que lo diferencia de los otros tumores mesenquimales como leiomiomas, leiomiosarcomas, leiomioblastomas y tumores neurogénicos, que no expresan esta proteína. Objetivo: El objetivo de nuestro trabajo es caracterizar los GIST de localización gástrica con respecto a su presentación clínica, diagnóstico, manejo, recurrencia y supervivencia. Métodos: Se trata de un estudio observacional, retrospectivo basado en una serie de casos. Se realizó una extracción de la información por medio de la revisión de las historias clínicas de los pacientes con GIST gástricos en un centro oncológico de Bogotá entre enero de 2005 y diciembre de 2015. La información recolectada incluyó tipo de manejo y abordaje quirúrgico, localización, tamaño, índice mitótico y clasificación de riesgo. Resultados: Se encontraron 31 pacientes con diagnóstico de GIST gástrico. La edad media fue de 62,3 años, con una mediana de 61 años. De los 31 pacientes, 18 fueron mujeres y 13 hombres. El tiempo de seguimiento estuvo entre un mínimo de 2,4 meses y un máximo de 214 meses, La mediana de seguimiento fue de 36 meses. Conclusiones: Los GIST son tumores potencialmente malignos, y el de localización gástrica es el más frecuente. El diagnóstico y tratamiento dependen de su tamaño y localización dentro del estómago. El manejo es variado y consiste en la resección quirúrgica, en la que los procedimientos son mínimamente invasivos, en combinación con la endoscopia, que son una buena alternativa al tratamiento abierto hasta que haya necesidad de terapia sistémica.

Abstract Introduction: Gastrointestinal stromal tumors (GIST) account for up to 2% of gastrointestinal neoplasms. They may appear anywhere in the gastrointestinal tract and are most frequently found in the stomach (60%). The diagnosis is made based on the expression of the tyrosine-protein kinase KIT CD117, which differentiates it from other mesenchymal tumors such as leiomyomas, leiomyosarcomas, leiomyoblastomas, and neurogenic tumors, that do not express this protein. Objective: To characterize the clinical presentation, diagnosis, treatment, recurrence, and survival of GISTs in the stomach. Materials and methods: This is an observational retrospective study based on a case series. Data was collected after reviewing the medical records of patients diagnosed with GIST at a cancer center in Bogotá between January 2005 and December 2015. The data included type of treatment and surgical approach, location, size, mitotic index, and risk classification. Results: There were 31 patients diagnosed with GIST. Their mean age was 62.3 years, with a median of 61 years. Of the 31 patients, 18 were women and 13 were men. Follow-up time ranged from a minimum of 2.4 months to a maximum of 214 months. The median follow-up time was 36 months. Conclusions: GISTs are potentially malignant tumors, with gastric location being the most frequent. Diagnosis and treatment depend on their size and location in the stomach. Treatment options vary, ranging from surgical resection, where minimally invasive procedures along with endoscopy are a suitable alternative to open surgery, to the need for systemic therapy.

Laparoscopic Roux / 中南大学学报(医学版)

Laparoscopic Roux-en-Y gastric bypass (LRYGB) has been proved to be a safe and effective treatment for Type 2 diabetes mellitus (T2DM) patients with body mass index (BMI) >27.5 kg/m

Treatment strategy of gastrointestinal stromal tumors in the background of COVID-19 / 中华胃肠外科杂志

COVID-19, caused by SARS-COV-2, has the characteristics of world epidemic, highly infectious and large base of death. In China, transmission route of SARS-COV-2 has been contained so effectively that COVID-19 has been well controlled due to the proactive national prevention and control strategy. However, not only does it bring a huge impact on the existing medical structure model, but also an objective impact on the treatment of patients with chronic diseases such as malignant tumors. Based on the progress reported in the domestic and international literatures and the actual management experience of our team, this paper reflects on the treatment strategies for patients with gastrointestinal stromal tumor (GIST) during the epidemic period of COVID-19. We focus on risk stratification for primary GIST and forming treatment strategies accordingly. Major considerations include the impact of delayed operation, the burden of medical resources, the waiting time for elective operation, and the principle of emergency operation. In addition, we focus on the level of evidence for non-surgical approaches with a view to developing a holistic strategy of "priority management principles" to guide clinical treatment in the context of limited resources and different GIST priorities.

Identification and inner relation between gastrointestinal stromal tumor and intra-abdominal desmoid tumor / 中华胃肠外科杂志

Intra-abdominal desmoid tumor (IADT) and gastrointestinal stromal tumor (GIST) are both mesenchymal tumors mostly found in gastrointestinal tracts and easily misdiagnosed, which would directly damage the survival prognosis and quality of life of patients. With the advent of the era of precision medicine, the understanding of the above two diseases is more in-depth, and the requirements for accurate diagnosis and individualized precision treatment are more stringent. Moreover, there seems to be some internal relationship between IADT and GIST, and the lack of systematic research and discussion makes clinical decision-making and patient management easy to fall into traps and misunderstandings. Therefore, this paper reviews the clinical characteristics, pathogenesis and treatments of the two, and explore their differences and internal relations, so as to provide research and practical reference for promoting more precise and individualized diagnosis and treatment regimens.

Clinicopathological features and prognosis of gastrointestinal stromal tumors with KIT/PDGFRA gene "homozygous mutation": a multicenter retrospective cohort study / 中华胃肠外科杂志

Objective: To investigate the clinicopathological features of gastrointestinal stromal tumor (GIST) with KIT/PDGFRA "homozygous mutation", the efficacy of targeted therapy and the prognosis. Methods: A retrospective cohort study and propensity score matching were used. "Homozygous mutation" was defined as the detection of KIT/PDGFRA gene status of GIST by Sanger sequencing, which showed that there was only mutant gene sequence in the sequencing map, lack of wild-type sequence or the peak height of mutant gene sequence was much higher than that of wild-type gene sequence (> 3 times). "Heterozygous mutation" was defined as the mutant gene sequences coexisted with wild type gene sequences, and the peak height was similar (3 times or less). The clinicopathological data and follow-up information of 92 GIST patients with KIT/PDGFRA "homozygous mutation" were collected from 4 hospitals in Shanghai from January 2008 to May 2021 (Renji Hospital, Shanghai Jiaotong University School of Medicine: 70 cases; Zhongshan Hospital, Fudan University: 14 cases; Changhai Hospital, Naval Military Medical University: 6 cases and Ruijin Hospital, Shanghai Jiaotong University School of Medicine: 2 cases). Patients with perioperative death, other malignancies, and incomplete clinicopathological information were excluded. The clinicopathological features of the patients and the efficacy of targeted drug therapy were observed and analyzed. The efficacy was evaluated using Choi criteria, which were divided into complete response (CR), partial response (PR), stable disease (SD) and progressive disease (PD). In addition, a total of 230 patients with high-risk GIST with "heterozygous mutation" in exon 11 of KIT gene and 117 patients with recurrent or metastatic GIST with "heterozygous mutation" in exon 11 of KIT gene were included. The propensity score matching method was used to match GIST patients with "heterozygous" and "homozygous" mutations in exon 11 of KIT gene (1∶1) for survival analysis. The disease-free survival (DFS) between two groups of high-risk GIST patients who underwent complete surgical resection were compared. And progression-free survival (PFS) in patients with recurrent or metastatic GIST were compared. Results: Of the 92 GIST cases with KIT/PDGFRA "homozygous mutation", 58 were males and 34 were females, with a median onset age of 62 (31-91) years. Primary GIST 83 cases. Primary high-risk GIST (53 cases), metastatic GIST (21 cases) and recurrent GIST (9 cases) accounted for 90.2% (83/92). There were 90 cases of KIT gene"homozygous mutation" (exon 11 for 88 cases, exon 13 for 1 case, exon 17 for 1 case), and 2 cases of PDGFRA gene "homozygous mutation" (exon 12 for 1 case, exon 18 for 1 case). The median follow-up time was 49 (8-181) months. Among the 61 cases of primary localized GIST undergoing complete surgical resection, 2 cases were intermediate-risk GIST, 5 cases were low-risk GIST, and 1 case was very low-risk GIST, of whom 1 case of intermediate-risk GIST received 1-year adjuvant imatinib mesylate (IM) therapy after operation, and no tumor recurrence developed during the follow-up period. The remaining 53 cases were high-risk GIST, and follow-up data were obtained from 50 cases, of whom 22 developed tumor recurrence during follow-up. Of 9 patients directly receiving neoadjuvant targeted therapy (IM or avapritinib), 5 had complete imaging follow-up data, and the evaluation of efficacy achieved PR. Of all the 92 GIST cases with KIT/PDGFRA "homozygous mutation", 50 (54.4%) had tumor metastasis or tumor recurrence or progression during follow-up, and 12 (13.0%) died of the tumor. Survival analysis combined with propensity score showed that in 100 cases of high-risk GISTs with complete resection, GISTs with "homozygous mutation" in exon 11 of KIT gene had shorter disease-free survival (DFS) than GISTs with "heterozygous mutation" in exon 11 of KIT gene (median DFS: 72 months vs. 148 months, P=0.015). In 60 cases of recurrent or metastatic GISTs with KIT gene exon 11 mutation, IM was used as the first-line treatment, and the progression-free survival (PFS) of GISTs with "homozygous mutation" was shorter compared to GISTs with "heterozygous mutation" (median PFS: 38 months vs. 69 months, P=0.044). The differences were statistically significant. Conclusions: "Homozygous mutation" in KIT/PDGFRA gene is associated with the progression of GIST. The corresponding targeted therapeutic drugs are still effective for GIST with KIT/PDGFRA gene "homozygous mutation". Compared with GIST patients with "heterozygous mutation" in KIT exon 11, GIST patients with "homozygous mutation" in KIT exon 11 are more likely to relapse after surgery and to develop resistance to IM. Therefore, it is still necessary to seek more effective treatment methods for this subset of cases.

Clinical significance of the deep learning algorithm based on contrast-enhanced CT in the differential diagnosis of gastric gastrointestinal stromal tumors with a diameter ≤ 5 cm / 中华胃肠外科杂志

Objective: Contrast-enhanced CT is an important method of preoperative diagnosis and evaluation for the malignant potential of gastric submucosal tumor (SMT). It has a high diagnostic accuracy rate in differentiating gastric gastrointestinal stromal tumor (GIST) with a diameter greater than 5 cm from gastric benign SMT. This study aimed to use deep learning algorithms to establish a diagnosis model (GISTNet) based on contrast-enhanced CT and evaluate its diagnostic value in distinguishing gastric GIST with a diameter ≤ 5 cm and other gastric SMT before surgery. Methods: A diagnostic test study was carried out. Clinicopathological data of 181 patients undergoing resection with postoperative pathological diagnosis of gastric SMT with a diameter ≤ 5 cm at Department of Gastrointestinal Surgery of Renji Hospital from September 2016 to April 2021 were retrospectively collected. After excluding 13 patients without preoperative CT or with poor CT imaging quality, a total of 168 patients were enrolled in this study, of whom, 107 were GIST while 61 were benign SMT (non-GIST), including 27 leiomyomas, 24 schwannomas, 6 heterotopic pancreas and 4 lipomas. Inclusion criteria were as follows: (1) gastric SMT was diagnosed by contrast-enhanced CT before surgery; (2) preoperative gastroscopic examination and biopsy showed no abnormal cells; (3) complete clinical and pathological data. Exclusion criteria were as follows: (1) patients received anti-tumor therapy before surgery; (2) without preoperative CT or with poor CT imaging quality due to any reason; (3) except GIST, other gastric malignant tumors were pathologically diagnosed after surgery. Based on the hold-out method, 148 patients were randomly selected as the training set and 20 patients as the test set of the GISTNet diagnosis model. After the GISTNet model was established, 5 indicators were used for evaluation in the test set, including sensitivity, specificity, positive predictive value, negative predictive value and the area under the receiver operating curve (AUC). Then GISTNet diagnosis model was compared with the GIST-risk scoring model based on traditional CT features. Besides, in order to compare the accuracy of the GISTNet diagnosis model and the imaging doctors in the diagnosis of gastric SMT imaging, 3 radiologists with 3, 9 and 19 years of work experience, respectively, blinded to clinical and pathological information, tested and judged the samples. The accuracy rate between the three doctors and the GISTNet model was compared. Results: The GISTNet model yielded an AUC of 0.900 (95% CI: 0.827-0.973) in the test set. When the threshold value was 0.345, the sensitivity specificity, positive and negative predictive values of the GISTNet diagnosis model was 100%, 67%, 75% and 100%, respectively. The accuracy rate of the GISTNet diagnosis model was better than that of the GIST-risk model and the manual readings from two radiologists with 3 years and 9 years of work experience (83% vs. 75%, 60%, 65%), and was close to the manual reading of the radiologist with 19 years of work experience (83% vs. 80%). Conclusion: The deep learning algorithm based on contrast-enhanced CT has favorable and reliable diagnostic accuracy in distinguishing gastric GIST with a diameter ≤ 5 cm and other gastric SMT before operation.

Significance of circulating tumor cell monitoring in targeted therapy for gastrointestinal stromal tumors / 中华胃肠外科杂志

Objective: To explore the significance of circulating tumor cell (CTC) monitoring in evaluating the efficacy of targeted therapy for gastrointestinal stromal tumor (GIST). Methods: A prospective cohort study was performed. The data of patients with locally advanced GIST or liver metastasis who were admitted to The Affiliated Hospital of Nantong University from August 2013 to December 2018 were collected. Inclusion criteria: (1) patients aged older than 18 years; (2) patients who were diagnosed with GIST based on pathology; (3) patients without surgery, whose preoperative imaging evaluation of GIST found the violations of the surrounding organs or partial transfer of an estimated difficulty to achieve R0 resection, or the maximum diameter of the tumor > 10 cm, or the liver metastasis, or the expectation of higher risk of surgical complications; (4) patients who were treated with the imatinib 400 mg/d for the first time; (5) Eastern Cooperative Oncology Group (ECOG) score of 0-2. Exclusion criteria: (1) genetic testing revealed a D842V mutation in exon 18 of the PDGFRA gene; (2) alanine aminotransferase and/or aspartate aminotransferase > 2.5 times the normal upper limit; (3) serum total bilirubin >1.5 times of normal upper limit; (4) neutrophil count < 1.5×10(9)/L, or platelet count < 75×10(9)/L, or hemoglobin < 60 g/L; (5) creatinine > normal upper limit; (6) patients had serious cardiovascular and cerebrovascular diseases within 12 months before enrollment; (7) female patients were pregnant or lactating; (8) patients suffered from other serious acute and chronic physical or mental problems, and were not suitable for participating in this study judged by researchers. The patients who could not tolerate treatment regimen, or developed serious adverse reactions and did not follow the medication scheme after enrollment were excluded. Before imatinib treatment and 1-month and 2-month after treatment, quantitative PCR was used to detect the DOG-1 expression of monocytes in peripheral blood, and the ratio of DOG-1/β-actin > 3×10(-5) was used as the CTC positive threshold of GIST. The positive rate of CTC, the efficacy of imatinib treatment (complete response, partial response, stable disease, progressive disease, and occurrence of adverse reactions), and the relationship between CTC positive rate and clinicopathological characteristics of patients were analyzed. Furthermore, the ratio of DOG-1 decrease/baseline DOG-1 after 1-month of treatment was used as an indicator to evaluate whether targeted therapy was effective. The receiver operating characteristic (ROC) curve was rendered, and the area under the curve (AUC) was calculated. Results: A total of 68 GIST patients were enrolled in this study, including 39 cases of locally advanced GIST and 29 cases with liver metastases, 32 males and 36 females with the mean age of (51.2±11.8) (range 31 to 74) years. After 2-month of imatinib treatment, 43 cases were evaluated as partial response, 11 cases as stable disease, and 14 cases as progressive disease, with an effective rate of 79.4% (54/68). During the treatment of imatinib, the incidence of grade 3 or higher adverse reactions was 22.1% (15/68), including 12 cases of grade 3 neutropenia and 3 of grade 4 drug eruption, which were all relieved after conservative treatment. The positive rates of CTC in 68 patients before treatment, 1-month and 2-month after treatment were 66.2% (45/68), 41.2% (28/68) and 23.5% (16/68), respectively. The positive rate of CTC was associated with tumor size, liver metastasis, mitotic count and risk level (all P<0.05). By analyzing the effective group and the ineffective group of targeted therapy, it was found that the positive rate of CTC in the effective group showed a decreasing trend, while the positive rate of CTC in the ineffective group showed an increasing trend. The AUC of predicting the efficacy of targeted therapy for GIST was 0.823 by detecting the change trend of CTC 1-month after treatment (P<0.001). When the DOG-1 content decreased by more than 57.5% 1-month after treatment, it can be used as an indicator to judge the effectiveness of the treatment, whose sensitivity was 72.2% and specificity was 100%. Conclusion: The detection of peripheral blood CTC can evaluate the efficacy of targeted therapy in GIST patients and can provide decision-making basis for further clinical treatment.

Adherence to adjuvant with therapy imatinib in patients with gastrointestinal stromal tumor: a national multi-center cross-sectional study / 中华胃肠外科杂志

Objective: To analyze the current adherence to imatinib in patients with gastrointestinal stromal tumors (GIST) in China and its influencing factors. Methods: A cross-sectional survey was conducted. Study period: from October 1, 2020 to November 31, 2020. Study subjects: GIST patients taking imatinib who were diagnosed and treated in public tertiary level A general hospitals or oncology hospitals; those who had not been pathologically diagnosed, those who never received imatinib, or those who had taken imatinib in the past but stopped afterwards were excluded. The Questionnaire Star online surgery platform was used to design a questionnaire about the adherence to adjuvant imatinib therapy of Chinese GIST patients. The link of questionnaire was sent through WeChat. The questionnaire contained basic information of patients, medication status and Morisky Medication Adherence Scale. Results: A total of 2162 questionnaires from 31 provinces, autonomous regions, and municipalities were collected, of which 2005 were valid questionnaires, with an effective rate of 92.7%. The survey subjects included 1104 males and 901 females, with a median age of 56 (22-91) years old. Working status: 609 cases (30.4%) in the work unit, 729 cases (36.4%) of retirement, 667 cases of flexible employment or unemployment (33.3%). Education level: 477 cases (23.8%) with bachelor degree or above, 658 cases (32.8%) of high school, 782 cases (39.0%) of elementary or junior high school, 88 cases (4.4%) without education. Marital status: 1789 cases (89.2%) were married, 179 cases (8.9%) divorced or widowed, 37 cases (1.8%) unmarried. Two hundred and ninety-four patients (14.7%) had metastasis when they were first diagnosed, including 203 liver metastases, 52 peritoneal metastases, and 39 other metastases. One thousand eight hundred and sixty-nine patients underwent surgical treatment, of whom 1642 (81.9%) achieved complete resection. The median time of taking imatinib was 25 (1-200) months. Common adverse reactions of imatinib included 1701 cases (84.8%) of periorbital edema, 1031 cases (51.4%) of leukopenia, 948 cases (47.3%) of fatigue, 781 cases (39.0%) of nausea and vomiting, 709 cases (35.4%) of rash, and 670 cases (33.4%) of lower extremity edema. The score of the Morisky Medication Adherence Scale showed that 392 cases (19.6%) had poor adherence, 1023 cases (51.0%) had moderate adherence, and 590 cases (29.4%) had good adherence. Univariate analysis showed that gender, age, work status, economic income, residence, education level, marriage, the duration of taking medication and adverse reactions were associated with adherence to adjuvant imatinib therapy (all P<0.05). Multivariate analysis showed that female (OR=1.264, P=0.009), non-retirement (OR=1.454, P=0.001), monthly income ≤4000 yuan (OR=1.280, P=0.036), township residents (OR=1.332, P=0.005), unmarried or divorced or widowed (OR=1.362, P=0.026), the duration of imatinib medication >36 months (OR=1.478, P<0.001) and adverse reactions (OR=1.719, P=0.048) were independent risk factors for poor adherence to adjuvant imatinib. Among patients undergoing complete resection, 324 (19.7%) had poor adherence, 836 (50.9%) had moderate adherence, and 482 (29.4%) had good adherence. Meanwhile, 55 patients with good adherence (11.4%) developed recurrence after surgery, 121 patients with moderate adherence (14.5%) developed recurrence, 61 patients with poor adherence (18.8%) developed recurrence, and the difference was statistically significant (P=0.017). Conclusions: The adherence to adjuvant therapy with imatinib in Chinese GIST patients is relatively poor. Females, non-retirement, monthly income ≤4000 yuan, township residents, unmarried or divorced or widowed, the duration of imatinib medication >36 months, and adverse reactions are independently associated with poor adherence of GIST patients. Those with poor adherence have a higher risk of recurrence after surgery. Positive interventions based on the above risk factors are advocated to improve the prognosis of patients with GIST.

Study of neurotrophic factor receptor tyrosine kinase gene fusion in the precise treatment of wild-type gastrointestinal stromal tumor / 中华胃肠外科杂志

The neurotrophin receptor kinase (NTRK) gene encodes neurotrophic factor receptor tyrosine kinase (NTRK), which plays an important role in the development and function of the nervous system. NTRK gene fusion mutation results in the production of chimeric NTRK proteins, which have carcinogenic potential through constitutive activation or overexpression. NTRK gene fusion mutation can lead to a special type of wild type gastrointestinal stromal tumor (GIST), whose clinical manifestations and treatment are completely different from other types of GIST. This fusion mutation can be detected clinically by a variety of methods, including tumor DNA and RNA sequencing and immunohistochemical staining. In patients with NTRK fusion positive tumors, NTRK inhibitors such as larotrectinib and entrectinib have shown good antitumor efficacy, with clinical response rates as high as 75%. Therefore, there is a need to improve the recognition and detection of fuch patients and to improve their prognosis by individualized and precise treatment with TRK inhibitors.