Gastrointestinal Stromal Tumor
Gastrointestinal Stromal Tumor

Video Endoscopic Sequence 1 of 13.

Gastrointestinal Stromal Tumor (GIST)

The Extraction of the Globe must be carried out in the operation room with EnThis 64 year-old, male due to an abdominal pain, a cat scan was performed finding a large mass in the stomach, an endoscopy was performed; a submucosal mass was detected.

A case of Jejunal GIST is displayed in the Jejunum-Ileum chapter. Also a case of Rectal GIST is in the Miscellaneous chapter.

For more endoscopic details download the video clips by clicking on the endoscopic images, wait to be downloaded complete then press Alt and Enter; thus you can observe the video in full screen.

All endoscopic images shown in this Atlas contain
video clips 

 

 

 

Gastrointestinal Stromal Tumor

Video Endoscopic Sequence 2 of 13.

Gastroscopy showed a large sub mucosal tumor

Gastrointestinal stromal tumour (GIST) is a new termemerging from reclassification of leiomyomas and leiomyosarcomas of the gastrointestinal tract. Histopathological refinement, molecular genetics and immunophenotypic characterization has resulted in better understanding and sub classification of this disease entity.

 

 

 

Gastrointestinal Stromal Tumor

Video Endoscopic Sequence 3 of 13.

Endoscopy of Gastrointestinal Stromal Tumor

Gastrointestinal stromal tumors formely classified as leiomyomas or leiomyosarcomas are mesenchymal tumors of the gastrointestinal tract that differ from true Leiomyomas and Leiomyosarcomas. Classification of mesenchymal tumors of the gastrointestinal tract has been the ၳubject of controversies for many years and several histological classification system has been proposed. GIST are now defined as spindle cell, epitheloid or occasionally pleomorphic mesenchymal tumors of the gastrointestinal tract without smooth muscle cell or schwann cell differentiation The term GIST is also limited to tumors originating from pacemaker cell of Cajal located between myenteric plexus cells and smooth muscle cells of the GIT. The immuno-histo chemical marker 'C-Kit' (CD-117) identifies these cell and seems to be the most specific diagnostic marker currently available.

 

Gastrointestinal Stromal Tumor

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Endoscopic Image of Gastrointestinal Stromal Tumors (GISTs).
Gastrointestinal Stromal Tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract.

 

Gastrointestinal Stromal Tumor

Video Endoscopic Sequence 5 of 13.

Endoscopic View of Gastrointestinal Stromal Tumor (GIST)

A palpable abdominal mass is the most frequent presentation but 50% of GISTs are silent until they reach a large size, then causing acute massive hemorrhage into the intestinal tract or peritoneal cavity from tumor rupture. This is the second most common presentation. Other presenting symptoms include nausea, dyspepsia and intestinal obstruction as a result of extrinsic compression.

 

 

 

Gastrointestinal Stromal Tumor

Video Endoscopic Sequence 6 of 13.

Resection remains the standard treatment for non-metastatic GISTs. These tumors may have a pseudocapsule and should be removed. Complete resection of GIST is not curative as recurrence is quite common. In patients with local disease, the recurrence rate is 35%. A major diagnostic criterion of GISTs is expression of CD117 and additional criteria include CD34, SMA, S100 and desmin.

 

Gastrointestinal Stromal Tumor

Video Endoscopic Sequence 7 of 13.

Endoscopy of Gastrointestinal Stromal Tumor

GIST:Differential Diagnosis:

Gastrointestinal carcinoid

Adenocarcinoma

Gastric carcinoma

Liposarcoma

Others to be Considered: Angiosarcoma Inflammatory fibroid polyp, Inflammatory myofibroblastic tumor (pseudotumor, fibrosarcoma) intra-abdominal fibromatosis Kaposi sarcoma,Lipoma, Lymphoma, abdominal Melanoma, metastatic Schwannoma, GI.

 

Gastrointestinal Stromal Tumor

Video Endoscopic Sequence 8 of 13.

Endoscopy of Gastrointestinal Stromal Tumor

Endoscopic ultrasound:

Hypoechoic masses that are contiguous with the fourth hypoechoic layer of the GI wall, which corresponds to the muscularis propria

Characteristics associated with malignancy include tumor size greater than 4 cm, an irregular extraluminal border, echogenic foci, and cystic spaces.


 

Gastrointestinal Stromal Tumor

Video Endoscopic Sequence 9 of 13.

In this sequence of images of the computer tomography
shows a large mass inside and outside of the stomach, a
left renal cyst is also seen.

 

Gastrointestinal Stromal Tumor

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CT is ideal in defining the endoluminal and exophytic extent of tumor.

Smaller GISTs appear as smooth, sharply defined intramural masses with homogenous attenuation.

Larger GISTs with necrosis appear as heterogeneous masses with enhancing borders of variable thickness and irregular central areas of fluid, air, or oral contrast attenuation that reflect necrosis

Occasionally, dense focal calcifications

Overlying mucosal ulcerations and extension into nearby structures may be present. 

 

Gastrointestinal Stromal Tumor

Video Endoscopic Sequence 11 of 13.

GIST: benign vrs malignant

Unfortunately, no standard exists for their classification.

Many criteria such as number of mitotic figures, size, presence of necrosis and hemorrhage among others.

Size is the most important and most reliable

Tumor <5 cm is described as having low malignancy potential.

Tumor >5 cm is described as being of high malignancy potential.

 

Gastrointestinal Stromal Tumor

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Upper GI bleeding is the most common clinical
manifestation of gastrointestinal stromal tumors (GISTs),
manifesting as hematemesis or melena in 40-65% of
patients. Bleeding occurs because of an ulcer forming in
the gastric mucosa overlying the tumor.

 

Gastrointestinal Stromal Tumor

Video Endoscopic Sequence 13 of 13.

Imaging studies, especially CT, play an important role not
only in the detection and the localization but also in the
evaluation of the extension and follow-up of theses tumors.
Small GISTs are intraluminal, localized, and well-defined,
whereas extensive GISTs are large and hypervascular and
may contain cystic and necrotic tumor components
combined with an intra-/extraluminal tumor growth. CT
diagnosis of malignant GISTs can be suggested in the
presence of a large, complex, gastro-intestinal mass,
without significant lymphadenopathy. It is difficult to
differentiate, using only CT imaging, the GIST from other
soft-tissue tumors. In all cases, histological diagnosis is
essential and compulsory.

 

Gastrointestinal Stromal Tumor

Video Endoscopic Sequence 1 of 6.

Enormous Gastric Gastrointestinal Stromal Tumor (GIST) with a central umbilicated ulceration.

A 34 year-old male with hepatic cirrhosis and esophageal varices, presented a submucosal tumor with central umbilicated ulcer. He was asymptomatic at the time of diagnosis. The central location of this ulcer is characteristic for an intramural neoplasm such a GIST.

 

 

Gastrointestinal Stromal Tumor

Video Endoscopic Sequence 2 of 6.

Endoscopy of Gastrointestinal Stromal Tumor

Grossly, GIST of the stomach most frequently develop in the lower half of the stomach but may also be seen at the fundus. They are usually smaller than 3 cm but occasionally may be large at the time of diagnosis. Ulceration of the mucosa overlying the tumor is reported in 50 – 70% of tumors larger than 2 cm in diameter. Most gastric leiomyomas present as endogastric submucosal lesions and may be pedunculated but some, originatin from the serosa, develop mainly as exogastric masses. 

 

Gastrointestinal Stromal Tumor

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Endoscopy of Gastrointestinal Stromal Tumor

Lateral view of this submucosal tumor.

The classic or usual GI tract GIST has a similar morphologic appearance to leiomyomas in other organs. In the gut, they are usually small, and well circumscribed. The tumors typically arise from the muscularis propria; growth may be intraluminal, extraluminal, or a combination with a dumb-bell shape. GIST can range in size from less than 0.5 cm (microgist) to as large as 30 cm.

 

Gastrointestinal Stromal Tumor

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Endoscopy of Gastrointestinal Stromal Tumor

Upper endoscopy image showing Gastrointestinal Stromal Tumor (GIST)

Most GIST of stomach are asymptomatic but ulceration may cause pain and signs of gastrointestinal bleeding.

Microscopically, GIST are formed of fasicles of benign-appearing spindle cells without nuclear atypia; mitoses are sparse or absent, and necrosis virtually never occurs. The nucleus is centrally located and oval but may be displaced to one side by distinct vacuoles suggesting signet-ring cells. These vacuoles do not contain fat or mucosubstances, which differentiates them from liposarcomas and carcinomas.


 

Gastrointestinal Stromal Tumor

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Endoscopy of Gastrointestinal Stromal Tumor

Magnifycation of the tip of the GIST. A Magnifying
endoscope was used.

 

Gastrointestinal Stromal Tumor

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Endoscopy of Gastrointestinal Stromal Tumor

Some biopsies were taken and proved to be a GIST

 

Gastrointestinal Stromal Tumor

Video Endoscopic Sequence 1 of 3.

Gastric Gastrointestinal Stromal Tumor (GIST)

This 59 year-old, female presented with abdominal pain and melena.

Gastrointestinal stromal tumors (GISTs) are mesenchymal neoplasms of the gastrointestinal (GI) tract and are thought to develop from the interstitial cells of Cajal, innervated cells associated with the Auerbach plexus. GISTs are typically defined by the expression of c-KIT (CD117) in the tumor cells, as these activating KIT mutations are seen in 85-95% of GISTs. About 3-5% of the remainder of KIT -negative GISTs contain PDGFR alpha mutations.

 

Video Endoscopic Sequence 2 of 3.

This image and the video clips shows the diameter of the tumor.

The discovery in 2000 of the efficacy of imatinib, an inhibitor of the BCR-ABL oncoprotein used in the treatment of chronic myeloid leukemia (CML), in treating metastatic gastrointestinal stromal tumor has revolutionized the care of patients with GISTs. Prior to the advent of immunohistochemical methods enabling the specific identification of c-KIT positive tumors, these tumors were inaccurately classified as gastric or intestinal smooth muscle tumors (leiomyomas or leiomyosarcomas).

 

Gastrointestinal Stromal Tumor

Video Endoscopic Sequence 3 of 3.

Note the submucosal tumor mass with the classic features of central umbilication and ulceration.

GISTs are typically diagnosed as solitary lesions, although in rare cases, multiple lesions can be found. These tumors can grow intraluminally or extraluminally toward adjacent structures. When the growth pattern is extraluminal, patients can harbor the disease symptom free for an extended period and present with very large exogastric masses.

Distant metastases tend to appear late in the course of the disease in most cases. In contrast to other soft tissue tumors, the common metastatic sites of GISTs are the liver and peritoneum. Lymph node involvement is rare, occurring in only 0-8% of cases.

 

Gastrointestinal Stromal Tumor

Video Endoscopic Sequence 1 of 9.

Gastrointestinal Stromal Tumor (GIST)

This is a 80 year-old,female who present with upper gastrointestinal hemorrhage, endoscopy found a large ulcerated mass.


 

 

 

 

Gastrointestinal Stromal Tumor

Video Endoscopic Sequence 2 of 9.

Gastroscopy showed a large sub mucosal tumor


 

 

 

Gastrointestinal Stromal Tumor

Video Endoscopic Sequence 3 of 9.

Endoscopy of Gastrointestinal Stromal Tumor

 

Gastrointestinal Stromal Tumor

Video Endoscopic Sequence 4 of 9.

Endoscopic Image of Gastrointestinal Stromal Tumor (GISTs)

 

 

Gastrointestinal Stromal Tumor

Video Endoscopic Sequence 5 of 9.

Endoscopic View of Gastrointestinal Stromal Tumor (GIST)

A palpable abdominal mass is the most frequent presentation but 50% of GISTs are silent until they reach a large size, then causing acute massive hemorrhage into the intestinal tract or peritoneal cavity from tumor rupture. This is the second most common presentation. Other presenting symptoms include nausea, dyspepsia and intestinal obstruction as a result of extrinsic compression.

 

 

 

Gastrointestinal Stromal Tumor

Video Endoscopic Sequence 6 of 9.

Endoscopy of Gastrointestinal Stromal Tumor

 

Gastrointestinal Stromal Tumor

Video Endoscopic Sequence 7 of 9.

Endoscopy of Gastrointestinal Stromal Tumor


 

Gastrointestinal Stromal Tumor

Video Endoscopic Sequence 8 of 9.

Gastrointestinal Stromal Tumor (GIST)

Surgical specimen obtained by laparoscopy and assisted endoscopy.

Click on the image to enlarge

Gastrointestinal Stromal Tumor

Video Endoscopic Sequence 9 of 9.

Gastrointestinal Stromal Tumor (GIST)

Surgical specimen obtained by laparoscopy and assisted endoscopy.

Click on the image to enlarge

 

Gastrointestinal Stromal Tumor

Multiple Gastric Gastrointestinal Stromal Tumor (GIST)

A 20 year-old female that have been under anemia screening. Endoscopically multiples gastric leiomiomas in the posterior wall of the stomach from the antrum to the fundus were found. The patient underwent a subtotal gastrectomy and local resection of leiomiomas of the fundus was performed. Medical literature describes five similar cases reported previously. 

 

Gastrointestinal Stromal Tumor (GIST)

Video Endoscopic Sequence 1 of 65.

Gastrointestinal Stromal Tumor (GIST).

This 42 year-old lady who underwent a routine endoscopy, a submucosa mass was found, a laparoscopic resection is performed with the attends of GI endoscopy.

 

Video Endoscopic Sequence 2 of 65.

Retroflexed image.

Gastrointestinal stromal tumors (GISTs) are rare.
Nevertheless, some may present with a life-threatening
hemorrhage or intestinal obstruction.

 

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Due to this ulcer some biopsies were taken.

 

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We tried to banding this submucous mass, but due to the size a little greater, we did not continue treating.

 

 

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Biopsies of great size were taken.

 

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Adrenalin dilution of 1/10000 and 50% Dextrose.

 

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Video Endoscopic Sequence 11 of 65.

Patient underwent an assisted laparoscopic resection.

Patient underwent a laparoscopic resection.

This video sequence shows the laparoscopic steps of this
surgery.

The increased use of laparoscopy in the management of
gastrointestinal problems continues to expand. Procedures
such as jejunostomies, diagnosis of intestinal obstruction or
ischemia, resection of the small bowel, and lysis of
adhesions can be managed with this technique
.

 

Video Endoscopic Sequence 12 of 65.

The surgeon is performing some marks were the exact site of the submucosa mass will be resected. 


Video Endoscopic Sequence 13 of 65.

This video clip shows the light of the laparoscope that transluminate through the gastric mucosa.

 

Video Endoscopic Sequence 14 of 65.

Laparoscopic resection was planned after the abdominal
distension subsided. Pneumoperitoneum was established
with a Veress needle. A 5mm trocar was introduced in the
umbilical incision; a 5mm (0°) telescope was introduced and
the other two 5mm ports were inserted under vision – one
in the right midclavicular line and the other in the left
midclavicular line, below the level of the umbilicus.

 

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For many GI malignancies, laparoscopic surgery is safe
and technically feasible, albeit with a somewhat longer
learning curve compared to open surgery. Advanced
procedures are technically demanding and require more
operative time.

 

Video Endoscopic Sequence 17 of 65.

Surgery remains the standard for nonmetastatic
gastrointestinal stromal tumors (GISTs). Laparoscopic
surgery should be considered for these tumors as their
biologic behavior lends them to curative resection without
requiring large margins or extensive lymphadenectomies.

 

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Intraoperative video clip showing the linear stampler
applied to the stomach.

Stapled laparoscopic resection is a safe and effective
treatment option for nonmetastatic primary jejunal GIST

 

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Low power: Stromal tumor showing the muscularis
propria of stomach.

 

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