Keywords
non-epithelial submucosal gastric lesions, endoscopic submucosal dissection, histopathological diagnosis, immunohistochemical study
How to Cite
Kuryk, O. G., Kolomoyets, M. Y., Yakovenko, V. O., & Tkachenko, R. P. (2018). Pathomorphological characteristics of non-epithelial submucosal gastric tumors removed by endoscopic submucosal dissection. Clinical and Preventive Medicine, (2-3), 103-115. https://doi.org/10.31612/2616-4868.2-5.2018.12
Abstract
Non-epithelial submucosal gastric lesions (NSGL) are frequently identified during routine upper endoscopies. Endoscopic ultrasonography is one of the most useful modalities for diagnosing NSGL. Endoscopic submucosal dissection (ESD) is an advanced endoscopic therapy for NSGL and ESD has rapidly become widely used. Histological diagnosis of the removed tumor is important for the further tactics and prognosis.
Methods. We studied clinical and morphological data of the 21 patients with NSGL who underwent ESD in our hospital “Oberig clinic” between 2009 and 2017 years. All patients underwent EUS before the procedure (Olympus EUS EXERA EU-M60, UM DP20-25R). ESD were performed by one experienced endoscopist. (Olympus Exera II, GIF Q-160Z; Olympus Exera III, GIF HQ-190).
Immunohistochemical staining for c-kit (CD117), DOG-1, CD34, desmin, smooth muscle antigen (SMA), or S-100 protein was performed to differentiate tumors of mesenchymal origin. Mesenchymal lesions that stained positive for SMA and desmin were diagnosed as leiomyomas. Lesions that stained positive for c-kit or DOG-1 and CD34 were diagnosed as GISTs. Lesions that stained positive for S-100, chromogranin A, neuron-specific enolase were diagnosed as neuroendocrine tumors. The malignant potential was categorized based on tumor size, mitotic counts and malignant potential was determined with Ki-67.
Results. The patients included 9 men and 14 women with a median age of 57 years (range: 25–67 years). On EUS, 18 tumors (81%)(79%; 95% confidence interval 62,4-95,6%) were located in the submucosal layer and 5 (21%; 95% confidence interval 4,4-37,6%) – in the muscularis propria layer. Median tumor size was 10 mm (range: 4–35 mm). The tumor sizes were ≤ 20 mm in 19 lesions (86%; 95% confidence interval 71,8-100%) and > 20 mm in 4 (14%; 95% confidence interval 0-28,2%). The histological diagnoses were neuroendocrine tumor (n = 9), GIST (n = 5), leiomyoma (n = 4), inflammatory fibrinoid polyp (n = 2), glomus tumor (n = 1), calcifying fibrous tumour (n = 1), aberrant pancreas (n = 1).
Conclusion. The ESD is an effective and safe treatment for gastric SMTs, which can resect the whole lesion. The final histopathological diagnosis for most NSGL is only possible after the immunohistochemical study.
References
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2. Skorik V. R. (2015). Definition of diagnostic and prognostic value of tumor-specific markers (CD117, DOG1, CD34, PDGFR-A), indicators of muscle (SMA, MSA, desmin) and hipohennoyi (S100) differentiation, expression of Ki-67, P16, P21 in gastrointestinal stromal tumors. Morphology, 3, 74-82. [In Ukrainian].
3. Shponka I. S., Yakovenko V. R. (2014). Definition of muscle differentiation markers SMA and MSA in CD117-positive and CD117-negative Ki-67 in gastrointestinal stromal tumors with different malignant potential. Pathology, 2 (31), 38-41. [In Ukrainian].
4. Agaimy A., Terracciano L. M., Dirnhofer S., Tornillo L., Foerster A., Hartmann A., Bihl M. P. (2009). V600E BRAF mutations are alternative early molecular events in a subset of KIT/PDGFRA wild-type gastrointestinal stromal tumours. J. Clin. Pathol. 62(4). P. 613–616. doi: 10.1136/jcp.2009.064550.
5. Akbulut S. (2012). Intussusception Due to Inflammatory Fibroid Polyp: A Case Report and Comprehensive Literature Review. World J. Gastroenterol., 18(40), 5745-5752. doi.org/10.3748/wjg.v18.i40.5745.
6. Andersson J., Bümming P., Meis-Kindblom J.M., Sihto H., Nupponen N., Joensuu H., Odén A., Gustavsson B., Kindblom L.G., Nilsson B. (2006). Gastrointestinal stromal tumors with KIT exon 11 deletions are associated with poor prognosis. Gastroenterology, 130(2), 1573–1581. DOI:10.1053/j.gastro.2006.01.043.
7. Attila T., Chen D., Gardiner W.G., Ptak W.T., Marcon N.E. (2006). Gastric calcifying fibrous tumour. Can. J. Gastroenterol., 20(7), 487–489.
8. Belev B., Brčić I., Prejac J., Golubić Z.A., Vrbanec D., Božikov J., Alerić I,. Boban M., Razumović J. J. (2013). Role of Ki-67 as a prognostic factor in gastrointestinal stromal tumors. World Journal of Gastroenterology, 19(4), 523-527. doi: 10.3748/wjg.v19.i4.523.
9. Białek A., Wiechowska-Kozłowska A., Pertkiewicz J., Polkowski M., Milkiewicz P., Karpińska K., Ławniczak M., Starzyńska T. (2012). Endoscopic submucosal dissection for treatment of gastric subepithelial tumors (with video). Gastrointest Endosc., 75(5), 276–286. DOI:10.1016/j.gie.2011.08.029.
10. Buicko J. L., Fakhoury E., Lopez M. A., Lopez-Viego M. A. (2012). Surgical Resection of a Rare Inflammatory Fibroid Polyp of the Stomach: A Case Review. Journal of Current Surgery, 2(2), 70-72. DOI:10.4021/jcs49w.
11. Chenn H., Hirota S., Isozaki K., Sun H., Ohashi A., Kinoshita K., O’Brien P., Dardick I., Obayashi T., Okazaki T., Shinomura Y., Matsuzawa Y., Kitamura Y. (2002). Polyclonal nature of diffuse proliferation of interstitial cells of Cajal in patients with familial and multiple gastrointestinal stromal tumours. Gut, 51(6), 793–796.
12. Chen L.L., Holden J.A., Choi H., Zhu J., Wu E.F., Jones K.A., Ward J.H., Andtbacka R.H., Randall R.L., Scaife C.L., Hunt K.K., Prieto V.G., Raymond A.K., Zhang W., Trent J.C., Benjamin R.S., Frazier M.L. (2008). Evolution from heterozygous to homozygous KIT mutation in gastrointestinal stromal tumor correlates with the mechanism of mitotic nondisjunction and significant tumor progression. Mod. Pathol., 21(7), 826–836. doi: 10.1038/modpathol.2008.46.
13. Chou H.P., Tiu C.M., Chen J.D., Chou Y.H. (2010). Glomus tumor in the stomach. Abdom. Imaging, 35(4), 90–392. DOI: 10.3892/ol.2014.1986.
14. Chun S. Y., Kim K. O., Park D. S., Lee I. J., Park J. W., Moon S. H., Baek I. H., Kim J. H., Park C. K., Kwon M. J. (2013). Endoscopic submucosal dissection as a treatment for gastric subepithelial tumors that originate from the muscularis propria layer: a preliminary analysis of appropriate indications. Surg. Endosc., 27 (9), 3271–3279. doi: 10.1007/s00464-013-2904-9.
15. Corless C. L., Barnett C. M., Heinrich M. C. (2011). Gastrointestinal stromal tumours: origin and molecular oncology. Nat. Rev. Cancer., 11(12), 865-878. doi: 10.1038/nrc3143.
16. Daniels M., Lurkin I., Pauli R., Erbstösser E., Hildebrandt U., Hellwig K., Zschille U., Lüders P, Krüger G., Knolle J., Stengel B., Prall F., Hertel K., Lobeck H., Popp B., Theissig F., Wünsch P., Zwarthoff E., Agaimy A., Schneider-Stock R. (2011). Spectrum of KIT/PDGFRA/BRAF mutations and Phosphatidylinositol-3-Kinase pathway gene alterations in gastrointestinal stromal tumors (GIST). Cancer Lett., 312 (1), 43–54. doi: 10.1016/j.canlet.2011.07.029.
17. Daum O., Hatlova J., Mandys V., Grossmann P., Mukensnabl P., Benes Z., Michal M. (2010). Comparison of morphological, immunohistochemical, and molecular genetic features of inflammatory fibroid polyps (Vanek's tumors). Virchows Arch., 456(5), 491-497. doi: 10.1007/s00428-010-0914-8.
18. Fang H.Q., Yang J., Zhang F.F., Cui Y., Han A.J. (2010). Clinicopathological features of gastric glomus tumor. World J. Gastroenterol., 16(36), 4616–4620. doi: 10.3748/wjg.v16.i36.4616.
19. Fujii M., Kawamoto H., Nagahara T. (2011). A case of gastric aberrant pancreas diagnosed with EUS-guided FNA. Gastrointestinal Endoscopy, 74(2), 407–408.
20. He Z., Sun C., Wang J., Zheng Z., Yu Q., Wang T., Chen X., Liu W., Wang B. (2013). Efficacy and safety of endoscopic submucosal dissection in treating gastric subepithelial tumors originating in the muscularis propria layer: a single-center study of 144 cases. Scand. J. Gastroenterol., 48(12), 1466–1473. doi: 10.3109/00365521.2013.845796.
21. Iwamuro M., Tsuzuki T., Ohya S., Okada H., Tanaka T., Hori K., Kita M., Kawano S., Kawahara Y., Yamamoto K. (2015). Ectopic Pancreas in the Stomach Successfully Resected by Endoscopic Submucosal Dissection. Case Reports in Medicine,Volume 2015, Article ID 147927, 5 pages. http://dx.doi.org/10.1155/2015/147927.
22. Jung S. H., Suh K. S., Kang D. Y., Kang D. W., Kim Y. B., Kim E. S. (2011). Expression of DOG1, PDGFRA, and p16 in gastrointestinal stromal tumors. Gut and Liver, 5(2), 171-180. doi: 10.5009/gnl.2011.5.2.171.
23. Kang G., Park H. J., Kim J., Choi D., Min B. H., Lee J. H., Kim J. J., Kim K.-M., Park C. K., Sohn T. S., Kim S. (2012). Glomus Tumor of the Stomach: A Clinicopathologic Analysis of 10 Cases and Review of the Literature. Gut and Liver, 6(1)1, 52-57. http://dx.doi.org/10.5009/gnl.2012.6.1.52.
24. Kim S. Y., Kim K. O. (2016). Management of gastric subepithelial tumors: The role of endoscopy. World J. Gastrointest.. Endosc., 8(11), 418–424. doi: 10.4253/wjge.v8.i11.418.
25. Lasota J., Corless C.L., Heinrich M.C., Debiec-Rychter M., Sciot R., Wardelmann E., Merkelbach-Bruse S., Schildhaus H.U., Steigen S.E., Stachura J., Wozniak A., Antonescu C., Daum O., Martin J., Del Muro J.G., Miettinen M. (2008). Clinicopathologic profile of gastrointestinal stromal tumors (GISTs) with primary KIT exon 13 or exon 17 mutations: a multicenter study on 54 cases. Mod. Pathol., 21(4), 476-84. doi: 10.1038/modpathol.2008.2.
26. Liu T. C., Lin M. T., Montgomery E. A., Singhi A. D. (2013). Inflammatory fibroid polyps of the gastrointestinal tract: spectrum of clinical, morphologic, and immunohistochemistry features. Am. J. Surg. Pathol., 7(4), 586-592. doi: 10.1097/PAS.0b013e31827ae11e.
27. Liu X., Wang G., Ge H. (2013). Endoscopic removal of symptomatic gastric heterotopic pancreas: a report of nine cases. Surgical Innovation, 20(6), 40–46, doi.org/10.1177/1553350613499453.
28. Maehata T., Goto O., Takeuchi H., Kitagawa Y., Yahagi N. (2015). Cutting edge of endoscopic full-thickness resection for gastric tumor. World J. Gastrointest. Endosc., 7(16), 1208-1215. doi: 10.4253/wjge.v7.i16.1208.
29. Miettinen M., Lasota J. (2011). Histopathology of gastrointestinal stromal tumor. Journal of surgical oncology. J. Surg. Oncol., 104(8), 865-73. doi: 10.1002/jso.21945.
30. Morales-Fuentes G. A., de Arino-Suarez M., Zarate-Osorno A., Rodriguez-Jerkov J., Terrazas-Espitia F., Perez-Manauta J. (2011). Vanek's polyp or inflammatory fibroid polyp. Case report and review of the literature. Cir. Cir., 79(3), 242-245.
31. Nascimento E. F., Fonte F. P., Mendonça R. L, Nonose R., de Souza C.A., Martinez C. A. (2011). Glomus tumor of the stomach: a rare cause of upper gastrointestinal bleeding. Case Rep. Surg., 2011. 37. 1082. doi: 10.1155/2011/371082.
32. Paikos D., Moschos J., Tzilves D., Koulaouzidis A., Kouklakis G., Patakiouta F., Kontodimou K.,Tarpagos A., Katsos I. Inflammatory Fibroid Polyp or Vanek’s Tumour. (2007). Dig. Surg., 24(2), 231–233. DOI: 10.1159/000103326.
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