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doi:10.3748/wjg.15.3376
ORIGINAL ARTICLES
Gwang Ha Kim, Do Youn Park, Suk Kim, Dae Hwan Kim, Dong Heon Kim, Cheol Woong Choi, Jeong Heo,
Geun Am Song
Gwang Ha Kim, Cheol Woong Choi, Jeong Heo, Geun
Am Song, Department of Internal Medicine, Pusan National
University School of Medicine and Medical Research Institute,
Pusan National University Hospital, Busan 602-739, South Korea
Do Youn Park, Department of Pathology, Pusan National
University School of Medicine, Busan 602-739, South Korea
Suk Kim, Department of Radiology, Pusan National University
School of Medicine, Busan 602-739, South Korea
Dae Hwan Kim, Dong Heon Kim, Department of Surgery,
Pusan National University School of Medicine, Busan 602-739,
South Korea
Author contributions: Kim GH, Park DY and Song GA
designed the research; Kim S, Kim DH, Choi CW and Heo J
performed the research; Kim GH and Kim DH analyzed the
data; Kim GH wrote the paper.
Supported by A Medical Research Institute Grant (2008-1),
Pusan National University and a grant from the National R&D
Program for Cancer Control, Ministry for Health, Welfare and
Family affairs, Republic of Korea (0920050)
Correspondence to: Geun Am Song, MD, PhD, Department
of Internal Medicine, Pusan National University School of
Medicine and Medical Research Institute, Pusan National
University Hospital, 1-10 Ami-dong, Seo-Gu, Busan 602-739,
South Korea. gasong@pusan.ac.kr
Telephone: +82-51-2407869 Fax: +82-51-2448180
Received: April 9, 2009
Revised: June 13, 2009
Accepted: June 20, 2009
Published online: July 21, 2009
Abstract
AIM: To evaluate the ultrasonography (EUS) features
of gastric gastrointestinal stromal tumors (GISTs)
as compared with gastric leiomyomas and then to
determine the EUS features that could predict malignant
GISTs.
METHODS: We evaluated the endoscopic EUS features
in 53 patients with gastric mesenchymal tumors
confirmed by histopathologic diagnosis. The GISTs were
classified into benign and malignant groups according to
the histological risk classification.
RESULTS: Immunohistochemical analyses demon
strated 7 leiomyomas and 46 GISTs. Inhomogenicity,
hyperechogenic spots, a marginal halo and higher
echogenicity as compared with the surrounding muscle
layer appeared more frequently in the GISTs than in
Kim GH, Park DY, Kim S, Kim DH, Kim DH, Choi CW, Heo
J, Song GA. Is it possible to differentiate gastric GISTs from
gastric leiomyomas by EUS? World J Gastroenterol 2009;
15(27): 3376-3381 Available from: URL: http://www.wjgnet.
com/1007-9327/15/3376.asp DOI: http://dx.doi.org/10.3748/
wjg.15.3376
INTRODUCTION
Mesenchymal tumors of the gastrointestinal tract are
usually incidentally discovered as a firm, protruding
submucosal lesion during upper gastrointestinal
examinations for unrelated conditions, although the larger
tumors may occasionally cause bleeding[1]. Pathologically,
most of these tumors are composed of spindle cells
and display smooth muscle differentiation. In recent
years, with the advance of immunohistochemistry, it is
known that most gastric and small bowel mesenchymal
tumors are gastrointestinal stromal tumors (GISTs) that
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3377
Table 1 Proposed approach for defining the risk of aggressive
behavior in GISTs
Size (cm)
Mitotic count
< 2
2-5
<5
5-10
>5
> 10
Any size
RESULTS
EUS features differentiating GISTs from leiomyomas
Immunohistochemical analyses demonstrated that 7 cases
were leiomyomas and 46 cases were GISTs. The baseline
characteristics and endosonographic features are shown in
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3378
ISSN 1007-9327
CN 14-1219/R
World J Gastroenterol
Leiomyomas
(n = 7)
Gender
Male
2 (28.6)
Female
5 (71.4)
Age (yr, mean SD)
52.6 13.5
Location
Upper
6 (85.7)
Middle
0 (0)
Lower
1 (14.3)
Originating layer
Second layer
0
Third layer
2 (28.6)
Fourth layer
5 (71.4)
Size (cm, mean SD)
3.6 2.6
Ulcer
Absent
7 (100)
Present
0 (0)
Growth
In
6 (85.7)
Out
1 (14.3)
Border
Regular
7 (100)
Irregular
0 (0)
Lobulation
Absent
5 (71.4)
Present
2 (28.6)
Marginal halo
Absent
6 (85.7)
Present
1 (14.3)
Echogenicity in comparison with
the surrounding muscle echo
Isoechoic
7 (100)
Hyperechoic
0 (0)
Homogeneity
Homogenous
6 (85.7)
Inhomogenous
1 (14.3)
Cystic change
Absent
6 (85.7)
Present
1 (14.3)
Hyperechogenic spots
Absent
4 (57.1)
Present
3 (42.9)
Calcification
Absent
6 (85.7)
Present
1 (14.3)
GISTs
(n = 46)
P -value
EUS features
0.193
0.272
29 (63.0)
13 (28.3)
4 (8.7)
0.644
1 (2.2)
7 (15.2)
38 (82.6)
3.5 2.3
Number 27
0.686
20 (43.5)
26 (56.5)
57.5 8.4
Volume 15
0.967
0.172
31 (67.4)
15 (32.6)
Echogenicity in
comparison with the
surrounding muscle echo
Homogeneity
Echogenic foci
Marginal halo
Of the above 4 features
1
2
3
All
100
100
26.9
80.4
89.1
78.3
85.7
57.1
85.7
97.4
93.2
97.3
40.0
44.4
37.5
97.8
89.1
84.8
34.8
57.1
85.7
85.7
100
93.8
97.6
97.5
100
80.0
54.5
46.2
18.9
33 (71.7)
13 (28.3)
0.082
29 (63.0)
17 (37.0)
0.426
23 (50.0)
23 (50.0)
0.002
10 (21.7)
36 (78.3)
0.004
19 (41.3)
27 (58.7)
0.001
9 (19.6)
37 (80.4)
0.661
31 (67.4)
15 (32.6)
0.012
5 (10.9)
41 (89.1)
1.000
39 (84.8)
7 (15.2)
DISCUSSION
GISTs are rare neoplasms that account for less than
1% of all gastrointestinal malignancies. GISTs have the
capability to become malignant and then metastasize,
whereas leiomyomas are almost invariably benign[4]. In
clinical practice, preoperative differentiation between
GISTs and leiomyomas is usually difficult, even if
EUS-guided fine-needle aspiration or trucut biopsy is
performed[13-15]. Thus, if it were possible to differentiate
GISTs from leiomyomas and then to predict the
malignant potential of GISTs by EUS imaging, then
this would be essential in the clinical management of
gastrointestinal mesenchymal tumors. There have been
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Figure 1 EUS features of gastric mesenchymal tumors. A: A gastric leiomyoma. The mass is homogenous and its echogenicity is similar to that of the surrounding normal
muscle layer. It is 35 mm 13 mm in size and a marginal halo is not observed; B: A gastric GIST with low risk potential. The mass is inhomogenous and its echogenicity is
somewhat higher than that of the surrounding muscle layer. It is 25 mm 18 mm in size. A marginal halo (arrow) and hyperechogenic spots are seen; C: A gastric GIST with
high risk potential. The mass is inhomogenous and 82 mm 76 mm in size. A marginal halo, hyperechogenic spots and irregular border (arrow head) are seen.
1.0
Malignant GIST
(n = 13)
P -value
6.0 2.7
0.001
0.299
7 (53.8)
6 (46.2)
Sensitivity
0.8
Variables
0.6
0.4
0.145
7 (53.8)
6 (46.2)
0.2
0.044
5 (38.5)
8 (61.5)
0.0
0.0
0.2
0.743
6 (46.2)
7 (53.8)
0.240
0.4
0.6
Specificity
0.8
1.0
1 (7.7)
12 (92.3)
0.115
3 (23.1)
10 (76.9)
0.199
1 (7.7)
12 (92.3)
0.082
6 (46.2)
7 (53.8)
P value
9.3 (1.6-53.6)
8.7 (0.6-119.8)
2.3 (0.2-22.7)
2.2 (0.1-48.0)
1.4 (0.1-19.5)
0.013
0.105
0.490
0.606
0.800
1.000
1 (7.7)
12 (92.3)
0.385
10 (76.9)
3 (23.1)
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3380
ISSN 1007-9327
CN 14-1219/R
World J Gastroenterol
Volume 15
Number 27
ACKNOWLEDGMENTS
We gratefully acknowledge Eun Sook Hong, Soon Im
Choi and Eun Hee Bae for their dedicated assistance.
COMMENTS
COMMENTS
Background
Research frontiers
Most previous studies did not differentiate the EUS features of GISTs and
leiomyomas, and they did not characterize the EUS features of GISTs according
to the histological risk classification. In addition, they did not restrict the study
subjects to those with gastric mesenchymal tumors. Therefore, we evaluated
the EUS features of gastric GISTs in comparison with gastric leiomyomas, and
tried to determine the EUS features that could predict the malignant potential of
gastric GISTs according to the histological risk classification.
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Applications
Terminology
GISTs are mesenchymal tumors derived from the interstitial cells of Cajal. The
incidence of GISTs is 10-20 per million and the stomach is the most common
location of GISTs (60%-70%).
Peer review
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