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doi:10.3748/wjg.15.3376

World J Gastroenterol 2009 July 21; 15(27): 3376-3381

World Journal of Gastroenterology ISSN 1007-9327

2009 The WJG Press and Baishideng. All rights reserved.

ORIGINAL ARTICLES

Is it possible to differentiate gastric GISTs from gastric

leiomyomas by EUS?

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

the leiomyomas (P < 0.05). The presence of at least

two of these four features had a sensitivity of 89.1%
and a specificity of 85.7% for predicting GISTs. Except
for tumor size and irregularity of the border, most of
the EUS features were not helpful for predicting the
malignant potential of GISTs. On multivariate analysis,
only the maximal diameter of the GISTs was an
independent predictor. The optimal size for predicting
malignant GISTs was 35 mm. The sensitivity and
specificity using this value were 92.3% and 78.8%,
respectively.
CONCLUSION: EUS may help to differentiate gastric
GISTs from gastric leiomyomas. Once GISTs are
suspected, surgery should be considered if the size is
greater than 3.5 cm.
2009 The WJG Press and Baishideng. All rights reserved.

Key words: Endoscopic ultrasonography; Gastro

intestinal stromal tumor; Stomach
Peer reviewer: Georgios Papachristou, MD, Assistant Professor
of Medicine, Division of Gastroenterology, Hepatology and
Nutrition, UPMC Presbyterian, Mezzanine Level, C-Wing, 200
Lothrop Street, Pittsburgh, PA 15213, United States

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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Kim GH et al . Endosonographic features of gastric GISTs

are derived from the interstitial cells of Cajal[1-3]. The

incidence of GISTs is 10-20 per million with the stomach
being the most common location as 60% to 70% of
GISTs arise in this organ[4].
Endoscopic ultrasonography (EUS) is a valuable
imaging tool for the diagnosis and evaluation of gastric
GISTs. Gastric GISTs generally appear as round,
hypoechoic lesions with a ground-glass echo texture,
and these lesions are contiguous with the fourth layer
of the stomach[5-7]. Several studies have attempted to
differentiate benign and malignant stromal tumors on
the basis of their EUS features[6-11]. However, most of
these studies were performed before the concept of
GISTs was introduced and they included non-gastric
tumors in their study samples. In addition, little is known
about differentiating GISTs and leiomyomas by EUS[11].
Therefore, the aim of this study was to evaluate
the EUS features of gastric GISTs in comparison with
gastric leiomyomas, and we wanted to determine if
the EUS features could predict the malignant potential
of gastric GISTs according to the histological risk
classification.

MATERIALS AND METHODS

Patients
From July 2005 to June 2008, the medical records of
all patients with histopathologically proven gastric
leiomyomas or GISTs who underwent EUS examination
at our endoscopic unit were retrospectively reviewed.
There were 53 patients (22 men and 31 women), with a
mean age of 59 years (range 29-75 years). The histologic
specimens were obtained by surgical resection in 50
patients (94.3%), by needle biopsy in two patients (3.8%),
and by endoscopic resection in 1 patient (1.9%). This
study was reviewed and approved by the Institutional
Review Board at Pusan National University Hospital.
Histopathology
The tumors were histopathologically proved to be
gastric mesenchymal tumors and they were classified
immunohistochemically as leiomyomas or GISTs[3]. In
particular, the leiomyomas were defined as being desmin
positive and c-kit (CD117) negative tumors and the
GISTs were defined as being c-kit positive tumors. The
GISTs were divided into 4 groups in accordance with the
consensus meeting report at the National Institute of
Health (Table 1)[12]. Then, the GISTs with a very low risk
or low risk were defined as benign GISTs, and the GISTs
with an intermediate risk or high risk were defined as
malignant GISTs.
EUS
EUS was performed with a radial scanning ultrasound
endoscope (GF-UM2000; Olympus, Tokyo, Japan)
using scanning frequencies of 7.5 and 12 MHz. All the
examinations were performed under intravenous conscious
sedation (midazolam with or without meperidine).
Scanning of the tumor was performed after filling the
stomach with 400-600 mL of deaerated water. About

3377
Table 1 Proposed approach for defining the risk of aggressive
behavior in GISTs

Very low risk

Low risk
Intermediate risk
High risk

Size (cm)

Mitotic count

< 2
2-5
<5
5-10
>5
> 10
Any size

< 5/50 HPF

< 5/50 HPF
6-10/50 HPF
< 5/50 HPF
> 5/50 HPF
Any mitotic rate
> 10/50 HPF

HPF: High-power field.

10-20 endosonograms were recorded for each patient,

and these images were stored on magneto-optical disks.
A review of the EUS photos was performed by a single
experienced endosonographer (Kim GH) who was kept
blinded to the final diagnosis, and this endosonography
had previously performed more than 1000 examinations.
The following EUS features were recorded for all the
tumors: (a) the maximal diameter, (b) the presence of
mucosal ulceration on endoscopy and/or EUS, (c) the
echogenicity in comparison with the surrounding normal
proper muscle layer (hyperechoic or isoechoic), (d) the
homogeneity (homogenous or heterogenous), (e) the
presence of a marginal halo and lobulation, (f) the presence
of cystic spaces, hyperechogenic spots and calcification, (g)
the regularity of the marginal border (regular or irregular)
and (h) the pattern of tumor growth (inside or outside the
gastric wall).
Statistical analysis
The differences in gender and the EUS findings between
leiomyomas and GISTs were assessed using the 2 test
or Fishers exact test, and the patient age and tumor size
were assessed using the Student t-test. Calculation of
the sensitivity, specificity and the positive and negative
predictive values of each EUS feature and combinations
of these features for differentiating GISTs from
leiomyomas were carried out manually.
Univariate analyses using the 2 test or Fishers exact
test were performed to identify the EUS features that
could predict malignant GISTs. Multivariate logistic
regression analyses were performed to identify the
independent predictors of malignant GISTs. The odds
ratios and their 95% confidence intervals were used to
predict malignant GISTs. Receiver operating characteristic
(ROC) curve was applied to find the best sensitivity and
specificity cut-off value of the tumor size for predicting
malignant GISTs. A P value < 0.05 was considered
statistically significant. The statistical calculations were
performed using the SPSS version 12.0 for Windows
software (SPSS Inc., Chicago, IL, USA).

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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World J Gastroenterol

Table 2 Baseline characteristics and EUS features of the

patients with leiomyomas and GISTs of the stomach n (%)
Variables

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)

July 21, 2009

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

Table 3 Sensitivity, specificity and positive and negative

predictive values of the EUS features that differentiate GISTs
from leiomyomas in the stomach (%)

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

Sensitivity Specificity Positive Negative

predictive predictive
value
value
58.7

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

Values are expressed as percentages.

0.660

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)

Table 2. The tumor size and presence of ulceration were

not different between the leiomyomas and the GISTs.
A marginal halo appeared more frequently in the GISTs
than in the leiomyomas (P = 0.002). The echogenicity
of all the leiomyomas was nearly similar to that of the
surrounding normal proper muscle layer, but more than
half of the GISTs showed higher echogenicity than that
of the surrounding normal muscle layer (Figure 1) (P =
0.004). Inhomogeneity of the tumor and hyperechogenic
spots were observed more frequently in the GISTs than in
the leiomyomas (P < 0.05).
Table 3 shows the value of each EUS feature for
differentiating GISTs from leiomyomas. Each criterion
had a high positive predictive value, but limited
sensitivity or specificity. The presence of at least two of
these four features in a given tumor had a sensitivity of
89.1%, a specificity of 85.7%, a positive predictive value

of 97.6% and a negative predictive value of 54.5% for

predicting GISTs.
EUS features predicting malignant potential of GISTs
When the GISTs were classified into benign and malignant
groups according to the histological risk classification, 33
cases were grouped as benign GISTs (very low risk, 11
cases; low risk, 22 cases) and 13 cases as malignant GISTs
(intermediate risk, 8 cases; high risk, 5 cases). Except for
the size and irregularity of the tumor border, most of the
endosonographic features were not helpful in predicting the
malignant potential of GISTs (Figure 1, Table 4). On the
multivariate logistic regression analysis, only the maximal
diameter of the GISTs was an independent predictor (OR,
9.3; 95% CI, 1.6-53.6) (Table 5). A ROC curve was created
to identify the discriminative value of size for predicting the
malignant potential of GISTs (Figure 2). The sensitivity was
almost optimized when the critical value of the size was
35 mm. Of the 19 patients with a tumor size 35 mm,
12/19 (63.2%) were malignant GISTs. However, of the
27 patients with a size < 35 mm, 26 (96.3%) were benign
GISTs and 1 (3.7%) was a malignant GIST. Therefore, this
model of prediction for malignant GISTs had a positive
predictive value of 63.2% and a negative predictive value
of 96.3%. This resulted in a sensitivity of 92.3% and a
specificity of 78.8%.

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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Kim GH et al . Endosonographic features of gastric GISTs

3379

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

Table 4 Univariate analysis of EUS features between benign

and malignant GISTs of the stomach n (%)
Benign GIST
(n = 33)

Size (cm, mean SD)

2.5 1.0
Ulcer
Absent
24 (72.7)
Present
9 (27.3)
Growth
In
26 (78.8)
Out
7 (21.2)
Border
Regular
24 (72.7)
Irregular
9 (27.3)
Lobulation
Absent
17 (51.5)
Present
16 (48.5)
Marginal halo
Absent
9 (27.3)
Present
24 (72.7)
Echogenicity in comparison with
the surrounding muscle echo
Isoechoic
16 (48.5)
Hyperechoic
17 (51.5)
Homogeneity
Homogenous
8 (24.2)
Inhomogenous
25 (75.8)
Cystic changes
Absent
25 (75.8)
Present
8 (24.2)
Hyperechogenic spots
Absent
4 (12.1)
Present
29 (87.9)
Calcification
Absent
29 (87.9)
Present
4 (12.1)

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

Figure 2 Receiver operating characteristic (ROC) curve of the tumor size

for predicting malignant GISTs in the stomach.

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)

Table 5 Multivariate analysis of EUS features between benign

and malignant GISTs of the stomach
Variables
Size
Growth
Border
Homogenicity
Cystic change

Odds ratio (95% CI)

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)

several studies that have attempted to differentiate

benign from malignant stromal tumors based on their
EUS features [2,5-11]. However, most of these 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 the gastric mesenchymal tumors.
Initially, we tried to find the EUS features that could

differentiate GISTs from leiomyomas. In a previous

study[9], the EUS features such as size greater than 4 cm,
ulceration or cystic foci were almost exclusively seen
in CD-117 positive tumors as compared with CD-117
negative tumors. In that study, immunohistochemical
staining such as for desmin or S-100 was not performed,
so the CD-117 negative tumors were not homogenous;
i.e. they may have been leiomyomas or schwannomas. In
the present study, we restricted the subjects to compare
GISTs with only leiomyomas, and the latter are almost
invariably benign. As a result, tumor size and the presence
of ulceration and cystic changes in the tumor were not
helpful for differentiating GISTs from leiomyomas in this
study. Instead, inhomogenicity, hyperechogenic spots, a

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World J Gastroenterol

marginal halo and higher echogenicity in comparison with

the surrounding muscle layer were helpful for predicting
GISTs. Especially, if at least two of these four features are
present, then the sensitivity and specificity for predicting
GISTs were 89.1% and 85.7%, respectively. This result
is similar to the results of a previous report[11] that a
marginal halo and the relatively higher echogenicity, as
compared to the adjacent normal muscular layer on EUS,
might suggest GISTs. In addition, the previous reports,
which were carried out before the concept of GISTs
was introduced, have suggested that inhomogeneity
and hyperechogenic spots are the EUS features that are
predictive of malignancy[6,7].
A hypoechoic halo is a well known characteristic
ultrasonographic sign of malignant liver tumors such
as hepatocellular carcinoma[16]. A pseudocapsule of the
collapsed surrounding tissues, which is the result of an
expansively growing tumor, is thought to be the cause of
the halo in malignant liver tumors[16]. A previous study
showed that on pathologic examination, the tumor cells of
GISTs were partially or completely circumscribed by the
residual muscle tissues of the surrounding muscular propria
and this formed a capsule-like structure[11]. In the present
study, a marginal halo was found in 78.3% of GISTs,
whereas this was seen in only 14.3% of leiomyomas.
In this study, higher echogenicity in comparison
with the surrounding muscle layer was found in more
than half of GISTs, whereas the echogenicity of the
leiomyomas was nearly equal to that of the surrounding
muscle layer. Pathologically, it is well known that the
cellularity of leiomyomas is normal to moderate with
eosinophilic cytoplasm, whereas GISTs show higher
overall cellularity, which creates a basophilic appearance
on hematoxylin and eosin staining [1-3]. It is assumed
that the difference in echogenicity between GISTs and
leiomyomas might reflect these pathologic differences of
cellularity and the structural components of the tumors.
Second, we tried to find the EUS features that
could predict the malignant potential of GISTs after
dividing the GISTs into 2 groups (benign and malignant)
according to the histological risk classification. Previous
studies have suggested that a large size, exogastric
growth, ulceration, cystic changes, hyperechogenic foci
and irregularity of the margin favored a diagnosis of
malignant gastrointestinal mesenchymal tumors[6,7,17,18],
but these studies were performed before the concept of
GISTs had been introduced, as was mentioned earlier.
In the present study, only tumor size and irregularity
of the border were helpful in predicting the malignant
potential of GISTs. Multivariate logistic regression
analysis showed that only size was an independent
predictor, which is consistent with a previous report
that conducted multivariate analysis according to the
histological risk classification of GISTs [10]. With the
critical size of 35 mm, the sensitivity and specificity were
92.3% and 78.8%, respectively. This could be explained
by the fact that tumor size, together with the mitotic
count, is used to determine the histological classification
system. Therefore, once we discriminate GISTs from
leiomyomas, the size of the tumor (> 35 mm) might be

July 21, 2009

Volume 15

Number 27

the most reliable indicator of malignancy.

This study had several limitations. First, this was a
retrospective study that compared the EUS features
of gastric GISTs and leiomyomas. In addition, there
might have been a potential bias when retrospectively
reviewing the endosonographic photos. During the EUS
examination, we took at least 10-20 endosonographic
photos to determine EUS characteristics of gastric
mesenchymal tumors. Therefore, this would compensate,
to some degree, the limitation of this retrospective study.
Second, although EUS examinations were performed,
patients were selected for surgery or biopsy according
to the clinical opinions and decisions of the medical
doctors. Third, the number of leiomyomas included in
this study was small relative to the number of GISTs. This
limitation might be due to the fact that the most common
mesenchymal tumors of the stomach are GISTs and other
tumors, such as leiomyomas and schwannomas, are rarely
encountered in clinics.
Gastric mesenchymal tumors are often asymptomatic,
and they are usually incidentally discovered during upper
gastrointestinal endoscopy for unrelated conditions.
The main problem in the asymptomatic patient is to
determine whether or not the tumors have a malignant
potential. Because GISTs have a malignant potential,
the gastric mesenchymal tumors, even if they are small,
should not be ignored if EUS features are suggestive of
GISTs. Further large prospective long-term studies are
needed to validate our results for gastric mesenchymal
tumors.
In conclusion, EUS is a useful method to diagnose
g astric mesenchymal tumors and to predict the
malignant potential of GISTs. The EUS features such as
inhomogeneity, hyperechogenic spots, a marginal halo and
higher echogenicity as compared with the surrounding
muscle layer may help to differentiate GISTs from
leiomyomas. Once GISTs are suspected by EUS, surgical
treatment should be considered if the size of the tumor is
greater than 3.5 cm.

ACKNOWLEDGMENTS
We gratefully acknowledge Eun Sook Hong, Soon Im
Choi and Eun Hee Bae for their dedicated assistance.

COMMENTS
COMMENTS
Background

Endoscopic ultrasonography (EUS) is a valuable imaging tool for the diagnosis

and evaluation of gastric gastrointestinal stromal tumors (GISTs). Several
studies have attempted to differentiate benign and malignant stromal tumors on
the basis of their EUS features. However, most of these studies were performed
before the concept of GISTs was introduced and they included non-gastric
tumors in their study samples.

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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Kim GH et al . Endosonographic features of gastric GISTs

Innovations and breakthroughs

To differentiate GISTs from leiomyomas by EUS, the following four features

were helpful; inhomogenicity, hyperechogenic spots, a marginal halo and higher
echogenicity as compared with the surrounding muscle layer. These features
appeared more frequently in GISTs than in leiomyomas. The presence of at least
two of these four features had a sensitivity of 89.1% and a specificity of 85.7% for
predicting GISTs. Except for tumor size and irregularity of the border, most of the
EUS features were not helpful in predicting the malignant potential of GISTs. On
multivariate analysis, only the maximal diameter of the GISTs was an independent
predictor. The optimal size for predicting malignant GISTs was 35 mm. The
sensitivity and specificity using this value were 92.3% and 78.8%, respectively.

Applications

EUS is a useful method to diagnose gastric mesenchymal tumors and to predict

the malignant potential of GISTs. The EUS features such as inhomogeneity,
hyperechogenic spots, a marginal halo and higher echogenicity as compared
with the surrounding muscle layer may help to differentiate GISTs from
leiomyomas. Once GISTs are suspected by EUS, surgical treatment should be
considered if the size of the tumor is greater than 3.5 cm.

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

This is a relatively large single-center study aiming to evaluate the EUS

features of gastric GISTs vs leiomyomas initially and subsequently focusing on
GISTs to determine EUS-features associated with malignancy.

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