Endoscopic ultrasound-guided radiofrequency ablation for management of gastric gastrointestinal stromal tumor
02 May 2019 (online)
A 56-year-old man presented with abdominal pain and dyspepsia. On upper digestive endoscopy, a submucosal lesion was found in the distal gastric lesser curvature, but no conclusive diagnosis could be achieved with conventional biopsies. Endoscopic ultrasound (EUS) showed a 12 × 7 mm well-defined, homogeneous, hypoechoic nodule without signs of infiltration into the muscularis propria, suggestive of benign gastrointestinal stromal tumor (GIST) ([Fig. 1]). Fine-needle aspiration with a 22-gauge needle (Expect; Boston Scientific, Marlborough, Massachusetts, USA) was performed, confirming a low risk GIST. Histopathological examination revealed a GIST presenting less than 5 mitoses per high-power field.
The patient rejected surgical treatment, so we proposed EUS-guided radiofrequency ablation (RFA) ([Video 1]). We punctured the lesion with an 18-gauge EUS-RFA electrode needle connected to a radiofrequency generator (VIVA-RF generator; STARme, Seoul, South Korea), and applied ablative radiofrequency four times (50 W for 10 seconds).
Video 1 Diagnosis of benign gastrointestinal stromal tumor (GIST) and treatment with endoscopic ultrasound (EUS)-guided radiofrequency ablation (RFA). EUS follow-up was performed after 4 weeks, and showed a slight mural thickening of the muscularis propria and submucosal layers, while the lesion itself could not be identified. A second EUS 6 months later confirmed eradication of the lesion, and showed a well-preserved layer pattern.
EUS follow-up was performed after 4 weeks, and showed a slight mural thickening of the muscularis propria and submucosal layers; the lesion itself could not be identified ([Fig. 2]). A fine-needle biopsy with 22-gauge histological needle (Acquire; Boston Scientific) was performed and confirmed the absence of GIST-type mesenchymal structures. A second EUS 6 months later confirmed eradication of the lesion, and showed a well-preserved layer pattern ([Fig. 3]).
Guidelines recommend radical surgical resection with a clear margin (R0) as the gold standard for localized primary GIST . Although endoscopic resection of GISTs has been reported , it is not supported by current guidelines because of the low rate of successful R0 resections achieved . RFA uses high frequency alternating current applied via an electrode to generate localized areas of coagulative necrosis and tissue desiccation  . Although it is usually applied percutaneously or laparoscopically, successful outcomes of EUS-guided RFA using an 18-gauge needle for benign and malignant pancreatic lesions have been reported recently . To our knowledge, this is the first report of a successful ablative radiofrequency therapy of a gastric GIST.
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