Download PDF
Ultraschall Med 2015; 36(05): 494-500
DOI: 10.1055/s-0034-1398970
Original Article
© Georg Thieme Verlag KG Stuttgart · New York

German Survey on EUS-Guided Diagnosis and Management of Gastrointestinal Stromal Tumors (GISTs) – Evidence or “Gut-Feeling”?

Deutsche Fragebogenstudie zur EUS-gesteurten Diagnose und Management Gastrointestinaler Stromatumoren (GIST) – Evidenz oder „Bauchgefühl“
C. Jenssen
1   Department of Internal Medicine/Gastroenterology, Krankenhaus Märkisch Oderland, Strausberg/Wriezen, Germany
,
A. P. Barreiros
2   Department of Internal Medicine, Uniklinikum Regensburg, Germany
,
U. Will
3   Department of Internal Medicine/Gastroenterology, SRH Wald-Klinikum, 3. Medizinische Klinik, Gera, Germany
,
E. Burmester
4   Department of Internal Medicine/Gastroenterology, Sana-Kliniken Lübeck, Germany
,
I. Schmidtmann
5   Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center, Johannes Gutenberg-Universität Mainz, Germany
,
A. J. Eckardt
6   Gastroenterology, DKD Helios Klinik Wiesbaden, Germany
› Author Affiliations
Further Information

Publication History

05 September 2014

27 December 2014

Publication Date:
28 April 2015 (online)

Also available at
    Permissions and Reprints

Abstract

Purpose: To examine practice patterns of endosonographers in diagnosing and managing gastrointestinal stromal tumors (GISTs) in Germany.

Materials and Methods: A modified published survey (Ha et al., Gastrointest Endosc 2009) was sent to endosonographic ultrasound (EUS) customers in Germany. The survey was also publicized on the homepage of an EUS interest group. To avoid duplicate opinions, participants were asked to return one survey per institution.

Results: 142 centers of roughly 850 German EUS centers responded. 25 % were from University hospitals and 74 % from community hospitals. 61 % performed > 2 EUS scans for suspected subepithelial lesions/week. Although 97 % of respondents believed that tissue acquisition with CD117 immunohistochemistry best predicts a GIST, 11 % do not perform EUS-FNA when suspecting a GIST, 68 % perform it occasionally and 18 % perform it regularly. The main EUS criteria used for a suspected GIST are the typical layer (85 %), hypoechoic appearance (80 %) and gastric location (51 %). 69 % would diagnose a GIST with negative CD117 if the EUS criteria and spindle cells are present. FNA was rated helpful in < 50 % by 55 % of participants. Size was the primary criterion for suspecting malignancy. 95 % of respondents would perform surveillance ≥ 1x/year of GISTs that are not resected.

Conclusion: There is significant variability in the diagnosis and management of GISTs in Germany. Diagnostic certainty of EUS-FNA is suboptimal in many centers and EUS is frequently used for guidance. The diagnosis of a GIST is often guided by a “gut feeling” rather than evidence. Efforts should be made to unify existing guidelines.

Zusammenfassung

Ziel: Untersuchung des praktischen Vorgehens endosonographierender Ärzte in Deutschland (GER) bei der Diagnostik und Management von gastrointestinalen Stromatumoren (GIST).

Material und Methode: Ein leicht modifizierter, publizierter Fragebogen (Ha et al, Gastrointest Endosc 2009) wurde an die Kunden von Endosonografie (EUS)-Systemen in GER versandt. Zusätzlich wurde die Umfrage auf der Homepage einer deutschen EUS-Interessensgruppe veröffentlicht. Um Doppelantworten zu vermeiden, baten wir um Rücksendung nur eines Fragebogens pro Institution.

Ergebnisse: 142 von etwa 850 EUS-Kunden antworteten, darunter 25 % aus Universitätsklniken und 74 % aus regionalen Häusern. 61 % führten mehr als 2 EUS/Woche bei Patienten mit subepithelialen Läsionen durch. Wenngleich 97 % der Teilnehmer angaben, dass eine Gewebeentnahme mit CD117-Immunhistochemie einen GIST am besten voraussagt, führen 11 % bei Verdacht auf GIST keine EUS-FNA durch, 68 % tun das gelegentlich und nur 18 % regelmäßig. Die wesentlichen EUS-Kriterien für die Verdachtsdiagnose eines GIST sind die typische Schichtenzuordnung (85 %), Echoarmut (80 %) und Magenlokalisation (51 %). 69 % würden die Diagnose eines GIST auch bei negativer CD117-Immunohistochemie stellen, wenn typische EUS-Kriterien und Spindelzellen nachweisbar wären. 55 % der Teilnehmer gaben an, die EUS-FNA sei in < 50 % der Fälle hilfreich. Tumorgröße war das primäre Kriterium für einen Malignitätsverdacht. 95 % der Umfrageteilnehmer würden GIST, die nicht reseziert werden, mindestens 1 x jährlich überwachen.

Schlussfolgerungen: Kriterien und Methoden zur Diagnose von GIST unterscheiden sich zwischen deutschen Zentren signifikant. Die diagnostische Treffsicherheit der EUS-FNA ist in vielen Zentren suboptimal und das EUS Bild entscheidet häufig über das Vorgehen. Das Management von GIST wird oft eher durch „Bauchgefühl“ als durch Evidenz gesteuert. Anstrengungen zur Vereinheitlichung von Leitlinien sind erforderlich.

Key words

abdomen - stomach - endoscopy - tumor - endoscopic ultrasound - fine-needle aspiration - subepithelial tumors - gastrointestinal stromal tumor - survey
 

  • References

  • 1 Jenssen C, Dietrich CF. Endoscopic ultrasound of gastrointestinal subepithelial lesions. Ultraschall in Med 2008; 29: 236-256 ; quiz 257 – 264
    Article in Thieme ConnectPubMedGoogle Scholar
  • 2 Kawanowa K, Sakuma Y, Sakurai S et al. High incidence of microscopic gastrointestinal stromal tumors in the stomach. Hum Pathol 2006; 37: 1527-1535
    CrossrefPubMedGoogle Scholar
  • 3 Yang J, Feng F, Li M et al. Surgical resection should be taken into consideration for the treatment of small gastric gastrointestinal stromal tumors. World J Surg Oncol 2013; 11: 273
    CrossrefPubMedGoogle Scholar
  • 4 Hwang JH, Saunders MD, Rulyak SJ et al. A prospective study comparing endoscopy and EUS in the evaluation of GI subepithelial masses. Gastrointest Endosc 2005; 62: 202-208
    CrossrefPubMedGoogle Scholar
  • 5 Karaca C, Turner BG, Cizginer S et al. Accuracy of EUS in the evaluation of small gastric subepithelial lesions. Gastrointest Endosc 2010; 71: 722-727
    CrossrefPubMedGoogle Scholar
  • 6 Eckardt AJ, Wassef W. Diagnosis of subepithelial tumors in the GI tract. Endoscopy, EUS, and histology: bronze, silver, and gold standard?. Gastrointest Endosc 2005; 62: 209-212
    CrossrefPubMedGoogle Scholar
  • 7 Buscaglia JM, Nagula S, Jayaraman V et al. Diagnostic yield and safety of jumbo biopsy forceps in patients with subepithelial lesions of the upper and lower GI tract. Gastrointest Endosc 2012; 75: 1147-1152
    CrossrefPubMedGoogle Scholar
  • 8 Lee CK, Chung IK, Lee SH et al. Endoscopic partial resection with the unroofing technique for reliable tissue diagnosis of upper GI subepithelial tumors originating from the muscularis propria on EUS (with video). Gastrointest Endosc 2010; 71: 188-194
    CrossrefPubMedGoogle Scholar
  • 9 Zhang Y, Ye LP, Zhu LH et al. Endoscopic submucosal dissection for treatment of gastric submucosal tumors originating from the muscularis propria layer. Dig Dis Sci 2013; 58: 1710-1716
    CrossrefPubMedGoogle Scholar
  • 10 Li QL, Yao LQ, Zhou PH et al. Submucosal tumors of the esophagogastric junction originating from the muscularis propria layer: a large qstudy of endoscopic submucosal dissection (with video). Gastrointest Endosc 2012; 75: 1153-1158
    CrossrefPubMedGoogle Scholar
  • 11 ESMO/European Sarcoma Network Working Group. Gastrointestinal stromal tumors: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2012; 23 (Suppl. 07) vii49-55
    CrossrefPubMedGoogle Scholar
  • 12 Kang YK, Kang HJ, Kim KM et al. Clinical practice guideline for accurate diagnosis and effective treatment of gastrointestinal stromal tumor in Korea. Cancer Res Treat 2012; 44: 85-96
    CrossrefPubMedGoogle Scholar
  • 13 Ha CY, Shah R, Chen J et al. Diagnosis and management of GI stromal tumors by EUS-FNA: a survey of opinions and practices of endosonographers. Gastrointest Endosc 2009; 69: 1039-1044
    CrossrefPubMedGoogle Scholar
  • 14 Landi B, Bouché O, Guimbaud R et al. Management of gastrointestinal stromal tumours of limited size: proposals from a French panel of physicians. Dig Liver Dis 2011; 43: 935-939
    CrossrefPubMedGoogle Scholar
  • 15 Vander 3rd NootMR , Eloubeidi MA, Chen VK et al. Diagnosis of gastrointestinal tract lesions by endoscopic ultrasound-guided fine-needle aspiration biopsy. Cancer 2004; 102: 157-163
    CrossrefPubMedGoogle Scholar
  • 16 Mekky MA, Yamao K, Sawaki A et al. Diagnostic utility of EUS-guided FNA in patients with gastric submucosal tumors. Gastrointest Endosc 2010; 71: 913-919
    CrossrefPubMedGoogle Scholar
  • 17 Iglesias-Garcia J, Poley JW, Larghi A et al. Feasibility and yield of a new EUS histology needle: results from a multicenter, pooled, cohort study. Gastrointest Endosc 2011; 73: 1189-1196
    CrossrefPubMedGoogle Scholar
  • 18 Storch I, Jorda M, Thurer R et al. Advantage of EUS Trucut biopsy combined with fine-needle aspiration without immediate on-site cytopathologic examination. Gastrointest Endosc 2006; 64: 505-511
    CrossrefPubMedGoogle Scholar
  • 19 Eckardt AJ, Adler A, Gomes EM et al. Endosonographic large-bore biopsy of gastric subepithelial tumors: a prospective multicenter study. Eur J Gastroenterol Hepatol 2012; 24: 1135-1144
    CrossrefPubMedGoogle Scholar
  • 20 Polkowski M, Gerke W, Jarosz D et al. Diagnostic yield and safety of endoscopic ultrasound-guided trucut [corrected] biopsy in patients with gastric submucosal tumors: a prospective study. Endoscopy 2009; 41: 329-334
    Article in Thieme ConnectPubMedGoogle Scholar
  • 21 Kim GH, Park doY, Kim S et al. Is it possible to differentiate gastric GISTs from gastric leiomyomas by EUS?. World J Gastroenterol 2009; 15: 3376-3381
    CrossrefPubMedGoogle Scholar
  • 22 Lim YJ, Son HJ, Lee JS et al. Clinical course of subepithelial lesions detected on upper gastrointestinal endoscopy. World J Gastroenterol 2010; 16: 439-444
    CrossrefPubMedGoogle Scholar
  • 23 Demetri GD, von Mehren M, Antonescu CR et al. NCCN Task Force report: update on the management of patients with gastrointestinal stromal tumors. J Natl Compr Canc Netw 2010; (Suppl. 02) S1-41 ; quiz S42–S44.
    PubMedGoogle Scholar
  • 24 ESMO/European Sarcoma Network Working Group. Gastrointestinal stromal tumors: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2012; (Suppl. 07) vii49-55
    PubMedGoogle Scholar
  • 25 Nishida T, Hirota S, Yanagisawa A et al. Clinical practice guidelines for gastrointestinal stromal tumor (GIST) in Japan: English version. Int J Clin Oncol 2008; 13: 416-430
    CrossrefPubMedGoogle Scholar
  • 26 Sepe PS, Brugge WR. A guide for the diagnosis and management of gastrointestinal stromal cell tumors. Nat Rev Gastroenterol Hepatol 2009; 6: 363-371
    CrossrefPubMedGoogle Scholar
  • 27 Tokunaga M, Ohyama S, Hiki N et al. Incidence and prognostic value of lymph node metastasis on c-Kit-positive gastrointestinal stromal tumors of the stomach. Hepatogastroenterology 2011; 58: 1224-1228
    CrossrefPubMedGoogle Scholar
  • 28 Kim MN, Kang SJ, Kim SG et al. Prediction of risk of malignancy of gastrointestinal stromal tumors by endoscopic ultrasonography. Gut Liver 2013; 7: 642-647
    CrossrefPubMedGoogle Scholar
  • 29 Savoy AD, Raimondo M, Woodward TA et al. Can endosonographers evaluate on-site cytologic adequacy? A comparison with cytotechnologists. Gastrointest Endosc 2007; 65: 953-957
    CrossrefPubMedGoogle Scholar