Endoscopic resection: A novel approach for treating oesophageal gastrointestinal stromal tumours

Abstract

In this letter, a commentary on the article by Xu et al has been provided. Gastrointestinal stomal tumours (GISTs) are rare tumours that originate commonly in stomach (60%-70%) and small intestine (30%-40%). The course of treatment especially oesophageal GIST is very complex and hard to diagnose because of limited availability of pathological and clinical data. Endoscopic resection (ER) is a minimally invasive approach for removing tumours from the oesophagus and digestive system that does not require open surgery and is especially successful for very small and low-risk GIST. A retrospective examination of 32 patients treated with ER between 2012 and 2023 was conducted to analyse clinical and pathological characteristics, effectiveness of therapy, and long-term prognosis. The findings demonstrate en bloc resection was achieved in 96.9% of cases with an R0 resection rate of 75% with a median size of tumour was approximately 2.12 cm. Post-surgery complication like hydrothorax, post-endoscopic submucosal dissection electrocoagulation syndrome occurred in about 25% of cases which later go resolved by conservative treatment. Recurrence of GIST was approximately 9.4% primarily in high-risk cases. ER should be widely adopted in clinical practise preferably for managing low-risk oesophageal GIST because of its high success rate, low recurrence rates and excellent survival results, ensuring better patient prognosis.

Key Words: Endoscopic resection; Gastrointestinal stomal tumours; Oesophageal gastrointestinal stomal tumours; Minimally invasive treatment; Low-risk tumours; Clinical practice; Survival outcomes; Tumour recurrence; Early detection; Patient prognosis

Core Tip: Gastrointestinal stomal tumours (GISTs) are safely and effectively treated by the endoscopic resection (ER) in the esophagus. It has a small camera to remove the tumour through small cuts. This makes the recovery process relatively easy for the patients. In fact, the best results were seen in smaller and low-risk tumours, with most showing good results. Nevertheless, there might be some complications: (1) The collection of fluid or some minor pain after the treatment; and (2) These usually get treated without the need for further surgery. ER is thus recommended for the management of low-risk esophageal GIST since there are fewer problems and better recovery thereafter.

TO THE EDITOR

Gastrointestinal stomal tumours (GISTs) are rare mesenchymal neoplasms that most commonly originate in the stomach (60%-70%) and small intestine (30%-40%). Conversely, oesophageal GISTs are especially rare and provide significant diagnostic and treatment difficulties because of the limited clinical and pathological data[1-3]. Although larger tumours are sometimes treated with traditional surgical methods like esophagectomy, these are quite intrusive operations connected with great risk. The difficulty of treating oesophageal GISTs is exacerbated by the need of exact risk classification since treatment choices and prognosis depend critically on tumour size, location, and mitotic index.

Recent research aiming at enhancing patient outcomes have concentrated on less intrusive therapy options meant to meet these difficulties[4]. Endoscopic resection (ER) has showed promise in the treatment of tiny, low-risk oesophageal GISTs. The clinical and pathological features, therapeutic efficacy, and long-term outcomes of thirty-two patients[5] who received ER between January 2012 and January 2023 were assessed in a retrospective analysis by Xu et al[6]. Supported by group efforts involving pathologists, endoscopists, and surgeons, the multidisciplinary treatment strategy included ER, adjuvant therapy, and systematic follow-up. This study's findings were hopeful. Of the 31 of 32 patients (96.9%), en bloc resections were obtained; of the 24 patients assessed for histological completeness, 75% had R0 resections—indicating total tumour removal with negative margins. The median tumour size was 1.50 cm; the mean was 2.12 cm ± 1.88 cm. With hydrothorax reported in four patients (12.5%), and post-endoscopic submucosal dissection electrocoagulation syndrome (PEECS) reported in five patients (15.6%), the complication rate was 25%. Crucially, conservative treatment helped to resolve all problems. The mean mitotic index was 3.34 ± 5.04; the median was 1.50. The 56.3% of cases were extremely low risk, 18.8% low risk, 18.8% intermediate risk, and 18.8% high risk according to modified National Institutes of Health risk classification. Three patients—9.4%—all from the high-risk group experienced recurrence during a median follow-up duration of 64.69 months ± 33.13 months. The disease-free survival rate was 90.6%; the total survival rate after five years was 100%.

ER shows a low recurrence rate for oesophageal GISTs, but the lack of comparative data on surgical alternatives such esophagectomy makes direct assessment of superiority challenging. Particularly in high-risk or incompletely resected cases, studies have found that recurrence rates following an esophagectomy might vary from 15% to 30%. For well-selected individuals, particularly those with low-risk tumours, ER offers a minimally invasive alternative with either equivalent or less recurrence. Clinically speaking, ER is a safer and more efficient choice for low-risk oesophageal GASTs[7,8]. Its less intrusive character helps to preserve oesophageal structure and function, speedier recovery, and less problems. By means of shorter hospital stays and less postoperative interventions, these benefits not only enhance quality of life but also help to lower healthcare costs. Moreover, most of the tumours treated in the study were found incidentally and were somewhat minor, which emphasizes the need of early diagnosis[9]. Early intervention made possible by proactive screening and surveillance campaigns could help to avoid the necessity for more intrusive treatments. ER has wider consequences beyond only affects for individual patients. From a social and healthcare systems standpoint, greater acceptance of ER could result in cost savings, improved patient throughput, and effective medical resource allocation. Moreover, the effective application of ER in oesophageal GISTs can offer a model for controlling other rare gastrointestinal tumours applying minimally invasive techniques. All things considered, the trial offers strong proof that ER is a safe and efficient therapy for low-risk oesophageal GISTs. ER is positioned to become more and more essential in modern gastroenterological oncology given its great long-term results, low recurrence and complication rates, and major advantages in terms of patient recovery and healthcare efficiency[10,11]. Maximizing its influence on patient care depends on ongoing improvement of patient selection criteria and wider application of early screening programs.

CLINICAL IMPLICATIONS

Therapeutic effects of ER for oesophageal GISTs are significant[12]. For low-risk GISTs specifically, ER is a safer alternative than more traditional surgical operations like esophagectomy. ER effectively eliminates tumours without compromising the structural integrity of the oesophagus with an amazing 96.9% en bloc resection rate and a 75% R0 resection rate. Maintaining the oesophagus's functioning and lowering the risk of major repercussions helps patients to have better lives. With a low recurrence rate of 9.4% compared to surgical operations, which have demonstrated higher rates, ER can be a useful long-term treatment for oesophageal GISTs[13]. Problems that could be controlled conservatively include hydrothorax and PEECS, therefore proving that ER is typically safe. ER for oesophageal GISTs aims generally to save healthcare costs by means of minimally invasive, efficient treatments so improve patient outcomes. ER is therefore a good option for low-risk oesophageal GISTs, particularly in cases where discovered early and smaller tumours might be addressed.

CONCLUSION

GISTs can be managed creatively with ER. It's safe and successful. The study shows that ER is quite successful with a 96.9% en bloc resection success rate, a 75% R0 resection success rate, a 9.4% recurrence rate, and a 100% 5-year overall survival rate. Less intrusive than conventional surgery, ER enable faster recovery for patients by preserving oesophageal function, hence improving patient outcomes. It is important to note that the use of ER for the treatment of oesophageal GISTs has major therapeutic impact. This strategy reduces the need for major surgical interventions and consequent treatment, therefore improving patient quality of life; it also helps to lower healthcare expenditures. The low complication rate, which was under control conservatively, supports even more the safety profile of ER. In general, ER is the recommended method for treating low-risk oesophageal GISTs. In order to achieve successful treatment outcomes, it is crucial to screen for these tumours regularly before they cause symptoms or rapid progression. Adding ER to clinical practice fits with the goals of modern healthcare, which are to improve patient results by making better use of resources.