Predictive Factors of Subepithelial Tumor and Gastrointestinal Stromal Tumor in the Patients with Upper Gastrointestinal Subepithelial Lesions

Ra Ri Cha; Hye Won Oh; Hyun Seon Yoo; Jeong Woo Hong; Sang Soo Lee; Hong Jun Kim; Chang Yoon Ha; Hyun Jin Kim; Tae Hyo Kim; Ok-Jae Lee

doi:10.4166/kjg.2014.64.4.189

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Cha, Oh, Yoo, Hong, Lee, Kim, Ha, Kim, Kim, and Lee: Predictive Factors of Subepithelial Tumor and Gastrointestinal Stromal Tumor in the Patients with Upper Gastrointestinal Subepithelial Lesions

Original Article

Korean J Gastroenterol 2014;64(4):189-197.

Published online: 4 October 2014

DOI: https://doi.org/10.4166/kjg.2014.64.4.189

Predictive Factors of Subepithelial Tumor and Gastrointestinal Stromal Tumor in the Patients with Upper Gastrointestinal Subepithelial Lesions

Ra Ri Cha¹, Hye Won Oh¹, Hyun Seon Yoo¹, Jeong Woo Hong¹, Sang Soo Lee¹, Hong Jun Kim¹, Chang Yoon Ha¹, Hyun Jin Kim^1,², Tae Hyo Kim^1,², Ok-Jae Lee^1,²

¹Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Korea

²Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea

Correspondence to: Ok-Jae Lee, Department of Internal Medicine, Institute of Health Sciences, Gyeongsang National University School of Medicine, 15 Jinju-daero 816beon-gil, Jinju 660-751, Korea. Tel: +82-55-750-8056, Fax: +82-55-758-9122, E-mail: ojlee@gnu.ac.kr

Received 23 July 201425 August 2014 Accepted 1 September 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background/Aims

Differentiating subepithelial tumor (SET) from non-neoplastic gastrointestinal subepithelial lesion (SEL) and gastrointestinal stromal tumor (GIST) from leiomyoma are very important for proper management. This study was conducted to analyze factors that could predict the presence of SET and GIST in patients with upper gastrointestinal (UGI) SELs.

Methods

A total of 527 patients were diagnosed with UGI SELs endosonographically at Gyeongsang National University Hospital from January 2008 to June 2013. Among these patients, histologic diagnosis was made in 84 patients. Data were collected by retrospectively reviewing the medical records. Variables that could differentiate neoplastic from non-neoplastic SELs and GIST from leiomyoma were analyzed.

Results

Among 84 patients with SELs, 64 (76.2%) had SETs including GIST (42.9%) and leiomyoma (19.0%). The patients’ mean age (p=0.047), peak age distribution (p=0.047), proportions of patient ≥50 years (p=0.015), and number of proper muscle-originated lesions (p=0.001) were higher in neoplastic than non-neoplastic group. There were no significant differences in gender (p=0.195), size (p=0.266) and echogenicity (p=0.051) of the lesions. Older age (57.7 vs. 47.0 years, p=0.049), age ≥50 years (p=0.016), location in gastric body (p<0.001), and proper muscle origin (p=0.003) were significantly related to the presence of GIST compared to leiomyoma. Multiple regression analysis showed that the patients’ age ≥50 years, size ≥30 mm, and proper muscle-origin of lesion were independent predictors of SET; however, there were no predictive factors that could differentiate GIST from leiomyoma.

Conclusions

In patients with SEL, the possibility of having SET should be considered for patients ≥50 years with UGI SELs ≥30 mm that arise from the proper muscle. Thorough monitoring and aggressive management is warranted for those with gastric muscular SET since factors predictive of GIST are lacking.

Keywords: Upper gastrointestinal, Subepithelial, tumor, Gastrointestinal stromal tumors, Predictor

References

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Fig. 1.

Flow chart of patients with upper gastrointestinal subepitelial lesion. Among a total 527 patients with upper gastrointestinal (UGI) subepithelial lesion (SEL) evaluated endosonographically, 84 underwent endoscopic or surgical resection of the lesion and confirmative histological diagnosis was made. Sixty-four (76.2%) patients had neoplastic lesions (subepithelial tumor) including gastrointestinal stromal tumor (GIST), leiomyoma, carcinoid tumor, granular cell tumor (GCT), and neurilemmo-ma. The remaining 20 patients had non-neoplastic lesions such as hete-rotopic pancreas, inflammatory fibroid polyp (IFP), lipoma, and cyst.

Table 1.

Baseline Characteristics of All Patients with Upper Gastrointestinal (UGI) Subepithelial Lesions (SEL) and Those with Histologically Confirmed Upper UGI SEL

Characteristic	No. of cases
Characteristic	Total UGI SEL (n=527)	Histologically confirmed SEL (n=84)
Age (yr)	52.7±12.8 (16–83)	52.2±14.3 (20–83)
Gender
Male	219 (41.6)	40 (47.6)
Female	308 (58.4)	44 (52.4)
Symptom
Asymptomatic	457 (86.7)	68 (80.9)
Dyspepsia	61 (11.6)	10 (11.9)
Abdominal pain	6 (1.1)	3 (3.6)
Bleeding	3 (0.6)	3 (3.6)
Location
Esophagus	26 (4.9)	7 (8.3)
Stomach	486 (92.2)	76 (90.5)
EGJ	47 (8.9)	7 (8.3)
Fundus	62 (11.8)	10 (11.9)
Body	242 (45.9)	40 (47.6)
Antrum	135 (25.6)	19 (22.6)
Duodenum	15 (2.8)	1 (1.2)
Size of lesion (mm)	11.0 (3–79)	20.0 (5–60)
<10	111 (21.1)	10 (11.9)
≥10, <30	369 (70.0)	46 (54.8)
≥30, <50	38 (7.2)	21 (25.0)
≥50	9 (2.8)	7 (8.3)
Echogenicity
Homogenous	495 (93.9)	81 (96.4)
Hyperechoic	18 (3.4)	5 (6.0)
Isoechoic	7 (1.3)	2 (2.4)
Hypoechoic	470 (89.2)	74 (88.1)
Heterogenous	14 (2.7)	3 (3.6)
Anechoic	18 (3.4)	0 (0)
Originating layer
Muscularis mucosa	39 (7.4)	13 (15.5)
Submucosa	194 (36.8)	14 (16.7)
Muscularis propria	294 (55.8)	57 (67.9)
Treatment modality
Surgery	-	54 (64.3)
Endoscopic resection	-	30 (35.7)
Histology
Neoplastic	-	64 (76.2)
Non-neoplastic	-	20 (23.8)

Values are presented as mean±SD (range), n (%), or median (range). EGJ, esophagogastric junction.

Table 2.

Histologic Diagnosis and Location of 84 Patients with Upper Gastrointestinal Subepithelial Lesions

Histologic diagnosis	Location
	Esophagus (n=7)	Stomach					Duodenum (n=1)
	Esophagus (n=7)	EGJ (n=7)	Fundus (n=10)	Body (n=40)	Antrum (n=19)	Total (n=76)	Duodenum (n=1)
Neoplastic lesion (n=64)	7	7	7	32	11	57	0
Gastrointestinal stromal tumor (n=36)	0	0	5	23	8	36	0
Leiomyoma (n=16)	6	6	1	3	0	10	0
Carcinoid tumor (n=5)	1	0	0	3	1	4	0
Granular cell tumor (n=4)	0	1	0	2	1	4	0
Neurilemmoma (n=3)	0	0	1	1	1	3	0
Non-neoplastic lesion (n=20)	0	0	3	8	8	19	1
Heterotopic pancreas (n=11)	0	0	0	4	6	10	1
Inflammatory fibroid polyp (n=4)	0	0	1	2	1	4	0
Lipoma (n=3)	0	0	0	2	1	3	0
Cyst (n=2)	0	0	2	0	0	2	0

EGJ, esophagogastric junction.

Table 3.

Comparison of Clinical and Ultrasonographic Characteristics of Neoplastic and Non-neoplastic Subepithelial Lesions

Characteristic	Neoplastic lesion (n=64)	Non-neoplastic lesion (n=20)	p-value
Age (yr)	53.9±13.7	44.0±15.1	0.037
<30	1 (1.6)	3 (15.0)	0.047
30-39	9 (14.1)	5 (25.0)
40-49	12 (18.8)	6 (30.0)
50-59	19 (29.7)	3 (15.0)
60-69	13 (20.3)	2 (10.0)
≥70	10 (15.6)	1 (5.0)
<50	22 (34.4)	14 (60.0)	0.005
≥50	42 (65.6)	6 (30.0)
Gender			0.195
Male	31 (48.4)	13 (65.0)
Female	33 (51.6)	7 (35.0)
Location of lesion			0.041
Esophagus	7 (10.9)	0 (0.0)
Esophagogastric junction	7 (10.9)	0 (0.0)
Gastric fundus	7 (10.9)	3 (15.0)
Gastric body	32 (50.0)	8 (40.0)
Gastric antrum	11 (17.2)	8 (40.0)
Duodenum	0 (0.0)	1 (5.0)
Size of lesion (mm)	21.4 (6–65)	19.0 (5–60)	0.266
<10	8 (12.7)	2 (15.0)
≥10, <30	36 (55.6)	10 (70.0)
≥30, <50	15 (25.4)	6 (5.0)
≥50	5 (6.3)	2 (10.0)
<30:≥30	44 (68.8):	17 (85.0):	0.155
	20 (31.2)	3 (15.0)
Echogenicity			0.064
Homogenous	63 (98.4)	18 (90.0)
Hyperechoic	2 (3.1)	3 (15.0)
Isoechoic	2 (3.1)	0 (0.0)
Hypoechoic	59 (92.2)	15 (75.0)
Heterogenous	1 (1.6)	2 (10.0)
Originating layer			0.001
Muscularis mucosa	6 (9.3)	7 (35.0)
Submucosa	7 (11.0)	7 (35.0)
Muscularis propria	51 (79.7)	6 (30.0)

Values are presented as mean±SD, n (%), or median (range).

Table 4.

Univariate and Multivariate Analysis on Predictive Factors That Could Differentiate Neoplastic from Non-neoplastic Subepithelial Lesions

Variable	Univariate analysis		Multivariate analysis
Variable	OR (95% CI)	p-value	OR (95% CI)	p-value
Age (yr)
<50 (n=20)	1		1
≥50 (n=48)	3.55	0.019	6.25	0.036
	(1.24-10.17)		(1.13-34.58)
Gender
Female (n=28)	1		1
Male (n=40)	1.98	0.200	1.50	0.607
	(0.70-5.60)		(0.32-6.96)
Size (mm)
<30 (n=40)	1		1
≥30 (n=28)	2.58	0.165	8.84	0.041
	(0.68-9.80)		(1.09-71.78)
Location		0.688		0.846
Echogenicity		0.126		0.268
Originating layer		0.001		0.004
MM (n=13)	1		1
SM (n=14)	1.17	0.842	0.61	0.675
	(0.26-5.29)		(0.06-6.02)
PM (n=57)	9.92	0.001	13.50	0.017
	(2.50-39.42)		(1.58-115.53)

MM, muscularis mucosa; SM, submucosa; PM, proper muscle.

Table 5.

Comparison of the Clinical and Ultrasonographic Characteristics of Gastrointestinal Stromal Tumor (GIST) and Leiomyoma

Characteristic	GIST (n=36)	Leiomyoma (n=16)	p-value
Age (yr)	57.7±14.4	47.0±10.1	0.049
<50	8 (22.2)	9 (56.3)	0.016
≥50	28 (77.8)	7 (43.8)
Gender			0.548
Male	17 (47.2)	7 (43.8)
Female	19 (52.8)	9 (56.3)
Location			<0.001
Esophagus	0 (0.0)	6 (37.5)
Stomach	36 (77.8)	10 (62.6)
EGJ	0 (0.0)	6 (37.5)
Fundus	5 (13.9)	1 (6.3)
Body	23 (63.9)	3 (18.8)
Antrum	8 (22.2)	0 (0.0)
Duodenum	0 (0.0)	0 (0.0)
Size of tumor (mm)	25.1 (7–65)	19.0 (3–57)	0.088
<10	1 (2.8)	3 (18.8)
≥10, <30	22 (61.1)	8 (50.0)
≥30, <50	12 (33.3)	3 (18.8)
≥50	1 (2.8)	2 (12.5)
<30:≥30	23 (63.9):	11 (68.8):	0.734
	13 (36.1)	5 (31.2)
Echogenosity			0.142
Hyperechoic	1 (2.8)	0 (0.0)
Isoechoic	0 (0.0)	2 (12.5)
Hypoechoic	34 (94.4)	14 (87.5)
Heterogenous	1 (2.8)	0 (0.0)
Originating layer			0.007
Muscularis mucosa	0 (0.0)	4 (25.0)
Muscularis propria	36 (100)	12 (75.0)

Values are presented as mean±SD, n (%), or median (range).

EGJ, Esophagogastric junction.

Table 6.

Univariate and Multivariate Analysis on Predictive Factors That Could Differentiate Gastrointestinal Stromal Tumor from Leiomyoma

Variable	Univariate analysis		Multivariate analysis
Variable	OR (95% CI)	p-value	OR (95% CI)	p-value
Age (yr)
<50 (n=17)	1
≥50 (n=35)	4.50	0.020		0.998
	(1.27-15.90)
Gender
Female (n=28)	1
Male (n=24)	0.70	0.549		1.000
	(0.21-2.28)
Size (mm)
<30 (n=34)	1
≥30 (n=18)	1.24	0.734		1.000
	(0.35-4.37)
Location		0.998		1.000
Echogenicity		1.000		1.000
Originating layer
MM (n=4)	1		1
PM (n=48)	15.91	0.016		0.999
	(1.67-151.15)

MM, muscularis mucosa; PM, proper muscle.

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