Clinicopathological characteristics and prognosis of gastrointestinal stromal tumors containing air-fluid levels

Abstract

An air-fluid level within a gastrointestinal stromal tumor (GIST) is unusual and indicates the presence of a fistula within the lumen of the GI tract. Until recently, the optimal management of such patients was not clear-cut. This retrospective study investigated the clinicopathological characteristics, surgical procedures, pre-and post-operative management, and prognosis of patients with GIST containing an air-fluid level. Data of GIST patients, spanning 5 years, including 17 GIST patients with air-fluid levels in the experimental group and 34 GIST patients without air-fluid levels in the control group, were retrieved from two hospitals in China. The clinicopathological characteristics, types of surgery, management, and clinical outcomes of GIST patients were compared between the two groups. GISTs containing air-fluid levels were significantly different from GISTs without air-fluid levels regarding tumor morphology, NIH risk category, invasion of adjacent organs, and necrosis or ulceration. Most GIST patients with air-fluid levels (14/17, 82.4%) received open surgery, significantly higher than the 20.6% in the control group. Targeted therapy with Imatinib mesylate (IM) was implemented in all GIST patients in the experimental group (17/17, 100%); markedly higher than those (3/34, 8.8%) in the control group. During follow-up, recurrence and death rates (5.9% and 5.9%) in the experimental group were higher than those (2.9% and 0%) in the control group. Open surgery is commonly performed in GIST patients with air-fluid levels who also require targeted therapy with IM. The Torricelli-Bernoulli sign could be a risk factor, adversely affecting the patient's prognosis.

Fig 1. Representative images of computed tomography scans and histological examinations of patients with an air-fluid level.

T1WI, T2WI, and Fat-suppression sequence showed (A) the mass and (B, C) air-fluid level (white arrow);.The tumor was extramural to (D) the colon wall and (E) the cavity (white arrowhead), which can be observed in the specimen; (F) Histopathological result of H&E staining showing the spindle cells (magnification, x100).

Fig 2. Representative CT images and histological examinations of duodenal GIST with an air-fluid level.

(A-C) Enhancement of duodenal GIST and air-fluid level within the mass (white arrow); (D) The fistula (black arrow) and fistula opening (black arrowhead) between the wall of duodenum and mass;. (E) Histopathological result by H-E staining showed the spindle cells (magnification, x100).

Fig 3. Representative CT images and histological examinations of GIST with an air-fluid level in the stomach.

(A, B) Enhancement of tumor located in the fundus of the stomach) and air within the mass (white arrow, A & B); (C) The fistula between gastric cavity and tumor in CT reconstruction coronal position (white arrow) and (D) specimen (white arrowhead); (E) Histopathological result by H&E staining showed the spindle cells (magnification, x200); (F) Immunohistochemical staining (magnification, x200) showed positive for CD117.