Comparison of treatment strategies for submucosal tumors originating from the muscularis propria at esophagogastric junction or cardia

Abstract

Background: The spectrum of gastric submucosal tumors (SMTs) in the upper gastrointestinal system ranges from non-neoplastic to malignant lesions, with gastrointestinal stromal tumors exhibiting inherent malignant potential. However, the diagnosis of SMTs remains challenging, and treatment methods, especially for tumors located at the cardia or esophagogastric junction (EGJ), are not well established. Minimally invasive techniques - such as endoscopic submucosal dissection (ESD), submucosal tunneling endoscopic resection (STER), and laparoscopic wedge resection (LWR) - have been developed for these lesions. However, comparative data on their feasibility, safety, and clinical outcomes in these locations remain limited.

Aim: To compare ESD, STER, and LWR for SMTs at the EGJ or cardia, focusing on procedural feasibility.

Methods: This single-center retrospective study included patients with SMTs less than 45 mm from the muscularis propria, growing intraluminally at the EGJ or cardia, and treated with ESD, STER, or LWR between July 2014 and September 2022. The primary outcome was relapse-free survival during follow-up.

Results: The median age (interquartile range) was 53.0 (40.0-57.5), 43.0 (39.0-57.0), and 56.0 (43.0-64.0) years for ESD, STER, and LWR, respectively. The median follow-up time (interquartile range) was 60.0 (26.5-66.5), 24.0 (13.0-38.0), and 35.0 (21.0-60.0) months. LWR had the largest tumors (30.0 mm) and the highest rate of high-risk gastrointestinal stromal tumors (68.0%, P < 0.001). Tumor recurrence occurred in one LWR patient (4.0%, P = 0.600). En bloc and macroscopic resection rates were 100% (P = 1.000), but microscopic resection rates differed (P = 0.021). Significant minor complications occurred in 5 patients (10.0%), all grade IIIa. Tumor location (cardia/fundus, P = 0.006) and prolonged procedure time (P < 0.001) were significantly associated with complications.

Conclusion: ESD, STER, and LWR are effective for SMTs at the EGJ and cardia, with minor complications associated with tumor location and procedure time, and comparable recurrence rates.

Keywords: Cardia; Esophagogastric junction; Gastrointestinal stromal tumors; Minimally invasive surgical procedures; Muscularis propria.

Figure 1

Endoscopic submucosal dissection. A: Endoscopic view of a submucosal tumor in the cardia of the stomach; B: Endoscopic ultrasonography showing a hypoechoic submucosal tumor in the muscularis propria; C: Circumferential markings around the lesion; D and E: Mucosal incision along the marked points after submucosal injection; F: The tumor was completely resected macroscopically; G: Resected specimen; H: Endoscopic view at the 3-month follow-up.

Figure 2

Submucosal tunneling endoscopic resection. A: Endoscopic view of the submucosal tumor in the cardia; B: Endoscopic ultrasound image showing a tumor originating from the muscularis propria; C: Incision 3-4 cm proximal to the tumor to create a submucosal tunnel after fluid cushion injection; D: Exposed tumor within the submucosal tunnel; E and F: Endoscopic dissection of the lesion through a tunnel; G: Tumor retrieval after en bloc resection; H: Endoscopic view at the 3-month follow-up.

Figure 3

Laparoscopic wedge resection. A: Endoscopic view of the submucosal tumor in the cardia; B: Endoscopic ultrasound image showing a tumor originating from the muscularis propria; C and D: Dissection of the anterior wall of the stomach to obtain an intragastric view with the submucosal tumor marked with clips; E and F: A laparoscopic linear stapler was used to perform wedge resection; G: Surgical suturing of the stomach; H: Endoscopic follow-up 6 months later showing no deformities.

Figure 4

Screening and analysis. LWR: Laparoscopic wedge resection; EGJ: Esophagogastric junction.

Figure 5

A patient who underwent laparoscopic wedge resection. A: A histology specimen from a patient who underwent a macroscopically complete resection during laparoscopic wedge resection, but with R1 resection in the final pathology report, showed no evidence of recurrence for > 5 years; B: Kaplan-Meier estimate of recurrence-free survival. ESD: Endoscopic submucosal dissection; STER: Submucosal tunneling endoscopic resection; LWR: Laparoscopic wedge resection.