Gastrointestinal stromal tumors (GIST): a proposal of a “CT-based predictive model of Miettinen index” in predicting the risk of malignancy



To identify the predictors of malignancy on CT for the evaluation of gastrointestinal stromal tumors (GIST) by correlating CT findings with the mitotic index in order to propose a “CT-based predictive model of Miettinen index.”


One radiologist and one resident in radiology with 14- and 4-year experience in oncological field reviewed the CT findings of 42 patients by consensus, with respect to lesion site, size, contour, tumor growth pattern, enhancing pattern, degree of enhancement of tumor, percentage of tumor necrosis, mesenteric fat infiltration, ulceration, calcification, regional lymphadenopathy, direct invasion to adjacent organs, and distant metastasis. All parameters were correlated with the mitotic index evaluated at histopathological analysis following surgery. Normality of variables was evaluated using Shapiro–Wilk test. Pearson’s correlation test was used to assess the interaction between variables. The diagnostic accuracy percentage of tumor necrosis was measured by receiver operating characteristic (ROC) analysis for detecting whether the number of mitosis per 50 high-power fields was > 5.


A significant statistical correlation was found between percentage of tumor necrosis and the mitotic index (p < 0.005), dimension, and location of the tumor.


CT could be an accurate technique in the prediction of malignancy of GIST in a CT risk assessment system, based on the location of the tumor, its size, and the percentage of tumor necrosis.

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  1. 1.

    T.M. Parab, M.J. DeRogati, A.M. Boaz, et al. (2019) Gastrointestinal stromal tumors: a comprehensive review. J Gastrointest Oncol 10:144–154.

    Article  Google Scholar 

  2. 2.

    A.D. Levy, H.E. Remotti, W.M. Thompson, L.H. Sobin, M. Miettinen (2003) From the Archives of the AFIP. Gastrointestinal Stromal Tumors: radiologic Features with Pathologic Correlation. Radiographics 23:283–304.

    Article  Google Scholar 

  3. 3.

    M. Miettinen, J. Lasota (2003) Gastrointestinal Stromal Tumors (GISTs): Definition, Occurrence, Pathology, Differential Diagnosis and Molecular Genetics. Pol J Pathol 54:3–24.

    PubMed  Google Scholar 

  4. 4.

    M. Bosoteanu, C. Bosoteanu, M. Deacu, M. Aschie (2011) Differential diagnosis of gastric stromal tumor: case report and literature review. Rom J Morphol Embryol 52:1361–1368.

    PubMed  Google Scholar 

  5. 5.

    M.A. Mazzei, G. Bagnacci, F. Gentili, et al. (2018) Gastric Cancer Maximum Tumour Diameter Reduction Rate at CT Examination as a Radiological Index for Predicting Histopathological Regression after Neoadjuvant Treatment: A Multicentre GIRCG Study. Gastroenterol Res Pract 2018:1794524.

    Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    H.C. Kim, J.M. Lee, S.H. Kim, et al. (2004) Primary Gastrointestinal Stromal Tumors in the Omentum and Mesentery: CT Findings and Pathologic Correlation. AJR 182:1463–1467.

    Article  Google Scholar 

  7. 7.

    M. Miettinen, J. Lasota (2006) Gastrointestinal stromal tumors: review on morphology, molecular pathology, prognosis, and differential diagnosis. Arch Pathol Lab Med 130:1466–1478.

    PubMed  CAS  Google Scholar 

  8. 8.

    N. Iorio, R.A. Sawaya, F.K. Friedenberg (2014) Review article: the biology, diagnosis and management of gastrointestinal stromal tumours. Aliment Pharmacol Ther 39:1376–1386.

    Article  CAS  Google Scholar 

  9. 9.

    A.D. Levy, H.E. Remotti, W.M. Thompson, L.H. Sobin, M. Miettinen (2003) Anorectal Gastrointestinal Stromal Tumors: CT and MR Imaging Features with Clinical and Pathologic Correlation. AJR 180:1607–1612.

    Article  Google Scholar 

  10. 10.

    G. De Manzoni, D. Marrelli, G.L. Baiocchi, et al. (2017) The Italian Research Group for Gastric Cancer (GIRCG) guidelines for gastric cancer staging and treatment: 2015. Gastric Cancer 20:20–30.

    Article  Google Scholar 

  11. 11.

    R. Grassi, A. Pinto, L. Mannelli, D. Marin, M.A. Mazzei (2016) New Imaging in Gastrointestinal Tract. Gastroenterol Res Pract 2016:5785871.

    Article  PubMed  PubMed Central  Google Scholar 

  12. 12.

    T. Chen, L. Xu, X. Dong, Y. Li, J. Yu, W. Xiong, G. Li (2019) The roles of CT and EUS in the preoperative evaluation of gastric gastrointestinal stromal tumors larger than 2 cm. Eur Radiol. [Epub ahead of print].

  13. 13.

    M. Liu, L. Liu, E. Jin (2018) Gastric sub-epithelial tumors: identification of gastrointestinal stromal tumors using CT with a practical scoring method. Gastric Cancer. [Epub ahead of print].

  14. 14.

    G.L. Pelandré, M.C. Djahjah, E.L. Gasparetto, M.S. Nacif, E. Marchiori, E.L.R. de Mello (2013) Tomographic findings of gastric gastrointestinal stromal tumor and correlation with the mitotic index. Arq Gastroenterol 50:244–250.

    Article  Google Scholar 

  15. 15.

    C.D. Fletcher, J.J. Berman, C. Corless, et al. (2002) Diagnosis of gastrointestinal stromal tumors: A consensus approach. Hum Pathol 33:459–465.

  16. 16.

    H. Joensuu, A. Vehtari, J. Riihimäki J, et al. (2012) Risk of recurrence of gastrointestinal stromal tumour after surgery: an analysis of pooled population-based cohorts. Lancet Oncol 13:265–274.

    Article  Google Scholar 

  17. 17.

    A.C. O’Neill, A.B. Shinagare, V. Kurra, et al. (2016) Assessment of metastatic risk of gastric GIST based on treatment –naive CT features. Eur J Surg Oncol 42:1222–1228.

    Article  Google Scholar 

  18. 18.

    M.R. Ambrosio, B.J. Rocca, M.G. Mastrogiulio, et al. (2014) Cystic gastrointestinal stromal tumors of the pancreas simulating cystoadenocarcinoma. Report of three cases and short review of the literature. Histol Histopathol 29:1583–1591.

    PubMed  CAS  Google Scholar 

  19. 19.

    M.A. Mazzei, V. Nardone, L. Di Giacomo, et al. (2018) The role of delta radiomics in gastric cancer. Quant Imaging Med Surg. 8:719–721.

    Article  Google Scholar 

  20. 20.

    I.G. Lupescu, M. Grasu, M. Boros, et al. (2007) Gastrointestinal Stromal Tumors: Retrospective Analysis of the Computer-Tomographic Aspects. J Gastrointestin Liver Dis 16:147–151.

    PubMed  Google Scholar 

  21. 21.

    T.H. Yang, J.I. Hwang, M.S. Yang, S.W. Hung, S.W. Chan, Jwang, Y.S. Tyan (2007) Gastrointestinal Stromal Tumors: Computed Tomographic Features and Prediction of Malignant Risk from Computed Tomographic Imaging. J Chin Med Assoc 70:367–373.

  22. 22.

    H.C. Kim, J.M. Lee, K. W. Kim, et al. (2004) Gastrointestinal Stromal Tumors of the Stomach: CT findings and Prediction of Malignancy. AJR 183:893–898.

    Article  Google Scholar 

  23. 23.

    S. Ulusan, Z. Koc, F. Kayaselcuk (2008) Gastrointestinal stromal tumours: CT findings. Br J Radiol 81:618–623.

    Article  CAS  Google Scholar 

  24. 24.

    S.H. Yin, C.M. Xie, Y.X. Mio, et al. (2009) Correlation of multi-slice spiral CT features to clinicopathologic manifestations of gastrointestinal stromal tumor: a report of 49 cases. Chinese Journal of Cancer 28:1–7.

    Article  CAS  Google Scholar 

  25. 25.

    T. Da Ronch, A. Modesto, M Bazzocchi (2006) Gastrointestinal stromal tumour: spiral computed tomography features and pathologic correlation. Radiol med 111:661–673.

    Article  Google Scholar 

  26. 26.

    T.V. Bartolotta, A. Taibbi, M. Galia, et al. (2006) Gastrointestinal stromal tumour: 40-row multislice computed tomography findings. Radiol med 111:651–660.

    Article  CAS  Google Scholar 

  27. 27.

    A. Rimondini, M. Belgrano, G. Favretto, A. Spivach, A. Sartori, F. Zanconati (2007) Contribution of CT to treatment planning in patients with GIST. Radiol med 112:691–702.

    Article  CAS  Google Scholar 

  28. 28.

    R. Wada, H. Arai, S. Kure, W.X. Peng, Z. Naito (2016) "Wild type" GIST: Clinicopathological features and clinical practice. Pathol Int. 66:431–437.

    Article  PubMed  CAS  Google Scholar 

  29. 29.

    A. Gaitanidis, M. El Lakis, M. Alevizakos, A. Tsaroucha, M. Pitiakoudis (2018) Predictors of lymph node metastasis in patients with gastrointestinal stromal tumors (GISTs). Langenbecks Arch Surg. 403:599–606.

    Article  PubMed  Google Scholar 

  30. 30.

    N. Gong, C.S. Wong, Y.C. Chu (2011) Is lymph node metastasis a common feature of gastrointestinal stromal tumor? PET/CT correlation. Clin Nucl Med. 36:678–682. Erratum in: Clin Nucl Med. 2011; 36:833. Jie, Gong Nan [corrected to Gong, Nanjie]; Sing, Wong Chun [corrected to Wong, Chun Sing]; Ching, Chu Yiu [corrected to Chu, Yiu Ching]; Tiffany [removed].

  31. 31.

    T. Lehnert (1998) Gastrointestinal sarcoma (GIST): a review of surgical management. Ann Chir Gynaecol. 87:297–305.

    PubMed  CAS  Google Scholar 

  32. 32.

    T. Tashiro, T. Hasegawa, M. Omatsu, S. Sekine, T. Shimoda, H. Katai (2005) Gastrointestinal stromal tumor of the stomach showing lymph node metastases. Histopathology. 47:438–439.

    Article  PubMed  CAS  Google Scholar 

  33. 33.

    S.M. Zwan Van der, R.P. De Matteo (2005) Gastrointestinal stromal tumor. 5 years later. Cancer. 104:1781–1788.

    Article  PubMed  CAS  Google Scholar 

  34. 34.

    A.E. Canda, Y. Ozsoy, O.A. Nalbant, O. Sagol (2008) Gastrointestinal stromal tumor of the stomach with lymph node metastasis. World J Surg Oncol. 6:97.

    Article  PubMed  PubMed Central  Google Scholar 

  35. 35.

    A. Shafizad, M. Mohammadianpanah, H. Nasrolahi, M. Mokhtari, S.A. Mousavi (2014) Lymph Node Metastasis in Gastrointestinal Stromal Tumor (GIST): to Report a Case. Iran J Cancer Prev. 7:171–174.

    PubMed  PubMed Central  Google Scholar 

  36. 36.

    M.A. Mazzei, F. Gentili, L. Volterrani (2019) Dual-Energy CT Iodine Mapping and 40-keV Monoenergetic Applications in the Diagnosis of Acute Bowel Ischemia: A Necessary Clarification. AJR Am J Roentgenol. 212:W93–W94.

    Article  Google Scholar 

  37. 37.

    P. Apfaltrer, M. Meyer, C. Meier, et al. (2012) Contrast-enhanced dual-energy CT of gastrointestinal stromal tumors: is iodine-related attenuation a potential indicator of tumor response?” Invest Radiol 47:65–70.

    Article  CAS  Google Scholar 

  38. 38.

    F.G. Mazzei, L. Volterrani, S. Guerrini, et al. (2014) Reduced time CT perfusion acquisitions are sufficient to measure the permeability surface area product with a deconvolution method. Biomed Res Int 2014:573268.

    Article  PubMed  PubMed Central  Google Scholar 

  39. 39.

    F.G. Mazzei, M.A. Mazzei, N. Cioffi Squitieri, et al. (2014) CT perfusion in the characterisation of renal lesions: an added value to multiphasic CT. Biomed Res Int 2014:135013.

    Article  PubMed  PubMed Central  Google Scholar 

  40. 40.

    M.A. Mazzei, N. C. Squitieri, E. Sani, et al. (2013) Differences in perfusion CT parameter values with commercial software upgrades: a preliminary report about algorithm consistency and stability. Acta Radiol 54:805–811.

    Article  Google Scholar 

  41. 41.

    M.A. Mazzei, L. Preda, A. Cianfoni, L. Volterrani (2015) CT perfusion: technical developments and current and future applications”. Biomed Res Int 2015:397521.

    Article  PubMed  PubMed Central  Google Scholar 

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A preliminary research with the title “Gastrointestinal stromal tumors of the stomach: CT percentage of tumor necrosis and prediction of malignancy” was presented as conference abstract at ECR 2015, Book of Abstracts—B—Scientific Sessions and Late-Breaking Clinical Trials.


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Correspondence to S. Guerrini.

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Mazzei, M.A., Cioffi Squitieri, N., Vindigni, C. et al. Gastrointestinal stromal tumors (GIST): a proposal of a “CT-based predictive model of Miettinen index” in predicting the risk of malignancy. Abdom Radiol 45, 2989–2996 (2020).

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  • Computed tomography
  • Gastrointestinal stromal tumor
  • Gastric GIST
  • Mitotic index