Management of a case of high-risk gastrointestinal stromal tumor in rectum by transanal minimal invasive surgery
Rectal gastrointestinal stromal tumor (GIST) is a very rare tumor of gastrointestinal tract. Surgical management of rectal GIST requires special attention for preserving of anal and urinary functions. Transanal minimal invasive surgery (TAMIS) is a well-developed minimally invasive technique for local excision of benign and early malignant rectal tumors; however, the application of TAMIS for rectal GIST is rarely and inadequately reported. We report the novel application of TAMIS for rectal GIST with considerations for anal and urinary functions.
A 67 years old female, who presented with history of per rectal bleeding, was diagnosed with submucosal GIST of 4.5 cm in diameter at right posterior wall of 7 cm from anal verge. Histology of biopsy showed abundant spindle-shaped cells arranged in bundles that were positive for CD34 and negative for C-Kit, desmin, smooth muscle actin (SMA), and S-100. The tumor was excised by TAMIS successfully. Final histopathology showed pT2 tumor with C-Kit positive and mitosis count 10 per 50 HPF. Postoperative period was uneventful, and she was discharged on adjuvant imatinib mesylate for 3 years.
TAMIS can be used safely in the management of rectal GIST after appropriate evaluation of tumor size, extent, location, and experience of operating surgeon.
KeywordsRectal GIST TAMIS Imatinib mesylate
Gastrointestinal stromal tumor
Magnetic resonance imaging
Transanal minimal invasive surgery
Transanal endoscopic microsurgery
Gastrointestinal stromal tumor (GIST) is a rare tumor of the gastrointestinal (GI) tract that constitutes less than 1% of all GI tumors. Nevertheless, they are the commonest of all the mesenchymal tumors of the GI tract . The usual sites of occurrence are the stomach (60–70%), intestines (20–30%), colon and rectum (5%), and esophagus (< 5%) . GISTs in the rectum demonstrate male predominance and rarely occur in individuals younger than 40 years .
Various surgical techniques have been described for the treatment of rectal GIST, including traditional transanal resection, trans-sacral approach, transanal endoscopic microsurgery (TEM), transanal minimal invasive surgery (TAMIS), and laparoscopic surgery [4, 5, 6, 7, 8, 9, 10, 11]. Although TAMIS has been undergoing a surge in popularity among surgeons, its application for management of rectal GISTs is rarely reported, and only few cases of rectal GISTs are included in large series of TAMIS [5, 6]. Here, we discuss a high-risk case of rectal GIST that was managed by TAMIS with due consideration for preserving anal and urinary functions and by postoperative adjuvant therapy with imatinib mesylate (IM).
Surgery with complete resection is the only curative option for rectal GISTs . It is very important to consider the balance of radical resection with the preservation of the anal and urinary functions in the treatment of middle to lower rectal GISTs. Various surgical techniques have been described for rectal GISTs, including conventional transanal resection, trans-sacral approach, transanal endoscopic microsurgery (TEM), transanal minimal invasive surgery (TAMIS), and laparoscopic surgery [4, 5, 6, 7, 8, 9, 10, 11]. Clinicians need to adopt these approaches according to appropriate evaluation of tumor size, extent, and location, as well as the operating surgeon’s experience of the techniques.
Summary of surgical procedures for the resection of rectal GIST
• Used usually for lower rectal lesions
• Easy and minimally invasive
Local recurrences is high due to poor quality of excision and fragmentation of tumor
Up to 22%
Beneficial for GISTS that are large and grow away from rectal lumen
• More invasive than TAMIS
• Increased risk of poor perineal wound healing and fecal fistula
Up to 21%
Superior quality of resection, decreased local recurrence, and improved survival
• Anorectal dysfunction may occur due to rigid anoscope
• Steep learning curve and need of highly qualified surgeon
Expensive than TAMIS
Up to 29%
• Superior operative results
• Convenient access device and less effects on anorectal functions
Difficult to access upper rectum and not suitable for large tumors
Up to 7.4%
With surgery alone, the 15 years recurrence-free survival (RFS) and overall survival (OS) time was found to be 59.9% and 12.4 years respectively . Use of IM as an adjuvant therapy can increase resectability or decrease surgical morbidity in unresectable or locally advanced cases and can improve recurrence-free survival . The tumor size, mitosis count, non-gastric location, male sex, and rupture of pseudocapsule are the independent adverse prognostic factors for GIST . In our case, the tumor diameter was 4.3 cm and initial biopsy was negative for C-Kit, so we proceeded with curative surgery rather than neoadjuvant IM. Neoadjuvant IM is recommended if R0 resection is not possible, surgery can be achieved by less mutilating surgery/functional preserving surgery, or can be made safer . In our case, the mitosis count was 10 per 50 HPF, so it was considered high-risk malignant GIST  and patient was discharged on adjuvant IM for 3 years.
This case provided a new strategy consisting of TAMIS using GelPOINT path with conventional laparoscopic instruments for patients with small size of tumor less than 5 cm in diameter. However, prospective studies are needed in the future to investigate safety and effects of this new strategy.
Rectal GIST is one of the most important differential diagnoses of rectal tumor that requires special consideration with regard to preservation of anal and urinary functions when the tumor is small. In our case, TAMIS using GelPOINT path contributed to curative resection of the tumor and satisfactory functions. The appropriate surgical technique should be selected depending upon location, size, and resectability of tumor, and the surgical expertise of the attending physician.
We appreciate the contributions of all the surgeons, coworkers, and friends involved in this study and thank the editors and reviewers for their help with this manuscript. We also thank Hugh McGonigle, from Edanz Group (www.edanzediting.com/ac), for editing a draft of the manuscript.
PN and SM conceived of the study, designed it, and acquired the data. YK, KT, KB, YU, HK, TA, MS, and KM participated in design of the study and coordination and analysis of data. PN drafted the manuscript. SN participated in manuscript preparation and critical revision. All authors read and approved the manuscript.
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