Gastrointestinal stromal tumor

Last revised by Mohammadtaghi Niknejad on 21 Nov 2022

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. They account for ~5% of all sarcomas and are mostly found within the stomach and mid-distal small bowel. They respond remarkably well to chemotherapy.

Previously these tumors have been previously referred to as leiomyoma, leiomyosarcoma ref, leiomyoblastoma, gastrointestinal autonomic nerve sheath tumor (GANT), and gastrointestinal pacemaker cell tumor (GIPACT) 21 as they were difficult to differentiate on histopathology until a characteristic expression of c-KIT (CD117) was identified ref.

Diagnostic criteria according to the WHO classification of soft tissue and bone tumors (5th edition) 21:

  • essential:

    • intramural, submucosal, or subserosal mass

    • spindle cell, epithelioid, or mixed morphology

    • KIT and/or DOG1 immunopositivity

    • SDHB loss in SDH-deficient GISTs

  • desirable: KIT or PDGFRA gene mutations in ~85%

  • incidence

    • overall uncommon when compared to gastrointestinal carcinoma, estimated ~0.0015% 13

    • small autopsy reports suggest the incidence of tiny (<1 cm) subclinical tumors ("tumorlets" or "microGISTS" 21) may be as high as 35% 21 in those over 50 years old

  • age

    • usually occur after 40 years of age, most commonly seen in older patients (median age 60-65 years) 1,21

    • may present earlier and often multiple in tumor syndromes (see below) 

  • gender

    • slight male predilection 21

The vast majority of GISTs are sporadic; however, a minority (5-10%) occur in the following syndromes, usually as SDH-deficient GISTs  2,21:

Clinical presentation is variable and reflects the variability of appearance, location, and biological behavior:

  • small tumors are more likely to be asymptomatic, regardless of location, and found incidentally 21

  • tend to grow intramural, bulging intraluminal or extramural if large enough

    • uncommon to cause dysphagia or bowel obstruction until very large

  • larger tumors are known to ulcerate and cause gastrointestinal hemorrhage 1

  • may present with non-specific gastrointestinal symptoms (e.g. abdominal pain, nausea, vomiting) 21

  • aggressive tumors may present with metastases or symptoms relating to local disease  1

GISTs are typically submucosal tumors, and the overlying mucosa often remains intact on pathological and imaging assessment.

They are believed to arise from the interstitial cells of Cajal 2,3, with 95% staining positive for CD117 (c-KIT) and 70% for CD34 2.

Grading GISTs requires an assessment of both tumor size and mitotic index 3. Smaller lesions have less aggressive biological behavior, as do stomach GISTs when compared to tumors elsewhere along the gastrointestinal tract 3. The risk of progressive disease depends on mitotic activity, size and anatomic site. Size criteria is divided into four categories 20:

  • ≤ 2cm

  • > 2cm to ≤ 5cm

  • > 5cm to ≤ 10 cm

  • > 10 cm

GISTs occur anywhere along the gastrointestinal tract. Approximately 10% of cases are disseminated at presentation 21. Common primary sites include 8.21:

In addition, extra-gastrointestinal GISTs are known to occur in the mesenteryomentum, and retroperitoneum 1,4 and are most likely to be recognized metastasis or detached primary lesion 21. Metastatic lesions (commonly liver 21) may also be seen in cases of malignant extra-gastrointestinal GISTs 7.

GISTS are typically rounded with frequent hemorrhage. Larger tumors may also demonstrate necrosis and cystic change 1,2. Size is variable, ranging from 1-30 cm 1.

Histology demonstrates a relatively cellular tumor composed of spindle cells (70-80%) or plump epithelioid cells (20-30%) 1,2,21. They appear to arise from the muscularis propria layer.

  • KIT (~75%) or PDGFRA (~10%) oncogene gain-of function mutations in encoding for type III receptor tyrosine kinases 21

  • many KIT and PDGFRA wildtype GISTs have SDH subunit gene alternation (5-10%) leading to a distinct subtype, SDH-deficient GIST, which more commonly present as gastric tumors in younger patients (particularly pediatric) and female patients 21

Specific appearances will vary according to location (see above), but in general, these tumors appear as rounded soft tissue masses, arising from the wall of a hollow viscus (most commonly the stomach) with an endoluminal or exophytic growth. The usual growth pattern in the small bowel is exoenteric, with a large extraluminal component 19. Bowel obstruction is rare even with large tumors 19. Mucosal ulceration is present in 50% of cases 1 with large necrotic cavities communicating with the lumen also seen.

Differentiating between a benign from a malignant GIST radiologically is difficult 19. The diagnosis of malignant GIST requires histopathologic analysis, but certain characteristics suggest malignancy 15:

  • exogastric growth

  • diameter >5 cm

  • central necrosis

  • extension to other organs

When large, secondary signs of the tumor may be visualized by radiograph, e.g. soft tissue density displacing bowel loops.

On upper abdominal studies, filling defect projecting from the wall of the stomach may be seen, with overlying ulceration or cavitation. The tumor margins are normally seen as smooth and may form right or obtuse angles with the adjacent mucosa due to its intramural origin.

Appearances vary with size and location. Typically the mass is of soft tissue density with central areas of lower density when necrosis is present (usually in larger tumors) that occasionally appear as fluid-fluid levels.

As the tumors are often exophytic, it can be difficult to delineate them on CT if the stomach is distended with barium, though the non-enhancing central necrotic area may be helpful. Deep crescent-shaped ulceration demonstrating an internal air-fluid level may be referred to as the Torricelli-Bernoulli sign 9.

Enhancement is typically peripheral (due to central necrosis) 1. Calcification is uncommon (3%) 1.

The presence of necrosis, hemorrhagic and cystic change make appearances variable:

  • T1

    • low signal intensity solid component

    • enhancement is usually present, and predominantly peripheral in larger lesions

  • T2: high signal intensity solid component

GISTs are FDG-avid tumors and F-18 FDG PET-CT can be used for initial staging and treatment response assessment 16. Areas of central necrosis can be photopenic on PET-CT (i.e. have low or absent tracer uptake) 17.

The Choi response criteria are used to assess treatment 11.

Surgical en-bloc resection is the primary mode of therapy for GISTs 4. Up to 50% of all GISTs will have evidence of metastatic disease at the time of presentation 3, which significantly impacts prognosis.

Adjuvant chemotherapy with imatinib is effective in the majority of cases and has had a dramatic impact on prognosis even with only one year of therapy, reducing recurrence at one year from 17% to 3% 4. Longer treatment regimens (2-3 years of imatinib) are currently under investigation 4. Other second-line agents (e.g. sunitinib) are also being studied and used for patients with imatinib-resistant tumors.

Historically, before imatinib up to 85% of tumors would locally recur or develop subsequent distant metastases despite treatment 3,4 and had proven to be resistant to standard chemotherapy 4.

Fluorine-18 FDG PET-CT may be used in monitoring treatment response and is considered superior to CT in monitoring treatment response in the initial phases of treatment 10,18.

Metastases (commonly liver and less commonly skeletal, soft tissue and rarely lung 21) or direct invasion into adjacent organs may be seen in more aggressive lesions. Lymph node enlargement is not a feature 1.

General imaging differential considerations include:

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Cases and figures

  • Figure 1: gross pathology - gastric GIST
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  • Case 1
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  • Case 2
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  • Case 3: GIST
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  • Case 4: jejunal GIST
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  • Case 5: H&E stain
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  • Case 6: at endoscopy
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  • Case 7
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  • Case 8: small bowel
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  • Case 9: on ultrasound
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  • Case 10
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  • Case 11
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  • Case 12: small omental lesion
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  • Case 13: large intra-abdominal GIST
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  • Case 14: esophageal GIST - arrowed
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  • Case 15: duodenal GIST
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  • Case 16: with hepatic metastases
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  • Case 17
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  • Case 18: on ultrasound
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  • Case 19
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  • Case 20: stomach
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  • Case 21
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  • Case 22
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  • Case 23: gastric
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  • Case 24
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  • Case 25: gastric
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  • Case 26: EUS
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  • Case 27: duodenum
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  • Case 28
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  • Case 29: antrum
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  • Case 30: rectal
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  • Case 31: gastric
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  • Case 32: gastric
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  • Case 33: gastric
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  • Case 34: gastric
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  • Case 35: with ulceration - stomach
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  • Case 36
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  • Cse 37: GIST on PET-CT
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  • Case 38
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  • Case 39: mimics adrenal metastasis
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  • Case 40
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  • Case 41: ulcerated
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  • Case 42: with malignant transformation
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  • Case 43
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  • Case 44: malignant
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  • Case 45: metastatic
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  • Case 46: causing ileoileal intussusception
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  • Case 47
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