[GIST (gastrointestinal stromal tumor). �������������. �������������] 1. SMT�� GIST - ������ ���� ������ �ٸ���? GIST�� �ϳ��� ���ܸ��Դϴ�. GIST�� heterogeneous�Ͽ� Kit (+) GIST, Kit (-) GIST�� ���� ������ �پ��� ������ �����з��� �����մϴ�. ���� GIST�� GIST�Դϴ�. �ϳ��� �������� ���ܸ��Դϴ�. SMT�� ���� ������ ���� ���� ��� finding�Դϴ�. GIST�� ���� ������ �ƴ� ���� �ֽ��ϴ�. SMT�� �������� ���ܸ��� �ƴմϴ�. SMT�� ���� ������ ã�Ƴ����� �Ϻΰ� GIST������, Ư�� �������� GIST�� SMT�� GIST�� �ƴ� SMT�� ��Ȯ�� ������ �� �����ϴ�. 2016�� Gastric Cancer�� 1��ȣ�� ���� �̷� ��Ȳ�� �� �����ݴϴ�. �� ������ ���Դϴ�. ���⼭ ù ������ �߿��մϴ�. Undiagnosed SET(SMT)�� histological GIST��� �� ���� �� ������ ������ �����ؾ� �մϴ�. ������ ������ ���� ���ð濡�� ������ ��κ��� SMT�� undiagnosed SMT�� ��, histological GIST�� �ƴմϴ�. ������ ������ 2 cm �̸� undiagnossed SMT�� ���� ǥ�� ���ٹ��� high risk features (ulceration, irregular border, increase in size)�� ���� �� CT, EUS, EUS-FNA�� �ϴ� ���� �ƴϰ� ���ð� ���������Դϴ�. 1-2 cm �̸��� SMT�� ���Ͽ� ��� EUS�� ���ϴ� ������ ������ ������ Ʋ���� ������ ����� ���Դϴ�. 2. GIST ��������(1) Spindle: Bland spindle cells with faintly eosinophilic cytoplasm in a syncytial pattern; elongated nuclei with inconspicuous nucleoli; artifactual paranuclear vacuoles common in stomach GIST. (2)
Epithelioid: Round cells with clear to eosinophilic cytoplasm in sheets or nests; increased tendency for pleomorphism versus spindle type (4) SDH deficient: epithelioid or mixed epithelioid / spindle cell morphology, multinodular pattern, minimal nuclear pleomorphism, occasional atypical mitoses (5) Dedifferentiated: anaplastic appearance with an unusual phenotype (may lose expression of KIT or may aberrantly express other markers such as cytokeratin) Histologic features and patterns of gastrointestinal stromal tumor (GIST).
(Arch Pathol Lab Med 2011) �� ������������ ���ð� �����˻翡�� GIST�� Ȯ�ε� ���� ���� �ʽ��ϴ�. �幰�� �ѷ��� �Ը��ΰ� �ִ� ���� ���ð� �����˻�� Ȯ�εDZ �մϴ�. GIST�� malignant risk�� ���� �з����� ���Ƽ� �� ȯ�ڰ� ���� �ٸ� risk�� �з��DZ �մϴ�. ���� ���� �����ϴ�. �Դٰ� ��� �ٲ�ϴ�. Stomach, body, wedge resection: Gastrointestinal stromal tumor of intermediate risk of malignant potential by proposed modification for adjuvant therapy (2008) (see note); 1) tumor size: 2.8x2.5 cm 2) mitosis: 7/50 HPF (high powered fields) 3) histological type: spindle 4) necrosis: absent 5) cellularity: intermediate 6) cellular atypia: moderate 7) invasion into mucosa: absent 8) resection margin involvement: absent Note: Intermediate risk by NIH (2002) and moderate risk (16%) of progressive disease by Miettinen (2006). Risk Stratification of Primary Gastrointestinal Stromal Tumors (GISTs) under the National Institutes of Health (NIH) Criteria and Modified NIH Criteria Risk stratification according to the National Institutes of Health (NIH) and modified NIH criteria. Twenty-two patients with intermediate risk under the original NIH criteria were reclassified into the high-risk category by the modified NIH criteria. Among the 22 reclassified patients, 6 patients experienced tumor recurrence. GISTs, gastrointestinal stromal tumors. �� ������ ���� �Z���ﺴ�� �嵿�� �������� editorial�� ���ҽ��ϴ�. Modified NIH criteria�� ���� high risk�� �з��� ȯ�ڿ��� adjuvant imatinib�� �ʿ��ϴ��� �����̾����ϴ�. ���� ���ؿ� ���� intermediate risk�� �з��Ǿ����� �ű��ؿ� ���� high risk�� �ٲ� ȯ�ڿ��� ������ �� �� �����ϴ�. 3. Mini-GIST Ȥ�� mini-SMT���� undiagnosed SMT �� ���� ���� ������ mini-GIST�� ���Դϴ�. ���� mini-GIST ���� �ſ� ���ϰ� ��κ� indolent�ϰ� �� ġ���ؾ� �ϴ��� ��Ȯ���� �ʽ��ϴ�. �ٸ� ���� ���ڵ��� mini-SMT Ȥ�� mini-GIST�� ���ϸ鼭 high-risk features�� irregular border�� ulceration�� �Բ� EUS�� �ؾ߸� �� �� �ִ� internal heterogeneity�� ����ϰ� �ֱ� ������ EUS�� ���� ó��ǰ� ���� ���Դϴ�. EUS���� �����Ǵ� internal heterogeneity�� ū GIST������ ���� �ǹ̰� ������, mini-GIST Ȥ�� mini-SMT���� �����Ǵ� internal heterogeneity�� �ӻ��� ���Ǵ� ��Ȯ���� �ʴٰ� ���� ���� �½��ϴ�. Undiagnosed SMT�� ���� ������ ���̵������ �����ϴ�. GIST ���̵������ �Ϻημ� ��ǰ� ���� ���Դϴ�. ���ð� �������� ������ ������ ���·� �������ٴ� �����Դϴ�. EGD�� EUS�� ȥ���ϰų� ��Ȯ�� �������� �ʰ� ������ ���̵������ ���� ���� �� �����Դϴ�. ���ǰ� �ʿ��մϴ�. ���� ���, 2016�� Gastric Cancer ������ �Ǹ� ���� ������ Table�� ����� ��ġ���� �ʽ��ϴ�. Misleading�� ���ɼ��� ���� Ʋ�� �����Դϴ�. "The standard diagnosis, treatment, and follow-up of GIST When small esophageal or gastric nodules (SMTs smaller than 2 cm) having no high-risk features are detected, they can usually be followed by periodic endoscopic ultrasonography (EUS) until the tumors increase in size or become symptomatic." ��ġ 5 mm SMT�� ���ؼ��� EUS�� �ؾ� �ϴ� ��ó�� ������ �ʽ��ϱ�? EGD�� EUS�� �������� �ʾҴٴ� ���� Ȳ���� ���Դϴ�. 2 cm �̸��̰� ������ ���ڰ� ���� �ĵ�/�� SMT�� (EUS�� �ƴ϶�) EGD�� �������� �� �� �ֽ��ϴ�. EUS�� �ʼ��� �ƴ϶� �����Դϴ�. ���� GIST ���̵���� �۾����� ���ð� �������� �����ؾ� �մϴ�. ������� �� �ѷ��� ��� ��ȭ�� ���� ������ ������ ���ϴ� ���� �����ϴ�. 4. GIST ġ��2 cm �̻��� GIST�� ǥ�� ġ��� ������ �����Դϴ�. ���ð� �������� �Ϻ� �õ��ǰ� ������ �ܰ��ǻ���� ���� positive margins�̳� tumor spillage�� �����ϰ� �ֽ��ϴ�. ���� ���� 3-4 cm ������ ���� GIST�� ���ɽ����� ���ð�ġ�Ḧ �� �� �� �ְڴٰ� �����մϴ�. 2 cm �̸��� GIST�� ������ Ȥ�� ��������� ������ �� �ֽ��ϴ�. ��� 2 cm �̸��� undiagnosed SMT������ �������� ������ �� �ʿ��� ���� �ƴմϴ�. 2 cm �̸����� ���������� ���� �ʴ� ö���� ���� �ǻ�� 2 cm �̸� GIST�� ���� ������ �����ϴ�. �Ʒ��� unresectable, metastatic Ȥ�� recurrent GIST�� ���� ġ�� algorithm�Դϴ�. �ʹ� Ŀ�� Gleevec ���� �����ϴ� ȯ���� �ܷ� ����Դϴ�. 5. �������� ������ ������ GIST MelenaStomach, subtotal gastrectomy: Gastrointestinal stromal tumor of high risk of malignant potential by NIH criteria: 1) tumor size: 6.5x6.0 cm 2) mitosis: 6 /50 HPF (high powered fields) 3) histological type: spindle 4) necrosis: absent 5) cellularity: intermediate 6) cellular atypia: mild 7) invasion into mucosa: present 8) myxoid change: present 9) resection margin involvement: absent 10) no metastasis in 4 regional lymph nodes Melena Stomach, cardia, wedge resection: Gastrointestinal stromal tumor of high risk of malignant potential by NIH (2002) and moderate risk(16 %) of progressive disease by Miettinen(2006) ; 1) tumor size: 3.5x2.5x2.4 cm 2) mitosis: 88/50 HPF (high powered fields) 3) histological type: mixed spindle and epithelioid 4) necrosis: present 5) cellularity: high 6) cellular atypia: moderate 7) invasion into mucosa: present 8) resection margin involvement: absent Melena�� ���̴µ� SMT ������ ���� ������ ���ٰ� �ǷڵǾ���. �ڼ��� ���� �˾��� �־���. Stomach, body, wedge resection: Gastrointestinal stromal tumor of high risk of malignant potential by proposed modification for adjuvant therapy (2008) (see note); 1) tumor size: 5.5x3.5 cm 2) mitosis: 40/50 HPF (high powered fields) 3) histological type: spindle 4) necrosis: absent 5) cellularity: high 6) cellular atypia: moderate 7) invasion into mucosa: absent 8) resection margin involvement: absent Note: high risk by NIH (2002) and high risk (55%) of progressive disease by Miettinen (2006). [Addendum] Ki-67 : Positive in 10% of tumor cells DOG-1 : Positive in tumor cells C-KIT (CD 117) : Positive in tumor cells 6. ù ���ܽ� ���̰� �־��� GIST GIST with hepatic metastasis. Fundus�� �ұ�Ģ�� �˾� �κ�(�ι�°, ����° ����)������ �Ǵ��ϸ� AGC, lymphoma, GIST ���� ��� ������ �� �ְ�����, �ұ�Ģ�� �˾�� �ֺ��� ���� SMT �κ�(ù��° ����)�� �����ϸ� AGC�� ���ɼ��� �ſ� �������� ������� �� �� �ֽ��ϴ�. C-kit (CD117) �缺 GIST�����ϴ�. Hepatic metastasis Hepatic metastasis ���ð濡�� ���� SMT�� �ִ� ��ó�� �������� CT������ proximal stomach ���� ��ü�� ���δ� GIST ������, MRI������ �� ���� metastastasis�� �־����ϴ�. �����˻�: Gastrointestinal stromal tumor, high risk of malignant behavior; 1) mitosis: 11/16 HPF 2) histological type: mixed 3) necrosis: absent 4) cellularity: high 5) myxoid change: present ó������ �� ���̰� �־ imatinib�� �����Ͽ����ϴ�. Liver biopsy: Gastrointestinal stromal tumor C-KIT (CD 117) : Diffusely positive in tumor cells Ki-67 : Positive in up to 8% of tumor cells DOG-1 : Focally positive in tumor cells Gleevec ���� �� ȣ����� ��. CT���� drug-induced BOOP �Ұ����� �ϴ� Gleevec �ߴ��Ͽ����ϴ�. Gleevec�� �幮 �պ����̶�� �մϴ�. (2017, 49�� ����) �쿬�� �����Ŀ��� �������� �߰ߵǾ����ϴ�. ���ð濡���� Ư�̼Ұ��� �������ϴ�. CT���� �̹� ������ ���� metastatic nodule ���� �����Ǿ����ϴ�. EUS-guided biopsy�� �Ͽ��� GIST�� Ȯ�εǾ����ϴ�. Gleevec ġ�Ḧ �Ͽ����ϴ�. Exophytic growth�� ���� gastric GIST�� ù ���ܽ� �� ħ���� ���� ���̰� �־��� ���ʷ� ����������ϴ�. ���ð� ���� �ǻ簡 ���� clot���� �ִµ� �����˻縦 �ص� ������ realtime���� ���ǰ� �ͼ� �����˻縦 �ϵ��� ���Ͽ��� c-kit positive GIST�� Ȯ�εǾ���. 7. ������� �� �˾��� ���Ͽ� ������ ���� 3�� ������� �� ũ�Ⱑ �����Ͽ��� �۰� ���� �˾��� ���Ͽ� ���� Stomach, fundus, wedge resection: Gastrointestinal stromal tumor of intermediate risk of malignant potential by proposed modification for adjuvant therapy (2008) (see note); 1) tumor size: 3.8x3.0 cm 2) mitosis: 9/50 HPF (high powered fields) 3) histological type: spindle 4) necrosis: absent 5) cellularity: intermediate 6) cellular atypia: moderate 7) invasion into mucosa: absent 8) resection margin involvement: absent Note: intermediate risk by NIH (2002) and moderate risk (16%) of progressive disease by Miettinen (2006). ������� �� �˾� Gastrointestinal tumor of high risk of aggresive behavior: 1) tumor size : 2.7x2x1.5 cm 2) mitosis: 26/50 HPF 3) histologic type : spindle 4) necrosis : present 5) cellularity : high 6) invasion into mucosa : present 7) resection margin involvement : absent 8) histologic subtype: cellular spindle cell type ������� �� �˾� Stomach, mid body, posterior, wedge resection: Gastrointestinal stromal tumor of low risk of malignant potential by NIH (2002) and very low risk (1.9 %) of progressive disease by Miettinen (2006): 1) tumor size: 3.5x3x2 cm 2) mitosis: 2/50 HPF (high powered fields) 3) histological type: spindle 4) necrosis: absent 5) cellularity: high 6) cellular atypia: mild 7) invasion into mucosa: absent 8) resection margin involvement: absent ó�� ���ð� ��ÿ��� ������ �����µ� ���� ��ٸ��� ��ĥ ���̿� melena�� ���� ���ѷ� ������ Stomach, body, posterior wall, wedge resection: Gastrointestinal stromal tumor of high risk of malignant potential: 1) tumor size: 4.2x3.8x3.3 cm 2) mitosis: 10/50 HPF (high powered fields) 3) histological type: spindle 4) necrosis: absent 5) cellularity: intermediate 6) cellular atypia: mild 7) invasion into mucosa: absent 8) resection margin involvement: absent 8. ������� �� ������ ������ GIST �������� �� melena Stomach, high body, wedge resection: Gastrointestinal stromal tumor of low risk of malignant potential by proposed modification for adjuvant therapy (2008), low by NIH and very low risk (1.9 %) of progressive disease by Miettinen (2006) : 1) tumor size: 2.2x2 cm 2) mitosis: 4 /50 HPF (high powered fields) 3) histological type: spindle 4) necrosis: absent 5) cellularity: intermediate 6) cellular atypia: moderate 7) invasion into mucosa: present 8) resection margin involvement: absent �������� �� melena Stomach, fundus, wedge resection: Gastrointestinal stromal tumor of low risk of malignant potential by NIH (2002) and very low risk (1.9 %) of progressive disease by Miettinen (2006): 1) tumor size: 2.1x1.9x1.7 cm 2) mitosis: 1/50 HPF (high powered fields) 3) histological type: spindle 4) necrosis: absent 5) cellularity: low 6) cellular atypia: mild 7) invasion into mucosa: absent 8) resection margin involvement: absent 9. ���ڰ� ������ ���� ū GIST 2�� ������ ���۵� ���� �ظ����� �����Ͽ����ϴ�. ���� CT������ 30x24cm�� �����Ǿ����� ��� �� Ŀ�������ϴ�. ��Ȯ�� ������ ���Ͽ� sono-guided biopsy�� �Ͽ����ϴ�. GIST (high risk of malignant potential)�� ���� ��� mitosis�� 4/17 HPFs, �������� mixed spindle and epitheloid�����ϴ�. Gleevec���� 16���� ġ���Ͽ��� ���Ұ� ������ �۾������ϴ�. Surgical wedge resection�� �Ͽ����ϴ�. ������ ũ��� 15x9x9cm����, neat total necrosis�� ���Ͽ� mitosis�� ������ �� �������ϴ�. �� 1�� �� �������ð濡�� ���� 1��, ���� 1���� �߰ߵǾ� ESD�� �Ͽ����ϴ�. Surgical wedge resection �� 5�Ⱓ adjuvant imatinib ����Ͽ����ϴ�. ���� ������� �� �ᱹ ����ϼ̽��ϴ�. �� ȯ�� ������ ũ�� �ʾƵ� locally advanced disease�� �ٷ� surgical resection�� ��Ʊ� ������ �ϴ� Gleevec ġ����� �����մϴ�. ������ ������ ������ �ϱ �մϴ�. 10. ������ ���������� �ź��ϰ� �����ٰ� ������ ���·� �Ƿڵ� ȯ������ �������� ������ �����ް� �� ���� �ܰ��� ã�Ҵٰ�, ȯ�ڰ� �������� �ʴ� ������ ������ �ٲپ� ��ȭ�⳻���� ã�� ���Դϴ�. �翬�� ������ �������� ���� follow-up loss �Ǿ����ϴ�. 3�� �� ���̵� ���·� �ٽ� �����ϼ̽��ϴ�. ��Ÿ��� ���Դϴ�. EUS guided biopsy�� c-kit positive malignant GIST�� �����Ͽ����ϴ�. 11. More cases of gastric GIST �쿬�� �߰ߵ� ���� gastric SMT�� ��κ��� Ŀ���� ������ ����� �ݹ��Դϴ�. �и� Ŀ���� ��쵵 �ֱ� �����Դϴ�. �Ʒ� ���ʴ� ����� ȯ�ڿ��� �쿬�� �߰ߵ� �� SMT�����ϴ�. ���������� ���Ͽ����� follow up loss �Ǿ����ϴ�. 6�⸸�� ���̴µ� ���� Ŀ�� ���¿����ϴ�. CT �˻� �� ������ �Ͽ����ϴ�. (2012. F/61) ������ 10�� ���̿� ũ�� ������ �־� �����Ͽ��� ȯ���Դϴ�. �Ƿ� �� Ư���� ������ ������ �־����ϴ�. ���ð� �����˻� �� ������ ��Ʋ ���� ���� ���� �־��µ� ȯ�ڲ����� ������ �� �� �������ٴ� ������ �α� ���к��� �Ű���� �湮�Ͽ� �Ӹ� MRI�� ��� �̻��� ���ٴ� �̾߱⸦ ����ٰ� �մϴ�. 119�� �� �� �Ƿ����µ� �ƹ��� ���ð� �˻� �ߴ���, ������ �������� ����� �ʾҴٰ� �մϴ�. �Ű�� �����Ե鲲 ��Ź�մϴ�. ���� û�븦 �� ���ֽñ� �ٶ��ϴ�.
�پ��� �����Դϴ�.
12. ���� GIST Duodenal GIST. 3.2x1.8cm �������� GIST�� necrosis�� ���ϸ� �����˻翡�� ������ ���� �� �ֽ��ϴ�. Melena�� �����Ͻ� ������ �� ���� EGD �����˻翡�� �������� Ȯ���� ���� �ʾ� ������ EUS-guided biopsy�� �������� Ȯ���� ���� �� �־��� duodenal GIST with hepatic metastais �����Դϴ�. (F/60, 2018) 13. ���� GIST ����
14. ��Ÿ ��� GIST �ĵ� GIST. ��� ������ ������ �� �ĵ� GIST�� ���� �����Դϴ�. �ĵ� GIST�� leiomyoma���� �ſ� rare�մϴ�. �Ϻνĵ��� ��ġ�ϰ� lobulated �Ǵ� ������ �ְ� leiomyoma���� soft �մϴ�. Leiomyoma�� ���� �ſ� �ܴ��մϴ�. ���� GIST 15. Code ������ �� GIST�� �ڵ忡 ���� ������ �־� �������� �����Ͽ����ϴ�. (2017/3) ���ڷ� �� Į�ڷ縦 ������ �ִ� ���ο����� ���غ��� �����ϰ� ������ �� ���Դϴ�. ȯ���� ������ ���Ͽ� ������ �ð��� �����ѵ� �ڵ� ������ �ڲ� �ð��� �����ϴٴ� ��Ÿ�����ϴ�. �����ϴ� �ٿ� ���� '�ϵ�Ϻ���'�� ������ �ƴմϴ�. �ƹ��� ������ �� �˷��ִ� ���� ���� �� ���Դϴ�. '�ϵ�Ϻ���'�� �� �� �ϳ��Դϴ�. [FAQ] [2016-11-14. 2016�� ��ǥ�� GIST management ������ ���� ���� ������ ����]
[2016-11-20. ������ �亯]
[2017-2-15. �ֵ��� ����]
[2017-2-15. ������ �亯]
[References]
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