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• W4248188934 abstract "We thank Professor Fan for the comments on our article entitled “Endoscopic versus surgical resection of GI stromal tumors in the upper GI tract.”1Joo M.K. Park J.J. Kim H. et al.Endoscopic versus surgical resection of GI stromal tumors in the upper GI tract.Gastrointest Endosc. 2016; 83: 318-326Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar We have carefully considered the comments and agree with them, especially in terms of selection bias between the endoscopy group and the surgery group. As was pointed out, the groups are basically disparate, which resulted in significant differences in tumor size, location, and risk stratification. We mentioned this in the text and tables. Furthermore, endoscopic submucosal dissection for tumors in the small intestine is very challenging technically,2Yun J.W. Park J.J. Kim K.H. et al.Successful endoscopic submucosal dissection for triple sporadic nonampullary duodenal adenomas using a “push and peel off” technique.Endoscopy. 2012; 44: E25-E26PubMed Google Scholar and this may require surgical removal of GI stromal tumors (GISTs) located in the duodenum. We also mentioned in the article the similar recurrence rates of the endoscopy and surgery groups despite the marked difference in the R0 resection rate between them; this may reflect a selection bias of baseline characteristics between the 2 groups in aspects such as tumor size, location, and risk stratification.1Joo M.K. Park J.J. Kim H. et al.Endoscopic versus surgical resection of GI stromal tumors in the upper GI tract.Gastrointest Endosc. 2016; 83: 318-326Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar In terms of mitotic index, less than 5/high power field (HPF) were evident in 84.4% of GISTs (76 of 90) in the endoscopy group, followed by 6 to approximately 10/HPF in 11.1% (10 of 90) and greater than 10/HPF in 4.4% (4 of 90). In the surgery group, however, 20.0% of GISTs (8 of 40) were greater than 10/HPF, and 12.5% (5 of 40) were 6 to approximately 10/HPF. This difference naturally resulted in a significant difference in distribution of risk stratification between groups. A prospective randomized trial with an even distribution of patients is an ideal study design; there is a clear-cut limitation in our study because it is a retrospective review of medical records. However, we were able to underscore the therapeutic role of the endoscopic procedure for GISTs in the upper GI tract (UGIT).3Kim G.H. Endoscopic resection of subepithelial tumors.Clin Endosc. 2012; 45: 240-244Crossref PubMed Google Scholar When we actually resected UGIT GISTs using endoscopy, we found during long-term follow-up that most corresponded to very low or low risk, smaller tumor size, and an acceptable recurrence rate. Therefore, we suggest that if a GIST is completely resected without residual tumor in an endoscopic view and is classified as lower risk by histopathologic evaluation, the endoscopic procedure can be an alternative choice for optimal treatment of GISTs in the UGIT even if it shows an R1 resection margin. However, if a tumor is larger and malignant behavior is strongly suspected because of irregular borders, cystic space, ulceration, echogenic foci, or heterogeneity by endoscopic ultrasonography, a surgical approach should be considered. In terms of the operational period, all the GISTs in the early period were resected using endoscopic mucosal resection or endoscopic submucosal dissection, whereas novel endoscopic techniques, including submucosal tunneling endoscopic resection and endoscopic full-thickness resection, were introduced during the late period. Accordingly, more challenging cases, including tumors broadly connected to the muscularis propria layer or with an exophytic growth pattern, were enrolled. This may have caused significant differences in the R0 resection rate between the 2 periods. Other characteristics, such as tumor size, location, layer of origin, adverse events, mitotic index, and risk stratification, were not significantly different. Finally, the postprocedural use of imatinib is another important issue regarding endoscopic resection of GISTs.4Na H.K. Lee J.H. Park Y.S. et al.Yields and utility of endoscopic ultrasonography-guided 19-gauge trucut biopsy versus 22-gauge fine needle aspiration for diagnosing gastric subepithelial tumors.Clin Endosc. 2015; 48: 152-157Crossref PubMed Scopus (39) Google Scholar The recent guideline from the National Comprehensive Cancer Network states that if GISTs are completely resected (including R1 resection), adjuvant therapy with imatinib can be considered, especially for patients with significant high risk of recurrence (intermediate or high risk by the recent World Health Organization classification).5von Mehren M. Randall R.L. Benjamin R.S. et al.Gastrointestinal stromal tumors, version 2.2014.J Natl Compr Canc Netw. 2014; 12: 853-862Crossref PubMed Scopus (83) Google Scholar However, adjuvant imatinib therapy followed by endoscopic resection is neither approved nor covered by the National Health Insurance system in Korea, and the guidelines of the Korean GIST Study Group suggest that a complete en bloc resection with negative margins should be achieved regardless of tumor size, and, therefore, even if tumors are small, an endoscopic shell-out procedure or enucleation should be avoided if a GIST is suspected.6Kang Y.K. Kim K.M. Sohn T. et al.Clinical practice guideline for accurate diagnosis and effective treatment of gastrointestinal stromal tumor in Korea.J Korean Med Sci. 2010; 25: 1543-1552Crossref PubMed Scopus (22) Google Scholar Under local circumstances, we could not prescribe adjuvant imatinib. Further discussion and an opinion approach are needed in our country based on long-term follow-up data of endoscopic procedures. All authors disclosed no financial relationships relevant to this publication. Questions for confirming superiority of endoscopy for GI stromal tumors in the upper GI tractGastrointestinal EndoscopyVol. 83Issue 4PreviewThe retrospective study by Joo et al1 reported in Gastrointestinal Endoscopy showed that endoscopic resection might be an alternative strategy for treating GI stromal tumor (GIST) in the upper GI tract. However, some questions need to be further clarified. Full-Text PDF" @default.
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