What Are Gastrointestinal Stromal Tumors?
Cancer starts when cells in the body begin to grow out of control. Cells in nearly any part of the body can become cancer, and can spread to other areas of the body. Gastrointestinal stromal tumors (GISTs) start in special cells in the wall of the gastrointestinal (GI) tract, also known as the digestive tract. To understand GISTs, it helps to know something about the structure and function of the GI tract.
Gastrointestinal stromal tumors (GISTs) are uncommon tumors of the GI tract. These tumors start in very early forms of special cells in the wall of the GI tract called the interstitial cells of Cajal (ICCs). ICCs are cells of the autonomic nervous system, the part of the nervous system that regulates body processes such as digesting food. ICCs are sometimes called the “pacemakers” of the GI tract because they signal the muscles in the GI tract to contract to move food and liquid along. More than half of GISTs start in the stomach. Most of the others start in the small intestine, but GISTs can start anywhere along the GI tract. A small number of GISTs start outside the GI tract in nearby areas such as the omentum (an apron-like layer of fatty tissue that hangs over the organs in the abdomen) or the peritoneum (the layer of tissue that lines the organs and walls of the abdomen). Some GISTs seem to be much more likely to grow into other areas or spread to other parts of the body than others. Doctors look at certain factors to help tell whether a GIST is likely to grow and spread quickly, such as how large the tumor is, where it’s located in the GI tract, and how fast the tumor cells are dividing.
Symptoms and Diagnosis
Most gastrointestinal stromal tumors (GISTs) occur in the stomach or small intestine. These tumors often grow into the empty space inside the gastrointestinal (GI) tract, so they might not cause symptoms right away unless they are in a certain location or reach a certain size. Small tumors might not cause any symptoms and may be found accidentally when the doctor is looking for some other problem. These small tumors often grow slowly. Symptoms related to blood loss GISTs tend to be fragile tumors that can bleed easily. In fact, they are often found because they cause bleeding into the GI tract. Signs and symptoms of this bleeding depend on how fast it occurs and where the tumor is located. Brisk bleeding into the esophagus or stomach can cause the person to throw up blood. When the blood is thrown up it may be partially digested, so it might look like coffee grounds.
- Brisk bleeding into the stomach or small intestine can make bowel movements (stools) black and tarry.
- Brisk bleeding into the large intestine is likely to turn the stool red with visible blood.
- If the bleeding is slow, it often doesn’t cause the person to throw up blood or have a change in their stool. Over time, though, slow bleeding can lead to a low red blood cell count (anemia), and make a person feel tired and weak.
- Bleeding from the GI tract can be very serious. If you have any of these signs or symptoms, see a doctor right away.
Other possible symptoms of GISTs Other symptoms of GISTs can include:
- Abdominal (belly) pain
- A mass or swelling in the abdomen
- Nausea, vomiting
- Feeling full after eating only a small amount of food
- Loss of appetite
- Weight loss
- Problems swallowing (for tumors in the esophagus) Sometimes the tumor grows large enough to block the passage of food through the stomach or intestine. This is called an obstruction, and it can cause severe abdominal pain and vomiting. Because GISTs are often fragile, they can sometimes rupture, which can lead to a hole (perforation) in the wall of the GI tract. This can also result in severe abdominal pain. Emergency surgery might be needed in these situations.
Medical history and physical exam
The doctor will ask you questions about your medical history, including your symptoms, possible risk factors, family history, and other medical conditions. Your doctor will give you a thorough physical exam to get more information about the possible signs of a GI tumor, like a mass in the abdomen, or other health problems. If there is a reason to suspect that you may have a GIST (or other type of GI tumor), the doctor will use imaging tests or endoscopy exams to help find out if it is cancer or something else. If it is a GIST, further tests will be done to help determine the stage (extent) of the cancer.
Imaging tests use x-rays, magnetic fields, or radioactive substances to create pictures of the inside of the body. Imaging tests may be done for a number of reasons, including:
● To help find out if a suspicious area might be cancer
● To learn how far cancer has spread
● To help determine if treatment has been effective
● To look for signs that the cancer has come back Most people who have or might have a GI tumor will have one or more of these tests.
Barium x-rays are not used as much today as in the past. In many cases they are being replaced by endoscopy – where the doctor actually looks into your colon or stomach with a narrow fiber-optic scope .For these types of x-rays, a chalky liquid containing barium is used to coat the inner lining of the esophagus, stomach, and intestines. This makes abnormal areas of the lining easier to see on x-ray. These tests are sometimes used to diagnose GI tumors, but they can miss some small intestine tumors. You will probably have to fast starting the night before the test. If the colon is being examined, you might need to take laxatives and/or enemas to clean out the bowel the night before or the morning of the exam.
This is often the first test done if someone is having a problem swallowing. For this test, you drink a liquid containing barium to coat the inner lining of the esophagus. A series of x-rays is then taken over the next few minutes.
Upper GI series
This test is similar to the barium swallow, except that x-rays are taken after the barium has time to coat the stomach and the first part of the small intestine. To look for problems in the rest of the small intestine, more x-rays can be taken over the next few hours as the barium passes through. This is called a small bowel follow through.
This test is another way to look at the small intestine. A thin tube is passed through your mouth or nose, down your esophagus, and through your stomach into the start of the small intestine. Barium is sent through the tube, along with a substance that creates more air in the intestines, causing them to expand. Then x-rays are taken of the intestines. This test can give better images of the small intestine than a small bowel follow through, but it is also more uncomfortable.
This test (also known as a lower GI series) is used to look at the inner surface of the large intestine. For this test, the barium solution is given through a small, flexible tube inserted in the anus while you are lying on the x-ray table. When the colon is about half full of barium, you roll over so the barium spreads throughout the colon. For a regular barium enema, x-rays are then taken. After the barium is put in the colon, air may be blown in to help push the barium toward the wall of the colon and better coat the inner surface. Then x-rays are taken. This is called an air-contrast barium enema or double-contrast barium enema.
Computed tomography (CT) scan
A CT scan uses x-rays to make detailed, cross-sectional images of your body. Unlike a regular x-ray, a CT scan creates detailed images of the soft tissues in the body. CT scans can be useful in patients who have (or might have) GISTs to find the location and size of a tumor, as well as to see if it has spread into the abdomen or the liver. In some cases, CT scans can also be used to guide a biopsy needle precisely into a suspected cancer. However, this can be risky if the tumor might be a GIST (because of the risk of bleeding and a possible increased risk of tumor spread), so these types of biopsies are usually done only if the result might affect the decision on treatment.
Magnetic resonance imaging (MRI) scans
Like CT scans, MRI scans show detailed images of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays. MRI scans can sometimes be useful in people with GISTs to help find the extent of the cancer in the abdomen, but usually CT scans are enough. MRIs can also be used to look for cancer that might have come back (recurred) or spread (metastasized) to distant organs, particularly in the brain or spine.
Positron emission tomography (PET) scan
For a PET scan, you are injected with a slightly radioactive form of sugar, which collects mainly in cancer cells. A special camera is then used to create a picture of areas of radioactivity in the body. The picture is not detailed like a CT or MRI scan, but a PET scan can look for possible areas of cancer spread in all areas of the body at once.
For these tests, the doctor puts a flexible lighted tube (endoscope) with a tiny video camera on the end into the body to see the inner lining of the gastrointestinal (GI) tract. If abnormal areas are found, small pieces can be biopsied (removed) through the endoscope. The biopsy samples can be looked at under the microscope to find out if they contain cancer and if so, what kind of cancer it is. GISTs are often below the surface (mucosa) of the inner lining of the GI tract. This can make them harder to see with endoscopy than more common GI tract tumors, which typically start in the mucosa. The doctor may see only a bulge under the normally smooth surface if a GIST is present. GISTs that are below the mucosa are also harder to biopsy through the endoscope. This is one reason that many GISTs are not diagnosed before surgery. If the tumor breaks through the inner lining of the GI tract and is easy to see on endoscopy, there is a greater chance that the GIST is cancerous (malignant).
For this procedure,an endoscope is passed through the mouth and down the throat to look at the inner lining of the esophagus, stomach, and first part of the small intestine. Biopsy samples may be taken from any abnormal areas. Upper endoscopy can be done in a hospital, in an outpatient surgery center, or in a doctor’s office. You are typically given medicine through an intravenous (IV) line to make you sleepy before the exam. The exam itself usually takes 10 to 20 minutes, but it might take longer if a tumor is seen or if biopsy samples are taken. If medicine is given to make you sleepy, you will need someone you know to drive you home (not just a cab or rideshare service). This test is also known as an EGD (short for esophagogastroduodenoscopy).
Colonoscopy (lower endoscopy)
For this test, a type of endoscope known as a colonoscope is inserted through the anus and up into the colon. This lets the doctor look at the inner lining of the rectum and colon and to take biopsy samples from any abnormal areas. To get a good look at the inside of the colon, it must be cleaned out before the test. Your doctor will give you specific instructions. You might need to follow a special diet for a day or more before the test. You will also likely have to drink a large amount of a liquid laxative the evening before, which means you will spend a lot of time in the bathroom. A colonoscopy can be done in a hospital, in an outpatient surgery center, or in a doctor’s office. You will be given intravenous (IV) medicine to make you feel relaxed and sleepy during the procedure. The exam typically takes 15 to 30 minutes, but it can take longer if a tumor is seen and/or a biopsy taken. Because medicine is given to make you sleepy, you will need someone you know to drive you home (not just a cab or rideshare service).
Unfortunately, neither upper endoscopy nor colonoscopy can reach all areas of the small intestine. Capsule endoscopy is one way to look at the small intestine. This procedure does not actually use an endoscope. Instead, you swallow a capsule (about the size of a large vitamin pill) that contains a light source and a very small camera. Like any other pill, the capsule goes through the stomach and into the small intestine. As it travels through the intestine (usually over about 8 hours), it takes thousands of pictures. These images are transmitted electronically to a device worn around your waist. The pictures can then be downloaded onto a computer, where the doctor can view them as a video. The capsule passes out of the body during a normal bowel movement and is discarded. This test requires no sedation – you can just continue normal daily activities as the capsule travels through the GI tract. This technique is fairly new, and the best ways to use it are still being studied. One disadvantage is that any abnormal areas seen can’t be biopsied during the test.
Double balloon enteroscopy (endoscopy)
This is another way to look at the small intestine. The small intestine is too long and has too many curves to be examined well with regular endoscopy. But this method gets around these problems by using a special endoscope that is made of 2 tubes, one inside the other. You are given intravenous (IV) medicine to help you relax, or even general anesthesia (so that you are asleep). The endoscope is then inserted either through the mouth or the anus, depending on if there is a specific part of the small intestine to be examined. Once inside the small intestine, the inner tube, which has the camera on the end, is advanced forward about a foot as the doctor looks at the lining of the intestine. Then a balloon on the end of the endoscope is inflated to anchor it. The outer tube is then pushed forward to near the end of the inner tube and is anchored in place with a second balloon. The first balloon is deflated and the endoscope is advanced again. This process is repeated over and over, letting the doctor see the intestine a foot at a time. The test can take hours to complete. This test may be done along with capsule endoscopy. The main advantage of this test over capsule endoscopy is that the doctor can take a biopsy if something abnormal is seen. Like other forms of endoscopy, because you are given medicine to make you sleepy for the procedure, someone you know will need to drive you home (not just a cab or rideshare service).
Endoscopic ultrasound (EUS)
This is a type of imaging test that uses an endoscope. Ultrasound uses sound waves to take pictures of parts of the body. For most ultrasound exams, a wand-like probe (called a transducer) is placed on the skin. The probe gives off sound waves and detects the pattern of echoes that come back. For an EUS, the ultrasound probe is on the tip of an endoscope. This allows the probe to be placed very close to (or on top of) a tumor in the wall of the GI tract. Like a regular ultrasound, the probe gives off sound waves and then detects the echoes that bounce back. A computer then translates the echoes into an image of the area being looked at. EUS can be used to find the precise location of the GIST and to determine its size. It is useful in finding out how deeply a tumor has grown into the wall of the GI tract. The test can also help show if the tumor has spread to nearby lymph nodes or has started growing into other tissues nearby. In some cases it may be used to help guide a biopsy (see below). You are typically given medicine before this procedure to make you sleepy. Because of this, you need to have someone you know drive you home (not just a cab or rideshare service).
Even if something abnormal is seen on an imaging test such as a barium x-ray or CT scan, these tests often cannot tell if the abnormal area is a GIST, some other type of tumor (benign or cancerous), or some other condition (like an infection). The only way to know what it is for sure is to remove cells from the area. This procedure is called a biopsy. The cells are then sent to a lab, where a doctor called a pathologist looks at them under a microscope and might do other tests on them. Not everyone who has a tumor that might be a GIST needs a biopsy before treatment. If the doctor suspects a tumor may be a GIST, biopsies are usually done only if they will help determine treatment options. GISTs are often fragile tumors that tend to break apart and bleed easily. Any biopsy must be done very carefully, because of the risk that the biopsy might cause bleeding or possibly increase the risk of cancer spreading. There are several ways to biopsy a GI tract tumor.
Biopsy samples can be obtained through an endoscope. When a tumor is found, the doctor can insert biopsy forceps (pincers or tongs) through the tube to take a small sample of the tumor. Even though the sample will be very small, doctors can often make an accurate diagnosis. However, with GISTs, sometimes the biopsy forceps can’t go deep enough to reach the tumor because it’s underneath the inner lining of the stomach or intestine. Bleeding from a GIST after a biopsy is rare, but it can be a serious problem. If this occurs, doctors can sometimes inject drugs into the tumor through an endoscope to constrict blood vessels and stop the bleeding.
Sometimes, a biopsy is done using a thin, hollow needle to remove pieces of the area. The most common way to do this is during an endoscopic ultrasound (described above). The doctor uses the ultrasound image to guide a needle on the tip of the endoscope into the tumor. Less often, the doctor may place a needle through the skin and into the tumor while guided by an imaging test such as a CT scan.
If a sample can’t be obtained from an endoscopic or needle biopsy, or if the result of a biopsy wouldn’t affect treatment options, your doctor might recommend waiting until surgery to remove the tumor to get a sample of it. If the surgery is done through a large cut (incision) in the abdomen, it is called a laparotomy. Sometimes the tumor can be sampled (or small tumors can be removed) using a thin, lighted tube called a laparoscope, which lets the surgeon see inside the belly through a small incision. The surgeon can then sample (or remove) the tumor using long, thin surgical tools that are passed through other small incisions in the abdomen. This is known as laparoscopic or keyhole surgery.
Your doctor may order some blood tests if he or she thinks you may have a GIST. There are no blood tests that can tell for sure if a person has a GIST. But blood tests can sometimes point to a possible tumor (or to its spread). For example, a complete blood count (CBC) can tell if you have a low red blood cell count (that is, if you are anemic). Some people with GIST may become anemic because of bleeding from the tumor. Abnormal liver function tests may mean that the GIST has spread to your liver.