Endoscopic resection for esophageal gastrointestinal stromal tumor: feasibility and oncologic limits

Esophageal gastrointestinal stromal tumors (e-GISTs) are exceptionally rare and biologically distinct neoplasms, accounting for less than 1% of all gastrointestinal stromal tumors (GISTs). Their management has traditionally been guided by oncologic caution rather than by comparative evidence, with surgical resection considered the standard of care. This conservative approach reflects not only the malignant potential of GISTs but also the anatomical complexity of the esophagus, where limited luminal space, absence of a serosal layer, and proximity to mediastinal structures increase procedural risk. As a result, the role of minimally invasive strategies has remained ill-defined.

In this context, the study by Zhou et al. provides a meaningful contribution by systematically comparing clinicopathological features and long-term outcomes of e-GISTs and gastric GISTs, with a focused analysis of endoscopic versus surgical resection in esophageal tumors (1). Their findings confirm that e-GISTs exhibit a more aggressive biological profile, characterized by higher rates of ulceration, bleeding, and increased mitotic activity, translating into inferior overall survival when compared with gastric counterparts. These observations reinforce prior evidence that esophageal location is associated with adverse prognosis, largely driven by tumor biology rather than size alone (2).

The most relevant aspect of this study is its balanced evaluation of endoscopic resection (ER) in carefully selected patients. Rather than advocating a paradigm shift away from surgery, the authors define oncologic boundaries for endoscopic treatment. In tumors measuring ≤5 cm, without ulceration or active bleeding and with low mitotic index, ER, performed after detailed assessment with endoscopic ultrasound, achieved outcomes comparable to surgical resection in terms of recurrence and overall survival. In the endoscopic group, R0 resection was achieved in 17 of 22 patients, reinforcing the importance of careful case selection. Importantly, treatment modality itself was not an independent predictor of survival, whereas tumor size, bleeding, and mitotic count were.

These results emphasize a central oncologic principle: outcomes in GIST are primarily driven by biological behavior and adequacy of resection, rather than by the invasiveness of the approach. From a practical standpoint, the findings of Zhou et al. (1) help delineate the boundaries within which ER may be considered, rather than redefining the standard of care (Table 1). Similar conclusions have been reached in guideline documents and risk stratification models, which consistently identify tumor size and mitotic activity as dominant prognostic determinants (3). Within this framework, ER may represent an acceptable alternative for selected e-GISTs, provided that oncologic principles are not compromised.

From a technical perspective, advances in third-space endoscopy, particularly submucosal tunneling endoscopic resection (STER), have expanded the feasibility of en bloc resection while preserving mucosal integrity. The experience reported by Zhou et al. suggests that STER can be safely applied to selected esophageal lesions, aligning with existing endoscopic guidelines for subepithelial tumors originating from the muscularis propria (1,4). Nevertheless, the occurrence of capsular disruption in larger tumors underscores the procedural limits of endoscopy and the potential oncologic risks of extending indications beyond biologically safe thresholds.

Despite its strengths, the study has inherent limitations. Its retrospective, single-center design and limited sample size restrict generalizability, and the impact of molecular profiling and adjuvant therapy could not be fully explored. However, given the rarity of e-GIST, such constraints are difficult to avoid and do not diminish the clinical relevance of the findings. Instead, they highlight the need for multicenter collaboration and prospective data collection to refine selection criteria and surveillance strategies. Future studies should also explore whether neoadjuvant imatinib may expand the applicability of ER by reducing tumor size in selected cases.

Clinically, this study supports a nuanced treatment algorithm. Surgical resection remains the reference standard for e-GIST, particularly in high-risk tumors. In clinical practice, this includes a spectrum of surgical approaches, ranging from local resection to esophagectomy, depending on tumor characteristics and anatomical considerations. ER should be reserved for highly selected cases, ideally after multidisciplinary discussion and performed in specialized centers with expertise in advanced endoscopy and surgical oncology, with strict adherence to oncologic principles. When applied within these limits, ER offers the potential benefits of reduced morbidity and organ preservation without compromising long-term outcomes. This approach may also be associated with faster recovery, improved quality of life, and more efficient use of healthcare resources in appropriately selected patients.

In summary, Zhou et al. provide important new evidence supporting the feasibility of ER for selected esophageal GISTs. Their work does not advocate replacing surgery but rather defines where endoscopy can be safely integrated into the therapeutic armamentarium. Progress in this field should continue to be guided by tumor biology, technical expertise, and oncologic responsibility.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Gastrointestinal Oncology. The article has undergone external peer review.

Peer Review File: Available at https://jgo.amegroups.com/article/view/10.21037/jgo-2026-1-0071/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jgo.amegroups.com/article/view/10.21037/jgo-2026-1-0071/coif). The authors have no conflicts of interest to declare.

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References

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4. ASGE Technology Committee. ASGE guideline for endoscopic full-thickness resection and submucosal tunnel endoscopic resection. VideoGIE 2019;4:343-50. [Crossref] [PubMed]