Analysis of the clinical features and surgical treatment of small intestinal stromal tumor: a retrospective study based on 119 cases

Introduction

Gastrointestinal stromal tumors (GISTs) represent the most prevalent mesenchymal neoplasms of the gastrointestinal tract, originating from the interstitial cells of Cajal, which regulate intestinal motility or their homologous mesenchymal stem cells. The annual global incidence is approximately 7–20 per million. In recent years, the incidence has exhibited an upward trend, attributable to factors including the continuous advancement and wider application of imaging and pathological diagnostic techniques, alongside population aging (1). GISTs are centrally driven by mutations in the c-KIT or PDGFRA genes. This molecular heterogeneity complicates the formulation of diagnostic and therapeutic strategies (2). Although the stomach is the most common primary site (60–65%), SIST, which occur at approximately half this incidence, are associated with significantly greater aggressiveness, higher postoperative recurrence rates, and increased patient mortality compared to gastric GIST (3).

The clinical management of SIST faces multiple challenges. Their clinical manifestations often lack specificity and are easily overlooked in the early stages or mistaken for other intestinal pathologies, leading to a substantial rate of missed diagnosis (3). Cases of mobile small intestinal stromal tumors (SISTs) encountered in clinical practice further exemplify the impact of this characteristic (non-specific and easily overlooked manifestations) on early diagnosis (4). The currently relied-upon diagnostic modalities—including imaging, endoscopy, and pathological biopsy—are inherently limited in the early identification of lesions and the accuracy of definitive diagnosis. These limitations stem from factors such as the deep-seated location of lesions and the variable morphology of tumors. These constraints further compound the difficulty of clinical diagnosis, and the complexity of the diagnostic process directly impacts the formulation of therapeutic strategies. As the cornerstone of treatment, the selection of surgical resection techniques and the achievement of R0 resection rates depend, to some extent, on the precise preoperative assessment of tumor location and extent of infiltration. Insufficient diagnostic information leading to assessment inaccuracies may increase the risk of incomplete intraoperative resection and postoperative recurrence.

While research on SIST has progressed both domestically and internationally, a lack of large-scale studies continues to constrain the development of a precision diagnostic and therapeutic framework. This study aims to contribute insights towards resolving diagnostic challenges through a retrospective analysis of clinical data from 119 SIST patients, systematically analyzing their clinical presentations, diagnostic pathways, treatment outcomes, and pathological characteristics. We present this article in accordance with the STROBE reporting checklist (available at https://cco.amegroups.com/article/view/10.21037/cco-25-84/rc).

Methods

Objects

The data for this study were obtained from a dataset of primary SIST surgeries at the Air Force Medical Center, spanning from November 2013 to March 2025, and comprising a total of 140 cases. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of the Air Force Medical Center (No. 2025-95-PJ01) and individual consent for this analysis was waived due to the retrospective nature.

Inclusion criteria

• Age ≥18 years;
• De novo primary SIST without prior treatment;
• Radical surgical resection (open or laparoscopic) with intraoperatively confirmed R0/R1 resection;
• Definitive histopathological diagnosis postoperatively, supported by immunohistochemistry [e.g., CD117, discovered on GIST-1 (DOG-1)];
• Comprehensive clinical documentation, including preoperative imaging studies, operative reports, and pathological records.

Exclusion criteria

• Recurrent or metastatic SIST;
• Concomitant other malignant neoplasms.

Study cohort selection

To ensure cohort homogeneity and analytical robustness, this study exclusively analyzed de novo primary SIST cases. Among the initial cohort of 140 patients, 21 cases were excluded:

• Seven due to incomplete medical records;
• Eight with concomitant malignancies;
• Six with non-primary/recurrent disease.

The final analytical cohort comprised 119 patients with treatment-naïve primary SIST.

Study methods

Clinical data from 119 patients were extracted from electronic medical record (EMR) systems. Collected parameters encompassed:

• Demographics: sex, age.
• Clinical presentation:
  • Primary symptoms at initial consultation [e.g., abdominal pain, distension, palpable abdominal mass, gastrointestinal bleeding (hematochezia, hematemesis, melena)], weight loss, and other non-specific symptoms;
  • Duration and severity of symptoms.
• Comorbidities & medical history:
  • Digestive disorders (e.g., gastric/duodenal ulcers, cholecystitis);
  • Cardiovascular diseases (e.g., hypertension, coronary artery disease);
  • Diabetes mellitus;
  • Prior surgical interventions, radiotherapy, or chemotherapy;
  • Note: these factors may influence SIST pathogenesis, progression, and treatment response.
• Family history: documented history of gastrointestinal malignancies, hereditary disorders, or cancers among first-degree relatives to explore potential genetic contributions to SIST etiology.
• Imaging studies:
  • Modalities: computed tomography (CT), magnetic resonance imaging (MRI), ultrasonography;
  • Parameters analyzed: tumor location (duodenum, jejunum, ileum), size, morphology, and spatial relationship to adjacent structures.
• Endoscopic records:
  • Tumor morphology and dimensions under endoscopy;
  • Biopsy sites and histopathological results.
• Pathological examination:
  • Gross specimen characteristics;
  • Histological subtype;
  • Mitotic count (per 50 high-power fields);
  • Immunohistochemical (IHC) profiles: expression status of CD117, CD34, DOG-1, smooth muscle actin (SMA), p53, and other relevant markers;
  • Note: these pathological data are pivotal for confirming SIST diagnosis, assessing malignant potential, and guiding therapeutic decisions.

Statistical analysis

Statistical analyses were performed using SPSS version 27.0 and OriginPro 2024b. Categorical variables are presented as frequencies and/or percentages. Chi-squared tests and Spearman correlation analyses were employed to evaluate symptom correlations. Inter-group comparisons were performed using the Mann-Whitney U test or the Kruskal-Wallis H test, while risk factor analysis was conducted using logistic regression. A two-sided P value <0.05 was considered statistically significant.

Results

Epidemiologic feature

Among the 119 SIST patient samples, 81 (68.1%) were male and 38 (31.9%) were female. The age of onset for SIST ranged from 22 to 82 years. Patients aged 50–69 years constituted the highest proportion (58.0%), reflecting a significantly higher incidence in older adults. Regarding the site of involvement, isolated jejunal lesions were observed in 78 cases (65.5%), lesions at the jejunoileal junction in 17 cases (14.3%), isolated ileal lesions in 14 cases (11.8%), duodenal lesions in 2 cases (1.7%), and lesions involving the jejunum or ileum combined with other intestinal segments (multisite involvement) in 8 cases (6.7%) (Table 1).

Clinical presentation

SIST patients exhibited diverse and non-specific clinical manifestations. Among initial presentations, gastrointestinal bleeding accounted for 84.9% (101/119) of cases, followed by abdominal mass in 8.4% (10/119), abdominal pain or discomfort in 5.0% (6/119), and other presentations in 1.7% (2/119). Throughout the disease course, gastrointestinal bleeding emerged as the cardinal accompanying symptom (89.1%, 106/119), with anemia manifesting in 67.2% (80/119) of patients.

The spectrum of comorbidities exhibited significant heterogeneity. Among the 119 cases, gastritis was present in 80 patients (67.2%), hepatic disorders in 70 patients (58.8%), gallbladder disorders in 40 patients (33.6%), and renal disorders in 45 patients (37.8%). Electrocardiographic abnormalities, including T-wave changes and sinus bradycardia, were documented in 43 patients (36.1%). Additionally, diastolic dysfunction was observed in 80 patients (67.2%) and arteriosclerosis in 49 patients (41.2%). Notably, among hepatic disorder cases, hepatic cysts accounted for 55 cases (46.2% of total cohort), while among renal disorders, renal cysts constituted 41 cases (34.5% of total cohort). Crucially, hemorrhagic shock occurred in 9 patients (7.5%) (Table 1).

Imaging features

Not all patients underwent the complete diagnostic protocol. Ultrasonography demonstrated a relatively low examination rate, with a detection rate of 24.2% (16/66). Ultrasound images primarily visualized hypoechoic masses within the lumen. CT demonstrated a mass detection rate of 69.8% (74/106), among which 50 cases were confirmed as SIST, accounting for 42.5% (45/106) of the total cohort. MRI demonstrated limited utilization in our study cohort, with a detection rate of 66.7% (6/9). Notably, one patient underwent MRI for a pelvic mass initially suspected to be of bladder origin; comprehensive evaluation suggested an intestinal origin instead.

Enteroscopy demonstrated a high detection rate of 82.0% (91/111) in the diagnosis of suspected SIST, yielding direct SIST diagnoses in 53.1% (59/111) of cases. Endoscopically, submucosal protrusions were observed (Figure 1A-1D), some with surface ulceration or bleeding (Figure 1E-1H). This modality allows direct visualization of lesion morphology and facilitates biopsy for histopathological acquisition, significantly enhancing diagnostic accuracy. Even when only a submucosal protrusion is observed during the initial examination, a diagnostic conclusion can still be reached by integrating the endoscopic findings with other imaging results (Figure 2A).

Figure 1 Endoscopic view of SIST. (A,B) A spherical submucosal protrusion measuring 3.0 cm × 3.5 cm in diameter was observed approximately 230 cm proximal to the ileocecal valve. (C,D) A semi-elliptical protrusion occupying two-thirds of the lumen was identified 300 cm distal to the pylorus. (E) At 150 cm distal to the pylorus, a roughly 2 cm ulcerated mass was observed, with a base covered by a white coating and surrounded by a raised, dike-like mucosal margin. (F) At 50 cm distal to the pylorus, a circumferential mass was identified, showing surface ulceration covered with a white exudate. (G,H) At approximately 660 cm distal to the pylorus, a 1.0 cm × 1.0 cm ulcer was noted. A suspicious submucosal elevation was present at its base, with a visible vessel stump and a small amount of blood clot at the edge. SIST, small intestinal stromal tumor.

Figure 2 Imaging characteristics, laboratory parameters, and surgical treatment statistics. (A) Detection rates of imaging modalities and endoscopy: ultrasound, CT, and enteroscopy. (B) Pathological parameters: stratified percentages by tumor size, mitotic index, and recurrence risk category. (C) IHC: stratified percentages of expression for CD117, CD34, DOG-1, SAM, Ki-67, and p53. (D) Surgical approaches: percentages of open surgery, laparoscopic surgery, and laparoscopic-converted open surgery. −, negative; +, weak; ++, moderate; +++, strong. CT, computed tomography; DOG-1, discovered on gastrointestinal stromal tumor 1; IHC, immunohistochemical; SIST, small intestinal stromal tumor.

Laboratory parameters

The largest tumor measured 18 cm × 12 cm × 6 cm, while the smallest measured 1.1 cm × 1.0 cm × 0.4 cm. Eighty tumors had a maximum dimension ≤5 cm, and 39 tumors had a maximum dimension >5 cm. Risk stratification for recurrence identified 41 patients at high risk, 8 at moderate risk, 69 at low risk, and 3 (2.5%) at very low risk or with no evidence of recurrence, as illustrated in Figure 2B.

IHC data were collected from pathology reports within the EMRs. The results indicated that: CD117: positive expression was detected in 97.5% (116/119) of cases. Expression intensity was weak (+) in 90.8% (108/119), moderate (++) in 1.7% (2/119), and strong (+++) in 5.0% (6/119). CD34: positive expression was observed in 71.4% (85/119) of cases. This comprised weak (+) expression in 68.1% (81/119), moderate (++) expression in 1.7% (2/119), and strong (+++) expression in 1.7% (2/119). DOG-1: demonstrated the highest positivity rate at 96.6% (115/119). Expression intensity was weak (+) in 89.9% (107/119), moderate (++) in 4.2% (5/119), and strong (+++) in 2.5% (4/119). Ki-67 expression was assessed by determining the percentage of positive cells, exhibited a positivity rate equivalent to DOG-1 at 96.6% (115/119). SMA: showed a lower positivity rate of 26.0% (31/119). Expression intensity was weak (+) in 24.3% (29/119), moderate (++) in 0.8% (1/119), and strong (+++) in 0.8% (1/119). p53: Positive expression was detected in 47.9% (57/119) of cases. Wild-type expression pattern was observed in 40.3% (48/119) of cases (Figure 2C).

Treatment

All 119 patients underwent surgical resection. The distribution of surgical approaches was as follows (Figure 2D): open surgery: laparoscopic surgery: 18 cases (Figure 3A-3C). Open surgery: 77 cases (Figure 3D,3E). Laparoscopic-assisted open surgery: 24 cases (Figure 3F). Postoperative complications occurred in seven cases. Additionally, 24 patients received Imatinib therapy.

Figure 3 Gross views of SIST. (A-C) Laparoscopic views of SIST. (D-F) Laparotomy demonstrating anatomical dissection under direct vision. SIST, small intestinal stromal tumor.

Correlation analysis

Tumor size (maximum dimension) demonstrated a strong positive correlation with abdominal distension (r=0.312, P<0.01), and abdominal pain or discomfort (r=0.208, P<0.05). A significant positive correlation was observed between gastrointestinal bleeding and gastritis (r=0.355, P<0.001), with a marginally significant correlation to anemia (r=0.216, P<0.05). Anemia exhibited a significant negative correlation with primary site location (r=−0.247, P<0.01).

The Ki-67 index itself also demonstrated a significant positive correlation with risk stratification (r=0.367, P<0.001). Additionally, a significant positive correlation was identified between abdominal distension and gallbladder lesions (r=0.221, P<0.05).

Significant positive correlations were evident between DOG-1 and SMA (r=0.322, P<0.001) and between DOG-1 and CD34 (r=0.353, P<0.001). CD117 expression showed significant positive correlations with SMA (r=0.264, P<0.01) and CD34 (r=0.335, P<0.001). Notably, a particularly strong positive correlation, indicative of co-expression, was observed between CD117 and DOG-1 (r=0.792, P<0.001). And a significant negative correlation was found between CD117 and Ki-67 index (r=−0.220, P<0.05). A significant correlation was observed between the length of postoperative hospital stay and the occurrence of postoperative complications (P<0.001), as well as with maximal tumor diameter (P<0.05) (Figure 4). Multivariate logistic regression analysis with backward stepwise selection was performed to adjust for potential confounders. The analysis revealed that high-risk classification was independently and significantly associated with Ki-67 expression level [P<0.001; odds ratio (OR) =11.875; 95% confidence interval (CI): 3.596–39.214].

Figure 4 Correlation analysis of each factor. *, P<0.05; **, P<0.01; ***, P<0.001. DOG-1, discovered on gastrointestinal stromal tumor 1; SMA, smooth muscle actin.

Discussion

The early and accurate diagnosis of SIST poses a significant clinical challenge. Due to their insidious biological behavior, the majority of patients present with lesions that have progressed to advanced stages by the time clinical manifestations become apparent and a high index of suspicion is raised. Within our cohort of 119 SIST patients, the age distribution exhibited specific characteristics. The youngest patient was 22 years old, while the oldest was 82 years old, with a mean age of 57 years. This finding aligns with previous studies reporting a mean age at diagnosis around 54 years, consistent with the predominance of SIST in the elderly population observed in our study (5). Within our cohort of 119 SIST patients, 81 were male (68.1%) and 38 were female (31.9%). This predominance of male patients is largely consistent with previous literature reports (6). Others reported no significant gender predilection (7). Family history assessment identified 15 patients (12.4%) with a history of other malignancies among relatives. Current genetic research primarily focuses on KIT or PDGFRA gene mutations in GIST (8), warranting further in-depth exploration for SIST.

Presenting complaints constitute the initial diagnostic encounter; Following symptom onset, the diagnosis is frequently delayed because most manifestations of stromal tumors are non-specific and overlap with symptoms of other abdominal pathologies. Imaging examinations often fail to precisely localize the lesion based on symptoms alone, leading to missed diagnoses. Furthermore, the limited availability of enteroscopy for direct visualization at many medical centers contributes to diagnostic challenges. In this study, 84.9% of patients presented with gastrointestinal bleeding (e.g., melena or hematochezia) as the initial symptom. The clinical course was often protracted and characterized by a chronic and recurrent pattern, with the longest documented history exceeding 30 years. Notably, the bleeding was typically intermittent rather than continuous. Chronic blood loss frequently resulted in cumulative gastrointestinal blood loss, culminating in anemia. This study identified 80 patients with anemia, demonstrating a statistically significant association with gastrointestinal bleeding (r=0.216, P<0.01). The mechanism underlying SIST-related gastrointestinal bleeding may involve tumor growth causing ischemic necrosis of surrounding tissues due to compression or direct tumor invasion leading to rupture of adjacent blood vessels (8). It is noteworthy that some studies identify an abdominal mass as the most common presentation (6). Severe cases of SIST may present with hemorrhagic shock as a complication (9). This contrasts with our findings (abdominal mass: 8.4%), a discrepancy potentially attributable to selection bias inherent in the single-center patient population of this study.

The diagnostic challenges for SIST stem not only from their insidious symptomatology but also from the inherent anatomical characteristics of the small bowel and the limitations of current diagnostic modalities. Most patients first undergo abdominal ultrasound. However, factors such as intraluminal bowel gas, deep-seated tumor location, and ultrasound’s inherent limitations in resolving submucosal lesions often yield negative findings. The detection rate by ultrasound in this study was only 24.2%. Patients typically proceed to CT or MRI evaluation. CT demonstrated a relatively higher detection rate among imaging modalities (69.8% in this cohort). Even when a primary lesion is not immediately apparent on initial CT, features suggestive of a mass may be revealed through three-dimensional reconstruction and contrast-enhanced imaging. MRI offers less advantage in diagnosing primary bowel lesions. Nevertheless, it can provide valuable diagnostic evidence regarding the nature of metastatic disease should a SIST metastasize, thereby offering indirect support for the primary diagnosis. Recent studies indicate a rising detection rate for GIST in recent years (10). This trend is largely attributed to advancements in endoscopic technology, wider availability of advanced imaging, and enhanced physician awareness of GIST (11,12). Within Air Force Medical Center’s diagnostic pathway, enteroscopy emerged as the preferred initial method, achieving a detection rate of 82.0%. However, its precise diagnostic rate for SIST was lower (53.1%). Enteroscopy is often primarily employed to exclude alternative sources of bleeding (such as polyps or vascular malformations), serving to guide the investigation of obscure lesions.

Beyond diagnostic challenges, SISTs exhibit significant site-specific characteristics. Within this cohort, the distribution of primary tumor locations was as follows: jejunum alone, 78 cases (65.5%); jejunoileal junction, 17 cases (14.3%); ileum alone, 14 cases (11.8%); duodenum, 2 cases (1.7%); and multiple intestinal segments, 8 cases (6.7%). This data indicates that the jejunum and ileum constitute the predominant sites of involvement (collectively accounting for 80.8%). Research by Wang et al. demonstrates that SISTs arising in different segments of the small intestine manifest distinct clinical presentations. For instance, duodenal SISTs are frequently associated with a protracted clinical course and exhibit a high incidence of melena (44.6%). Jejunal SISTs, conversely, are characterized by the presence of abdominal masses and acute gastrointestinal hemorrhage, demonstrating the highest emergency surgery rate among all segments. Ileal SISTs show a predilection for older patients. Furthermore, Wang et al. (5) reported a progressive increase from the duodenum to the ileum in several parameters, including IHC marker expression, tumor diameter, mitotic activity, and risk stratification.

In this study, a statistically significant correlation was observed between abdominal pain/discomfort and tumor size (r=0.208, P<0.05), with pain intensity increasing proportionally to tumor enlargement. Gastritis was documented in 80 patients within this cohort, yielding a concomitant rate of 67.2%. Previous studies have indicated a correlation between GIST and Helicobacter pylori gastritis (13), with H. pylori infection associated with GIST across diverse ethnic populations (14). The chronic inflammatory environment may serve as a potential “background” or “catalyst” that indirectly contributes to the development of SIST, possibly by promoting genomic instability and providing proliferative signals. However, at present, the primary clinical significance of gastritis in the context of SIST lies in its potential to mask early-stage disease. Owing to its distinctive growth pattern, SIST seldom infiltrates the intestinal mucosal surface in its early phases, making it difficult to detect via conventional gastroscopy or colonoscopy. As the tumor enlarges, the overlying mucosa may ulcerate due to increased tension or compromised blood supply, resulting in a chronic bleeding source. Due to their characteristic growth pattern, SIST seldom invades the mucosal surface in their early stages. Consequently, conventional gastroscopy or colonoscopy often fails to detect them. As the submucosal mass enlarges, the overlying mucosa may ulcerate due to increased mural tension or compromised blood supply, establishing a chronic bleeding source. Initially, these ulcers are minute, resulting in minimal blood loss that is difficult to detect, manifesting as intermittent occult bleeding. Such cases are not isolated, as substantial bleeding events have been well-documented in the literature (15,16). Therefore, in the clinical setting, patients presenting with anemia, gastrointestinal bleeding disproportionate to the apparent lesion severity, persistently positive fecal occult blood tests, or unexplained hemodynamic instability should prompt investigation for SIST.

SIST patients exhibited high-prevalence comorbidities: hepatic cysts (46.2%), renal cysts (34.5%), and gallbladder pathology (33.6%). In contrast to gastritis, hepatic/renal cysts and gallbladder lesions were typically detected via imaging studies during hospitalization in SIST patients. Although no causal link to SIST is established, their frequent co-occurrence suggests shared pathophysiology or common etiological factors.

Surgical intervention represents the cornerstone therapy for SIST (17), where precise selection of operative approach serves as a critical determinant of patient prognosis. The indications for laparoscopic surgery in the treatment of GISTs remain controversial. Existing studies suggest that minimally invasive techniques may contribute to improved postoperative outcomes (18). According to NCCN guidelines, surgical resection is strongly recommended for jejunal and ileal SIST, while management of duodenal lesions depends on their specific location and extent. Laparoscopic resection is considered appropriate for tumors ≤5 cm in diameter that are technically mobilizable. Laparoscopy plays a valuable role in intraoperative tumor localization (19). When preoperative imaging modalities such as CT or MRI fail to clearly define the nature, location, or extent of tumor involvement, diagnostic laparoscopy allows for comprehensive abdominal exploration. However, laparoscopic surgery is discouraged in cases with a high risk of tumor rupture due to the potential for intra-abdominal seeding (20). Conversion to open laparotomy is mandatory when exploration reveals large tumor size, capsule rupture, or severe adhesions to ensure achievement of R0 resection. Traditional laparotomy offers optimal exposure of the abdominal cavity and is indicated for: Large tumor bulk (diameter >10 cm) or infiltrative growth patterns involving multiple intestinal segments or adjacent organs. Severe intestinal adhesions, intra-abdominal abscess, or compromised anatomy due to tumor capsule rupture. SIST management is optimized through a precision diagnostic and therapeutic pathway: “Clinical symptom/sign evaluation → Imaging assessment → Intraoperative dynamic decision-making → Surgical resection” (Figure 5). This stepped approach to surgical technique selection maximizes the potential for curative resection while minimizing surgical trauma. No significant association was observed between the surgical approach and either postoperative complications or length of hospital stay in this study. Further prospective studies with larger sample sizes are warranted to validate these findings.

Figure 5 SIST diagnosis and treatment system. CT, computed tomography; MRI, magnetic resonance imaging; SIST, small intestinal stromal tumor.

Immunohistochemistry demonstrated CD117/DOG-1 coexpression, with Ki-67 positivity and intensity significantly elevated in high-risk cases. Pathological diagnosis was established in accordance with established guidelines, and recurrence risk was evaluated based on tumor size and mitotic count (21). While some studies suggest no association between Ki-67 and SIST recurrence/metastasis (22), prior research indicates that patients with a Ki-67 index >5% exhibit higher rates of metastasis and high-risk disease compared to those with Ki-67 ≤5% (23). Our analysis demonstrated that Ki-67 expression correlated significantly with recurrence risk, suggesting its potential utility as an adjunct prognostic indicator. In the correlation analysis, recurrence risk was associated with both Ki-67 expression and primary tumor location. However, multivariate logistic regression analysis identified Ki-67 expression as the only factor significantly associated with recurrence risk, while primary tumor site showed no significant association—a finding consistent with previous studies (24). An immunomarker network (CD117/DOG-1/CD34/SMA) demonstrated a co-expression pattern, consistent with findings reported by Rehman et al. in studies of GIST (25). This study is a single-center cross-sectional retrospective study, with inherent limitations in causal inference, deviation control, and longitudinal dynamic evaluation, and needs further deepening.

Conclusions

SIST exhibits insidious onset and nonspecific symptoms. Clinicians must maintain vigilance against missed diagnoses, particularly in middle-aged/elderly patients with recurrent hematochezia/anemia. Enhanced CT plus double-balloon enteroscopy should be prioritized for lesion identification, moving beyond single-etiology assumptions. Adherence to the “minimally invasive first, safety paramount, radical resection core” principle minimizes trauma. This study supports SIST precision management; future multicenter collaborations should optimize multidisciplinary strategies.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://cco.amegroups.com/article/view/10.21037/cco-25-84/rc

Data Sharing Statement: Available at https://cco.amegroups.com/article/view/10.21037/cco-25-84/dss

Peer Review File: Available at https://cco.amegroups.com/article/view/10.21037/cco-25-84/prf

Funding: The study was funded by the Air Force Medical University Clinical Program (School Subject [2022]7th) and the Air Force Medical Center’s Outstanding Young Talent Program (No. 22BJQN004).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://cco.amegroups.com/article/view/10.21037/cco-25-84/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of the Air Force Medical Center (No. 2025-95-PJ01) and individual consent for this analysis was waived due to the retrospective nature.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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