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Lam TJR, Udonwa SA, Masuda Y, Yeo MHX, Farid Bin Harunal Ras M, Goh BKP. A systematic review and meta-analysis of neoadjuvant imatinib use in locally advanced and metastatic gastrointestinal stromal tumors. World J Surg 2024; 48:1681-1691. [PMID: 38757916 DOI: 10.1002/wjs.12210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 04/10/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Several doubts remain regarding the optimal use of neoadjuvant imatinib in gastrointestinal stromal tumors (GISTs), such as ideal treatment duration, patient selection, and long-term survival outcomes. This manuscript provides a comprehensive review on neoadjuvant imatinib treatment outcomes and facilitate evidence-based decision-making for the use of imatinib therapy in GISTs. METHODS Four databases (PubMed, EMBASE, Scopus, and Cochrane Library) were searched from inception to September 9, 2023. Meta-analyses of proportions were performed for the outcomes of R0 resection, disease responses, and 1-year, 3-year, and 5-year overall survival (OS) as well as 1-year, 3-year, and 5-year disease free survival (DFS). Sensitivity analyses in the form of leave-one-out analyses, meta-regression, and subgroup analyses were performed for outcomes with substantial statistical heterogeneity. RESULTS The search yielded 1254 articles, and 36 studies were included in our analysis. Meta-analysis of proportions revealed that 1-year, 3-year, and 5-year OS was 100%, 94%, and 88%, while 1-year, 3-year and 5-year DFS was 99%, 89%, and 79%, respectively. An R0 resection rate of 89% and a disease response rate of 67% was achieved after a mean duration of treatment of 8.41 ± 0.367 months. KIT exon 9 mutation was significantly associated with poorer 5-year DFS. CONCLUSION This study quantified key outcomes for neoadjuvant imatinib in locally advanced and metastatic or recurrent GIST. Patients with gastric and rectal tumous stand to benefit from neoadjuvant imatinib with an optimal treatment duration of 8 months. Furthermore, the potential utility of mutational analysis in guiding treatment with neoadjuvant imatinib was demonstrated.
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Affiliation(s)
- Timothy Jia Rong Lam
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Shamill Amedot Udonwa
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yoshio Masuda
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Ministry of Health Holdings, Singapore, Singapore
| | - Mark Hao Xuan Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Ministry of Health Holdings, Singapore, Singapore
| | | | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore, Singapore
- Surgery Academic Clinical Programme, Duke-National University of Singapore Medical School, Singapore, Singapore
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Liu Z, Zhang Y, Yin H, Geng X, Li S, Zhao J, Zeng Z, Ye X, Yu J, Feng F, Kang W. Comparison of Prognosis Between Microscopically Positive and Negative Surgical Margins for Primary Gastrointestinal Stromal Tumors: A Systematic Review and Meta-Analysis. Front Oncol 2022; 12:679115. [PMID: 35515109 PMCID: PMC9062001 DOI: 10.3389/fonc.2022.679115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 03/21/2022] [Indexed: 12/25/2022] Open
Abstract
Background This meta-analysis aimed to determine the prognostic impact of microscopically positive margins (R1) on primary gastrointestinal stromal tumors. Methods A literature search was performed using PubMed, Embase, Web of Science, and Cochrane Library for studies up to 23 November 2020. The pooled disease-free survival (DFS) and overall survival (OS) between R1 and negative margins (R0) were estimated using a random-effects model. Results Twenty studies with 6,465 patients were included. Compared with R0 resection, R1 was associated with poor DFS in patients who did not receive adjuvant Imatinib (HR: 1.62, 95% CI: 1.26-2.09; P = 0.48, I2 = 0%; reference: R0). This negative impact of R1 disappeared with the use of adjuvant Imatinib (HR: 1.23, 95% CI: 0.95-1.60; P = 0.38, I2 = 6%; reference: R0). R1 was related to poor DFS in gastric GISTs (HR: 2.15, 95% CI: 1.15-5.02, I2 = 0%; reference: R0), which was attenuated in the subgroup of adjuvant Imatinib (HR: 2.24, 95% CI: 0.32-15.60; P = 0.84, I2 = 0%; reference: R0). Rectal GIST with R1 margin who even received adjuvant Imatinib still had poor DFS (HR: 3.79, 95% CI: 1.27-11.31; P = 0.54, I2 = 0%; reference: R0). Patients who underwent R1 resection had similar OS compared with those underwent R0 resection regardless of the use of adjuvant Imatinib. Conclusion R1 was associated with poor DFS for primary GISTs, which was attenuated by adjuvant therapy with Imatinib. Similar result was observed in the gastric GISTs subgroup. Rectal GIST patients with R1 resection had poor DFS even when they received adjuvant Imatinib. The R1 margin did not influence the OS of GISTs.
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Affiliation(s)
- Zhen Liu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yichunzi Zhang
- National Health Commission (NHC) Key Laboratory of Systems Biology of Pathogens and Christophe Mérieux Laboratory, Institute of Pathogen Biology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Han Yin
- Ministry of Health (MOH) Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, and Center for Tuberculosis Research, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiuzhu Geng
- Ministry of Health (MOH) Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, and Center for Tuberculosis Research, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Sishang Li
- Ministry of Health (MOH) Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, and Center for Tuberculosis Research, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jinrong Zhao
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ziyang Zeng
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xin Ye
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jianchun Yu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Fan Feng
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, The Air Force Medical University, Xi’an, China,*Correspondence: Weiming Kang, ; Fan Feng,
| | - Weiming Kang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China,*Correspondence: Weiming Kang, ; Fan Feng,
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Mu J, Sun X, Zhao Z, Sun H, Sun P. BRD9 inhibition promotes PUMA-dependent apoptosis and augments the effect of imatinib in gastrointestinal stromal tumors. Cell Death Dis 2021; 12:962. [PMID: 34667163 PMCID: PMC8526701 DOI: 10.1038/s41419-021-04186-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 09/02/2021] [Accepted: 09/15/2021] [Indexed: 12/20/2022]
Abstract
Gastrointestinal stromal tumors (GISTs) are primarily characterized by activating mutations of tyrosine kinase or platelet-derived growth factor receptor alpha. Although the revolutionary therapeutic outcomes of imatinib are well known, the long-term benefits of imatinib are still unclear. The effects of BRD9, a recently identified subunit of noncanonical BAF complex (ncBAF) chromatin remodeling complexes, in GISTs are not clear. In the current study, we evaluated the functional role of BRD9 in GIST progression. Our findings demonstrated that the expression of BRD9 was upregulated in GIST tissues. The downregulation or inhibition of BRD9 could significantly reduce cellular proliferation, and facilitates apoptosis in GISTs. BRD9 inhibition could promote PUMA-dependent apoptosis in GISTs and enhance imatinib activity in vitro and in vivo. BRD9 inhibition synergizes with imatinib in GISTs by inducing PUMA upregulation. Mechanism study revealed that BRD9 inhibition promotes PUMA induction via the TUFT1/AKT/GSK-3β/p65 axis. Furthermore, imatinib also upregulates PUMA by targeting AKT/GSK-3β/p65 axis. In conclusion, our results indicated that BRD9 plays a key role in the progression of GISTs. Inhibition of BRD9 is a novel therapeutic strategy in GISTs treated alone or in combination with imatinib.
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Affiliation(s)
- Jianfeng Mu
- Department of Gastric and Colorectal Surgery, The First Hospital of Jilin University, Changchun, China
| | - Xuezeng Sun
- Department of Gastrointestinal Nutrition and Hernia Surgery, The Second Hospital of Jilin University, Changchun, China
| | - Zhipeng Zhao
- Department of Gastrointestinal Nutrition and Hernia Surgery, The Second Hospital of Jilin University, Changchun, China
| | - Hao Sun
- Department of Gastrointestinal Nutrition and Hernia Surgery, The Second Hospital of Jilin University, Changchun, China
| | - Pengda Sun
- Department of Gastrointestinal Nutrition and Hernia Surgery, The Second Hospital of Jilin University, Changchun, China.
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Association between R1 resection and oncological outcome in resectable gastrointestinal stromal tumors without tumor rupture: A systematic review and meta-analysis. Eur J Surg Oncol 2021; 47:1526-1534. [PMID: 33573855 DOI: 10.1016/j.ejso.2021.01.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/15/2021] [Accepted: 01/31/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The influence of positive microscopic margin (R1) resection on the prognosis of gastrointestinal stromal tumors (GISTs) is controversial. Tumor rupture is significantly associated with the occurrence of R1 resection and may be a confounder of R1 resection in GISTs. The present meta-analysis evaluated the real influence of R1 resection on the prognosis of GISTs by excluding the confounding effect of tumor rupture. METHODS The PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov databases were searched. Studies that compared R1 with negative microscopic margin (R0) resection in GIST patients and reported the time-to-event data of recurrence-free survival (RFS) or disease-free survival (DFS) were eligible for inclusion. The quality of the observational studies was assessed using the Newcastle-Ottawa scale. RESULTS Of the 4896 records screened, 23 retrospective studies with 6248 participants were selected. In the overall analysis, R1 resection resulted in a significantly shorter RFS/DFS than R0 resection for GISTs (HR = 1.80, 95% CI = 1.54-2.10, P < 0.001, I2 = 14%). However, the inferior RFS/DFS vanished when tumor rupture cases were excluded (HR = 1.34, 95% CI = 0.98-1.83, P = 0.07, I2 = 33%). Sensitivity analysis by high-quality studies brought about a more robust HR of 1.15 (95% CI = 0.88-1.50, P = 0.29), with low heterogeneity (I2 = 0%). The qualities of evidence for the outcomes were high. CONCLUSIONS This meta-analysis shows that R1 resection did not influence the survival outcome of GISTs. Reresection may not be necessary when positive microscopic margins exist. This analysis could provide high-quality evidence for the development of guidelines.
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Do microscopic surgical margins matter for primary gastric gastrointestinal stromal tumor? Surgery 2020; 169:419-425. [PMID: 32863011 DOI: 10.1016/j.surg.2020.07.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although tumor size and mitotic rate are established prognostic factors for worse survival in patients undergoing surgical resection for gastric gastrointestinal stromal tumors, the impact of microscopic margins, or R1 resection, is not completely established. METHODS Patients who received no neoadjuvant therapy and underwent surgical resection for stage I to III gastric gastrointestinal stromal tumors were identified from the 2010 to 2013 National Cancer Database and divided into 2 cohorts, R0 and R1 resections. Cox proportional hazards ratio and Kaplan Meier survival estimates were utilized to analyze 5-y overall survival. RESULTS Of 2,084 patients, those with R1 resection (57, 2.7%) were more likely to have tumors >10 cm (28.1% vs 11.9%, odds ratio 3.51, P = .017) and stage III disease (26.3% vs 11.2%, odds ratio 2.26, P = .047). Although margin status was associated with higher risk tumors, it was not associated with receipt of adjuvant therapy. After multivariate Cox regression, R1 and R0 patients did not have a difference in 5-y overall survival (82.5% vs 88.6%, hazards ratio 1.26, P = .49). When stratified by stage of disease, there remained no difference in survival across all stages when comparing R1 and R0 patients. CONCLUSION Positive microscopic margins are uncommon but do not appear to impact survival outcomes in patients with resected localized gastric gastrointestinal stromal tumors.
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Surgical Treatment of Gastrointestinal Stromal Tumors Located in the Stomach in the Imatinib Era. Am J Clin Oncol 2016; 38:502-7. [PMID: 24064754 DOI: 10.1097/coc.0b013e3182a78de9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Imatinib has changed the treatment of gastrointestinal stromal tumors (GISTs). Preoperative imatinib treatment can be administered to patients with locally advanced disease to reduce the risk of incomplete resection, tumor spill, and lessen the extent of resection. In metastatic GIST, surgery follows imatinib in responding patients with resectable disease. In this study, the outcome of surgically treated patients with a gastric GIST with and without preoperative imatinib was investigated. METHODS Patients surgically treated for a gastric GIST at our institute between 1999 and 2011 were included. Patient data were retrieved from a prospectively maintained database. RESULTS A consecutive series of 47 patients was identified: 17 patients were treated with primary surgery (group 1) and 30 patients received imatinib before surgery (group 2). Preoperative imatinib led to a 33% reduction in tumor size. All patients in group 1 and 23 patients (77%) in group 2 had a complete resection (R0) without tumor spill. At a median follow-up of 30 months, 4 patients in group 2 had died of GIST. In these 4 patients, either the resection had been irradical or tumor spill had occurred, and 3 of them had radiologic progressive disease at the time of surgery. CONCLUSIONS In this surgical series of gastric GIST patients, preoperative imatinib led to a major reduction in tumor size. Irradical resection, tumor spill, and progressive disease at the time of surgery were associated with poor prognosis.
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Zhi X, Jiang B, Yu J, Røe OD, Qin J, Ni Q, Sun L, Xu M, Zhu J, Ma L. Prognostic role of microscopically positive margins for primary gastrointestinal stromal tumors: a systematic review and meta-analysis. Sci Rep 2016; 6:21541. [PMID: 26891953 PMCID: PMC4759596 DOI: 10.1038/srep21541] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 01/26/2016] [Indexed: 02/06/2023] Open
Abstract
The impact and management of microscopically positive margins in gastrointestinal stromal tumors (GISTs) remain unclear. The aim of this study is to estimate the prognostic value of surgical margins for disease-free survival (DFS) and overall survival (OS) in patients with primary GISTs. Twelve studies with 1985 GIST patients were included. The overall recurrence rate in R1 resection and R0 resection group was 0.364 (95% CI 0.299-0.429) and 0.296 (95% CI 0.161-0.430), respectively. Meta-analysis confirmed that a microscopically positive margin could significantly impact the disease-free survival (HR 1.596, 95% CI 1.128-2.258; I(2) = 37.5%, P value = 0.091), but had no influence on overall survival (HR 1.430, 95% CI 0.608-3.363; I(2) = 60.8%, P value = 0.013). Importantly, subgroup analysis revealed that adjuvant imatinib treatment could attenuate the risk of recurrence for primary GIST patients who received R1 resection. (HR 1.308, 95% CI 0.583-2.935; I(2) = 53.2%, P value = 0.074). The level of evidence achieved in this study was "moderate" for DFS and "low" for OS. In conclusion, this study revealed that a microscopically positive margin is an unfavorable prognostic factor for GIST patients with R1 resection, and adjuvant imatinib treatment is proved to be effective.
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Affiliation(s)
- Xiaofei Zhi
- Department of General Surgery, the Affiliated Hospital of Nantong University, 20 Xisi Road, Nantong 226001, China
| | - Baofei Jiang
- Department of General Surgery, Huai’an First People’s Hospital, Nanjing Medical University, 6 West Beijing Road, Huai’an 223001, China
| | - Junbo Yu
- Emergency Department, the Affiliated Hospital of Nantong University, 20 Xisi Road, Nantong 226001, China
| | - Oluf Dimitri Røe
- Clinical Cancer Research Center, Aalborg University Hospital, Clinical Institute, Aalborg, Denmark
- Cancer Clinic, Levanger Hospital, Nord-Trøndelag Health Trust, Levanger, Norway
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jun Qin
- Department of General Surgery, the Affiliated Hospital of Nantong University, 20 Xisi Road, Nantong 226001, China
| | - Qingfeng Ni
- Department of General Surgery, the Affiliated Hospital of Nantong University, 20 Xisi Road, Nantong 226001, China
| | - Luning Sun
- Research Division of Clinical Pharmacology, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China
| | - Meirong Xu
- Department of General Surgery, the Affiliated Hospital of Nantong University, 20 Xisi Road, Nantong 226001, China
| | - Jianwei Zhu
- Department of General Surgery, the Affiliated Hospital of Nantong University, 20 Xisi Road, Nantong 226001, China
| | - Lilin Ma
- Department of General Surgery, the Affiliated Hospital of Nantong University, 20 Xisi Road, Nantong 226001, China
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Lyseng-Williamson KA. Imatinib: a guide to its use as adjuvant therapy for gastrointestinal stromal tumour (GIST) in the EU. DRUGS & THERAPY PERSPECTIVES 2015. [DOI: 10.1007/s40267-014-0179-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Rutkowski P, Przybył J, Zdzienicki M. Extended adjuvant therapy with imatinib in patients with gastrointestinal stromal tumors : recommendations for patient selection, risk assessment, and molecular response monitoring. Mol Diagn Ther 2013; 17:9-19. [PMID: 23355099 PMCID: PMC3565084 DOI: 10.1007/s40291-013-0018-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
On the basis of the recently published results of a clinical trial comparing 12 and 36 months of imatinib in adjuvant therapy for gastrointestinal stromal tumors (GISTs), which demonstrated clinical benefit of longer imatinib treatment in terms of delaying recurrences and improving overall survival, both the US Food and Drug Administration and the European Medicines Agency have updated their recommendations and approved 36 months of imatinib treatment in patients with v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog (KIT)-positive GISTs (also known as CD117-positive GISTs) at high risk of recurrence after surgical resection of a primary tumor. This article discusses patient selection criteria for extended adjuvant therapy with imatinib, different classifications of risk of recurrence, and assessment of the response to therapy.
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Affiliation(s)
- Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland.
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Gastrointestinal stromal tumors: risk assessment and adjuvant therapy. Hematol Oncol Clin North Am 2013; 27:889-904. [PMID: 24093166 DOI: 10.1016/j.hoc.2013.07.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Adjuvant imatinib prolongs recurrence-free survival and probably overall survival of patients who have undergone surgery for gastrointestinal stromal tumor (GIST). Estimation of the risk of recurrence with a prognostication tool and tumor mutation analysis is essential before imatinib initiation, because approximately 60% of patients with GIST with operable tumor are cured by surgery alone and some mutated tyrosine kinases are insensitive to imatinib. Adjuvant imatinib is usually administered for 3 years at the dose of 400 mg once daily. Early detection of tumors that recur despite adjuvant therapy with longitudinal imaging of the abdomen is likely beneficial.
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Rutkowski P, Gronchi A. Efficacy and economic value of adjuvant imatinib for gastrointestinal stromal tumors. Oncologist 2013; 18:689-96. [PMID: 23709752 DOI: 10.1634/theoncologist.2012-0474] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE This article presents the clinical effectiveness and cost-effectiveness of the use of adjuvant imatinib mesylate for treating patients with localized primary gastrointestinal stromal tumors (GISTs) and discusses the impact of prolonged treatment with adjuvant imatinib on health care costs. METHODS A systematic review of the medical literature was conducted to explore recently reported clinical trials demonstrating the clinical benefit of adjuvant imatinib in GISTs, along with analyses discussing the economic impact of adjuvant imatinib. RESULTS Two phase III trials have demonstrated a significant clinical benefit of adjuvant imatinib treatment in GIST patients at risk of recurrence after tumor resection. Guidelines now suggest adjuvant treatment for at least 3 years in patients at high risk of recurrence. Despite this clinical effectiveness, prolonged use of adjuvant imatinib can lead to an increase in the risk for adverse events and to increased costs for both patients and health care systems. However, the increased cost is partially offset by cost reductions associated with delayed or avoided GIST recurrences. Three years of adjuvant treatment in high-risk patients was concluded to be cost-effective. Therefore, the careful selection of patients who are most likely to benefit from treatment can lead to improved clinical outcomes and significant cost savings. CONCLUSION Although introducing adjuvant imatinib has an economic impact on health plans, this effect seems to be limited. Several analyses have demonstrated that adjuvant imatinib is more cost-effective for treating localized primary GISTs than surgery alone. In addition, 3 years of adjuvant imatinib is more cost-effective than 1 year of adjuvant therapy.
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Affiliation(s)
- Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland.
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Abstract
Tyrosine kinase inhibitors that target the key molecular drivers of gastrointestinal stromal tumour (GIST) are effective treatments of advanced-stage GIST. Yet, most of these patients succumb to the disease. Approximately 60% of patients with GIST are cured by surgery, and these individuals can be identified by risk stratification schemes based on tumour size, mitosis count and site, and assessment of rupture. Two large randomized trials have evaluated imatinib as adjuvant treatment for operable, KIT-positive GIST; adjuvant imatinib substantially improved time to recurrence. One of these trials reported that 3 years of adjuvant imatinib improves overall survival of patients who have a high estimated risk for recurrence of GIST compared with 1 year of imatinib. The optimal adjuvant strategy remains unknown and some patients might benefit from longer than 3 years of imatinib treatment. However, a strategy that involves GIST risk assessment following surgery using a validated scheme, administration of adjuvant imatinib for 3 years, patient monitoring during and after completion of imatinib to detect recurrence early, and reinstitution of imatinib if GIST recurs is a reasonable choice for care of patients with high-risk GIST.
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