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Judson I, Jones RL, Wong NACS, Dileo P, Bulusu R, Smith M, Almond M. Gastrointestinal stromal tumour (GIST): British Sarcoma Group clinical practice guidelines. Br J Cancer 2024:10.1038/s41416-024-02672-0. [PMID: 38840030 DOI: 10.1038/s41416-024-02672-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND British Sarcoma Group guidelines for the management of GIST were initially informed by those published by the European Society of Clinical Oncology. This update was written by a group of experts to includes a discussion of the highlight improvements in our knowledge of the disease and recent treatment developments. The guidelines include sections on Incidence, Aetiology, Diagnosis, including risk assessment, Treatment and Follow-up. METHODS A careful review of the literature was performed to ensure that wherever possible recommendations are supported by the results of clinical trials or substantive retrospective reports. Areas of uncertainty are indicated appropriately. CONCLUSION Guidelines represent a consensus view of current best clinical practice. Where appropriate, key recommendations are given and the levels of evidence and strength of recommendation gradings are those used by the European Society for Medical Oncology (ESMO).
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Affiliation(s)
- Ian Judson
- The Institute of Cancer Research, London, UK.
| | | | | | | | | | - Myles Smith
- Royal Marsden NHS Foundation Trust, London, UK
| | - Max Almond
- Birmingham University Hospitals, Birmingham, UK
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Thibaut F, Veziant J, Warlaumont M, Gauthier V, Lefèvre J, Gronnier C, Bonnet S, Mabrut JY, Regimbeau JM, Benhaim L, Tiberio GAM, Mathonnet M, Regenet N, Chirica M, Glehen O, Mariani P, Panis Y, Genser L, Mutter D, Théreaux J, Bergeat D, Le Roy B, Brigand C, Eveno C, Guillaume P. Prognostic impact of positive microscopic margins (R1 resection) in patients with GIST (gastrointestinal stromal tumours): Results of a multicenter European study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108310. [PMID: 38598874 DOI: 10.1016/j.ejso.2024.108310] [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: 10/13/2023] [Revised: 02/28/2024] [Accepted: 03/24/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Although several prognostic factors in GIST have been well studied such as tumour size, mitotic rate, or localization, the influence of microscopic margins or R1 resection remains controversial. The aim of this study was to evaluate the influence of R1 resection on the prognosis of GIST in a large multicentre retrospective series of patients. METHODS From 2001 to 2013, 1413 patients who underwent surgery for any site of GIST were identified from 61 European centers. 1098 patients were included, excluding synchronous metastases, concurrent malignancies, R2 resection or GIST recurrence. Tumour rupture (TR) was reclassified according to the Oslo sarcoma classification. Cox proportional hazards ratio and Kaplan-Meier survival estimates were used to analyse 5-year recurrence-free survival (RFS). RESULTS Of 1098 patients, 38 (3%) underwent R1 resection with a risk of TR of 11%. The 5-year RFS was 89.6% with a median follow-up of 81 months [range: 31.2-152 months]. On univariate analysis, lower RFS was significantly associated with R1 resection [HR = 2.13; p = 0.04], high risk score according to the modified NIH classification, administration of adjuvant therapy [HR = 2.24; p < 0.001] and intraoperative complications [HR = 2.82; p < 0.001]. Only intraoperative complications [HR = 1.79; p = 0.02] and high risk according to the modified NIH classification including the updated definition of TR [HR = 3.43; p = 0.04] remained significant on multivariate analysis. CONCLUSION This study shows that positive microscopic margins are not an independent predictive factor for RFS in GIST when taking into account the up-dated classification of TR. R1 resection may be considered a reasonable alternative to avoid major functional sequelae and should not lead to reoperation.
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Affiliation(s)
- Flore Thibaut
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, F-59000, Lille, France; Department of General and Digestive Surgery, Seclin Hospital, rue d'Apolda, 59471, Seclin, France.
| | - Julie Veziant
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, F-59000, Lille, France; Univ. Lille, CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000, Lille, France
| | - Maxime Warlaumont
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, F-59000, Lille, France; Department of General and Digestive Surgery, Cambrai Hospital, 516 Avenue de Paris, 59400, Cambrai, France
| | - Victoria Gauthier
- Univ Lille, INSERM, CHU Lille, Institut Pasteur de Lille, U1167 - RID-AGE- Facteurs de risque et déterminants moléculaires des maladies liées au vieillissement, F59-000, LILLE, France
| | - Jérémie Lefèvre
- Department of Digestive Surgery, Sorbonne Université, AP-HP, Saint-Antoine Hospital, Paris, France
| | - Caroline Gronnier
- Oeso-Gastric Surgery Unit, Department of Digestive Surgery, Magellan Center, Bordeaux University Hospital, 33600, Pessac, France; Faculty of Medicine, Bordeaux Ségalen University, 33000, Bordeaux, France
| | - Stephane Bonnet
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Jean-Yves Mabrut
- Department of Digestive Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices CIVils de Lyon, Lyon, France
| | - Jean-Marc Regimbeau
- Department of Digestive Surgery, Amiens University Hospital, Amiens, France; UR UPJV 7518, SSPC (Simplification of Surgical Patients Care), Picardie Jules Verne University, Amiens, France
| | - Léonor Benhaim
- Department of Digestive Surgery, Gustave Roussy Institute, Villejuif, France
| | - G A M Tiberio
- Surgical Unit, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Muriel Mathonnet
- Department of Digestive Surgery, Dupuytren University Hospital, Limoges, France
| | - Nicolas Regenet
- Department of Digestive Surgery, Nantes University Hospital, Nantes, France
| | - Mircea Chirica
- Department of Digestive Surgery, Grenoble University Hospital, Grenoble, France
| | - Olivier Glehen
- Department of Surgical Oncology, Lyon Sud University Hospital, Lyon, France
| | | | - Yves Panis
- Department of Colorectal Surgery, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly-sur-Seine, France
| | - Laurent Genser
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, AP-HP, Department of Hepato-Biliary and Pancreatic Surgery, liver transplantation, Pitié-Salpêtrière University Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France; INSERM, Nutrition and Obesities Systemic Approaches, NutriOmics Research Unit, Sorbonne Université, 91 Boulevard de l'Hôpital, Paris, France
| | - Didier Mutter
- Department of Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France; Research Institute Against Digestive Cancer, IRCAD, Strasbourg, France
| | - Jérémie Théreaux
- Department of Visceral and Digestive Surgery, Cavale Blanche University Hospital, Brest, France; Inrae, Inserm, Univ Rennes, Nutrition Metabolisms and Cancer, NuMeCan, Rennes, St Gilles, France
| | | | - Bertrand Le Roy
- Department of Digestive and Oncologic Surgery, University Hospital of Saint-Etienne, Saint-Priest-en-Jarez, France
| | - Cécile Brigand
- Department of General and Digestive Surgery, University Hospital of Hautepierre, Strasbourg, France
| | - Clarisse Eveno
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, F-59000, Lille, France; Univ. Lille, CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000, Lille, France
| | - Piessen Guillaume
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, F-59000, Lille, France; Univ. Lille, CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000, Lille, France
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Muniandy J, Huang CW, Ke TW, Chen WTL. Prone Jack-Knife Transanal Minimally Invasive Surgery: A Safe and Effective Approach for Anterior Low Rectal GI Stromal Tumors. Dis Colon Rectum 2024; 67:e291. [PMID: 38323637 DOI: 10.1097/dcr.0000000000003078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Affiliation(s)
- Jothinathan Muniandy
- Melaka Hospital, Department of General Surgery, Ministry of Health Malaysia, Malaysia
- Division of Colorectal Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Wei Huang
- Division of Colorectal Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Tao-Wei Ke
- Division of Colorectal Surgery, China Medical University Hospital, Taichung, Taiwan
| | - William Tzu-Liang Chen
- Division of Colorectal Surgery, China Medical University Hospital, Taichung, Taiwan
- Division of Colorectal Surgery, China Medical University Hospital, Hsinchu, Taiwan
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Outcomes of Local Excision Compared to Radical Excision of Rectal Gastrointestinal Stromal Tumors: A Propensity-Score Matched Analysis of the NCDB. World J Surg 2023; 47:269-277. [PMID: 36221005 DOI: 10.1007/s00268-022-06778-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gastrointestinal stromal tumors (GISTs) account for <1% of gastrointestinal cancers. The present study aimed to assess the outcomes of local and radical excision of non-metastatic rectal GISTs. METHODS This study was a retrospective cohort analysis of patients with non-metastatic rectal GISTs in the NCDB. Patients were divided according to the surgical approach into local and radical excision and were compared in regard to the baseline characteristics and outcomes. A propensity-score matched analysis was performed to match the two groups for baseline confounders. The main outcomes were 5-year overall survival (OS), surgical margins, hospital stay, short-term mortality, and readmission. RESULTS 228 patients (54.8% male) with rectal GISTs were included. Before matching, 127 (55.7%) patients underwent local excision and 101 (44.3%) had radical excision. Patients who underwent local excision had more cT1-T2 and low-grade GISTs whereas patients who had radical excision received more neoadjuvant systemic treatment. After matching for clinical T stage, tumor grade, and neoadjuvant systemic therapy, 52 patients were included in each group. Local excision had a significantly higher rate of positive resection margins (42.2% vs. 19.1%, p = 0.02) and a shorter hospital stay (0 vs. 3 days, p < 0.001) than radical excision. The two groups had similar mean OS (139.8 vs. 133.1 months, p = 0.52). CONCLUSIONS Local excision was associated with a significantly higher incidence of positive resection margins and shorter hospital stay, yet similar overall survival to radical excision.
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Khan SI, O’Sullivan NJ, Temperley HC, Rausa E, Mehigan BJ, McCormick P, Larkin JO, Kavanagh DO, Kelly ME. Gastrointestinal Stromal Tumours (GIST) of the Rectum: A Systematic Review and Meta-Analysis. Curr Oncol 2022; 30:416-429. [PMID: 36661683 PMCID: PMC9857930 DOI: 10.3390/curroncol30010034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 12/11/2022] [Accepted: 12/22/2022] [Indexed: 12/30/2022] Open
Abstract
Background: Rectal gastrointestinal stromal tumours (GISTs) have many treatment options, but uncertainty remains regarding the best treatment regimen for this rare pathology. The aim of this review is to assess the optimal management approach including timing of chemotherapy. Methods: PubMed, EMBASE, and Cochrane databases were searched for relevant articles comparing the impact of radical vs. local excision, and neoadjuvant vs. adjuvant therapy had on outcomes in the management of rectal GISTs. We specifically evaluated the influence that the aforementioned factors had on margins, recurrence, overall survival, 5-year disease-free survival, and hospital length of stay. Results: Twenty-eight studies met our predefined criteria and were included in our study, twelve of which were included in the quantitative synthesis. When comparing neoadjuvant versus adjuvant chemotherapy, our meta-analysis noted no significance in terms of margin negativity (R0) (odds ratio [OR] 2.01, 95% confidence interval [CI], 0.7−5.79, p = 0.20) or recurrence rates (OR 0.22, 95% CI, 0.02−1.91, p = 0.17). However, there was a difference in overall 5-year survival in favour of neoadjuvant therapy (OR 3.19, 95% CI, 1.37−7.40, * p = 0.007). Comparing local excision versus radical excision, our meta-analysis observed no significance in terms of overall 5-year survival (OR1.31, 95% CI, 0.81−2.12, p = 0.26), recurrence (OR 0.67, 95% CI, 0.40−1.13, p = 0.12), or 5-year disease-free survival (OR 1.10, 95% CI, 0.55−2.19, p = 0.80). There was a difference in length of hospital stay with a reduced mean length of stay in local excision group (mean difference [MD] 6.74 days less in the LE group; 95% CI, −6.92−−6.56, * p =< 0.00001) as well as a difference in R0 rates in favour of radical resection (OR 0.68, 95% CI, 0.47−0.99, * p = 0.05). Conclusion: Neoadjuvant chemotherapy is associated with improved overall 5-year survival, while local excision is associated with reduced mean length of hospital stay. Further large-volume, prospective studies are required to further define the optimal treatment regimen in this complex pathology.
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Affiliation(s)
| | - Niall J. O’Sullivan
- Department of Surgery, St James’s Hospital, D08 NHY1 Dublin, Ireland
- School of Medicine, Trinity College Dublin, D08 W9RT Dublin, Ireland
- Department of Surgery, Tallaght University Hospital, D24 NR0A Dublin, Ireland
| | - Hugo C. Temperley
- Department of Surgery, St James’s Hospital, D08 NHY1 Dublin, Ireland
| | - Emanuele Rausa
- Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| | - Brian J. Mehigan
- Department of Surgery, St James’s Hospital, D08 NHY1 Dublin, Ireland
- School of Medicine, Trinity College Dublin, D08 W9RT Dublin, Ireland
| | - Paul McCormick
- Department of Surgery, St James’s Hospital, D08 NHY1 Dublin, Ireland
- School of Medicine, Trinity College Dublin, D08 W9RT Dublin, Ireland
| | - John O. Larkin
- Department of Surgery, St James’s Hospital, D08 NHY1 Dublin, Ireland
- School of Medicine, Trinity College Dublin, D08 W9RT Dublin, Ireland
| | - Dara O. Kavanagh
- Royal College of Surgeons, D02 YN77 Dublin, Ireland
- Department of Surgery, Tallaght University Hospital, D24 NR0A Dublin, Ireland
| | - Michael E. Kelly
- Department of Surgery, St James’s Hospital, D08 NHY1 Dublin, Ireland
- School of Medicine, Trinity College Dublin, D08 W9RT Dublin, Ireland
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Liu HR, Feng J, Li R. Endoscopic submucosal dissection for ultra-low large rectal stromal tumor after preoperative imatinib therapy: A case report and review. J Dig Dis 2022; 23:720-723. [PMID: 36756792 DOI: 10.1111/1751-2980.13157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 01/25/2023] [Accepted: 02/07/2023] [Indexed: 02/10/2023]
Affiliation(s)
- Hao Ran Liu
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Ji Feng
- Department of Gastroenterology, The First People's Hospital of Kunshan, Suzhou, Jiangsu Province, China
| | - Rui Li
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
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Yang D, Ren H, Yang Y, Niu Z, Shao M, Xie Z, Yang T, Wang J. Risk stratification of 2- to 5-cm gastric stromal tumors based on clinical and computed tomography manifestations. Eur J Radiol 2022; 157:110590. [DOI: 10.1016/j.ejrad.2022.110590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 09/12/2022] [Accepted: 10/29/2022] [Indexed: 11/06/2022]
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Shigaki T, Tsukada Y, Teramura K, Hasegawa H, Ikeda K, Nishizawa Y, Sasaki T, Ito M. Trans-anal surgery with the taTME technique for rectal gastrointestinal stromal tumors: a retrospective study. Int J Colorectal Dis 2022; 37:1975-1982. [PMID: 35943579 DOI: 10.1007/s00384-022-04233-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/03/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Rectal gastrointestinal stromal tumors (GISTs) surgery is often challenging owing to the anatomical constraints of the narrow pelvis and tumor hugeness. Despite the increasing number of patients undergoing trans-anal total mesorectal excision (taTME) globally, the feasibility of trans-anal surgery with the taTME technique for rectal GISTs remains unclear. We aimed to evaluate the feasibility of trans-anal surgery with the taTME technique for rectal GISTs. METHODS Using a prospectively collected database, we retrospectively analyzed the clinical findings, surgical outcomes, pathological outcomes, urinary and anal functions, and prognoses of patients who underwent trans-anal surgery with the taTME technique for primary rectal GISTs at the National Cancer Center Hospital East from September 2014 to March 2020. RESULTS Twenty-one patients with primary rectal GISTs were included in this study. The median distance from the anal verge to the lower edge of the tumor was 40 mm (range, 15-60 mm), and the median tumor size was 59 mm (range, 11-175 mm). Moreover, seven and 14 patients underwent one-team and two-team surgeries, respectively, with curative intent. Nineteen patients (90.5%) underwent anus-preserving surgery, and the urinary tracts were preserved in all cases. Two-team surgery showed a significantly lower blood loss volume and shorter operation time than one-team surgery (58 vs. 222 mL, P = 0.017; 184 vs 356 min, P = 0.041, respectively). The pathological negative-margin resection rate was 100%. During the follow-up period, no patient developed local GIST recurrence and one (4.8%) developed distant metastasis. CONCLUSION Trans-anal surgery with the taTME technique is feasible for rectal GISTs, and two-team surgery may be more advantageous than one-team surgery in terms of operation time and blood loss.
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Affiliation(s)
- Takahiro Shigaki
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Yuichiro Tsukada
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Koichi Teramura
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Hiro Hasegawa
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Koji Ikeda
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Yuji Nishizawa
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Takeshi Sasaki
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Masaaki Ito
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
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Wallenhorst T, Jacques J, Lièvre A, Pagenault M, Bouguen G, Pioche M, Brochard C. Endoscopic resection of a rectal gastrointestinal stromal tumor using the submucosal tunneling endoscopic resection (STER) technique. Endoscopy 2022; 54:E273-E274. [PMID: 34144621 DOI: 10.1055/a-1508-5241] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Timothée Wallenhorst
- Department of Endoscopy and Gastroenterology, Centre Hospitalier Universitaire Pontchaillou, Rennes, France
| | - Jérémie Jacques
- Department of Hepatogastroenterology, Centre Hospitalier Universitaire Dupuytren, Limoges, France
| | - Astrid Lièvre
- Department of Endoscopy and Gastroenterology, Centre Hospitalier Universitaire Pontchaillou, Rennes, France
| | - Mael Pagenault
- Department of Endoscopy and Gastroenterology, Centre Hospitalier Universitaire Pontchaillou, Rennes, France
| | - Guillaume Bouguen
- Department of Endoscopy and Gastroenterology, Centre Hospitalier Universitaire Pontchaillou, Rennes, France
| | - Mathieu Pioche
- Department of Gastroenterology, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Charlène Brochard
- Department of Endoscopy and Gastroenterology, Centre Hospitalier Universitaire Pontchaillou, Rennes, France
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Abstract
Over the past 20 years, gastrointestinal stromal tumor (GIST) has evolved into an increasingly complex clinical entity with ever more challenges. While surgical resection is the gold standard, advancements in genetic testing, therapeutic options, immunotherapy, and management of metastatic disease necessitate a comprehensive, multimodal approach for these tumors. This chapter highlights the importance of genomic testing of GIST, the use of neoadjuvant and adjuvant therapy for localized disease, surgical principles for GIST, as well as current and new approaches for addressing metastatic disease.
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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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Reis NRP, Barbosa LER. Prognostic Factors and Management of Colorectal Gastrointestinal Stromal Tumors. JOURNAL OF COLOPROCTOLOGY 2022. [DOI: 10.1055/s-0041-1740297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Introduction The gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm of the gastrointestinal tract. Even though it can be found in any location of the digestive tract, the colorectal GIST is rare. With this study, we aim to review the current knowledge regarding the prognosis and management of colorectal GIST.
Methods A literature search was conducted in PubMed, and 717 articles were collected. After analyzing these studies, 60 articles were selected to use in this review.
Results The mitotic index, as well as tumor size and location were identified as good discriminators of prognosis in various studies. Surgery remains the only curative therapy for potentially resectable tumors. However, even after surgical resection, some patients develop disease recurrence and metastasis, especially those with high-risk tumors. Therefore, surgical resection alone might be inadequate for the management of all colorectal GISTs. The discovery of GIST's molecular pathway led to a shift in its therapy, insofar as tyrosine kinase inhibitors became part of the treatment schemes for this tumor, revolutionizing the treatment's outcome and prognosis.
Discussion/Conclusion The controversy concerning colorectal GIST prognosis and treatment can be, in part, attributed to the limited number of studies in the literature. In this review, we gathered the most recent knowledge about the prognosis and management of GIST in this rare location and propose two algorithms for its approach. Lastly, we highlight the importance of an individualized approach in the setting of a multidisciplinary team.
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Affiliation(s)
- Nuno Rafael Pereira Reis
- Department of Surgery and Physiology, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Laura Elisabete Ribeiro Barbosa
- Department of Surgery and Physiology, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
- Department of General Surgery, Centro Hospitalar Universitário São João, Serviço de Cirurgia Geral, Porto, Portugal
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Wei J, Zhong J, Chen Z, Huang Q, Wei F, Wang Q, Cao J. Survival outcome of local vs. radical excision in rectal gastrointestinal stromal tumor: a SEER database analysis. BMC Surg 2022; 22:21. [PMID: 35065645 PMCID: PMC8783417 DOI: 10.1186/s12893-022-01485-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 01/12/2022] [Indexed: 12/03/2022] Open
Abstract
Background The choice of surgical strategy for patients with rectal gastrointestinal stromal tumor (GIST) remains controversial. This study aims to address whether the surgical procedure [local excision (LE) vs. radical excision (RE)] influences the survival outcomes. Methods The information of the patients recruited in this study was obtained from the Surveillance, Epidemiology, and End Results (SEER) database. A survival curve was used to evaluate the differences in cancer-specific survival (CSS). Results No significant difference was detected in the CSS between the LE and RE groups. Also, no significant differences were observed in the CSS between the two groups with respect to different T classification, N classification, tumor differentiation, tumor size, regional LN surgery, age, gender, race, chemotherapy, and radiotherapy. The T classification and age were independent prognostic factors in rectal GIST patients. Conclusions LE and RE have similar survival time after surgery, and LE could be considered as an effective surgical approach for rectal GIST.
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Shao M, Niu Z, He L, Fang Z, He J, Xie Z, Cheng G, Wang J. Building Radiomics Models Based on Triple-Phase CT Images Combining Clinical Features for Discriminating the Risk Rating in Gastrointestinal Stromal Tumors. Front Oncol 2021; 11:737302. [PMID: 34950578 PMCID: PMC8689687 DOI: 10.3389/fonc.2021.737302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 11/15/2021] [Indexed: 12/24/2022] Open
Abstract
We aimed to build radiomics models based on triple-phase CT images combining clinical features to predict the risk rating of gastrointestinal stromal tumors (GISTs). A total of 231 patients with pathologically diagnosed GISTs from July 2012 to July 2020 were categorized into a training data set (82 patients with high risk, 80 patients with low risk) and a validation data set (35 patients with high risk, 34 patients with low risk) with a ratio of 7:3. Four diagnostic models were constructed by assessing 20 clinical characteristics and 18 radiomic features that were extracted from a lesion mask based on triple-phase CT images. The receiver operating characteristic (ROC) curves were applied to calculate the diagnostic performance of these models, and ROC curves of these models were compared using Delong test in different data sets. The results of ROC analyses showed that areas under ROC curves (AUC) of model 4 [Clinic + CT value of unenhanced (CTU) + CT value of arterial phase (CTA) + value of venous phase (CTV)], model 1 (Clinic + CTU), model 2 (Clinic + CTA), and model 3 (Clinic + CTV) were 0.925, 0.894, 0.909, and 0.914 in the training set and 0.897, 0.866, 0,892, and 0.892 in the validation set, respectively. Model 4, model 1, model 2, and model 3 yielded an accuracy of 88.3%, 85.8%, 86.4%, and 84.6%, a sensitivity of 85.4%, 84.2%, 76.8%, and 78.0%, and a specificity of 91.2%, 87.5%, 96.2%, and 91.2% in the training set and an accuracy of 88.4%, 84.1%, 82.6%, and 82.6%, a sensitivity of 88.6%, 77.1%, 74.3%, and 85.7%, and a specificity of 88.2%, 91.2%, 91.2%, and 79.4% in the validation set, respectively. There was a significant difference between model 4 and model 1 in discriminating the risk rating in gastrointestinal stromal tumors in the training data set (Delong test, p < 0.05). The radiomic models based on clinical features and triple-phase CT images manifested excellent accuracy for the discrimination of risk rating of GISTs.
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Affiliation(s)
- Meihua Shao
- Department of Radiology, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Zhongfeng Niu
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Linyang He
- Hangzhou Jianpei Technology Company, Hangzhou, China
| | - Zhaoxing Fang
- Hangzhou Jianpei Technology Company, Hangzhou, China
| | - Jie He
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zongyu Xie
- Department of Radiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Guohua Cheng
- Hangzhou Jianpei Technology Company, Hangzhou, China
| | - Jian Wang
- Department of Radiology, Tongde Hospital of Zhejiang Province, Hangzhou, China
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15
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Ling JY, Ding MM, Yang ZF, Zhao YD, Xie XY, Shi LS, Wang HM, Cao WT, Zhang JW, Hu HB, Cai Y, Wang H, Deng YH. Comparison of outcomes between neoadjuvant imatinib and upfront surgery in patients with localized rectal GIST: An inverse probability of treatment weighting analysis. J Surg Oncol 2021; 124:1442-1450. [PMID: 34494280 DOI: 10.1002/jso.26664] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/26/2021] [Accepted: 08/28/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND OBJECTIVES This study aimed to compare outcomes between neoadjuvant imatinib and upfront surgery in patients with localized rectal gastrointestinal stromal tumors (GIST) patients. METHODS Eighty-five patients with localized rectal GIST were divided into two groups: upfront surgery ± adjuvant imatinib (Group A, n = 33) and the neoadjuvant imatinib + surgery + adjuvant imatinib (Group B, n = 52). Baseline characteristics between groups were controlled for with inverse probability of treatment weighting (IPTW) adjusted analysis. RESULTS The response rate to neoadjuvant imatinib was 65.9%. After the IPTW-adjusted analysis, patients who underwent neoadjuvant therapy had better distant recurrence-free survival (DRFS) and disease-specific survival (DSS) compared with those who underwent upfront surgery (5-year DRFS 97.8 vs. 71.9%, hazard ratio [HR], 0.15; 95% CI, 0.03-0.87; p = 0.03; 5-year DSS 100 vs. 77.1%; HR, 0.11; 95% CI, 0.01-0.92; p = 0.04). While no significant association was found between overall survival (OS) and treatment groups (p = 0.07), 5-year OS was higher for the neoadjuvant group than upfront surgery group (97.8% vs. 71.9%; HR, 0.2; 95% CI, 0.03-1.15). CONCLUSIONS In patients with localized rectal GIST, neoadjuvant imatinib not only shrunk the tumor size but also decreased the risk of metastasis and tumor-related deaths when compared to upfront surgery and adjuvant imatinib alone.
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Affiliation(s)
- Jia-Yu Ling
- Department of Medical Oncology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, China
| | - Miao-Miao Ding
- Department of Medical Oncology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, China
| | - Zi-Feng Yang
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, China.,Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yan-Dong Zhao
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, China.,Department of Pathology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiao-Yu Xie
- Department of Medical Oncology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, China
| | - Li-Shuo Shi
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, China.,Center for Clinical Research, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Huai-Ming Wang
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, China.,Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wu-Teng Cao
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, China.,Department of Radiology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jian-Wei Zhang
- Department of Medical Oncology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, China
| | - Hua-Bin Hu
- Department of Medical Oncology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, China
| | - Yue Cai
- Department of Medical Oncology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, China
| | - Hui Wang
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, China.,Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yan-Hong Deng
- Department of Medical Oncology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, 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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Radical resection versus local excision for low rectal gastrointestinal stromal tumor: A multicenter propensity score-matched analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2021; 47:1668-1674. [PMID: 33581967 DOI: 10.1016/j.ejso.2021.01.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/18/2021] [Accepted: 01/27/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND The surgical approaches and resection extent for rectal gastrointestinal stromal tumors (GISTs) are controversial due to the low incidence of this disease. A multicenter retrospective cohort study was conducted to compare the postoperative and oncologic outcomes of local excision (LE) and radical resection (RR) in patients with low rectal GIST. PATIENTS AND METHODS The medical records of rectal GIST patients from 11 large-scale medical centers in China (January 2000-December 2019) were reviewed. All patients were divided into either the LE group or the RR group. Propensity score matching (PSM) was conducted to reduce confounders. RESULTS A total of 280 patients with low rectal GIST were enrolled. After PSM, 144 patients were included (72 in each group). The LE group showed a higher anal preservation rate (100.0% vs. 76.4%, P < 0.001), shorter operation time (77.1 ± 68.4 min vs. 159.1 ± 83.6 min, P < 0.001), fewer complications (8.3% vs. 22.2%, P = 0.021) and shorter postoperative hospital stay (4.9 ± 4.1 d vs. 10.7 ± 8.1 d, P < 0.001) than the RR group. There was no significant difference in recurrence-free survival (RFS) between the RR and LE groups among patients with tumors ≤2 cm (P = 0.220), and the RR group had a superior RFS than the LE group in patients with tumors >2 cm (P = 0.046). CONCLUSIONS LE resulted in improved postoperative outcomes and comparable oncological safety with a low rectal GIST of ≤2 cm. However, for patients with a low rectal GIST of >2 cm, RR might be a more appropriate option with better RFS.
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Rivera AKU, Jabiles AG, Passiuri IC, Leon EG, Quiroga MG, Baca RC, Figueroa JE, Rosillo NP, Meza EP. Gastrointestinal stromal tumour of the rectum and intestinal obstruction: case report. Ecancermedicalscience 2020; 14:1139. [PMID: 33281931 PMCID: PMC7685769 DOI: 10.3332/ecancer.2020.1139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Indexed: 12/12/2022] Open
Abstract
We report the case of a 75-year-old female patient with a big tumour in the lower rectum with intestinal obstruction and lower gastrointestinal bleeding history who underwent a tumour biopsy under laparotomy and end colostomy at another hospital in Peru. She came to our institution for clinical evaluation with a pathology result of a rectal gastrointestinal stromal tumour. An extra elevator abdominoperineal resection was performed with tumour-free margins. The histology confirmed a high-grade (G2) rectal gastrointestinal stromal tumour with a mitotic index of 27/50. DOC-1 (+) and CD117 (+) in immunohistochemistry. Genomic DNA was extracted from the paraffin-fixed tumour sample, and c.1504_1509dupGCCTAT (p.Ala502_Tyr503dup) mutation was detected in exon 9 of the KIT gene. Imatinib 400 mg per day for 3 years was indicated as adjuvant treatment. Currently, she has a disease-free survival of 12 months.
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Affiliation(s)
| | | | - Ivan Chavez Passiuri
- Department of Abdominal Surgery at National Cancer Institute (INEN), Lima 34, Peru
| | - Elica Garcia Leon
- Department of Medical Oncology at Regional Hospital of Lambayeque, Lambayeque, Peru
| | | | - Renier Cruz Baca
- Fellow of Oncological Pathology at National Cancer Institute (INEN), Lima 34, Peru
| | | | | | - Eduardo Payet Meza
- Department of Abdominal Surgery at National Cancer Institute (INEN), Lima 34, Peru
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Lussiez A, Suwanabol PA. Invited Commentary on "Radical excision versus local resection for primary rectal gastrointestinal stromal tumors. A cohort study" (Int J Surg 2020; 77:190-197). Int J Surg 2020; 78:145-146. [PMID: 32360503 DOI: 10.1016/j.ijsu.2020.04.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 04/22/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Alisha Lussiez
- Department of Surgery, University of Michigan, United States.
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Rectal GIST - A review. An invited commentary on “Clinical outcomes of different therapeutic modalities for rectal gastrointestinal stromal tumor: Summary of 14-year clinical experience in a single center--Retrospective cohort study”. Int J Surg 2020; 77:116. [DOI: 10.1016/j.ijsu.2020.03.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 03/22/2020] [Indexed: 12/19/2022]
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