Gastrointestinal Stromal Tumor

GIST Quiz: TesNt your knowledge

Having a strong understanding of the epidemiology, pathophysiology, and clinical management of Gastrointestinal Stromal Tumors (GIST) is critical for clinicians who may encounter this cancer. The quiz below is designed for medical students, residents, fellows, and practicing physicians to test their knowledge and review key concepts for understanding GIST.

Effect and safety of ripretinib in the treatment of advanced gastrointestinal stromal tumor: A systematic review and meta-analysis

BACKGROUND

Imatinib (IMA) has received approval as the primary treatment for gastrointestinal stromal tumors (GIST). Nonetheless, approximately half of the patients with advanced GIST show disease advancement following IMA treatment. Presently, the efficacy of secondary and tertiary medications in addressing various GIST secondary mutations is somewhat restricted. Consequently, there is a significant medical demand for the creation of kinase inhibitors that extensively block secondary drug-resistant mutations in advanced GIST. Ripretinib (RPT) is a new, switch-control tyrosine kinase inhibitors that can suppress different mutations of KIT and PDGFRA via a dual mechanism of action.

AIM

To investigate the literature on RPT to assess an effective, safe, and successful treatment strategy against advanced GIST.

METHODS

The present systematic review and meta-analysis was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Embase, Cochrane, Web of Science and ClinicalTrials.gov databases were screened from January 1, 2003 to May 1, 2024.

RESULTS

A total of 4 studies were included, with a total of 507 patients enrolled. The objective response rate (ORR) of the RPT-treated advanced GIST was 17% (95%CI: 0.11-0.27), while the disease control rate (DCR) was 66% (95%CI: 0.59-0.73). The overall occurrence of adverse events with varying degrees was 97% (95%CI: 0.93-1), whereas that of grade ≥ 3 adverse reactions was 42% (95%CI: 0.28-0.63). The sensitivity analysis revealed that omitting some studies did not yield statistically notable variances in the aggregate data regarding the ORR, DCR, and the occurrence of adverse events of grade 3 or higher. The publication bias was absent because no significant asymmetry was observed in Begg's funnel plot in all studies.

CONCLUSION

RPT has favorable efficacy profiles in GIST patients, but the adverse reactions are obvious, and patient management needs to be strengthened to achieve better safety and tolerability.

Regorafenib-related erythrocytosis in metastatic extra-gastrointestinal stromal tumor: a case report

Introduction

Regorafenib is an oral multi-targeted tyrosine kinase inhibitor (TKI) indicated for the treatment of various tumor types, including metastatic gastrointestinal stromal tumors (GIST), as a third-line systemic therapy. Erythrocytosis, which is characterized by an increase in erythrocyte count, hemoglobin, and hematocrit levels, has been described as a side effect of some antiangiogenic TKIs but has never been associated with regorafenib administration.

Case presentation

An extra-GIST was diagnosed in a 58-year-old woman after she underwent surgery to remove a pelvic mass. Three years later, systemic therapy with imatinib was started due to pelvic disease recurrence. However, after six months, due to disease progression, we prescribed sunitinib, which the patient received for four years. Regorafenib was initiated in June 2019, and after six months, we noted an increase in the erythrocytes' count and hemoglobin (Hb) levels. Given that the patient had clinical benefit and hematocrit was within normal range, we only monitored the blood cell count and continued to give regorafenib at the same dose. The drug was then stopped for over six weeks due to hospitalization for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and Hb levels returned to normal. Therefore, we decided to restart regorafenib at a lower dose. However, Hb levels rose again in conjunction with increased hematocrit, resulting in the need for multiple phlebotomies. We attempted to restart regorafenib every other day, but it was unsuccessful, so we stopped it permanently in May 2023, and all values returned to normal.

Conclusion

Regorafenib may cause secondary erythrocytosis that could not be dose-related, as this case report suggests. Secondary erythrocytosis might be a marker of TKI efficacy, given the patient's prolonged clinical benefit during regorafenib treatment (48 months). In patients receiving regorafenib, monitoring blood count as well as any symptoms associated with erythrocytosis may be suggested.

Pan-Canadian consensus recommendations for GIST management in high- and low-throughput centres across Canada

Gastrointestinal stromal tumours (GISTs) are mesenchymal tumours that originate from the interstitial cells of Cajal. GISTs are mainly driven by gain-of-function mutations in receptor tyrosine kinase or platelet-derived growth factor receptor alpha. Surgical resection is the only curative treatment for localized tumours and all currently approved medical GIST treatments are based on orally available tyrosine kinase inhibitors. Recent discoveries in the molecular and clinical features of GISTs have greatly impacted GIST management. Due to the provincially rather than nationally administered Canadian healthcare system, there have been inconsistencies in the treatment of GISTs across the country. Therefore, guidance on the latest knowledge, clinical management and treatment of GIST is needed to standardize the approach to GIST management nationwide. To establish pan-Canadian guidance, provide up-to-date data and harmonize the clinical practice of GIST management in high- and low-throughput centres across Canada; a panel of 20 physicians with extensive clinical experience in GIST management reviewed relevant literature. This included radiologists, pathologists, interventional radiologists, surgeons and medical oncologists across Canada. The structured literature focused on seven key domains: molecular profiling, radiological techniques/reporting, targeted localized therapy, intricacies of systemic treatments, emerging tests, multidisciplinary care and patient advocacy. This literature review, along with clinical expertise and opinion, was used to develop this concise and clinically relevant consensus paper to harmonize the knowledge and clinical practice on GIST management across Canada. The content presented here will help guide healthcare providers, especially in Canada, in terms of approaching and managing GIST.

Diagnostic Complexity and Long-Term Management of Gastrointestinal Stromal Tumor Mimicking Ovarian Origin: A Case Report

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors occurring in the gastrointestinal tract particularly the stomach or small intestine originating from interstitial cells of Cajal. This case report describes a 50-year-old postmenopausal female presenting with a gradually increasing abdominal mass which clinically was thought to be a neoplasm originating in the ovaries. A clinical and imaging diagnosis of primary ovarian malignancy was made but during laparotomy, a mesenteric component to the malignancy as well as bilateral ovarian cysts were seen. The mass was removed with care and histopathological analysis confirmed it to be GIST. Follow-up of the patient was done for three years and there was no sign of any disease in the patient and she had an uncomplicated postoperative period. This case describes the intricacy of GISTs' diagnosis, the significance of detailed intraoperative analysis, and appropriate postoperative surveillance. Differences and similarities with other similar cases shed light on how such patients present themselves for treatment, thus encouraging differentiated care. Supervisory care is therefore vital in the monitoring of the patient for prolonged periods and to check for any relapse.

Postoperative encapsulated hemoperitoneum in a patient with gastric stromal tumor treated by exposed endoscopic full-thickness resection: A case report

BACKGROUND

Gastric stromal tumors, originating from mesenchymal tissues, are one of the most common tumors of the digestive tract. For stromal tumors originating from the muscularis propria, compared with conventional endoscopic submucosal dissection (ESD), endoscopic full-thickness resection (EFTR) can remove deep lesions and digestive tract wall tumors completely. However, this technique has major limitations such as perforation, postoperative bleeding, and post-polypectomy syndrome. Herein, we report a case of postoperative serous surface bleeding which formed an encapsulated hemoperitoneum in a patient with gastric stromal tumor that was treated with exposed EFTR. Feasible treatment options to address this complication are described.

CASE SUMMARY

A 47-year-old male patient had a hemispherical protrusion found during gastric endoscopic ultrasonography, located at the upper gastric curvature adjacent to the stomach fundus, with a smooth surface mucosa and poor mobility. The lesion was 19.3 mm × 16.1 mm in size and originated from the fourth ultrasound layer. Computed tomography (CT) revealed no significant evidence of lymph node enlargement or distant metastasis. Using conventional ESD technology for mucosal pre-resection, exposed EFTR was performed to resect the intact tumor in order to achieve a definitive histopathological diagnosis. Based on its morphology and immunohistochemical expression of CD117 and DOG-1, the lesion was proven to be consistent with a gastric stromal tumor. Six days after exposed EFTR, CT showed a large amount of encapsulated fluid and gas accumulation around the stomach. In addition, gastroscopy suggested intracavitary bleeding and abdominal puncture drainage indicated serosal bleeding. Based on these findings, the patient was diagnosed with serosal bleeding resulting in encapsulated abdominal hemorrhage after exposed EFTR for a gastric stromal tumor. The patient received combined treatments, such as hemostasis under gastroscopy, gastrointestinal decompression, and abdominal drainage. All examinations were normal within six months of follow-up.

CONCLUSION

This patient developed serous surface bleeding in the gastric cavity following exposed EFTR. Serosal bleeding resulting in an encapsulated hemoperitoneum is rare in clinical practice. The combined treatment may replace certain surgical techniques.

Nomogram for Predicting Recurrence-Free Survival of Primary Localized Gastrointestinal Stromal Tumor

PURPOSE

This study aimed to establish a new nomogram that predicts recurrence-free survival (RFS) after a complete surgical resection of primary localized gastrointestinal stromal tumors (GISTs); it also aimed to evaluate the discrimination, calibration, and clinical utility of the decision-making nomogram.

METHODS

The clinicopathological data of patients with primary localized GISTs at the First Affiliated Hospital of Chongqing Medical University from January 2000 to June 2022 were retrospectively analyzed. The clinicopathological data were randomly split into two sets (7:3 ratio) for training and validation. Suitable variables for the construction of a nomogram for the 1-, 3-, and 5-year RFS were selected using univariate and multivariate Cox regression analyses. Receiver operating characteristic (ROC) analysis and a concordance index (C-index) were used to quantify the discrimination of the nomogram and were compared with four commonly used prognostic scoring systems: Memorial Sloan Kettering Cancer Center prognostic nomogram, National Institutes of Health-Fletcher staging system, Chen's prognostic nomogram, and Air Forces Institute of Pathology risk criteria-Miettinen staging system. The calibration and clinical utility for the decision-making nomogram were validated using calibration curves and decision curves, respectively.

RESULTS

In total, 641 patients were screened and analyzed in this retrospective, observational study. RFS was significantly related to tumor size, mitotic count, gender, DOG-1, and adjuvant therapy with imatinib according to the results of the multivariate and univariate Cox analyses. The nomogram was constructed using the above variables (all p < 0.05) for the 1-, 3-, and 5-year RFS. In the training set, the 1-, 3-, and 5-year ROC and C-index values of the nomogram were 0.868, 0.838, 0.816, and 0.830, respectively. For internal validation, we performed model fitting on the validation set, and the 1-, 3-, and 5-year ROC and C-indices were 0.977, 0.845, 0.869, and 0.849, respectively. Among the five GIST prognostic scoring systems, our nomogram had almost all the largest area under these decision curves and had a good calibration capability.

CONCLUSIONS

The newly constructed nomogram based on tumor size, gender, mitotic count, DOG-1, and adjuvant treatment with imatinib exhibited an excellent performance and may serve as a prognostic scoring system to support therapeutic decision-making and individualized treatment for GISTs in China.

Advances of endoscopic and surgical management in gastrointestinal stromal tumors

As one of the most common mesenchymal malignancies in the digestive system, gastrointestinal stromal tumors (GISTs) occur throughout the alimentary tract with diversified oncological characteristics. With the advent of the tyrosine kinase inhibitor era, the treatment regimens of patients with GISTs have been revolutionized and GISTs have become the paradigm of multidisciplinary therapy. However, surgery resection remains recognized as the potentially curative management for the radical resection and provided with favorable oncological outcomes. The existing available surgery algorithms in clinical practice primarily incorporate open procedure, and endoscopic and laparoscopic surgery together with combined operation techniques. The performance of various surgery methods often refers to the consideration of risk evaluation of recurrence and metastases; the degree of disease progression; size, location, and growth pattern of tumor; general conditions of selected patients; and indications and safety profile of various techniques. In the present review, we summarize the fundamental principle of surgery of GISTs based on risk assessment as well as tumor size, location, and degree of progress with an emphasis on the indications, strengths, and limitations of current surgery techniques.

Primary Localized Gastrointestinal Stromal Tumors: Medication Adherence and Prognosis According to Gender

OBJECTIVE

Gender is associated with medication adherence for imatinib, but whether it is related to the prognosis of primary localized gastrointestinal stromal tumors (GISTs) is unclear. The goal of this study was to clarify the relationship between gender and prognosis in GIST patients, with differences in medication adherence considered.

METHODS

The data of 320 GIST patients were retrospectively collected from the First Affiliated Hospital of Chongqing Medical University. Survival analysis was performed using the Kaplan-Meier method (Log rank test) and the risk factors of recurrence were determined using Cox multivariate analysis. Medication adherence-stratified analyses were performed to control for confounding factors.

RESULTS

Kaplan-Meier analysis revealed that among patients who received postoperative adjuvant imatinib therapy, men had a higher recurrence rate than women (P<0.01). Pearson's chi-square test revealed better medication adherence in women than in men (P<0.01). Cox regression analysis revealed that gender was not an independent risk factor for recurrence-free survival (RFS; P=0.25), but medication adherence was (P<0.01). Among GIST patients with a medication possession ratio (MPR) of less than 90%, 62.86% of male patients took imatinib irregularly or not at all due to limited understanding of the disease, whereas 55.74% of female patients' took imatinib irregularly because they could not tolerate adverse drug reactions.

CONCLUSION

Adherence was poorer in male than in female patients, which might explain the worse prognoses of the former among patients who received adjuvant treatment with imatinib. The gender difference in the degree of adherence should be considered in postoperative pharmacotherapy for patients with primary localized GISTs.