Metastatic gastrointestinal stromal tumor to the thoracic and lumbar spine: first reported case and surgical treatment

Multiple Myeloma Rather Than Metastatic Lung Cancer: An Unexpected Cause of Spinal Cord Compression

Spinal cord compression caused by cancer metastasis is a medical emergency that should be managed positively. Both multiple myeloma and lung cancer can lead to metastatic deposits in the spinal column to induce compression of the spinal cord. However, co-occurring multiple myeloma and lung cancer in a single patient causing spinal cord compression are rarely reported in the literature. We describe a case of a 61-year-old female with multiple myeloma and lung cancer whose radiologic characteristics of spinal cord compression mimicked those of metastatic lung cancer. Finally, the diagnosis was multiple myeloma. We showed the systematic imaging manifestations of metastatic multiple myeloma and discussed their therapeutic management.

Radiotherapy in the Management of Gastrointestinal Stromal Tumors: A Systematic Review

Simple Summary

Gastrointestinal stromal tumors are considered to be insensitive to radiotherapy. However, with the development of radiation techniques and the accumulation of cases, some studies have indicated that radiotherapy could help achieve objective response in advanced or metastatic gastrointestinal stromal tumors. Therefore, it is necessary to conduct a systematic review to reassess the role of radiotherapy in gastrointestinal stromal tumors. The purpose of this study was to draw the attention of scholars and clinicians to radiotherapy and promote further research on radiotherapy in gastrointestinal stromal tumors.

Abstract

Gastrointestinal stromal tumors (GISTs) are considered insensitive to radiotherapy. However, a growing number of case reports and case series have shown that some lesions treated by radiotherapy achieved an objective response. The aim of the study was to perform a systematic review of all reported cases, case series, and clinical studies of GISTs treated with radiotherapy to reevaluate the role of radiotherapy in GISTs. A systematic search of the English-written literature was conducted using PubMed, Web of Science, and Embase databases. Overall, 41 articles describing 112 patients were retrieved. The included articles were of low to moderate quality. Bone was the most common site treated by radiotherapy, followed by the abdomen. In order to exclude the influence of effective tyrosine kinase inhibitors (TKIs), a subgroup analysis was conducted on whether and which TKIs were concurrently applied with radiotherapy. Results showed that radiotherapy alone or combined with resistant TKIs could help achieve objective response in selected patients with advanced or metastatic GISTs; however, survival benefits were not observed in the included studies. Pain was the most common symptom in symptomatic GISTs, followed by neurological dysfunction and bleeding. The symptom palliation rate was 78.6% after excluding the influence of effective TKIs. The adverse reactions were mainly graded 1–2. Radiotherapy was generally well-tolerated. Overall, radiotherapy may relieve symptoms for GIST patients with advanced or metastatic lesions and even help achieve objective response in selected patients without significantly reducing the quality of life. In addition to bone metastases, fixed abdominal lesions may be treated by radiotherapy. Publication bias and insufficient quality of included studies were the main limitations in this review. Further clinical studies are needed and justified.

Staged surgical approach for metastatic GIST, how far should we go? Case report

Introduction

Gastrointestinal stromal tumor (GIST) is an uncommon mesenchymal neoplasm that commonly arises from the stomach and proximal small intestine but can develop in any part of the gastrointestinal tract. The disease can range from primary localized to an advanced metastatic unresectable disease in up to 30% of patients. Usually, metastasis involves the liver, peritoneum, and occasionally the lungs. The current standard treatment of localized resectable tumors is complete oncological resection, while advanced metastatic GISTs treatment remains contentious.

Case presentation

We report a case of a 34 years old pregnant female presenting with a 3 days history of multiple episodes of hematemesis and melena. Laboratory investigations were unremarkable except for severe anemia (Hgb 4.4 g/dL). After further investigations a diagnosis of duodenal GIST (DGIST) with liver metastasis was made. She received and showed good response to neoadjuvant Imatinib therapy, which was followed by a successful 2-stage surgery in the form of extended right hepatectomy and Whipple procedure with a good survival.

Clinical dissection

The evolution of Imatinib had a tremendous impact on surgery in metastatic GIST even in initially unresectable cases, thereby providing a better survival. However, the duration of neoadjuvant Imatinib course and the matter of resistance are still unclear those necessitating the use of different agents or the surgical approach.

Conclusion

Although with the advancements in surgical approaches and perioperative care, liver resection might be a curative option. The role of surgery in advanced GIST remains a controversial matter that needs critical selection of cases based on further future research.

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GIST is considered a relatively rare entity, accounting for only 1% of all primary gastrointestinal tumors with the incidence being 10-13 per million population per year.

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We present a case of a 34 pregnant female presenting with vomiting blood and passing melena, which after further examination and investigation was revealed to be due to a duodenal GIST.

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The evolution of Imatinib had a tremendous impact on surgery in metastatic GIST even in initially unresectable cases.

Gastrointestinal stromal tumor with multisegmental spinal metastases as first presentation: A case report and review of the literature

BACKGROUND

Gastrointestinal stromal tumor (GIST) usually originates in the stomach, followed by the small intestine, rectum, and other parts of the gastrointestinal tract. The most common sites of metastasis are the liver and peritoneum, whereas spinal metastases from GIST are extremely rare.

CASE SUMMARY

We found a case of GIST with the first presentation of multilevel spinal metastases involving the thoracic and lumbar vertebrae. A 61-year-old Chinese man presented to our clinic because of pain in his lower back and hip for 10 d without cause. Subsequently, computed tomography (CT) and magnetic resonance imaging (MRI) revealed abnormal signals in the vertebral appendages of T12 and L4 accompanied by spinal canal stenosis, which was considered as tumor metastasis. As there were no metastases to vital organs, posterior thoracic and lumbar spinal decompression + adnexal mass resection + pedicle internal fixation was adopted to achieve local cure and prevent nerve compression. The results of histopathological studies were consistent with the metastasis of GIST. No local recurrence or new metastases were found at the 6-mo follow-up at the surgical site. The patient has no neurological symptoms at present. It is worth mentioning that a rectal mass was found and surgically removed 1 mo after the patient was discharged from hospital, and the pathological diagnosis of the mass was GIST.

CONCLUSION

By reviewing 26 previously reported cases of spinal metastasis in GIST, it was found that spinal metastasis of GIST has become more common in recent years, so the possibility of early spinal metastasis should be recognized. CT and MRI are of great value in the diagnosis of spinal metastatic tumors, and pathological biopsy is the gold standard for the diagnosis of metastatic tumors. It is safe and feasible to treat isolated spinal metastasis in GIST by excising metastatic masses, decompressing the spinal canal, and stabilizing the spine.

Surgical management of vertebral metastatic gastrointestinal stromal tumor: Case illustration, literature review, and pooled analysis

Background:

Gastrointestinal stromal tumors (GISTs) very rarely metastasize to the vertebrae. Tyrosine kinase inhibitors (TKIs) confer favorable long-term survival and durable disease control for metastatic disease. Here, we reviewed a case and the literature to determine the various management options, and neurological outcomes for these patients.

Case Description:

A 63-year-old Chinese female with metastatic jejunal GIST previously treated with various TKIs presented with the left lower limb weakness and a sensory level at T10. MRI revealed a T9 vertebral body tumor with cord compression. The tumor was excised and surgical fixation was performed. She received 30Gy of fractionated adjuvant radiotherapy. She achieved near-complete neurological recovery but died 2 months later from systemic disease progression.

Conclusion:

Based on this case and a review of the literature, surgical intervention and treatment with TKIs with adjuvant RT can lead to comparable survival and neurological outcomes.

Bone Metastases of Gastrointestinal Stromal Tumor: A Review of Published Literature

Background

With the occurrence and improvement of immunohistochemistry and other pathological diagnostic techniques, gastrointestinal stromal tumor (GIST) has been gradually recognized. With the prolonged survival of patients with GISTs, reports about the bone metastasis of GIST increased. However, the knowledge of GISTs is rather limited due to its very low incidence.

Methods

Cochrane and Medline database (via PubMed) were searched in July 2019 with related keywords to acquire the literature related to the bone metastasis of GIST. Then, the literature was reviewed and references were also scanned to identify the possible related reports. Study data comprising age, sex, primary location, metastasis interval time, immunohistochemistry index, management and prognosis were recorded and analyzed.

Results

Forty-five patients with bone metastases of GIST, with a mean age of 61.09 years, were included. The small intestine and stomach were the most common primary sites, followed by the rectum. Patients with small intestine primary sites had bone metastases that occurred earlier than the bone metastases stomach and rectum primary sites. The spine was the most common site of bony metastases. The mean survival time after GIST diagnosis was more than 64.02 months. Patients younger than 60 years old had a worse prognosis than those older than 60 years old. Furthermore, patients with spinal involvement had a worse prognosis than those without spinal involvement. Surgical interventions combined with targeted therapies guaranteed a better prognosis.

Conclusion

Bone metastasis of GIST, which mainly occurs in the spine, is rather rare. Patients with GISTs of the small intestine and stomach suffered from bone metastasis more frequently and earlier than patients with GISTs in other primary sites. Age, sex, primary tumor location, treatment mode for the primary lesions and metastases, and spine involvement may be potential factors that affect the prognosis of GIST patients with bone metastases.

Clinical features and surgical treatments of rare gastrointestinal stromal tumor spinal metastases

OBJECTIVE

To increase our knowledge of the characteristics of rare gastrointestinal stromal tumors (GISTs) spinal metastatic diseases and share our experience of dealing with these diseases.

METHODS

A total of 6 patients with spinal cord compression caused by GISTs spinal metastases operated in our department were identified from Oct, 2010 to Oct, 2018. The clinical and operative notes, radiographic images, and pathological reports with histochemistry of all these patients were reviewed.

RESULTS

Among these six, four were male. The average age was 57.2 ± 9.0 years-old. The average duration between GISTs resections and diagnosis of spinal metastases was 80.8 ± 91.9 months. Four patients died from their disease during follow-up. The average duration between operation and death was 8.5 ± 4.4 months.

CONCLUSIONS

Generally, patients with GISTs spinal metastatic diseases had a poor prognosis. The average survival of these patients did not exceed 12 months. Palliative treatments are recommended mainly to control symptoms.

Long-Term Survival After Multidisciplinary Treatment Including Surgery for Metachronous Metastases of Small Intestinal Gastrointestinal Stromal Tumors after Curative Resection: A Case Report

Patient: Male, 56-year-old

Final Diagnosis: Metachronous metastases of small intestinal gastrointestinal stromal tumors

Symptoms: Abdominal and/or epigastric pain

Medication: —

Clinical Procedure: Operation • chemotharapy

Specialty: Gastroenterology and Hepatology

Clinical and pathological characteristics of gastrointestinal stromal tumor (GIST) metastatic to bone

Our aim in this study was to describe the clinical, morphological, and molecular profile of gastrointestinal stromal tumor (GIST) metastatic to bone. We analyzed the morphological, phenotypic, and molecular characteristics of seven cases, and in addition reviewed 17 cases from literature. Sequence analysis of KIT and PDGFRA genes was possible for six cases. For the GIST cases with bone metastasis, the most common primaries were small intestine (29%), stomach (25%), and rectum (21%). Sites of bone metastases were vertebrae (11), pelvis (8), femur (8), ribs (6), humerus (5), skull (3), scapula (1), and mandible (1). The size ranged from 1.5 to 13 cm (median, 3.8 cm). Bone metastases without involvement of any other organ were seen in 17% of the cases and were solitary in 14 (58%). Adjacent soft tissue involvement was present in nearly half of the patients. Bone metastasis was either manifest at the time of diagnosis (28%) or occurred after a mean period of 4.7 years (3 months-20 years). Morphologically, neoplastic cells were spindle in 67%, epithelioid in 13%, and mixed epithelioid and spindle in 20%. CD117, DOG1, and CD34 were positive in 88, 86, and 85% of the cases, respectively. KIT Exon 11 mutations were the most frequent gene alteration (78%), followed by KIT Exon 13 mutations. Of 17 of the cases with available follow-up information, 7 (41%) patients developed bone metastasis under imatinib therapy. Five patients (29%) died of disease within a mean of 17 months. Bone metastases from GIST are usually found in patients with advanced disease and typically present as lytic masses with occasional soft tissue involvement. We could not identify any KIT or PDGFRA alterations predisposing to bone metastasis.

Gastrointestinal Stromal Tumour with Synchronous Bone Metastases: A Case Report and Literature Review

Gastrointestinal stromal tumours (GISTs) are mesenchymal tumours of the digestive tract, derived from Cajal interstitial cells. Bone metastases are very rare, and there is no consensus regarding their treatment. Here, we present the unusual case of a 66-year-old man with a gastric GIST with synchronous bone and liver metastases, fully documented at the pathological and molecular levels with a KIT exon 11 mutation. After 9 months of imatinib, the scanner showed a 33% partial response of target lesions. We also review the literature and describe the characteristics, treatment, and outcome of all cases previously reported.