Management of Gastrointestinal Stromal Tumors

GIST: Correlation of risk classifications and outcome

In clinical practice, there are often discrepancies between the oncological prognosis of gastrointestinal stromal tumors (GIST) and the actual clinical course. This study aimed to check with our collective how reliably the current classifications (Miettinen, Fletcher) predict the prognosis of GIST and to evaluate whether an extension of the classifications by the parameter proliferation activity could make sense. This prospective study enrolled 58 patients who underwent surgery on GIST from 01/2006 to 12/2016. The postoperative course (curation, recurrence, progress) was correlated with the identified risk classification and the proliferative activity. Coincidences with other tumors were strikingly common in patients with GIST (43%). Based on the risk group assignment of GIST, no assessment of the probability of the occurrence of second neoplasia could be derived. Individual patients were under- or over-graduated concerning the assessment of biological behavior based on the standard risk classifications. The inclusion of proliferative activity did not allow for a more precise predictive power - neither to the risk of recurrence and metastasis nor to the development of a second neoplasia. The study showed that there is currently no parameter or logarithm that reliably predicts the biological behavior of GIST. Due to the frequency of coincidence of second neoplasia and (rare) distant metastases, for everyday clinical practice, appropriate staging diagnostic and regular follow-up care should also be used for benign GIST.

OTSC assisted EFTR for the treatment of GIST: 40 cases analysis

BACKGROUND AND AIMS

To verify the safety and efficacy of over-the-scope clip (OTSC)-assisted endoscopic full-thickness resection (EFTR) for the excision of stromal tumors.

MATERIAL AND METHODS

Forty patients with gastric stromal tumors treated in the Department of Gastroenterology, Binzhou Medical University Hospital from December 2015 to March 2017 were included in this study. The surgical procedures included marking the lesion boundaries, cutting open the top surface of the lesion, installing an OTS, sucking the lesion into the transparent cap of the anatomical clip which was then released, application of an endoloop for EFTR, and confirming the complete resection and pathological examination of the lesion. Statistical analysis of the tumor site and size, operation time, success rates, complications, pathological examination results, and follow-up status was performed.

RESULTS

The average operation duration was 38.40 ± 24.9 min. Three cases had an incomplete resection, but the lesion was later found to have fallen off together with the OTSC. Therefore, the treatment success rate was 100%. Postoperative pathological examination revealed leiomyomas in four cases and stromal tumors in the remaining 36 cases.

CONCLUSIONS

OTSC-assisted EFTR is safe and effective for resection of gastrointestinal stromal tumors, especially for those <20 mm in size.

Gastrointestinal stromal tumors of the stomach: A 10-year experience of a single-center

Background

Gastrointestinal tract stromal tumors (GIST) are the most common mesenchymal tumors in the gastrointestinal tract (GIS). GISTs may cause significant morbidity and mortality rates.

Aim

In this study, it was aimed to evaluate 10 years of gastric GIST cases followed in our hospital, and to analyze the prognostic factors.

Subjects and Methods

In this single-center retrospective study, a total of 64 patients who were operated between May 2010 and May 2020 due to gastric GIST tumor were reviewed. Clinical and pathological features, risk classifications, overall survival (OS) and disease-free survival (DFS) were evaluated.

Results

According to the risk classification, 18.8% of the patients were in the high-risk group. The overall 5-year OS and DFS rates were 85.7%. The mean OS of the patients was 47.9 SD36.2 months, and the duration of DFS was 45.5 months. Patients with a 5-year OS rate above 5 cm in diameter (P = 0.024), with a mitotic index above 5/50 high power field (HPF) (P = 0.038), and those with a high-risk group (P = 0.011) were significantly lower than the other group. In the correlation analysis, it was found that tumor diameter correlated significantly with OS (P = 0.034; r = -0.317). Tumor diameter and mitotic index were found to be inversely correlated with DFS duration (P = 0.004; r = -0.425 and P = 0.035; r = -0.316, respectively).

Conclusion

Our findings showed that in gastric GIST cases, as the primary tumor diameter and mitotic index increase, correlate with survival rates and the mean overall and disease-free survival times decrease.

National Utilization of Imatinib in the Management of Resected Gastrointestinal Stromal Tumors

BACKGROUND

Imatinib decreases recurrence risk and improves overall survival (OS) in localized gastrointestinal stromal tumors (GISTs); however, the extent to which patients receive appropriate treatment in the US has not been well characterized.

METHODS

Patients with non-metastatic, resectable GIST were included in this study (National Cancer Database, 2010-2015). Those with a low-risk of recurrence were classified as receiving overtreatment or guideline-concordant treatment, while those with a high-risk of recurrence were classified as receiving undertreatment or guideline-concordant treatment. Multivariable logistic regression was used to determine factors associated with non-concordant treatment. The association between non-concordant treatment and OS was evaluated using multivariable Cox regression and propensity score matching.

RESULTS

Among 3088 patients with high-risk GIST, 41% were undertreated, and among 3908 patients with low-risk GIST, 18.8% were overtreated. For patients with high-risk GIST, age > 60 years, African American race, and treatment at a community or comprehensive cancer program were associated with undertreatment. Among low-risk patients, small bowel primary, tumor size > 2 cm, and tumors with > 1 mitotic figure per 50 high-power fields were more likely to be overtreated. After propensity score matching, guideline-concordant therapy was associated with an 8.8% improvement in 5-year OS (81.9% vs. 73.1%, p = 0.002) for those with high-risk GIST and decreased risk of death (hazard ratio 0.63, 95% confidence interval 0.47-0.84). There was no statistically significant difference in survival for patients with low-risk GIST with the addition of imatinib overtreatment (overtreatment 93.9% vs. 89.6%, p = 0.053).

CONCLUSIONS

Nearly 30% of GIST patients do not receive guideline-concordant treatment and future work is needed to understand the factors driving non-concordant treatment.

Prognostic value of Onodera's nutritional index for intermediate- and high-risk gastrointestinal stromal tumors treated with or without tyrosine kinase inhibitors

Background

Immunoinflammatory and nutritional markers, such as the peripheral blood neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and Onodera’s prognostic nutritional index (OPNI), have gained considerable attention and have been preliminarily revealed as prognostic markers of gastrointestinal stromal tumors (GISTs).

Methods

In this study, we first investigated the prognostic value of OPNI in GISTs treated with or without TKIs based on the propensity score matching (PSM) method. All of the patients had received surgical resection for primary GIST, and data from 2010 to 2018 were initially and retrospectively identified from our gastrointestinal center. Recurrence-free survival (RFS) was calculated by the Kaplan–Meier method and compared by the log-rank test.

Results

The patients were divided into groups treated and not treated with TKIs, and we used the propensity score matching method to homogenize their baseline data. Multivariate Cox proportional hazard regression models were applied to identify associations with outcome variables. A total of 563 GISTs were initially chosen, and 280 of them were included for analysis under the inclusion criteria. After PSM, there were 200 patients included. Multivariate analyses identified OPNI as an independent prognostic marker that was associated with primary site, tumor size, mitotic index, tumor rupture, necrosis, and modified NIH risk classification. Low OPNI (< 42.6; HR 0.409; P < 0.001) was associated with worse RFS.

Conclusions

Preoperative OPNI is a novel and useful prognostic marker for GISTs both treated and not treated with TKIs. Higher NLR and PLR have negative effects on RFS.

Novel Prognostic Nomogram for Recurrence-Free Survival of Patients With Primary Gastrointestinal Stromal Tumors After Surgical Resection: Combination of Prognostic Nutritional Index and Basic Variables

Background

Gastrointestinal stromal tumor (GIST) is the most common type of mesenchymal tumors in the digestive tract, often recrudescing even after R0 resection. Adjuvant tyrosine kinase inhibitor therapy prolonged recurrence-free survival (RFS). This study aimed to develop a novel nomogram for predicting the RFS of patients following surgical resection of GISTs.

Methods

Clinicopathologic data of patients with GISTs at Tianjin Medical University General Hospital (Tianjin, China) from January 2000 to October 2019 were retrospectively reviewed. Univariate and multivariate Cox regression analyses were used to select the suitable variables from the training cohort to construct a nomogram for 2- and 5-year RFS. The 1,000 bootstrap samples and calibration curves were used to validate the discrimination of the nomogram. The receiver operating characteristic analysis(ROC) was used to compare the predictive ability of the nomogram and present four commonly used risk stratification systems: National Institutes of Health (NIH)–Fletcher staging system; NIH–Miettinen criteria; Modified NIH criteria; and Air Forces Institute of Pathology risk criteria (AFIP).

Results

Univariate and multivariate analyses showed that the tumor site, tumor size, mitotic index, tumor rupture, and prognostic nutritional index were significant factors associated with RFS. These variables were selected to create the nomogram for 2- and 5-year RFS (all P<0.05). The 2- and 5-year the ROC of the nomogram were 0.821 (95% confidence interval [CI]: 0.740–0.903) and 0.798 (95% CI: 0.739–0.903); NIH–Fletcher criteria were 0.757 (95% CI: 0.667–0.846) and 0.683 (95% CI: 0.613–0.753); NIH–Miettinen criteria were 0.762 (95% CI: 0.678–0.845) and 0.718 (95% CI: 0.653–0.783); Modified NIH criteria were 0.750 (95% CI: 0.661–0.838) and 0.689 (95% CI: 0.619–0.760); and AFIP were 0.777 (95% CI: 0.685–0.869) and 0.708 (95% CI: 0.636–0.780). Hence, the predictive probabilities of our nomogram are better than those of other GIST risk stratification systems.

Conclusion

This nomogram, combining tumor site, tumor size, mitotic index, tumor rupture, and prognostic nutritional index, may assist physicians in providing individualized treatment and surveillance protocols for patients with GISTs following surgical resection.

Co-Incidence of Paraesophageal Hernia and Perforated Gastrointestinal Stromal Tumor: A Case Report on Rare Presentation of GIST

Introduction: The most common connective tissue neoplasm of the gastrointestinal tract is gastrointestinal stromal tumors (GISTs). Its presentations are usually abdominal pain and gastrointestinal bleeding. Case Presentation: We report a 31-year-old man with abdominal pain presented to our hospital with 10 days history of abdominal pain. After radiologic investigations, total distended stomach paraesophageal hernia and antral deformity were seen in the CT scan. Subsequently, the patient underwent surgery and after releasing the stomach, a large sealed perforated mass was seen in the antrum near the diaphragmatic hiatus and small localized abscess that subtotal gastrectomy and hernia repair was done. Pathologic examination revealed that the perforated mass is a GIST. Conclusions: We report a rare complication of gist that is perforation and the first report of simultaneous paraesophageal hernia and perforated gist.

KIT and PDGFRa mutational patterns in Sardinian patients with gastrointestinal stromal tumors

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal malignancy of the gastrointestinal tract. We provide in the present article the molecular characterization of a series of primary GISTs in a cohort of Sardinian patients (Italy), with the aim to describe the patterns of KIT and PDGFRa mutations and the corresponding clinical features. Ninety-nine Sardinian patients with histologically-proven diagnosis of GIST were included in the study. Medical records and pathology reports were used to assess the demographic and clinical features of the patients and the disease at the time of the diagnosis. Formalin-fixed, paraffin-embedded tissue samples were retrieved for each case, and mutation analysis of the KIT and PDGFRa genes was performed. KIT and PDGFRa mutations were detected in 81.8% and 5% of the cases, respectively. The most common KIT mutation was W557_K558del in exon 11, while D842V in exon 18 was the most common PDGFRa genetic alteration; V561D was the only PDGFRa mutation found in exon 12. The global "wild-type" cases, with no mutations in either the KIT or PDGFRa genes, were 13 (13.1%). The mean survival of those patients was approximately 46.9 (±43.9) months. Globally, 86.9% of Sardinian patients with GIST had a KIT or PDGFRa mutation; the former were more frequent in comparison with other Italian cohorts, while PDGFRa mutations were rare. No statistical differences in survival between mutated and wild-type cases, and between KIT and PDGFRa mutated cases were detected in our study.

Gastrointestinal Stromal Tumours (GIST): Indian Experience of Rare Malignancy

GISTs are rare tumours of the GI tract arising from the intestinal cells of Cajal. Though various risk stratification systems have been proposed, none has been universally accepted. We audited the survival and recurrence patterns in our patients and evaluated clinicopathological features to identify prognostic factors affecting survival. We conducted a retrospective analysis of patients treated at our hospital from 1999 to 2012. Patient variables, clinicopathological factors and treatment variables were collected. Sixty-three patients were evaluated and treated at our institute of which 38 were non-metastatic. The most common site of origin was the stomach. On univariate analysis, presence of metastasis, male gender, high mitotic rate, non-gastric primary and epithelioid histology were significantly associated with poor overall survival. Tumour size > 10 cm, mitotic rate > 10/50 hpf and presence of necrosis significantly affected disease-free survival for non-metastatic patients. Multivariate analysis showed higher mitotic rate and non-gastric primary to correlate with worse outcome. In our experience, a high mitotic rate and non-gastric primary independently predicted a poor prognosis in GIST.

The Landmark Series: Systemic Therapy for Resectable Gastrointestinal Stromal Tumors

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract. Complete resection is the only potentially curative treatment, although recurrence is common, occurring in approximately 40–50% of patients. The introduction of effective molecularly targeted therapies for GISTs has dramatically changed the clinical management paradigms for, and prognosis of, patients with intermediate- and high-risk GISTs, as well as those with locally advanced and metastatic disease. In this article, we review landmark studies that evaluated the use and efficacy of the tyrosine kinase inhibitors imatinib and sunitinib in the adjuvant and neoadjuvant settings for resectable primary and limited resectable metastatic GISTs.

Gastrointestinal stromal tumour of stomach: Feasibility of laparoscopic resection in large lesions and its long-term outcomes

Background:

Gastric gastrointestinal stromal tumours (GISTs) are rare neoplasms that require excision for cure. Although the feasibility of laparoscopic resection of smaller gastric GIST has been established, the feasibility and long-term efficacy of these techniques are unclear in larger lesions. This study is done to assess the feasibility of the laparoscopic resection of gastric GISTs and their long-term outcomes.

Methods:

Patients who underwent laparoscopic resection of gastric GISTs were identified in a prospectively collected database. Outcome measures included patient demographics, operative findings, morbidity and histopathologic characteristics of the tumour. Patient and tumour characteristics were analysed to identify risk factors for tumour recurrence.

Results:

There were 42 patients with a mean age of 56.7 years and had a mean tumour size was 4.5 ± 2.7 cm. Laparoscopic wedge resection was the most common procedure done. There were no major perioperative complications or mortalities. All lesions had negative resection margins. At a mean follow-up of 48 months, 36/39 (92.3%) patients were disease free and 3/39 (7.6%) had progressive disease. Univariate analysis showed that there was a statistically significant association of disease progression with tumour size, high mitotic index, tumour ulceration and tumour necrosis. The presence of >10 mitotic figures/50 high-power field was an independent predictor of disease progression.

Conclusion:

Our study establishes laparoscopic resection is feasible and safe in treating gastric GISTs for tumours >5 cm size. The long-term disease-free survival in our study shows acceptable oncological results in comparison to historical open resections.

Gastrointestinal stromal tumour masquerading as a diverticular bleed

Gastrointestinal stromal tumours (GISTs) only account for a small percentage of gastrointestinal malignancies with a wide range of clinical presentations depending on the location and size of the tumour. Herein, we present the case of a 55-year-old woman with occult gastrointestinal bleeding (GIB) despite imaging and two separate oesophagogastroduodenoscopy colonoscopies. On double-balloon enteroscopy, an oozing diverticular-appearing lesion in the ileum was identified which on laparoscopy was connected to a large pelvic GIST. This case highlights the importance of considering GISTs in patients with occult GIB, as a high index of suspicion is required for diagnosis.

Anti-tumoral activity of single and combined regorafenib treatments in preclinical models of liver and gastrointestinal cancers

Regorafenib is a sorafenib-derived chemotherapy drug belonging to the multikinase inhibitor family. This agent effectively targets a wide range of tyrosine kinases involved in cancer biology, such as those implicated in oncogenesis, angiogenesis, and tumor microenvironment control. The beneficial effects of regorafenib in clinical trials of patients who suffer from advanced hepatocellular carcinoma (HCC), colorectal cancer (CRC) or gastrointestinal stromal tumors (GISTs) refractory to standard treatments led to regorafenib monotherapy approval as a second-line treatment for advanced HCC and as a third-line treatment for advanced CRC and GISTs. Multiple in vitro and in vivo studies have been performed over the last decade to reveal the molecular mechanisms of the favorable actions exerted by regorafenib in patients. Given the hypothetical loss of sensitivity to regorafenib in tumor cells, preclinical research is also searching for novel therapeutic approaches consisting of co-administration of this drug plus other agents as a strategy to improve regorafenib effectiveness. This review summarizes the anti-tumor effects of regorafenib in single or combined treatment in preclinical models of HCC, CRC and GISTs and discusses both the global and molecular effects that account for its anti-cancer properties in the clinical setting.

The cancer drug regorafenib exhibits a broad range of anti-tumor activities that could be enhanced by combination with other treatments. A team led by José L. Mauriz from the University of León, Spain, review the ways in which regorafenib, blocking several enzymes involved in cancer biology, has been shown to shrink tumors in different models of liver, colon and gastrointestinal cancer. Its mechanisms of action include blockade of new blood vessel formation, induction of cell death and modulation of the immune microenvironment. Research studies show that co-administration of regorafenib with other drugs directed at various molecular targets or immune pathways produces synergistic effects against cancer cells. The preclinical data highlights the potential of combination drug regimens to improve outcomes among patients eligible for regorafenib treatment.

Surviving Cancer without a Broken Heart

Chemotherapy-associated myocardial toxicity is increasingly recognized with the expanding armamentarium of novel chemotherapeutic agents. The onset of cardiotoxicity during cancer therapy represents a major concern and often involves clinical uncertainties and complex therapeutic decisions, reflecting a compromise between potential benefits and harm. Furthermore, the improved cancer survival has led to cardiovascular complications becoming clinically relevant, potentially contributing to premature morbidity and mortality among cancer survivors. Specific higher-risk populations of cancer patients can benefit from prevention and screening measures during the course of cancer therapies. The pathobiology of chemotherapy-induced myocardial dysfunction is complex, and the individual patient risk for heart failure entails a multifactorial interaction between the selected chemotherapeutic regimen, traditional cardiovascular risk factors, and individual susceptibility. Treatment with several specific chemotherapeutic agents, including anthracyclines, proteasome inhibitors, epidermal growth factor receptor inhibitors, vascular endothelial growth factor inhibitors, and immune checkpoint inhibitors imparts increased risk for cardiotoxicity that results from specific therapy-related mechanisms. We review the pathophysiology, risk factors, and imaging considerations as well as patient surveillance, prevention, and treatment approaches to mitigate cardiotoxicity prior, during, and after chemotherapy. The complexity of decision-making in these patients requires viable discussion and partnership between cardiologists and oncologists aiming together to eradicate cancer while preventing cardiotoxic sequelae.

The influence of marital status on the survival of patients with operable gastrointestinal stromal tumor: A SEER-based study

BACKGROUND

Marital status has been demonstrated as a predictive factor for prognosis in diverse malignancies, but its role in the survival of gastrointestinal stromal tumor (GIST) remains unclear.

MATERIAL AND METHODS

This study was aimed to investigate the impact of marital status on the overall survival (OS) and cancer-specific survival (CSS) of operable GIST cases, by using data from Surveillance, Epidemiology, and End Results (SEER) database. In total, 6582 GIST patients between 1973 and 2013 were identified from SEER database.

RESULTS

Univariate and multivariate analyses demonstrated the marital status as an independent predictive factor for survival. Married group had better 5-year OS and CSS than unmarried group (OS: 79.2% vs 71.3%, P < .001; CSS: 88.9% vs 84.8%, P < .001). And compared to married, divorced/separated, and single group, widowed group had the lowest 5-year OS and CSS (61.3% and 82.2%). Further subgroup analyses validated the relationship between marital status and survival among all SEER stages and different age groups. And additional sensitivity analyses according to other clinicopathological features confirmed that married cases had higher survival rate than unmarried cases.

CONCLUSION

In conclusion, marriage could be a protective prognostic factor for survival, and widowed patients had a higher risk of death.

Clinicopathologic features and outcomes of gastrointestinal stromal tumors arising from the esophagus and gastroesophageal junction

Background

Our aim was to characterize the clinicopathological features and outcomes of gastrointestinal stromal tumors (GISTs) arising from the esophagus and gastroesophageal junction (GEJ) and describe the survival of patients treated at our institution as well as from a national hospital-based registry.

Methods

Twenty-eight cases were identified using the Mayo Clinic Cancer Registry from 1997 to 2016, and 1,010 cases from the National Cancer Database (NCDB) between 2004 and 2014, with analysis of TNM staging, histopathological features, mitotic index, immunohistochemical studies, and KIT mutational analysis.

Results

At Mayo Clinic, the tumors ranged in size from 0.3-13 cm (mean 5.40 cm). IHC results were: CD117 (KIT) in 100% (23/23 cases) and DOG1 in 100% (6/6), followed by CD34 (85.7%, 12/14), smooth muscle actin (27.8%, 5/18), desmin (18.2%, 2/11), and S-100 protein (13.3%, 2/15). Mutational analysis (performed in 10 cases) showed KIT exon 11 mutations in 8 cases; KIT mutation was not identified in 2 cases (presumed wild-type). Two-thirds of patients underwent surgery, of which 70% had an esophagectomy. Fourteen patients received adjuvant imatinib mesylate. Five patients had liver metastases at the time of diagnosis; none had lymph node metastases. A total of 38.9% of cases had recurrent or metastatic disease. Complete clinical follow-up was available for 10 patients (median follow-up duration 31.5 months; range, 10-145 months): one (male) had a local recurrence at the anastomotic site and one (female) suffered a liver metastasis; the others were either disease-free or had stable disease at the time of last follow-up. There was a significant association seen among metastatic disease and mitotic count >5/50 high-powered field (HPF) (P=0.016), with median mitotic rate 90/50 HPF (range, 7-500) for metastatic tumors versus 6/50 HPF (range, 0-100) for non-metastatic tumors. For metastatic disease, median tumor size was 7.3 cm (range, 1-66 cm) compared to 4.8 cm (range, 0.02-71 cm) for non-metastatic disease, which was also statistically significant (P≤0.0001). Two hundred and fifty-eight NCDB cases were risk stratified using the Joensuu criteria. Among 89 low risk category tumors, only 2 (2.2%) were ultimately metastatic. A total of 10.9% (15/138) of high risk category tumors were metastatic. The median overall survival (OS) from the time of diagnosis for the Mayo Clinic cohort was 129.5 months (95% CI, 55.7-not reached), with 5-year OS 85.7%. Median OS for the NCDB cohort was 135.95 months (95% CI, 104.08-not reached) with 5-year OS 68.2%. Superior OS was seen in females (HR 0.67, 95% CI, 0.49-0.89, P=0.006).

Conclusions

Among esophageal and GEJ GISTs, metastatic disease was associated with increased mitotic count and increased tumor size. Men were found to have inferior OS. The Joensuu risk criteria were validated for risk stratification of esophageal and GEJ GISTs.

Advances and Challenges on Management of Gastrointestinal Stromal Tumors

Gastrointestinal stromal tumors (GISTs) originate from interstitial cells of Cajal and account for over 5,000 newly diagnosed cases in the United States. The discovery of activated KIT and PDGFRA mutations and introduction of imatinib revolutionized the treatment strategy and opened up the new era of target therapy for solid tumors. Although surgery remains the primary modality of treatment for curative purpose, almost half of the patients experienced disease recurrence. Tailoring (neo)-adjuvant treatment with imatinib is ongoing to meet the need for an effective therapy. Currently, two drugs (sunitinib and regorafenib) have obtained Food and Drug Administration approval for GISTs after imatinib failure. However, most of the patients eventually progress due to primary or secondary resistance. Deeper understanding of the molecular mechanisms will guide us to develop personalized strategies in the future. Discussion in this review includes current standard management and the most recent advances and multiple ongoing clinical trials with different approaches. This review will provide further steps to be taken to conquer refractory disease.

Clinicopathological Features and Prognosis of Gastrointestinal Stromal Tumor Located in the Jejunum and Ileum

BACKGROUND

Data about the clinicopathological features and prognosis of gastrointestinal stromal tumors (GISTs) located in jejunum and ileum are lacking. The present study aims to investigate the features and prognosis of jejunal and ileal GISTs based on the Surveillance, Epidemiology, and End Results (SEER) database.

PATIENTS AND METHODS

Cases of jejunal and ileal GISTs were extracted from SEER database. Clinicopathological characteristics and survival data of patients were recorded. The clinicopathological features and prognosis of patients were analyzed.

RESULTS

There were 399 male (56.8%) and 303 female (43.2%). The median age was 60 years (17-96). Four hundred and seventy-two tumors were located in the jejunum (67.2%) and 230 tumors in the ileum (32.8%). The median tumor size was 7.0 cm (0.5-90). The 5-, 10-, and 20-year disease specific survival (DSS) was 84.4, 71.2, and 54.2% respectively. Clinicopathological features were comparable between tumors located in the jejunum and ileum (all p > 0.05) except gender and tumor size (both p < 0.05). Jejunal GISTs, rather than ileal GISTs (p = 0.043), were commonly found in the males. The tumor size of jejunal GISTs was smaller than that of ileal GISTs (p = 0.010). The DSS of jejunal GISTs was comparable to that of ileal GISTs (p = 0.269).

CONCLUSIONS

Jejunal GISTs were more common than ileal GISTs. The prognosis was comparable between jejunal and ileal GISTs.

Management of hemorrhage in gastrointestinal stromal tumors: a review

Gastrointestinal stromal tumors (GISTs) are relatively common mesenchymal tumors. They originate from the wall of hollow viscera and may be found in any part of the digestive tract. The prognosis of patients with stromal tumors depends on various risk factors, including size, location, presence of mitotic figures, and tumor rupture. Emergency surgery is often required for stromal tumors with hemorrhage. The current literature suggests that stromal tumor hemorrhage indicates poor prognosis. Although the optimal treatment options for hemorrhagic GISTs are based on surgical experience, there remains controversy with regard to optimum postoperative management as well as the classification of malignant potential. This article reviews the biological characteristics, diagnostic features, prognostic factors, treatment, and postoperative management of GISTs with hemorrhage.

SSAT State-of-the-Art Conference: Current Surgical Management of Gastric Tumors

INTRODUCTION

The current era of gastric surgery is marked by low morbidity and mortality rates, innovative strategies to approach resections with a minimally invasive fashion or hyperthermic intraperitoneal chemotherapy (HIPEC), as well as improved understanding of the biology of sporadic and hereditary stromal, neuroendocrine, and epithelial malignancies.

METHODS

In 2017, the Society for Surgery of the Alimentary Tract convened a State-of-the-Art Conference on Current Surgical Management of Gastric Tumors with both international experts and emerging leaders in the field of gastric surgery.

RESULTS

Martin D. McCarter, MD of the University of Colorado discussed the current management of gastric gastrointestinal stromal tumors (GIST). Kaitlyn J. Kelly, MD of the University of California, San Diego discussed the management of gastric carcinoid tumors. Jeffrey A. Norton of Stanford University discussed recent advances in the management of gastric adenocarcinoma including a focus on hereditary diffuse gastric cancer (HDGC). Joseph Kim, MD of Stony Brook University discussed a systematic approach to minimally invasive gastrectomy for cancer. Joyce Wong, MD of Pennsylvania State University discussed the role for cytoreductive surgery (CRS) and HIPEC for gastric adenocarcinoma.

CONCLUSIONS

This review provides gastrointestinal surgeons with a concise update on the current surgical management of gastric tumors.

Percutaneous microwave ablation liver partition and portal vein embolization for planned hepatectomy due to large gastrointestinal stromal tumor metastases: A case report

RATIONALE

The liver is the most frequent site of relapse of gastrointestinal stromal tumors (GISTs). Surgery is always considered to be unsuitable because of the multiple metastases.

PATIENT CONCERNS

In this report, we describe a case of large, multiple GIST liver metastases that were treated with percutaneous microwave ablation liver partition and portal vein embolization for planned hepatectomy (PALPP). A 44-year-old woman had undergone pancreaticoduodenectomy 4 years previously because of the diagnosis of a large duodenal GIST. Large, multiple liver metastases were observed 2 years later.

DIAGNOSES

GIST liver metastasis was diagnosed using percutaneous ultrasound-guided biopsy.

INTERVENTIONS

After 6 months of treatment with imatinib, the liver metastasis was stable. PALPP was performed because of insufficient future liver remnant (FLR) and right trisegmentectomy was successfully completed 10 days later.

OUTCOMES

The patient has had no signs of local or systemic disease during 17 months of postsurgical follow-up.

LESSONS

PALPP provides a new methodology for treatment of GIST liver metastasis in patients with insufficient FLR, and may have benefit in prolonging a durable remission.