High mitotic index associated with poor prognosis in gastrointestinal autonomic nerve tumour

Establishment and Verification of a Nomogram for Predicting Survival in Patients with Small Intestinal Gastrointestinal Stromal Tumors

BACKGROUND

This study aimed to develop and validate nomograms for predicting overall survival (OS) and cancer-specific survival (CSS) in small intestinal gastrointestinal stromal tumors (SI GISTs).

METHODS

Patients diagnosed with SI GISTs were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database and further randomly divided into training and validating cohorts. Univariate and multivariate Cox analyses were conducted in the training set to determine independent prognostic factors to build nomograms for predicting 3- and 5-year OS and CSS. The performance of the nomograms was assessed by using the concordance index (C-index), calibration plot, and the area under the receiver operating characteristic curve (AUC).

RESULTS

Data of a total of 776 patients with SI GISTs were retrospectively collected from the SEER database. The OS nomogram was constructed based on age, surgery, imatinib treatment, and American Joint Committee for Cancer (AJCC) stage, while the CSS nomogram incorporated age, surgery, tumor grade, and AJCC stage. In the training set, the C-index for the OS nomogram was 0.773 (95% confidence interval [95% CI]: 0.722-0.824) and for the CSS nomogram 0.806 (95% CI: 0.757-0.855). In the internal validation cohort, the C-index for the OS nomogram was 0.741, while for the CSS nomogram, it was 0.819. Well-corresponded calibration plots both in OS and CSS nomogram models were noticed. The comparisons of AUC values showed that the established nomograms exhibited superior discrimination power than the 7th Tumor-Node-Metastasis staging system.

CONCLUSION

Our nomogram can effectively predict 3- and 5-year OS and CSS in patients with SI GISTs, and its use can help improve the accuracy of personalized survival prediction and facilitate to provide constructive therapeutic suggestions.

Predictive Effectiveness of the Glasgow Prognostic Score for Gastrointestinal Stromal Tumors

The aim of this study was to evaluate the significance of the Glasgow prognostic score (GPS) in patients with resected gastrointestinal stromal tumors (GISTs). Forty-six GIST patients who underwent radical resection between January 2004 and December 2011 were enrolled in this retrospective study. The clinicopathological parameters examined included predictors of recurrence-free survival (RFS). Univariate and multivariate analysis of prognostic factors related to RFS were calculated using Cox proportional hazards model. The GPS classification system revealed 37 (80.4%), 6 (13.1%), and 3 (6.5%) patients with a GPS of 0, 1, and 2, respectively. Patients with GPS 1/2 had a significantly shorter RFS compared to those with GPS 0 (P = 0.01). The 3- and 5-year RFS rates for patients with GPS 0 were 94.0% and 90.9%, respectively, compared to 66.7% and 53.3%, respectively, for patients with GPS 1/2. Univariate analyses indicated that tumor size (P < 0.01), mitotic rate (P < 0.01), higher GPS (P < 0.01), and platelet count (P = 0.04) were prognostic factors for RFS; tumor size (P = 0.01) and GPS (P = 0.04) were independent prognostic factors in multivariate analysis. Preoperative high GPS were predictors of long-term prognosis in patients with resected GISTs.

Gastrointestinal Stromal Tumor (GIST) Causing Obscure Gastrointestinal Bleeding: An Uncommon Way of Diagnosing An Uncommon Disease

Gastrointestinal stromal tumors (GISTs) are neoplasms that arise from the wall of the gastrointestinal tract or, rarely, from other intra-abdominal tissues. They are the most common mesenchymal tumors of the gastrointestinal tract and they should be considered in the differential diagnosis of obscure gastrointestinal bleeding. Computed tomography angiogram (CTA) can be utilized as an alternative imaging study when endoscopic and colonoscopy results are non-diagnostic. We report a case of a 59-year-old woman who presented with recurrent episodes of obscure overt gastrointestinal bleeding secondary to a gastrointestinal stromal tumor (GIST).

Gastrointestinal autonomic nerve tumors: a clinical review

PURPOSE

Gastrointestinal autonomic nerve tumors (GANTs) are believed to be rare accounting for 1 % of all malignant gastrointestinal tumors. Many gastrointestinal surgeons and gastroenterologists are unaware of this entity. This review aims to highlight the salient clinical features and prognosis of GANTs.

METHODS

Using the common search engines and manual cross-referencing, a search of the English literature was conducted for "gastrointestinal autonomic nerve tumor."

RESULTS

All of the published literature on GANTs is either case reports or small case series. From 49 retrieved articles, a total of 107 GANT cases were collected with a mean age of 54 years and equal male to female preponderance. The most commonly affected site was small bowel followed by stomach. Esophageal and colorectal GANTs were less frequent. Clinical presentation was variable ranging from non-specific symptoms, abdominal pain, weight loss, iron-deficiency anemia, to obstruction and gastrointestinal bleeding. Acute presentation due to free rupture or perforation with subsequent peritonitis was extremely rare. Endoscopic and radiological investigations were valuable in tumor localization and determination of distant spread. Thirteen patients were lost to or had no follow-up, leaving 94 patients for long-term outcome analysis. All patients were treated by radical surgical resection of the involved organ as this offered the only hope of cure. Local recurrence, metastases, or both developed in 40 % of cases despite radical surgical resection. Resection for local recurrences and hepatic metastases was feasible in some selected cases. Response to adjuvant chemoradiation was poor and imatinib mesilate was effective in cases of metastatic or inoperable CD117-positive GANTs.

CONCLUSION

Radical surgical resection of GANTs is the mainstay of treatment. The aggressive behavior after radical resection coined with the poor response to adjuvant chemotherapy call for the urgent need to develop new adjuvant therapies.

Gastrointestinal autonomic nerve tumor of the stomach

Patient: Female, 32

Final Diagnosis: Gastrintestinal Autonomic Nerve Tumor (GANT)

Symptoms: anemia • anorexia • fatigue • fever • hearburn • nausea • weight loss

Medication: —

Clinical Procedure: —

Specialty: Gastroenterology and Hepatology

Gastrointestinal stromal tumours: consensus statement on diagnosis and treatment

In the multidisciplinary management of gastrointestinal stromal tumours (GISTs), there is a need to coordinate the efforts of pathology, radiology, surgery and oncology. Surgery is the mainstay for resectable nonmetastatic GISTs, but virtually all GISTs are associated with a risk of metastasis. Imatinib 400 mg/day with or without surgery is the recommended first-line treatment for recurrent or metastatic GIST; a higher dose may be considered in patients who progress, develop secondary resistance or present with specific genotypic characteristics. Adjuvant or neoadjuvant imatinib is not advised for resectable nonmetastatic GISTs. Neoadjuvant imatinib may be considered when surgery would result in significant morbidity or loss of organ function. Follow-up computed tomography imaging is recommended every three to six months for at least five years. Patients with metastatic disease should be continued on imatinib due to the high risk of recurrence on discontinuation of therapy. Treatment should be continued until there is progression or intolerable adverse effects. If dose escalation with imatinib fails, a clinical trial with novel agents alone or in combination may be considered. The present recommendations were developed at a surgical subcommittee meeting and a subsequent full Advisory Committee meeting held in Toronto, Ontario, in April 2005, under the sponsorship of Novartis Pharmaceuticals Canada Inc.

Prognostic significance of c-kit mutation in localized gastrointestinal stromal tumors

PURPOSE

Constitutive mutational activation of c-kit has been found to be associated with the pathogenesis of gastrointestinal stromal tumors (GISTs). The prognostic significance of c-kit mutations, however, is still controversial.

EXPERIMENTAL DESIGN

We examined 86 patients curatively resected for localized GIST. Genomic DNA was extracted from paraffin-embedded tumor tissues. Exons 9, 11, 13, and 17 of the c-kit gene were amplified by PCR and sequenced.

RESULTS

Mutations in exon 11 were detected in 61 tumors, and mutations in exon 9 were observed in three tumors, whereas no mutations were detected in exons 13 or 17. The overall c-kit mutation frequency was 74%. Amino acid alterations in the 61 tumors with exon 11 mutations were deletion in 33 tumors, substitution in 20, both deletion and substitution in 4, insertion in 1, and duplication in 3. Histologically, tumors with c-kit mutations showed higher mitotic counts and higher cellularity. The 5-year relapse-free survival (RFS) in patients having GISTs with c-kit mutations was 21%, compared with 60% in those without c-kit mutations. Significantly higher RFS rates were observed in patients with tumors having mitotic counts < 5 mitoses/50 high power field, spindle-cell histology, tumor size < 5 cm, or gastric GISTs. Multivariate analyses indicated association of poorer RFS with a higher mitotic count > or = 5 of 50 high power fields; odds ratio (OR) = 3.0], presence of c-kit mutations (OR = 5.6), and a larger tumor size (> or = 5 cm; OR = 4.2).

CONCLUSIONS

The presence of c-kit mutation, along with high mitotic count and larger tumor size, was an independent factor for poor prognosis in patients with localized GISTs.

Gastrointestinal autonomic nerve tumors: A surgical point of view

AIM: Gastrointestinal autonomic nerve tumors are uncommon stromal tumors of the intestinal tract. Their histological appearance is similar to that of other gastrointestinal stromal tumors. We report two cases and performed an analysis of the literature by comparing our findings with the available case reports in the medical literature.

METHODS: Two patients were admitted with abdominal tumor masses. One occurred in the stomach with large multiple liver metastases and the second originated in Meckel´s diverticulum. The latter site has never been reported previously. Both patients underwent surgery. In one patient gastrectomy, right liver resection and colon transversum resection were performed to achieve aggressive tumor debulking. In the other patient the tumor bearing diverticulum was removed.

RESULTS: Postoperative recovery of both patients was uneventful. Histological examination, immunohistochemical analysis and electron microscopy revealed the diagnosis of a gastrointestinal autonomic nerve tumor. The patient with the tumor in Meckel’s diverticulum died 6 mo after surgery because of pneumonia. The patient with liver metastases have been alive 13 years after initial tumor diagnosis and 7 years after surgery with no evidence of tumor progression. In light of our results, we performed a thorough comparison with available literature reports.

CONCLUSION: Radical surgical resection of gastrointestinal autonomic nerve tumors seems to be the only available curative approach to date, and long term survival is possible even in large metastasized tumors.

Frequent occurrence of low grade cases among metastatic gastrointestinal stromal tumours

AIM

Gastrointestinal stromal tumours (GISTs) are uncommon mesenchymal neoplasms. Some metastasise, whereas others remain asymptomatic for years, but it is difficult to distinguish between them histologically. This report analyses the characteristics of seven metastasising GISTs and compares clinicopathological parameters of the metastatic and non-metastatic groups.

METHODS/RESULTS

Histology revealed typical GIST features with spindle, epithelioid, or mixed appearance. All seven cases were positive for vimentin, five for neurone specific enolase, six for c-kit, four for S-100, three for PGP-9.5, three for CD-34 and synaptophysin, but all were negative for cytokeratin, neurofilament, chromogranin A, and desmin. Four showed a focal reaction for smooth muscle actin. Three of the tumours were GI, and two each were GII and GIII. The Ki-67 index varied from 4% to 44%, the three GI cases had 4%, 10%, and 16%. Tumours from the metastatic GIST group were significantly larger than those from the non-metastatic group.

CONCLUSIONS

Three cases exhibited bland, GI histological features with moderate or low proliferative activity. Among the c-kit positive metastasising stromal tumours, some were low grade, with moderate or low mitotic and Ki-67 indices, emphasising the necessity to develop a reliable grading system for GIST to predict clinical behaviour, the importance of careful analysis of "benign looking" tumours, and the key role of c-kit status in identifying patients who could benefit from treatment with STI-571. Larger tumours had a higher chance of metastasising, and only the size of the primary tumour played a role in predicting metastatic potential.

Gastrointestinal autonomic nerve tumor: immunohistochemical and molecular identity with gastrointestinal stromal tumor

Gastrointestinal autonomic nerve tumor (GANT) is a gastrointestinal neoplasm that ultrastructurally recapitulates the enteric neural plexus. This study identifies and defines the features of 10 cases of this rare mesenchymal tumor and compares its clinicopathologic and molecular genetic features with the data on gastrointestinal stromal tumor (GIST). The majority of patients in this series presented at an older age (mean 64 years). Tumors arose from the stomach (6), small intestine (2), and retroperitoneum (2). Mean tumor size was 14 cm; however, four neoplasms were <6 cm. Histologically, tumors were spindled or epithelioid; one epithelioid tumor demonstrated a previously undescribed rhabdoid histologic phenotype. All tumors were positive for CD117 (KIT), while eight of 10 were positive for CD34. In contrast, only two were positive for S-100, and all were negative for actin and desmin. Five GANTs demonstrated GIST-specific gain-of-function mutations in the juxtamembrane domain of the c-kit gene (50%). Three of 10 patients died of disease in 22-30 months, one patient died in the postoperative period, and one patient died of complications of CML. The clinicopathologic, histologic, immunohistologic, and molecular features of GANT are similar to GIST, indicating that GANT merely represents a phenotypic variant of GIST.