Current Standard and Future Perspectives in the Treatment of Gastrointestinal Stromal Tumors

The relationship between Ki-67 expression and imaging signs and pathological features in GISTs

Introduction

To investigate the correlations between the Ki-67 index and plain-scan computerized tomography (CT) signs and pathological features of gastrointestinal stromal tumor (GIST) tissue.

Materials and methods

Data from 186 patients with GIST diagnosed by pathology and immunohistochemistry (IHC) in Peking University First Hospital from May 2016 to May 2022 were analyzed. The patients were divided into two groups: Ki-67 ≤5% and >5%. Correlation analysis, univariate and multivariate Logistic regression analysis were used to explore the correlations between CT signs, pathological features, and Ki-67 expression.

Results

Univariate indicators correlated with the Ki-67 index were mitotic count, pathological grade, tumor hemorrhage, tumor necrosis, tumor size, and tumor density. Multivariate Logistic regression indicated that the mitotic count [odds ratio (OR) 10.222, 95% confidence interval (CI) 4.312–31.039], pathological grade (OR 2.139, 95% CI 1.397–3.350), and tumor size (OR 1.096, 95% CI 1.020–1.190) were independently associated with the Ki-67 expression level. The concordance indexes (C-index) for the pathological features and CT signs models were 0.876 (95% CI 0.822–0.929) and 0.697 (95% CI 0.620–0.774), respectively, with positive predictive values of 93.62% and 58.11% and negative predictive values of 81.29% and 75.89%, respectively. After internal verification by the Bootstrap method, the fitting degree of the pathological features model was found to be better than that of the CT signs model.

Conclusion

Mitotic count, pathological risk grading, and tumor size are independent risk factors correlating with high Ki-67 index. These results indicate that the Ki-67 index reflects tumor malignancy and can predict recurrence and metastasis of GIST.

Wandering small intestinal stromal tumor: A case report

BACKGROUND

The occurrence of gastrointestinal stromal tumors (GISTs) in the small intestine is rare, and a case of wandering small intestinal stromal tumor has been rarely reported to date. Dissemination of this case can help inform future diagnosis and effective treatment.

CASE SUMMARY

A 68-year-old patient presented to us with tarry stools. Computed tomography showed a mobile tumor moving widely within the abdominal cavity. As the laboratory data showed a low range of red blood cells and an immediate surgery was not indicated, we performed digital subtraction angiography and embolization to achieve hemostasis. Surgical resection was performed after the patient’s condition improved. The tumor was successfully removed laparoscopically. Histological examination revealed submucosal GIST with infarction, which was of intermediate-risk, with mitotic count < 1 per 10 high-power field. Immunohistochemical studies revealed the following: CD117+, Dog1+, CD34+, SMA+, S100-, CK-, Des-, SOX-11-, STAT6-, Ki67 Hotspots 10%+. The patient was ultimately diagnosed with wandering small intestinal stromal tumor.

CONCLUSION

When a highly vascularized tumor is clinically encountered in the small intestine, the possibility of stromal tumors should be considered. However, when the tumor cannot be visualized at its original location, the possibility of tumor migration is considered.

Inflammation-related indicators to distinguish between gastric stromal tumors and leiomyomas: A retrospective study

BACKGROUND

Gastric leiomyomas and gastric stromal tumors are the most common types of gastric tumors encountered. In recent years, the incidence of the two types of tumors has been increasing, but the differential diagnosis is still a challenge in clinical work. However, as there are many reports on stromal tumors and inflammation-related indicators are gradually being paid attention to as important factors in predicting tumor prognosis, the two main purposes of this study were to explore the inflammation-related differences between the two types of tumors and to develop a nomogram as a predictive model.

AIM

To explore the differences in platelet-lymphocyte ratio (PLR), neutrophil-lymphocyte ratio (NLR), lymphocyte mononuclear cell ratio (LMR), and SII between the two types of tumors, and simultaneously create the nomogram model.

METHODS

This study enrolled 88 patients in the gastric stromal tumor group and 56 patients in the gastric leiomyoma group, and the relevant data of the two groups were entered into the system for an integrated analysis. The primary objective of this study was to identify the differences in the inflammation index between the two types of tumors.

RESULTS

There were statistically significant differences between the two groups in sex, age, and tumor location. In comparison, gastric leiomyomas seem to be more common in women, young patients, and gastric cardia, which is in line with our previous research; the groups showed the following statistical differences: PLR (158.2% vs 134.3%, P = 0.028), NLR (2.35 vs 1.68, P = 0.000), LMR (5.75 vs 10.8, P = 0.004), and SII (546.2 vs 384.3, P = 0.003). The results of the multivariate logistic regression analysis showed that sex, age, tumor location, and LMR were independent risk factors for the identification of the two types of tumors. After considering the risk factors selected by the above analysis into the predictive model, a predictive model for distinguishing gastrointestinal stromal tumors from gastric leiomyomas was established as the nomogram.

CONCLUSION

Gastric leiomyomas and gastric stromal tumors are not only different in factors such as age of the patient, but also in inflammatory indicators such as LMR and PLR. We have established a predictive model related to the laboratory indicators and are looking forward to further research conducted in this clinical area.

Gastrointestinal Stromal Tumors of the Small Intestine: Progress in Diagnosis and Treatment Research

In recent years, the diagnosis and treatment of gastrointestinal stromal tumors (GISTs) of the small intestine have been a hot topic due to their rarity and non-specific clinical manifestations. With the development of gene and imaging technology, surgery, and molecular targeted drugs, the diagnosis and treatment of GISTs have achieved great success. For a long time, radical resection was prioritized to treat GISTs of the small intestine. At present, preoperative tumor staging is a novel treatment for unresectable malignant tumors. In addition, karyokinesis exponent is the sole independent predictor of progression-free survival of GISTs. The DNA, miRNA, and protein of exosomes have also been found to be biomarkers with prognostic implications. The research on the treatment of GISTs has become a focus in the era of precision medicine, ushering in the use of standardized, normalized, and individualized treatment.

A comprehensive evaluation of clinical efficacy and safety of celecoxib in combination with chemotherapy in metastatic or postoperative recurrent gastric cancer patients: A preliminary, three-center, clinical trial study

AIM

To evaluate the efficacy and safety of celecoxib combined with chemotherapy in the treatment of metastatic or postoperative recurrent gastric cancer.

METHODS

This preliminary, three-center, clinical trial study was conducted between September 2010 and December 2016. In the experimental group (n = 100), patients were treated with celecoxib combined with chemotherapy, and chemotherapy alone was used in the control group. Progression-free survival (PFS) was considered as the primary efficacy parameter. Overall survival (OS), remission rate (RR), quality of life (QOL) and drug safety were considered as the secondary efficacy parameters.

RESULTS

The PFS of the experimental group was 6 months, which was not significantly longer than that of the control group (5 months, P = .73). The average OS was not significantly different between the experimental group (12 months) and the control group (10 months, P = .59). The average OS of the COX-2 positive patients in the experimental group was 14 months and it was significantly longer than the 10-month OS in the control group (P = .01). The PFS of the COX-2 positive patients in the experimental group was 7.5 months, significantly longer than the 5-month PFS of patients in the control group (P < .001). No statistical significance was identified in the incidence of nausea, neutropenia, anorexia, peripheral neurotoxicity, diarrhea, vomiting, asthenia and thrombocytopenia. The EORTC QLQ-C30 questionnaire revealed that the overall QOL of the experimental group was significantly higher than that of the control group (P < .05). No statistical significance was found in the scores of functioning scale between the 2 groups. However, the scores of the symptom scale, especially for pain and fatigue in the experimental group was remarkably higher than that in the control group (P < .05). The overall score of EORTC QLQ-STO22 for the experimental group was considerably higher compared to that for the control group (P < .05). No statistical significance was identified in term of the domains of restrictions on feeding, dysphagia, anxiety, reflux, sense of taste, dry mouth, hair loss and body shape between the 2 groups (P > .05 for all mentioned outcomes).

CONCLUSION

Celecoxib combined with chemotherapy offers more clinical benefits for COX-2 positive advanced gastric cancer patients.

Transient Receptor Potential Ankyrin 1 and Substance P Mediate the Development of Gastric Mucosal Lesions in a Water Immersion Restraint Stress Rat Model

BACKGROUND

Activation of substance P (SP) contributes to the development and maintenance of gastric lesions, but the mechanisms underlying the release of SP and SP-mediated damage to the gastric mucosa remain unknown. Transient receptor potential ankyrin 1 (TRPA1) is expressed in SP-positive neurons in the dorsal root ganglion (DRG) and stomach of rats. We hypothesized that water immersion restraint stress (WIRS) may activate and sensitize TRPA1 in DRG neurons, subsequently inducing the release of SP from DRG and stomach cells, causing the development of acute gastric mucosal lesions (AGML).

METHODS

Changes in TRPA1 and SP expression in T8-11 DRG sensory neurons and the stomach in an AGML rat model were determined by reverse transcription polymerase chain reaction, western blotting and immunohistochemistry. The SP levels of serum and gastric mucosa were measured by using an enzyme-linked immunosorbent assay (ELISA). Gastric lesions were evaluated by histopathological changes. The TRPA1 antagonist HC-030031 and TRPA1 agonists allyl isothiocyanate were used to verify effect of TRPA1 and SP on AGML.

RESULTS

SP and TRPA1 in the DRG and stomach were upregulated, and the serum and gastric mucosa levels of SP were increased after WIRS, which are closely associated with AGML. The release of SP was suppressed and AGML were alleviated following a selective TRPA1 antagonist HC-030031. TRPA1 agonists AITC increased release of SP and led to moderate gastric lesions. We confirmed that WIRS induced the release of SP in the DRG, stomach, serum and gastric mucosa, and in a TRPA1-dependent manner.

CONCLUSIONS

Upregulated SP and TRPA1 in the DRG and stomach and increased serum and gastric mucosa SP levels may contribute to stress-induced AGML. TRPA1 is a potential drug target to reduce stress-induced AGML development in patients with acute critical illnesses. This study may contribute to the discovery of drugs for AGML treatment.

Long-Term Imatinib Treatment for Patients with Unresectable or Recurrent Gastrointestinal Stromal Tumors

BACKGROUND

Only limited data are available concerning the long-term outcomes of imatinib treatment among Japanese or Asian patients with advanced or recurrent gastrointestinal stromal tumors (GIST). Our multicenter study, which was conducted in northern Kanto, Japan, aimed to assess the efficacy of imatinib mesylate against advanced or recurrent GIST.

SUMMARY

The clinicopathological data of 234 GIST patients who were treated at one of the 11 participating hospitals from 2001 to 2011 were retrospectively reviewed (GREAT study). Imatinib was administered as a first-line therapy in cases involving unresectable disease or postoperative recurrence (41 cases). The patients treated with imatinib (n = 41) exhibited 1-, 3-, and 5-year overall survival (OS) rates of 92.3, 74.9, and 53.8% respectively. In univariate and multivariate analyses, imatinib continuation with dose reduction and achieving a complete or partial response were found to be associated with increased OS. The results of 2 large-scale, long-term trials demonstrate that the risk of tumor progression decreases with increased treatment duration. Furthermore, the interruption of imatinib treatment in responsive and controlled patients results in a high risk of disease progression. Key Messages: Long-term imatinib treatment is recommended for patients with nonprogressive disease. If patients experience significant toxicities, temporary dose reduction and treatment continuation might be useful.

Unusual case of a small bowel leiomyoma presenting as an adnexal mass

This case report will discuss an interesting case of a premenopausal woman who presented with an adnexal mass consistent with a leiomyoma on imaging. However, intraoperatively, the mass was thought to be a gastrointestinal stromal tumour but histological diagnosis subsequently confirmed a leiomyoma arising from the small bowel.

Comparison of three prognostic models for predicting cancer-specific survival among patients with gastrointestinal stromal tumors

AIM

To evaluate the predictive value for cancer-specific survival of the models of the American Joint Committee on Cancer (AJCC) stage, NIH and Armed Forces Institute of Pathology (AFIP) among patients with gastrointestinal stromal tumors (GISTs).

METHODS

Surveillance, Epidemiology and End Results database (2010-2014) was accessed. Overall survival analysis and adjusted cancer-specific Cox regression hazard was calculated.

RESULTS

For gastric GISTs, concordance-index according to AJCC was 0.834; according to NIH was 0.833; according to AFIP was 0.836. Concordance-index for nongastric GISTs according to AJCC was 0.800, according to NIH was 0.801 and according to AFIP was 0.799.

CONCLUSION

The performance of the three models is comparable with regards to cancer-specific survival prediction.