gastrointestinal stromal tumor(gist)
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Gastrointestinal Stromal Tumor(GIST)
Dr. Amit Goswami
IntroductionMazur and Clark(1983)Mesenchymal tumorFrom embryological mesoderm of
gastrointestinal tract<1% of all GIT tumorsHirota et.al(1998):Mutation in KITInterstitial cell of Cajal: Common precursor?
DemographyIncidence:15-20 per millionM>FAge:40-80yrs(median age 60yrs)Mostly sporadicFamilial( Neurofibromatosis, Carney triad)
Eisenberg BL,Judson I.Surgery and imitanib in the management of GIST:emerging approaches to adjuvant and neoadjuvant therapy.Ann Surg Oncol 2004;11:465-475
Gold JS,Matteo RP.Combined surgical and molecular therapy: The gastrointestinal stromal tumor model.Ann surg 2006;244:176
DeMatteo RP,Lewis JJ,Leung D et al.Two hundred Gastrointestinal stromal tumors: recurrence patterns and prognostic factors for survival.Ann surg 2000;231(1):51-8
Takazawa Y,sakurai S,Sakuma Y et al.Gastrointstinal stromal tumors of neurofibromatosis type I.Am J surg Pathol 2005;29(6):755-63
Location
Stomach :50% MCEsophagus:5%Small Intestine:25%Colon and rectum:10%Extra-intestinal:10%
Rubin BP.Gastrointestinal stromal tumors: an update.Histopathology 2006;48:83-96Clin Cancer Res 9(9):2003
Clinical PresentationNon specificDepends on siteGIST of GIT: GI bleeding MCOthers -Abd. Mass -Pain abdomen -Abd.distension -Intestinal obstruction Asymptomatic:30%
PathologyMost commonly involves muscularis propriaUlceration:50%Well circumscribedCut surface: Tan/Grey, fibrous to fleshySpindle cell type: MC
Malignant Potential• Features favoring benign lesions :
– Size less than 5 cm
– Low number of mitosis per HPF
– No mucosal invasion
– Low cellularity
– Low markers of cell proliferationTumor site: Stomach vs bowelSite of metastasis:
Liver(50%),peritoneum(20-40%)
M. Miettinen, et al. Am J Surg Pathol. 2005
DiagnosisClinical, radiological and pathological
characteristics
CECT- Imaging modality of choice
Endoscopic ultrasound: Small tumor
MRI: Rectal GISTs
PET scan: Assessment of therapy
Blay JY,Bonvalot S,Casali P et al.Consensus meeting for the management of gastrointestinal stromal tumors.Ann Oncology 2005;16:566-578
CECTHeterogenous appearance with central
necrosis and areas of cystic degenerationExtension to other structuresDistant spreadLow attenuating liver metastasis
King DM.The radiology of gastrointestinal stromal tumors(GIST).Cancer Imaging 2005;5:150-156
MRI
Solid portion-low intensity on T1 weighted and high intensity on T2 weighted images
Enhancement with gadolinium
Endoscopic UltrasoundSmooth protrusion of bowel wall lined by
normal mucosaHypoechoic mass contiguous with fourth
hypoechoic layer(muscularis propria)Benign Vs Malignant
EndoscopyGastric and colorectal GISTSubmucosal mass
Pre-op BiopsyUsually not done -Tumor seedling -BleedingEndoscopic biopsy -Less bleeding -Confirm diagnosis
TreatmentSurgical resection is preferred
Locally advanced: Targeted therapy
Radiation/Chemotherapy: Ineffective
DemetriGD,BenjaminRS,BlankeCD,etal.NCCNTaskForcereport:managementofpatientswithgastrointestinalstromaltumor(GIST)dupdateoftheNCCNclinicalpractice
guidelines.JNatlComprCancNetw2007;5(Suppl2):S1–29
Surgical therapyComplete en-block removalSite specificAvoidance of tumor ruptureLymphadenectomy not advocatedFinal goal: complete tumor resection with a
negative margin, intact pseudocasulePositive resection margin: Re-excision
DeMatteo RP,Lewis JJ,Leung D et al.Two hundred Gastrointestinal stromal tumors: recurrence patterns and prognostic factors for survival.Ann surg 2000;231(1):51-8
Blay JY,Bonvalot S,Casali P et al.Consensus meeting for the management of gastrointestinal stromal tumors.Ann Oncology 2005;16:566-57
Site specific surgery
Esophagus: esophagestectomy/esophageal sparing wide local excision
Stomach Small-wedge resection Large-subtotal/total gastrectomy
BlumMG,BilimoriaKY,WayneJD,etal.S urgical considerations for the management andResection of esophageal gastrointestinal stromal tumors.AnnThoracSurg2007;84(5):
1717–23.WinfieldRD,HochwaldSN,VogelSB,etal. Presentation and management of gastrointes-
tinal stromaltumors of the duodenum.AmSurg2006;72(8):719–22[discussion:722–3
WayneJD,BellRHJr.Limited gastric resection.SurgClinNorthAm2005;85(5):1009–20,
vii.
Small intestine
Duodenum: Partial duodenal resection/Whipple’s
Small Intestine: Segmental resectionColorectum
Colon: Colectomy
Rectum: Anterior resection/Abdominoperineal
resectionExtra-intestinal: En block resection with
adequate marginBerman J,O’Leary TJ.Gastrointestinal stromal tumor workshop.Hum Pathol 2001;32:578-582
Blay JY,Bonvalot S,Casali P et al.Consensus meeting for the management of gastrointestinal stromal tumors.Ann Oncology 2005;16:566-57
Molecular targeted therapy(TKI)Joensuu and colleague(2001)Success: Lack of progressionStandard starting dose :400 mg/dayIdeal dose: not determinedNeoadjuvant role: -Severe organ dysfunction (eg: for rectal
or esophageal tumors) -Negative margin difficultResistance: Primary/Secondary
Imitanib trialsTRIALS DOSE PARTIAL
RESPONSESTABLE DIS
PROGRESS
COMMENTS
EORTC2001,2002
400,600,800 or 1000mg/d
51% 31% 8% TTR 1WKMTD 800mg/d
US MULTICENTER2002,2004
400mg/d600mg/d
67%66%
16%18%
17%8%
No difference
EORTC2003
400mg/d800mg/d
50%54%
32%32%
13%8%
32% severe tox50%severe toxImproved PFS for 800mg/d
INTERGROUP2003
400mg/d800mg/d
49%48%
22%22%
36%severe tox52%severe toxNo difference in PFS
TTR=Time to recurrence, MTD=Maximal tolerated dose, PFS=Progression free survivalGoldJS,DeMatteoRP.Combined surgical and moleculartherapy:the gastrointestinal
stromal tumor model. AnnSurg2006;244:176
Newer ApproachesSUNITINIB: multitargated tyrosine kinase
inhibitorHACE/RFA: liver metastasisOther TKI: -Nilotinib -Mastitinib -BMS-354,825
KobayashiK,GuptaS,TrentJC,etal.Hepatic artery chemoembolization for 110Gastrointestinal stromal tumors.Cancer2006;107(12):2833–41.
SummaryRareMostly sporadic and singleAnywhere in GI Tract- Stomach MCEvaluation – EUS, CT, PET CTVaried clinical presentation- GI bleed MCTreatment of choice – Surgery, potentially
curative
Summary Regular follow up Imatinib mesylate ( both neoadjuvant and
adjuvant) Definite role Improved outcome Problem - Resistance to imatinib
High recurrence
Currently Available Trials
Neoadjuvant study RTOG S-0132/ACRIN 6665 Patients with recurrent or measurable
peritoneal disease 8 wks Imatinib followed by resection
Currently Available TrialsAdjuvant study EORTC 64024 Patients with R0 resections eligible Patients stratified according to risk
factors Patients randomized to either
Imatinib 400 mg/day X 2 years Observation
Thank you