Surgically Managed Gastrointestinal Stromal Tumors: A Comparative and Prognostic Analysis^-www.drkeyurbhatt.in*

Presented in part at the annual meeting of the Society of Surgical Oncology, April 2007, Washington, DC.

Annals of Surgical Oncology 15(1):52–59

Background: Tyrosine kinase inhibitors have been shown to have marked clinical efficacy in patients with unresectable or metastatic gastrointestinal stromal tumors (GIST). We performed a comparative and prognostic analysis of our experience with surgically managed GIST to determine factors associated with adverse oncologic outcomes.
Methods: Oncologic outcomes of 191 patients with primary GIST surgically managed between 1978 and 2004 at a single institution were reviewed. Prognostic factors were analyzed by Cox analysis (hazard ratio [HR] and 95% confidence interval [95% CI]) and included age, sex, disease presentation (asymptomatic vs. symptomatic), tumor site (stomach, small bowel, colorectal), disease extent (localized vs. metastatic) and risk levels (high, intermediate, low, very-low) assigned on the basis of size and number of mitoses according to current National Institutes of Health recommendations. Primary end points were disease-free survival (DFS)  and disease-specific survival (DSS).
Results: A total of 186 patients (97%) had c-kit–positive GIST. There were 54% high, 22% intermediate, 18% low, and 8% very low risk GIST originating from the stomach (54%), small bowel (36%), and colon and rectum (10%). Median patient age was 65 (range, 13–91) years, and 108 subjects (57%) were male. Seventy-two percent of patients had symptomatic local disease, and 21% patients had synchronous metastases. Most (95%) underwent R0 resections of their primary tumor. Among 146 patients (76%) with localized disease at presentation undergoing R0 resection, the 5-year DFS was 65%. High-risk GIST (HR 12, 95% CI, 5–32, P < .0001), symptomatic presentation (HR 2.5, 95% CI, 1.1–6, P = .04), and GIST in the small bowel (HR 2.8, 95% CI, 1–5, P = .003) were independently associated with decreased DFS. After a median follow-up of 63 months among survivors, the 5-year DSS was 68%. High-risk disease (HR 14.3, 95% CI, 5–41, P < .0001), symptomatic presentation (HR 3.1, 95% CI, 1.2–7.9, P = .02), and GIST in the small bowel (2.6,3 95% CI, 1–5, P = .006) were independently associated with decreased DSS. Conclusions: High-risk GIST are associated with increased disease recurrence and decreased survival despite complete surgical resection. These patients should receive adjuvant therapy in the form of tyrosine kinase inhibitors

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Rectal GIST^-www.drkeyurbhatt.in*

World J Gastroenterol 2008 February 28; 14(8): 1302-1304

Rectal GISTs make up 0.1% of all tumours originating in the rectum


Since the incidence of rectal GIST is much lower than that of GIST in the stomach or small intestine,
the clinicopathological profiles of rectal GIST have not yet been accurately characterised, and there is therefore the tendency to validate the same prognostic factors for the latter as for such tumours at other sites, particularly gastric GIST.
A rate of ≤ 5 mitoses per 50 HPF is commonly used as a limit for a tumour with expected benign behaviour, and according to a large study, this can discriminate between benign and malignant tumours, especially gastric GIST.Tumours of 2 cm in diameter Transrectal ultrasound confirming a predominantly exophytic, heterogenous, hypoechoic submucosal mass (measuring 35 mm × 26 mm) on the
lateral left rectal wall. TC confirming the sonographic findings of the presence of a mass with a marked, irregular, eccentric thickening of the lateral left wall of the lower third of the rectum, but providing no evidence for either pelvic lymphadenopathy or distant metastasis. are generally expected to behave in a benign fashion.
Tumours of < 5 cm in diameter are associated with a better survival rate than those of 5 cm-10 cm in diameter, which in turn have a better prognosis than those of > 10 cm in diameter.

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Imatinib where does it stays^-www.drkeyurbhatt.in*

The role of neoadjuvant therapy of Imatinib in GIST is under evaluation by the Radiation Therapy Oncology Group (RTOG) that will correlate molecular markers with clinical response as assessed by imaging and pathological evaluation of the resected specimen. The neoadjuvant therapy will be useful in patients with large-size tumor or location of the tumor at the site where resection is associated with the risk
of severe organ dysfunction where a negative margin is difficult to achieve. The aim of such a treatment is to
downsize the tumor for a less morbid surgical procedure. In addition, the use of Imatinib neoadjuvant therapy with or without an adjuvant treatment might help in controlling micrometastatic disease. Again, the duration and dose of Imatinib in the neoadjuvant setting are yet undecided. Less than 5% patients have complete clinical response to Imatinib.


Now the first line of treatment of the recurrent or 

metastatic GIST is Imatinib. The use of Imatinib mesylate 

in recurrent or metastatic GIST in prospective trial has 

shown response in 50% patients. 

Surgical resection of the localized GIST is the mainstay therapy, as a resection of tumor renders only a chance of cure

Gastrointestinal cancers symposium, San Francisco, 2004.



Imatinib adjuvant therapy
The use of Imatinib as an adjuvant therapy after the complete resection of primary GIST is under evaluation. The American College of Surgeons Oncology Group (ACOSOG) is conducting a phase-II prospective trial on patients of GIST.

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Gastrointestinal stromal tumor (GIST)^-www.drkeyurbhatt.in*

Chirurgia (Bucur). 2010 Jul-Aug;105(4):577-85.      Surgical Oncology (2008) 17, 129–138

Although their overall incidence is low, GISTs are distinctive subgroup of gastrointestinal mesenchymal tumors which express CD117 or platelet derived growth factor receptor alpha (PDGFRA). Considered as rare digestive cancers, tumors like schwannomas, neurofibromas, gastrointestinal leiomiomas are now reclassified as GIST based on immunohistochemistry studies. 

GIST are more frequent in stomach (40-70%), small bowel (20-40%), colon (5-15%), meanwhile locations such as mesentery, omentum, retro peritoneum in less of 5%. 10 GIST patients were surgically managed during 2004-2009. 5 gastric and 5 small bowel GIST. Most with symptomatic disease: palpable tumor, abdominal pain, anemia, fatigue, superior digestive hemorrhage or occlusion. Imagistic diagnosis consisted of: barium swallow, abdominal sonography, CT and PET-CT. 

Confirmation was made by hystopathological exam and immunohistochemistry. All patients had more or less wide surgical resections. For some patients there was also a specific adjuvant treatment. All patients survived after surgery. 

The principle of surgery for GIST is RO resection of the tumor. Tumor rupture or R1 resection of the primary tumor has a negative impact on disease free survival. Some patients (great volume tumors, R1 or R2 resection) had adjuvant treatment. Imatinib mesylate and derivates showed a significant improvement of recurrence free survival with one condition: permanent treatment. Surgery remains the mainstay of treatment in patients with localized, resectable GIST. Recurrence rate of 17-21% and 5 years survival rate of 48-70%, even in resectable GIST, impose an adjuvant treatment

A long-term follow-up is essential for all patients with GIST independent of a benign or malignant designation, since these tumors have an uncertain biological behavior. Although active post-operative surveillance program is important there is no consensus on a standard protocol for the follow-up of these patients. As most of the recurrences occur within the first 3–5 years, intense surveillance is required during this period

FOLLOW UP:

According to the National Comprehensive Cancer Network guidelines, contrast CT of

the abdomen and pelvis is recommended every 3–6 months for 3–5 years and then yearly [105]. The European Society of Medical Oncology guidelines stratify the surveillance based on the tumor size and mitoses [106]. Tumor size 45 cm and mitoses 45/HPF require contrast CT for every 3–4 months for 3 years followed by every 6 months for the next 2 years, and later yearly. Smaller size tumors (o5 cm) and lowmitotic count (o5/HPF) requires contrast CTevery 6 months for 5 years [106]. According to Novitsky et al. [6] most of the recurrence occurs during the first 2 years after surgical resection. They follow-up the patient with physical examination

every 3–4 months for 2 years, then every 6 months for the next 2 years, then yearly. Chest X-ray and abdominal CT scan and blood test were obtained yearly. Flexible upper endoscopy is performed at 6 months and 1-year postoperatively

and then annually for 2 years. PET scanning of abdomen, MR imaging, or chest CT scan is done if abnormalities are found in any of the surveillance studies.

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CASE : JEJUNAL MALIGNANCY WITH PERFORATION^-www.drkeyurbhatt.in*

ULCERATED GROWTH IN JEJUNUM

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PERFORATION WITH MASS IN PROXYMAL JEJUNUM

40 yrs lady with pain in abdomen for 2 days with some distension..

Known case of DM FOR 4 YEARS/ MRM done 4 yrs back.(NO LOCO REGIONAL RECURRENCE)

CECT S/O gross peritonitis with ? ileal perforation..

Surprisingly on Exploration it was a small bowel mass (1.5 feet from DJ) which was perforated... REST WHOLE OF ABDOMEN NO MASS, NO METS, LIVER NORMAL, CXR NORMAL

did R/A With 10 cm margins on each side....BUT IF ITS adeno Ca than its stage IV WITH PERFORATED MALIGNANCY

waiting for bx report

Its really rare to find something like this

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