Outcome of surgical resection for localized gastrointestinal stromal tumors (original) (raw)
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Surgical Treatment of Gastrointestinal Stromal Tumors (GISTs)
InTech eBooks, 2012
However, when esophagogastric or duodenal subepithelial nodules with < 2 cm diameter are detected, the standard procedure consists in endoscopic ultrasound (EUS) assessment and active surveillance of the individual patient, because many of these small nodules, when they correspond to GISTs, are tumors of low biological risk (Fletcher, Berman et al. 2002; Miettinen and Lasota 2006) or whose clinical behavior remains to be clarified. Surgery is reserved for patients whose tumor increases in dimension or is symptomatic. The results of a recent retrospective analysis (Lok, Lai et al. 2009) indicate that only some (3 out of 23; 13.0%) of the small tumors without high-risk EUS characteristics (large dimension, irregular extraluminal limits, heterogeneous echo pattern, presence of cystic areas, and hyperechoic foci) progressed during the long-term follow-up with EUS. As an alternative, the decision can be shared in an individual base with the patient, either to opt for an initial histological evaluation (needle biopsy) or for the tumor excision, when the morbidity is not substantial. On the other hand, when facing intra-abdominal nodules without endoscopic evaluation, the laparoscopy/laparotomy resection is the standard approach. Also for rectal nodules (or in the recto-vaginal space), the best management must be the accomplishment of biopsy/resection, after EUS evaluation, regardless of the tumor dimension, because GISTs in this location display high biological risk, and the local implications of a surgical intervention in this region is more critical, mostly in tumors of great dimensions. The guidelines of the ESMO and the NCCN coincide in the recommendation that tumors with dimension > 2 cm must be resected (Casali and Blay 2010; Demetri, von Mehren et al. 2010), because being GISTs, they imply a higher risk of aggressive behavior. For patients with localized primary GIST, the surgical resection continues to be the only possibility of cure of their illness. In our experience we obtained complete macroscopic resection (R0 or R1) in 92.3% of GISTs and microscopic negative margins (R0) in 75% of cases. 5-year disease-specific survival (DSS) and recurrence-free survival (RFS) was 87.7% and 89.8%, respectively, after surgical resection of patient's primary GIST. The recurrence rate was significantly (p=0.045) lower in R0 cases. In the multivariate analysis, only the presence of macroscopic residual tumor (R2) was significantly associated (p=0.013) with shorter DSS (Gouveia, Pimenta et al. 2008). The DSS and RFS values in our patients fit with results published in other studies (
An audit of surgical management of gastrointestinal stromal tumours (GIST)
European Journal of Surgical Oncology (EJSO), 2006
Aim: To analyze GIST outcome after primary resection and to determine if a new grading system could adequately predict there prognosis. Methods: A retrospective review (1993)(1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001)(2002) identified 80 patients who underwent primary surgical resection for, c-KIT positive, GIST. Follow-up was complete for all patients (median follow-up 42, range 1-132, months). GIST were classified as low or high grade according to the following parameters: size, mitotic rate, mitotic index (MiB1), presence of necrosis, invasion of adjacent structure and presence of metastasis. Results: GIST originated from the stomach (46), small bowel (30), colon and rectum two and mesentery two. At surgery, 94% of cases presented with localized disease and 6% blood born metastasis with or without lymph node invasion. Resections were complete (R0) in 72 cases. R0 resection correlated with prognosis (p!0.01). Sixty GIST were classified as low grade (median follow-up 60 months) and 20 as high grade (median follow-up 27 months). Five-year actuarial survival of patients with low or high grade GIST were of 95 and 21%, respectively, (p!0.001). Conclusion: Prognosis of GIST after surgical treatment is influenced by completeness of primary resection and tumour malignant potential. Low grade GIST have an excellent prognosis after surgery alone, while high grade GIST have a high rate of recurrence after primary resection. Adjuvant treatment should be advocated for patient with either high grade GIST or after incomplete primary resection. The presented grading system can reliably predict GIST outcome after primary surgical treatment.
2009
GISTs are the most common mesenchimal tumors and represent approximately 1% of all of the gastrointestinal tract cancers. The treatment for localized GISTs is the surgical excision with macroscopically negative margins. However, recurrence is a relatively common event even after a complete resection. Almost 30% of recurrences are locally and distant metastases represent the 50% of total recurrences. Materials and methods: From July 2002 to March 2009 a total of nineteen patients (12 males, 7 females), median age 65 years (49-79),underwent curative resection (R0). Tumor site: stomach 12; small intestine 5; colon rectum 2. Surgical treatments: segmental resection of small intestine (5); gastric wedge resection (9), subtotal gastrectomy (2); gastric resection extended to distal splenopancreasectomy (1); right colectomy (1); anterior resection (1). Results: Gastric GISTs were high grade in 4 patients, intermediate in 1 patient and low-risk in 7 patients. Small intestine GISTs were high ...
Wide Surgical Margin Improves the Outcome for Patients with Gastrointestinal Stromal Tumors (GISTs)
World journal of surgery, 2018
Surgical resection is still the main treatment for gastrointestinal stromal tumor (GIST), and R0 excision, regardless of surgical margins, is considered sufficient. A cohort of 79 consecutive GIST cases treated at the Karolinska University Hospital, who were without metastasis at diagnosis and who had not received any pre-or postoperative treatment with tyrosine kinase inhibitors, was included. Surgical margins were evaluated at the time of surgery and classified as wide, marginal or intralesional. Time to local/peritoneal recurrence, distant metastasis, and survival were recorded. Cox regression analysis was used to investigate the association between surgical margin, and recurrence and survival. Local/peritoneal recurrence was diagnosed in 2/39 cases with wide margins, in 7/22 cases with marginal margins, and in 13/18 cases with intralesional surgery. Compared to wide margins this gives a hazard ratio of 6.8 (confidence interval 1.4-32.7) for marginal margins and 13.5 (3-61) for i...
Journal of the Egyptian National Cancer Institute, 2012
Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract (GIT) and are believed to originate from the interstitial cell of Cajal. Management of GIST has evolved very rapidly in the last decade. To report our surgical experience in the treatment of GIST patients, to evaluate the prognostic factors and to discuss some controversial issues about the role of target therapy. One hundred and twenty seven consecutive patients who underwent surgical resection for GISTs at Nasser Institute (98 patients) and NCI, Cairo University (29 patients) from January 2000 to December 2009 were reviewed retrospectively. The clinical and pathological features of patients were collected. Also data about treatment variables, patterns of failure and factors that predict survival were collected and analyzed. Of the 127 patients, 81 (64%) had primary disease without metastasis, 11 (9%) had metastatic lesions at presentation, and 35 (27%) presented with recurr...
5 years Experience in the Treatment of GIST Tumors in the Virgen Macarena University Hospital
SciDoc Publishers, 2019
Introduction: Gastrointestinal stromal tumors (GIST) are the most common and diagnosed mesenchymal tumors. Its most frequent location is the stomach, and although they are very heterogeneous, most of them present mutations for the KIT receptor or for the platelet-derived growth factor receptor PDGRA. Even so, the clinical manifestations will depend mostly on their location and size, without being GIST identifying characteristics. This great variability makes it difficult to elaborate diagnostic protocols, as well as guidelines and universal treatment algorithms. Thus, they are usually diagnosed accidentally during the study of other pathologies. The main difference with other gastrointestinal neoplasms is the impossibility of predicting GIST malignancy based on the histopathological study, which is also limited to a submucosal location of the lesion. In addition, we also find great variability at the macroscopic level, which complicates the preoperative assessment by imaging. It seems that the malignant potential resides in the inherent characteristics of the tumor and not so much in its progression, which explains the need in some patients for prolonged treatment even after the tumor has been removed. Even so, the gold standard treatment in GIST is surgical resection, although, thanks to the mutations that they present, target therapies with inhibitors of the tyrosine kinase receptors in advanced and metastatic GISTs can be used. Objective of the study: To know the results in safety and efficacy of the surgical treatment of GIST, as well as to establish the comparative between open and laparoscopic approach, and to analyze the coincidences with the literature. Materials and methods: We collected 40 cases of GIST diagnosed and operated by the General Surgery Service at the Virgen Macarena University Hospital (Seville) in the last four years (2012-2016), where age, sex, tumor location and surgical factors are analyzed. Results: The mean age of the patients was 58.76 years, with the median being 60 years, with 51.43% women (18) of 57.56 years on average, and 48.57% men (17).), of 60.2 years on average. There are the same number of cases located in the stomach as in the small intestine (15 patients, 42.86%), followed by colon, (5.71%), pancreas (5.71%) and greater omentum (2.86%)., among which there are 5 cases of recurrence. 80% of the cases (28) were operated on by open surgery, and of all the interventions, 91.43% were performed by specialist physicians and 8.57% by medical residents. A 8.57% of the cases had to be reoperated urgently by open approach, with postoperative complications appearing in 5.71%. Discussion: Comparing our results with the literature regarding the diagnosis and therapeutic management of GIST tumors collected in our series. Conclusion: The results collected in this study conform to the most significant publications, despite the small sample size. The morbidity of surgical treatment can be considered minimal, and the protocol, safe. The comparison between laparoscopy and open surgery does not influence the stay of patients but is more beneficial in terms of the appearance of complications. However, our study is limited by the absence of prognostic data.
Surgical Margin Status and Prognosis of Gastrointestinal Stromal Tumor
World Journal of Surgery, 2008
Background Surgery is the best treatment for primary GIST and may be curative, but resection extension/completeness impact on the prognosis remains controversial. The authors aim was to evaluate the clinicopathological (CP) parameters and surgical margins status influence on GIST patients’ outcome. Materials and methods The study evaluated 113 consecutive patients with sporadic GIST; the influence of CP parameters on recurrence-free survival (RFS) and disease-specific survival (DSS) was determined by univariate analysis (UA) and multivariate analysis (MA). Results Of 104 cases, macroscopically complete resection was achieved in 96: R0 surgical margin status in 78 and R1 in 18. Recurrence rates (12.5%) were significantly lower in R0 (9.0%) than in R1 (27.8%). Tumor >10 cm, mitotic count >5/50 high power field (HPF), and high-risk GIST predicted poor RFS and DSS (UA). Disease-specific survival was significantly shorter after macroscopic incomplete (R2) resection, for mixed cellular morphology, and in tumors with necrosis (UA). High-risk GIST (p = 0.016) and R2 resection (p = 0.013) predicted poor DSS of patients (MA). Conclusions High risk and positive macroscopic surgical margin status are parameters associated with poor disease-specific survival in GIST patients.
Annals of Surgical Oncology, 2007
Background The introduction of adjuvant imatinib in gastrointestinal stromal tumors (GISTs) raised debate over the accuracy of National Institutes of Health risk criteria and the significance of other prognostic factors in GIST. Methods Tumor aggressiveness and other clinicopathological factors influencing disease-free survival (DFS) were assessed in 335 patients with primary resectable CD117-immunopositive GISTs (median follow-up, 31 months after primary tumor resection) from a prospectively collected tumor registry. Results Overall median DFS was 37 months, and estimated 5-year DFS was 37.8 %. In univariate analysis, high or intermediate risk group (P < .000001), mitotic index >5/50 high-power field (P < .00001), primary tumor size >5 cm (P < .00001), nongastric primary location (P = .0001), male sex (P = .01), R1 resection/tumor rupture (P = .0003), and epithelioid cell or mixed cell pathological subtype (P = .05) negatively affected DFS. In multivariate analysis, statistically significant factors negatively influencing DFS for model 1 were mitotic index >5/50 high-power field (P = .004), primary tumor size >5 cm (P = .001), male sex (P = .003), R1 resection/tumor rupture (P = .04), and nongastric primary tumor location (P = .02), and for model 2 were high/intermediate risk primary tumor (P < .0001 and P = .008, respectively), male sex (P = .007), resection R1/tumor rupture (P = .01), and nongastric primary tumor location (P = .02). Five-year DFS for high, intermediate, and low/very low risk group was 20%, 54%, and 96%, respectively. Conclusions The risk criteria for assessing the natural course of primary GISTs were validated, but additional independent prognostic factors—primary tumor location and sex—were also identified.