Surgical Management of Metastatic Gastrointestinal Stromal Tumors

Selective internal radiation with Y-90 resin microspheres (SIRT) for liver metastases of gastro-intestinal stromal tumors (GIST) resistant to tyrosine kinase inhibitor (TKI) therapy

BACKGROUND

Hepatic metastases of GIST might be the dominant site of progression and resistant to available tyrosine kinase inhibitors (TKIs). Selective internal radiation therapy (SIRT) offers treatment by intratumoral radiation up to 200 Gy. We analyzed the hepatic progression-free survival (H-PFS) in a consecutive patient cohort.

METHODS

Twenty-six patients (median age 57.6 years) with biopsy proven liver metastases of GIST were treated by SIRT. All had RECIST documented tumor progression, and 24/26 patients had up to four lines of pretreatment. Mutational status was 'quadruple wildtype' (q-wt, n = 5), KIT exon 11/9/13 in n = 15/4/1 cases and PDGFRα (n = 1). Median follow-up of this retrospective analysis of a prospectively kept database is 33.6 months.

RESULTS

Median H-PFS was 16 months (range, 4-54+ months, 95% CI 6.5-25.4 months) and OS after SIRT was 28 months (95% CI 17.2-28.7 months). Best H-PFS was observed in patients with 'q-wt' at 25 months (range, 6+-54 months, 95% CI 16.2-33.8 months). The worst outcome was for KIT exon 11 mutations plus secondary mutations with 7 months (range, 4-33 months, 95% CI, 4.2-9.8 months).

CONCLUSIONS

90Y-SIRT is a potent treatment for patients with liver metastases of GIST resistant to TKI therapy. In patients with 'q-wt' GIST, SIRT is an option for first-line use.

Clinicopathological characteristics and long-term prognosis of peritoneal and retroperitoneal gastrointestinal stromal tumors

BACKGROUND

Peritoneal and retroperitoneal gastrointestinal stromal tumors (PRGISTs) are exceedingly uncommon, and their clinicopathological characteristics and long-term prognosis remain unreported. Therefore, our objective is to analyze these aspects of patients with PRGISTs using the Surveillance, Epidemiology, and End Results (SEER) database.

METHODS

Patients diagnosed with PRGISTs and small intestine stromal tumors (SISTs) between 2000 and 2019 were included in the study. Differences between groups were compared using Chi-square tests. Kaplan-Meier analysis and Cox proportional hazards models were used to evaluate overall survival (OS) and cancer-specific survival (CSS).

RESULTS

A total of 3817 patients were enrolled, with 3513 diagnosed with SISTs and 304 with PRGISTs. Compared to SISTs, PRGISTs patients were older, with larger tumors, higher mitotic rates, and greater risk of lymph node (5.3%) and distant (30.6%) metastasis (P < 0.001). Multivariate analysis identified N stage and mitotic rate as risk factors for distant metastasis in PRGISTs. In comparison to SISTs, PRGISTs patients exhibited a significantly worse OS (hazard ratio [HR] 1.83, 95% confidence interval [CI] 1.57-2.15, P < 0.001) and CSS (HR 2.11, 95% CI 1.73-2.58, P < 0.001). Subgroup analyses by age, sex, surgical status, chemotherapy, and marital status consistently demonstrated poorer OS and CSS for PRGISTs patients compared to SISTs patients (P < 0.05). The 1-, 3-, 5-, and 10-year OS rates for PRGISTs patients were 77.9%, 61.6%, 51.6%, and 32.8%, respectively, with corresponding CSS rates of 84.5%, 71.7%, 63.3%, and 49.0%. Multivariate Cox regression analysis identified age, race, surgical status, and mitotic rate as risk factors influencing OS, while race, surgical status, and mitotic rate were identified as risk factors affecting CSS.

CONCLUSIONS

In comparison to SISTs, PRGISTs patients exhibit distinct clinicopathological features and have a worse prognosis. However, surgical intervention can improve the prognosis of PRGISTs patients.

Neoadjuvant Imatinib in Recurrent/Metastatic Gastrointestinal Stromal Tumors: A Systematic Review and Meta-analysis of Proportions

INTRODUCTION

Metastatic and recurrent gastrointestinal stromal tumors (GISTs) present challenging clinical management. Imatinib is the standard first-line therapy, improving survival and reducing tumor burden in the neoadjuvant use, facilitating surgical intervention. This systematic review and meta-analysis assessed the efficacy of neoadjuvant imatinib in metastatic/recurrent GISTs, highlighting its potential to enhance surgical outcomes and overall patient management.

METHODS

A systematic search was conducted in PubMed, Embase and Scopus (end-of-search: February 13, 2025) for records on neoadjuvant imatinib therapy in recurrent/metastatic GISTs. Pooled proportions and 95% confidence intervals were calculated with common-effect and random-effects models. Subgroup and meta-regression analysis were performed, addressing heterogeneity and examining any potential association between the factors that varied and the outcomes reported. The present meta-analysis was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

RESULTS

The search identified 957 articles, and 14 were analyzed. The meta-analysis of proportions indicated that 2-year and 5-year PFS were 76% (95% CI 58-88%) and 43% (95% CI 17-74%), respectively, while 2-year and 5-year OS were 84% (95% CI 78-89%) and 60% (95% CI 51-68%), respectively. The pooled R0 resection rate was 82% (95% CI 64-92%), associated positively with that of radiological partial response (PR) (β = 3.92, p < 0.001). Further meta-regression analysis yielded no significant association with preoperative imatinib duration.

CONCLUSION

The present meta-analysis of trials and studies on metastatic or recurrent GISTs highlights key insights into post-surgery patient outcomes following neoadjuvant treatment with imatinib. Pooled effect estimates revealed promising 2-year and 5-year PFS rates of 76% and 43%, respectively, and 2-year and 5-year OS rates of 84% and 60%, respectively. Furthermore, the high pooled R0 resection rate of 82% emphasizes a substantial surgical efficacy in this population, while it was significantly correlated with successful R0 resections in patients with favorable outcomes.

A new endoscopic treatment for gastric fundal subepithelial lesions using loop-assisted inversion and double suture technique

The loop-assisted inversion and double suture technique has been used as an endoscopic treatment for gastric fundal subepithelial lesions. This study aimed to analyse the efficacy and safety of the loop-assisted inversion and double suture technique for the treatment of gastric fundal subepithelial lesions. Consecutive patients with gastric fundal tumours who underwent the loop-assisted inversion and double suture technique at our centre between January 2023 and January 2024 were retrospectively assessed. The primary outcome was surgical success. Twelve patients with 14 gastric fundal subepithelial lesions underwent the loop-assisted inversion and double suture technique during the study period. Two patients had double lesions. Pathology confirmed that out of 14 lesions, 12 were gastrointestinal stromal tumors and 2 were leiomyomas.All the gastrointestinal stromal tumors were of low-risk G1. Operative success was achieved in 14 lesions with complete resection, with no intraoperative transfer to surgery; no adverse effects, including postoperative perforation and bleeding; and no postoperative antibiotic use. During the follow-up period, all 14 lesions showed no recurrence. The loop-assisted inversion and double suture technique is a safe, effective, and time-saving endoscopic treatment for gastric fundal subepithelial lesions. However, prospective large-scale multicentre studies are required.

Survival trends of gastrointestinal stromal tumor in real-world settings: a population-based retrospective study

Purpose

This study aims to evaluate whether survival outcomes for GIST patients have improved over the past decades and to identify the specific patient subgroups that have benefited from advances in treatment.

Patients and methods

A total of 4,127 GIST patients diagnosed between January 1980, and December 2019, were included in this study using data from the Surveillance, Epidemiology, and End Results (SEER)-9 Registries. Survival differences among GIST patients were analyzed across five time periods (1980-1999, 2000-2004, 2005-2009, 2010-2014, and 2015-2019) and within demographic, neoplastic, temporal, economic, and geographic categories using the log-rank test. Multivariable Cox regression models were employed to identify risk factors associated with GIST-specific survival. Associations between time periods and GIST-specific mortality (TSM) were examined using a multivariable Cox regression model.

Results

Survival outcomes for GIST patients significantly improved in the 2000-2009 period but showed no substantial improvement in the 2010-2019 period. After adjusting for age, gender, tumor location, ethnicity, tumor stage, median household income, and geographic area, the multivariable Cox regression models revealed that older age (≥65 years) (HR = 1.977, 95% CI = 1.470-2.657), tumors located outside the gastrointestinal tract (HR = 1.505, 95% CI = 1.267-1.786), regional lesions (HR = 2.225, 95% CI = 1.828-2.708), and distant lesions (HR = 5.177, 95% CI = 4.417-6.069) were independent risk factors for TSM (p < 0.05). After adjusting for time periods and age, gender, tumor location, tumor stage, median household income, patients in 2000-2004 (HR = 0.662, 95% CI = 0.523-0.839), 2005-2009 (HR = 0.431, 95% CI = 0.339-0.549), 2010-2014 (HR = 0.437, 95% CI = 0.341-0.561), and 2015-2019 (HR = 0.365, 95% CI = 0.273-0.489) had a significantly lower risk of TSM than patients in 1980-1999 (p < 0.05). Similarly, patients in 2005-2009 (HR = 0.661, 95% CI = 0.555-0.788), 2010-2014 (HR = 0.696, 95% CI = 0.578-0.838), and 2015-2019 (HR = 0.607, 95% CI = 0.476-0.773) also had a significantly lower risk of TSM than patients in 2000-2004 (p < 0.05). However, patients in 2010-2014 (HR = 1.042, 5% CI = 0.863-1.258) and 2015-2019 (HR = 0.945, 95% CI = 0.734-1.216) did not have a significantly lower risk of TSM compared to patients in 2005-2009 (p > 0.05).

Conclusion

GIST survival has significantly improved during the period 2000-2009 but showed no substantial improvement in 2010-2019, with the turning point for lower risk of TSM being 2005. Innovative strategies are needed to further improve survival outcomes for GIST patients, particularly for older patients and those with tumors originating outside the gastrointestinal tract.

Influence of lymph node removal on the prognosis of high malignancy potential gastric gastrointestinal stromal tumors: Insights from population-based study

High malignancy potential gastric gastrointestinal stromal tumors (HMP-gGISTs) generally require surgical resection. However, the necessity of lymph node removal (LR) for patients with such tumors remains unclear. Therefore, we conducted a population-based study to analyze the impact of LR on the long-term prognosis of patients with HMP-gGISTs. Patients with HMP-gGISTs were gathered from the Surveillance, Epidemiology, and End Results (SEER) database. Propensity score matching (PSM) was utilized to address potential selection bias. Overall survival (OS) and cancer-specific survival (CSS) were evaluated using Kaplan-Meier analyses and multivariate Cox proportional hazards models. A total of 840 patients with HMP-gGISTs were included in the study, with 317 undergoing LR and 523 not undergoing LR. The prognosis for OS (P = 0.026) and CSS (P < 0.001) in the LR group was worse compared to the No-LR group. After PSM, 634 patients were matched for comparison. The results showed that the OS (P = 0.028) and CSS (P = 0.006) in the LR group remained poorer than those in the No-LR group. Subgroup analysis further indicated that patients who did not undergo LR had a better prognosis. Our findings suggest that LR may not improve the prognosis of patients with HMP-gGISTs, implying that LR may not be necessary for these patients.

Gastrointestinal Stromal Tumors (GISTs) in Pediatric Patients: A Case Report and Literature Review

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms that primarily affect adults, with pediatric cases constituting only 0.5-2.7% of the total. Pediatric GISTs present unique clinical, genetic, and pathological features that distinguish them from adult cases. This literature review aims to elucidate these differences, emphasizing diagnostic and therapeutic challenges. We discuss the resistance of pediatric GISTs to conventional chemotherapy and highlight the importance of surgical intervention, especially in emergency situations involving intra-abdominal bleeding. The review also explores the molecular characteristics of pediatric GISTs, including rare mutations such as quadruple-negative wild-type GIST with an FGF3 gene gain mutation. To illustrate these points, we conclude with a case from our clinic involving a 15-year-old female with multiple CD117-positive gastric GISTs and a quadruple-negative wild-type genetic profile who required urgent surgical intervention following a failed tumor embolization. This case underscores the critical need for early diagnosis and individualized therapeutic strategies combining oncologic and surgical care to improve outcomes in pediatric GIST patients.

Ibero-American Consensus for the Management of Peritoneal Sarcomatosis: Updated Review and Clinical Recommendations

Peritoneal sarcomatosis is a rare malignant disease with a poor prognosis, secondary to peritoneal dissemination of abdominopelvic soft tissue sarcomas. Its rarity, together with the characteristic histological heterogeneity and the historically poor response to systemic treatments, has prevented the establishment of widely accepted treatment criteria with curative intent. In this sense, radical cytoreductive surgery (CRS) with peritonectomy procedures and hyperthermic intraperitoneal chemotherapy (HIPEC), widely used in peritoneal carcinomatosis with excellent results, have not had the same evolutionary development in patients with peritoneal sarcomatosis. A multidisciplinary working group of experts in sarcomas and peritoneal oncological surgery established a series of recommendations based on current scientific evidence for the management of peritoneal sarcomatosis, taking into account the different histological subgroups of abdominopelvic sarcomas that can cause it depending on their origin: retroperitoneal sarcomas, uterine sarcomas, and visceral/peritoneal sarcomas of GIST (gastrointestinal stromal tumor) and non-GIST origin. This article shows the results of sarcoma experts' voting on the recommendations presented during the I Ibero-American Consensus on the Management of Peritoneal Sarcomatosis, which took place during the recent celebration of the III Hispanic-Portuguese Meeting for Updates on the Treatment of Sarcomas.

The influence of lymphadenectomy on the prognosis of small intestinal stromal tumors: a study based on the SEER database

BACKGROUND

Small intestinal stromal tumors (SISTs) typically require surgical treatment. However, the impact of lymphadenectomy (LA) on long-term prognosis in patients remains unclear. Therefore, we plan to analyze the effect of LA on the prognosis of patients with SISTs using the Surveillance, Epidemiology, and End Results (SEER) database.

METHODS

Data on SISTs patients between 2000 and 2019 were obtained from the SEER database. Multiple imputation (MI) was employed to handle missing data, while propensity score matching (PSM) was conducted to mitigate selection bias in the comparative assessments between the LA group and the No-LA group. Kaplan-Meier analyses and multivariate Cox proportional hazards models were utilized to evaluate both overall survival (OS) and cancer-specific survival (CSS).

RESULTS

A total of 2412 patients diagnosed with SISTs were included in the study, with 879 undergoing LA and 1533 not undergoing LA. There were no significant differences observed between the two cohorts concerning long-term OS (hazard ratio [HR] 0.97, 95% confidence interval [CI] 0.84-1.13, P  = 0.720) and CSS (HR 1.05, 95% CI 0.86-1.29, P = 0.622). After PSM, 1596 patients (798 in the LA group and 789 in the No-LA group) were matched for comparison. There was also no difference in long-term OS and CSS between the two groups. Subgroup analysis revealed that in the age group > 60 years, the CSS in the No-LA group was superior to that in the LA group. Multivariate Cox regression analysis revealed that age, M stage, marital status, and mitotic rate are significant risk factors influencing OS and CSS.

CONCLUSIONS

Conducting LA in patients with SISTs does not enhance long-term prognosis. For patients aged over 60 years, it may be more advisable to refrain from performing LA.

Update of epidemiology, survival and initial treatment in patients with gastrointestinal stromal tumour in the USA: a retrospective study based on SEER database

OBJECTIVES

An updated epidemiological analysis of gastrointestinal stromal tumour (GIST), the change of cancer-specific survival (CSS) and patterns of initial treatment are of interest.

DESIGN

A retrospective study using data from the Surveillance, Epidemiology and End Results (SEER) database.

SETTING AND PARTICIPANTS

A total of 5625 patients with GIST diagnosed between 2010 and 2019 were identified.

PRIMARY OUTCOME MEASURES

Age-standardised incidence rate (ASIR) and annual prevalence rate were calculated. SEER combined stage, period CSS rate and initial treatment were summarised. All the data were calculated by SEER*Stat software.

RESULTS

From 2010 to 2019, the ASIR of GIST increased from 0.79 to 1.02 per 100 000 person-years, with an increase of 2.4% annually. The increase was across age and sex subgroups. The prevalence trend was similar with the ASIR trend in each subgroup. The stage distributions were similar between different age groups, but varied among different primary tumour sites. More importantly, a stage shift from regional stage to localized stage at diagnosis was found, which may result in the improvement of CSS over years. Overall, the 5-year CSS rate of GIST was approximately 81.3%. Even for metastatic GIST, the rate exceeded 50%. Surgery was the most common treatment regimen for GIST, followed by surgery and systemic treatment. Whereas approximately 7.0% patients were undertreated, which was more pronounced among patients with distant and unknown stages.

CONCLUSIONS

The findings of this study suggest an improving early detection of GIST and an improving ability of accurate staging. Though most patients are effectively treated and perform good survivals, approximate 7.0% patients may be undertreated.

Tumor-associated macrophages mediate gastrointestinal stromal tumor cell metastasis through CXCL2/CXCR2

BACKGROUND

Tumor-associated macrophages (TAMs) are linked with the progression and poor prognosis of multifarious solid tumors, but the regulatory mechanisms involved in gastrointestinal stromal tumors (GIST) remain indistinct. This study intended to delve into the job of TAM-derived chemokines in promoting metastasis in GIST microenvironment.

METHODS

Expression levels of M2-TAM markers and CXCL2 in primary and metastatic tissues of GIST were analyzed by bioinformatics methods, and we analyzed the correlation between CXCL2 and M2-TAM markers. Immunofluorescence was applied to assay CXCL2 and M2-TAM marker protein (CD68 and CD206) expression in tumor tissues. Serum CXCL2 concentration in metastatic and non-metastatic patients was assayed by ELISA. The differentiation of THP-1 cells was tested by flow cytometry. Cell function test was utilized to analyze the viability, invasion and migration of GIST cells. Western blot was used to examine the expression of epithelial-mesenchymal transition (EMT)-related proteins. The mouse liver metastasis model was established, and the effects of CXCL2 and EMT-related genes on metastasis were confirmed by hematoxylin-eosin staining and immunohistochemistry experiments.

RESULTS

Bioinformatics analysis ascertained that M2-TAM marker proteins and chemokine CXCL2 were highly expressed in GIST metastatic tissues, and CXCL2 and TAM were co-located in tumor tissues. Results of in vitro cell function experiments displayed that CXCL2 secreted by M2-TAM promoted the invasion, migration and EMT of GIST tumor cells, and the anti-CXCL2 antibody could block the metastasis promoting effect of CXCL2. Additionally, the silencing of CXCR2 in GIST cells inhibited the metastasis promoting effect of CXCL2. Animal studies further confirmed that CXCL2 promoted liver metastasis of GIST in vivo.

CONCLUSION

This study preliminarily revealed the mechanism of M2-TAM promoting tumor metastasis by secreting CXCL2 in GIST tumor microenvironment, and proffered theoretical reference for the development of immunotherapy strategies targeting M2-TAM.

Advances of endoscopic and surgical management in gastrointestinal stromal tumors

As one of the most common mesenchymal malignancies in the digestive system, gastrointestinal stromal tumors (GISTs) occur throughout the alimentary tract with diversified oncological characteristics. With the advent of the tyrosine kinase inhibitor era, the treatment regimens of patients with GISTs have been revolutionized and GISTs have become the paradigm of multidisciplinary therapy. However, surgery resection remains recognized as the potentially curative management for the radical resection and provided with favorable oncological outcomes. The existing available surgery algorithms in clinical practice primarily incorporate open procedure, and endoscopic and laparoscopic surgery together with combined operation techniques. The performance of various surgery methods often refers to the consideration of risk evaluation of recurrence and metastases; the degree of disease progression; size, location, and growth pattern of tumor; general conditions of selected patients; and indications and safety profile of various techniques. In the present review, we summarize the fundamental principle of surgery of GISTs based on risk assessment as well as tumor size, location, and degree of progress with an emphasis on the indications, strengths, and limitations of current surgery techniques.

The Effect of Different Nutritional Nursing Support on the Nutritional Status and Disease Recovery of Elderly Patients with Gastrointestinal Tumors during the Perioperative Period

Objective

This study explored the effect of different nutritional nursing support on nutritional status, immune function, postoperative bowel motility, and complications in elderly patients with gastrointestinal tumors during the perioperative period.

Methods

300 patients with gastrointestinal tumors treated in the Department of Gastroenterology and anorectal surgery of Hangzhou First People's Hospital Affiliated with the Medical College of Zhejiang University from February 2018 to March 2020 were selected as the research objects in this study. Patients were divided into the early enteral nutrition (EEN) and total parenteral nutrition (TPN) groups (150 cases in each group) according to the principle of odd and even admission numbers. The patients in the EEN and TPN groups were given enteral nutrition nursing support and parenteral nutrition nursing support, respectively. The nutritional status, immune function, postoperative bowel motility, and complication rate of the two groups were evaluated 7 days after the operation.

Results

The nutritional indexes decreased 3 days after the operation and gradually recovered 7 days after the operation in both groups with different nutritional nursing support. The Hb, TRF, PAB, and ALB indexes in the TPN group were significantly lower than those in the EEN group (P < 0.01). On the 7th day after the operation, the indexes of peripheral blood immunoglobulin (IgG, IgM, and IgA) were significantly lower than those in the TPN group, and T lymphocyte subsets (CD4, CD8, and CD4/CD8) demonstrated that the immunological indexes of patients in the EEN group were significantly higher than those in the TPN group (P < 0.01). In terms of intestinal peristalsis, the time of first exhaust and first defecation in the EEN group was significantly shorter than that in the TPN group (P < 0.01) during the perioperative period. Furthermore, both groups had different degrees of complications, while patients demonstrated a lower complication rate in the EEN group compared to those in the TPN group, suggesting a safer postoperative mode. The results of subgroup analysis showed that the nutritional indexes of the gastric cancer group 7 days after operation were significantly higher than those of the colorectal cancer group under EEN and TPN nutritional support modes.

Conclusion

Clinical results have suggested that enteral nutrition nursing support can improve the perioperative nutritional status of elderly patients with gastrointestinal tumors by enhancing the immune function and promoting intestinal peristalsis. Meanwhile, the postoperative EEN mode reduces the rate of complications and demonstrates higher safety. Therefore, it has a high clinical application value.