Gastrointestinal stromal tumours: ESMO-EURACAN-GENTURIS Clinical Practice Guidelines for diagnosis, treatment and follow-up

Ulcerated benign jejunal gastrointestinal stromal tumor causing gastrointestinal bleeding: A case report

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors that rarely present with gastrointestinal (GI) bleeding due to tumor erosion. GISTs commonly arise in the stomach, followed by the small bowel. They are typically diagnosed through histopathology and immunohistochemistry. The presence of mucosal ulceration and tumor locations outside the stomach are linked with a greater risk of tumor progression to malignancy. This case highlights a benign ulcerated jejunal GIST presenting as GI bleeding.

CASE SUMMARY

A 42-year-old male presented with dark stools and light-headedness over five days. On examination, he was hypotensive, tachycardic, tachypneic, and had pallor. Laboratory tests revealed normocytic normochromic anemia, with a significant one-day drop in hemoglobin (from 7.2 g/dL to 6.4 g/dL). Upper GI endoscopy and colonoscopy were normal, but double-balloon enteroscopy revealed a subepithelial lesion distal to the duodenojejunal flexure, and an overlying ulcer. These findings were suggestive of GIST and were corroborated by a contract-enhanced computed tomography abdomen scan, which revealed a well-defined, homogenously-enhancing solid exophytic lesion (30 mm × 22 mm × 26 mm) arising from the proximal jejunal loops. He underwent resection anastomosis with complete en-bloc surgical removal of the lesion. Histopathological analysis of the resected specimen confirmed a GIST with presence of spindle cells and positive CD117 staining. His hemoglobin levels were stable on regular follow-ups, and there was no documented recurrence six months later.

CONCLUSION

GISTs should be suspected in cases of unexplained GI bleeding. Early diagnosis and complete surgical resection are key to favorable outcomes.

Oligoprogressive liver metastasis from gastrointestinal stromal tumour treated with stereotactic body radiotherapy (SBRT)

While metastatic gastrointestinal stromal tumours (GIST) are generally treated using systemic therapy, surgery and/or ablative procedures, radiotherapy appears to have a restricted role. We present a case of a woman in her 40s with metastatic GIST treated over 10 years with two lines of tyrosine kinase inhibitors (TKIs). During sunitinib therapy, a solitary oligoprogressive lesion was found. Since she was unable to afford a subsequent line of TKI, the lesion was assessed for local ablative options. It was deemed suitable for stereotactic body radiotherapy (SBRT) at a dose of 42 Gy in 6 Fractions. She tolerated the treatment well and continued sunitinib. At the 2-year follow-up, the liver lesion showed partial response, with the patient having no late post-SBRT sequelae and continuing the same TKI. SBRT seems to be a safe and effective local ablative option for the treatment of oligoprogressive lesions in GIST.

Adjuvant treatment of gastrointestinal stromal tumor: State of the art in 2025

The management of gastrointestinal stromal tumors (GISTs) has been revolutionized by the discovery of their sensitivity to imatinib. Most localized GISTs can be cured by surgery alone. The present overview aims to discuss the results of four recent randomized trials or updates assessing adjuvant imatinib. The duration of adjuvant treatments varied in these 4 trials (1 year versus zero, 2 years versus zero, 3 years versus 1 year and 6 years versus 3 years). All these trials showed that adjuvant imatinib improves disease/relapse-free survival in patients at high-risk of GIST relapse. Nevertheless, only one trial showed an overall survival improvement, in favor of 3-year treatment compared to 1-year treatment. But these randomized trials did not assess KIT or PDGFRA mutational status at study entry. Moreover, the definition of high-risk GIST differed across these trials. So, the patient subset that benefits the most from adjuvant imatinib therapy remains undetermined. The optimal duration of adjuvant imatinib therapy remain unclear.

Navigating Ongoing Challenges in GI Stromal Tumors

GI stromal tumors (GISTs) are mesenchymal neoplasms with variable natural histories, originating in the GI tract, most commonly in the stomach. They are frequently characterized by KIT or platelet-derived growth factor receptor alpha (PDGFRA) oncogenic mutations. Surgical resection remains the cornerstone treatment for localized GISTs. Clinical trials have demonstrated the benefits of adjuvant imatinib in patients selected on the basis of recurrence risk and gene mutations, although the optimal duration of therapy is yet to be established. Some data suggest that longer durations of adjuvant imatinib (>3 years) may provide additional benefit, which is being investigated in ongoing trials. Management of imatinib-related adverse effects is essential during treatment, and longitudinal abdominal imaging is mandatory both during and after adjuvant therapy. Once GISTs are more advanced and unresectable, KIT- and PDGFRA-directed tyrosine kinase inhibitors (TKIs) become the key treatment in most patients with KIT mutation. Several TKIs have regulatory approval for advanced GISTs, but in most patients, resistance to TKIs eventually emerges, mainly from secondary resistance mutations in KIT. Each TKI has different coverage of oncogenic KIT mutations, suggested by preclinical and clinical findings, which has given rationale to an ongoing clinical trial that includes molecular selection as eligibility criteria. Furthermore, novel treatment approaches, from TKI combinations to an antibody-drug conjugate, are being investigated. Despite the significant advance in managing GISTs with KIT mutations, those without KIT or PDGFRA mutation, which consists of 10%-15% of patients with GIST, can be a clinical challenge in the advanced setting. These non-KIT/PDGFRA GISTs could be driven by genomic or epigenomic alterations in SDHx, NF1 mutations, and other genomic alterations. Non-KIT/PDGFRA GISTs are less responsive to currently available TKIs than GISTs driven by KIT/PDGFRA mutations, and each subset of non-KIT/PDGFRA GIST has distinctive biology and clinical features. Therefore, individualized, multidisciplinary, biology-based management and consideration for clinical trial enrollment are critical for non-KIT/PDGRFA GISTs.

Clinical outcomes and cost-effectiveness analysis of robotic and endoscopic cooperative surgery for treating gastric submucosal tumors: a longitudinal nested cohort study

BACKGROUND

Robotic and endoscopic cooperative surgery (RECS) is an emerging and promising therapeutic approach for treating gastric submucosal tumors (GSMTs). However, the efficacy of RECS has not been well established, and its high medical costs significantly limit its application.

METHODS

This nested cohort study examined patients with GSMTs managed with different surgical techniques. A total of 314 consecutive patients were enrolled in this study, including 61 patients treated with RECS, 196 patients treated laparoscopically, and 57 patients treated with open surgery. To mitigate confounding bias, 1:1:1 propensity score matching (PSM) was utilized. The perioperative outcomes, postoperative gastrointestinal symptoms, long-term outcomes, and cost-effectiveness among the three groups were compared.

RESULTS

After PSM, 51 patients were included in each group. Compared with the laparoscopic and open surgical groups, the RECS group presented significantly lower intraoperative bleeding volumes, times to first flatus, times to liquid intake, and postoperative hospital stay. The severity of gastrointestinal symptoms in the RECS group was notably better than that in the laparoscopic and open groups 3, 6, and 12 months postsurgery. Regarding long-term outcomes, there were no differences in overall or relapse-free survival among the three groups. The total hospitalization cost was significantly greater in the RECS group, primarily due to surgical cost differences. The incremental cost-effectiveness ratios per quality-adjusted life year for the RECS group relative to the laparoscopic and open groups were 18,244 and 56,914 Chinese yuan (CNY), respectively. Analysis of the cost-effectiveness acceptability curves indicated that across all willingness-to-pay thresholds, the probability that RECS was cost-effective exceeded 90%.

CONCLUSIONS

RECS is a safe and effective method for treating GSMTs, offering faster postoperative recovery and fewer gastrointestinal symptoms than laparoscopic and open surgeries. Despite the increased costs associated with the introduction of RECS technology, it remains a cost-effective option.

Characterization of a novel cell line established from mice gastrointestinal stromal model by chemical induction

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are a type of tumor that originates from gastrointestinal mesenchymal tissue. Although several somatic or germline mutation GIST mice were established, however, there is still a lack of an authentic mice GIST cell lines for further experimental study.

METHODS

We developed a chemically induced C57BL/6 J GIST model using 3- methylcholanthrene. Tumor characteristics were confirmed through histology and IHC. Primary cells were isolated to establish the mGSTc01 cell line, and molecular profiling was conducted. Additionally, we established GIST model in immunocompetent mice to evaluate their sensitivity to imatinib.

RESULTS

Our study successfully developed a chemically induced murine GIST model, characterized by positive staining of c-kit and DOG-1. The mGSTc01 monoclonal cell line exhibited slender morphology and expressed the c-kit marker, Whole exome sequencing uncovered mutations of Lamb1, MMP9, and c-kit in GIST cells and provided a detailed picture of the entire genome's copy number variations. RNA sequencing indicated genes associated with cell adhesion and focal adhesion were enriched in mGSTc01 cells. The mGSTc01 cells demonstrated obvious malignant behaviors, notably elevated migration, adhesion, and proliferation. In immunocompetent mice, subcutaneous xenografts not only reserved the aggressive phenotype but also displayed a response to imatinib, underscoring the model's applicability for advancing therapeutic research.

CONCLUSION

We firstly established a mGSTc01 cell line derived from C57BL/6 J mice GIST tumor offers, which closely mimicking human disease characteristics. It is a potent platform for investigating tumor microenvironment of GIST in mice model, and provides a novel way for new therapeutic discoveries in GIST.

Molecular imaging of gastrointestinal stromal tumor using anti-c-KIT antibody and its fragments

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are malignant subepithelial tumors, known for their poor prognosis due to distant metastasis. Because GIST is covered by a normal mucosal layer, effective tissue biopsy under conventional endoscopy is difficult, thereby leading to delayed diagnosis and a dismal prognosis. We performed molecular imaging of GIST targeting c-KIT using fluorescence-labeled anti-c-KIT antibody/fragments and fluorescent endoscopy.

METHODS

Mouse anti-human c-KIT monoclonal antibody, its F(ab')2 and Fab fragments were labeled with AF680. Two GIST cell lines (GIST-T1, GIST-882M) were used for experiments. Antibodies were intravenously administered to mice xenografted with GIST-T1 or GIST-882M, and each tumor was observed using IVIS Spectrum and self-developed simple fluorescent endoscopy.

RESULTS

The GIST-T1 cell live imaging revealed strong signals on cell membranes after 1 min incubation, and thereafter, they aggregated and internalized inside the cells within 130 min in all antibody/fragment groups. In vivo mouse experiments, AF680-labeled IgG slowly accumulated in tumors peaking at 24 h after injection. However, AF680-labeled F(ab')2 and Fab rapidly accumulated in tumors peaking at 1-2 h, and completely cleared from the body within 24 h. Fab showed the strongest fluorescence intensity in tumors. Fluorescence endoscopy could clearly detect GIST xenograft tumors 1-2 h after AF680-labeled F(ab')2 and Fab injection.

CONCLUSIONS

AF680-labeled antibody/fragments showed clear and specific fluorescence signals in GIST xenografts in mice. Particularly, AF680-labeled Fab showed the strongest signal intensity at 1-2 h post-administration and rapid clearance, suggestive of the safety. This approach may enable molecular imaging diagnosis of GIST by endoscopy in outpatient settings in the future.

Minimally invasive approaches to small gastric stromal tumors: The less with the more

In this paper, we comment on the article by Gu et al published in 2024, investigating whether there were differences in the clinical/perioperative outcomes of endoscopic and laparoscopic resections of gastric stromal tumors. Compared with most carcinomas, gastrointestinal stromal tumors are quite common worldwide and have a better prognosis. However, they respond to specific chemotherapies and do not routinely require standard lymphadenectomy. The gastric origin is known to be the most represented. Survival after proven radical surgery is excellent, with recurrences being extremely infrequent. Currently, induction/perioperative chemotherapy for high-risk tumors larger than 5 cm can downstage neoplasia and maintain good survival. Therefore, the standard of care for nonmetastatic, resectable tumors is surgical excision (avoiding formal lymphadenectomy) with or without chemotherapy. In the case of small- (2 cm) to medium- (5 cm) sized tumors, minimally invasive surgical approaches (laparoscopic or robotic) have been advocated, and more recently, a purely endoscopic technique has also been proposed. All these interventions are feasible and effective, although no definitive results have been published to prove the superiority of one over another; however, further investigation of its associated oncologic outcomes is still needed. Unfortunately, rigorous, prospective, randomized controlled trials are challenging to conduct, develop, and receive ethical approval for, whereas the final decision of the surgical route is often related to the availability of instrumentation and local expertise.

Laparoscopic Pancreas-Preserving Duodenal Resection for Duodenal Gist

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms, commonly arising in the stomach (60-70%) or small intestine (20-30%). Duodenal GISTs are less common and present unique technical challenges for surgical management.1,2 PATIENTS AND METHODS: This video presents the case of a 66-year-old woman with a primary, localized duodenal GIST, incidentally discovered in the second portion of the duodenum. Investigations confirmed a 27-mm KIT exon 9-mutated GIST. Due to its proximity to the ampulla, preoperative imatinib at 800 mg daily was initiated. After nine months of modest tumor shrinkage, surgery was proposed, but the patient opted to delay due to concerns about surgical morbidity. Given the tumor's stability, imatinib was continued until a laparoscopic resection was performed two years after starting imatinib, preserving both the pancreas and the ampulla. The duodenum was mobilized via a transmesocolic approach, with careful dissection from the pancreatic head. The first jejunal loop was transected, and the duodenum was divided just below the ampulla under direct endoscopic guidance. An intracorporeal, side-to-side, isoperistaltic, antecolic duodenojejunal anastomosis was performed.

RESULTS

Complete en-bloc resection with negative margins was achieved. The patient's recovery was uneventful, and she was discharged on postoperative day 7. The length of stay reflects institutional practices influenced by limited home support and patient travel needs.

CONCLUSIONS

This case illustrates the value of multidisciplinary planning and minimally invasive techniques for managing duodenal GISTs. Even with a modest response to imatinib, oncologically sound and anatomically conservative surgery can be achieved.

Regulatory roles of non-coding RNAs in programmed cell death pathways and drug resistance in gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract, primarily driven by KIT or PDGFRA mutations. Programmed cell death (PCD), including apoptosis, autophagy, and ferroptosis, plays a crucial role in GIST pathogenesis, progression, and treatment response. Non-coding RNAs (ncRNAs) have emerged as key regulators of PCD pathways, influencing GIST proliferation, metastasis, and drug resistance, particularly in response to tyrosine kinase inhibitors (TKIs) such as imatinib. Apoptosis suppression is strongly associated with poor prognosis, while autophagy contributes to tumor dormancy and TKI resistance. Ferroptosis, a novel iron-dependent cell death pathway, represents a promising therapeutic target. Recent evidence suggests that ncRNAs modulate these PCD pathways through interactions with key molecular regulators such as miR-494, miR-30a, and lncRNAs, which affect signaling networks including PI3K/AKT, MAPK, and mTOR. Furthermore, ncRNAs have mediated secondary resistance to imatinib by promoting autophagic flux and altering ferroptosis sensitivity. Understanding the molecular interplay between ncRNAs and PCD in GIST provides novel insights into disease mechanisms and offers potential therapeutic strategies to overcome drug resistance. Targeting ncRNA-mediated regulation of apoptosis, autophagy, and ferroptosis may enhance treatment efficacy and improve patient outcomes. Future research should focus on elucidating the mechanistic roles of ncRNAs in PCD pathways to develop innovative diagnostic and therapeutic approaches for GIST.

Diagnostic challenges of inflammatory submucosal tumor-like lesions: a multicenter propensity score-matching analysis

BACKGROUND

Gastrointestinal submucosal tumors (SMTs) are frequently encountered in clinical practice, with diverse etiologies and overlapping endoscopic features. Inflammatory SMT-like lesions (I-SMTLs), though rare and benign, mimic SMTs endoscopically but are fundamentally inflammatory. Limited research exists on their specific diagnostic characteristics.

METHODS

This multicenter retrospective study analyzed 59 I-SMTLs among 1,226 pathologically confirmed SMTs from five hospitals in China. The diagnostic efficacy of endoscopic ultrasound (EUS) for I-SMTLs was assessed, and comparison with non-inflammatory SMT-like lesions (non-I-SMTLs) was made using propensity score matching (PSM) balanced for sex, age, lesion location and size. Correlation between endoscopic and pathological characteristics were quantified using Cramer's V coefficient.

RESULTS

I-SMTLs accounted for 4.81% (59/1,226) of SMTs, with 98.31% (58/59) measuring under 2 cm. EUS demonstrated low sensitivity (3.39-4.00%) and a high misdiagnosis rate (96.61%) for I-SMTLs, with over 55% misdiagnosed as potentially malignant and 15% remaining inconclusive. In the PSM cohort (59 I-SMTLs, 118 non-I-SMTLs), I-SMTLs were more frequently located in submucosa (71.19% vs. 42.37%), exhibited mixed-echoic category (18.64% vs. 1.69%), heterogeneous echogenicity (62.71% vs. 21.19%) and unclear boundaries (42.37% vs. 13.56%). Correlation analysis showed cases with smooth muscle hyperplasia in pathology were more likely to arise from the muscularis propria or muscularis mucosae (Cramer's V = 0.490), and cases with fibrous tissue alterations were more likely to exhibit mixed or hyperechoic patterns (Cramer's V = 0.545) and heterogeneous echotexture (Cramer's V = 0.336) on EUS.

CONCLUSIONS

I-SMTLs pose significant diagnostic challenges. Distinguishing EUS features, including submucosal location, mixed-echoic patterns, heterogeneous textures, and unclear boundaries, may improve diagnostic accuracy and facilitate appropriate clinical decision-making.

Evaluation of the effectiveness and safety of avapritinib in real-world Spanish cases with gastrointestinal stromal tumor and D842V-PDGFRA mutation

INTRODUCTION

Gastrointestinal stromal tumors (GISTs) are the most common sarcoma subtype. Patients with unresectable or metastatic GISTs harboring the D842V mutation in the PDGFRA gene have a poor prognosis due to intrinsic resistance to imatinib and all other approved tyrosine kinase inhibitors. Avapritinib, targeting this mutation, is the first agent approved for patients with unresectable or metastatic GIST that have the PDGFRA D842V mutation. This study assesses the effectiveness and safety of avapritinib in real-world clinical scenarios involving Spanish patients with this mutation.

MATERIALS AND METHODS

The AVARWE study is a descriptive, retrospective, multicenter observational study of 21 patients treated with avapritinib across 13 Spanish centers from June 9, 2023, to December 18, 2023. Data collected included patient demographics, disease characteristics, treatment history, and response rates based on RECIST criteria. The main outcomes, progression-free survival (PFS) and overall survival (OS), were measured, with safety assessed through adverse events documentation according to CTCAE criteria.

RESULTS

Median PFS 35.6 was months and median OS was 42.2 months, with survival rates at 1, 5, and 3 years demonstrating avapritinib effectiveness. The objective response rate was 76.2% for partial response and 4.8% for complete response. Avapritinib enabled surgical intervention in previously unresectable cases and was generally well-tolerated, with manageable adverse events.

CONCLUSION

Avapritinib extends PFS and OS among patients with PDGFRA D842V-mutant GIST in real-world practice, mirroring pivotal trial outcomes. Its substantial activity supports its use as a first-line therapy for this subgroup. The manageable safety profile reinforces avapritinib viability for routine use. Given the rarity of these cases, it is advised to consult sarcoma-expert units.

Endoscopic versus laparoscopic resection of gastrointestinal stromal tumors at the esophagogastric junction using propensity score matching analysis

The esophagogastric junction (EGJ) has a complex anatomy and critical physiological functions, making postoperative quality of life an important consideration in the surgical resection of gastrointestinal stromal tumors at this location (EGJ-GISTs). We conducted a propensity score-matched (1:1) analysis to compare the safety and efficacy of endoscopic resection (ER) and laparoscopic resection (LR) for patients with EGJ-GIST treated at the First Affiliated Hospital of Zhengzhou University, China, from December 2013 to November 2023. We reviewed 176 patients (ER 82; LR 94) with EGJ-GIST, of whom 85 patients with a tumor size of 2-5 cm met the matching criteria (ER 42; LR 43), yielding 20 pairs of patients. ER showed advantages over LR, with a shorter postoperative nil per os time (4.0 days (IQRs, 3.0-5.0) vs. 5.5 days (IQRs, 4.3-7.8), p = 0.005) and postoperative hospitalization time (6.0 days (IQRs, 5.0-6.8) vs. 8.5 days (IQRs, 6.0-11.8, p = 0.002). Long-term adverse events were significantly lower in the ER group (15% vs. 55%, p = 0.005). No recurrence or metastasis was observed in either group during a mean follow-up of 42.3 months. These findings suggest that for 2-5 cm EGJ-GISTs, ER is a safe and effective alternative, offering minimal invasiveness, faster recovery, fewer complications, and improved long-term quality of life.

Pimitespib in patients with advanced gastrointestinal stromal tumors in Japan: an expanded access program

BACKGROUND

Pimitespib, an oral heat shock protein 90 inhibitor, significantly prolonged progression-free survival in patients with advanced gastrointestinal stromal tumors (GIST) in CHAPTER-GIST-301 study. This expanded access program was conducted to evaluate the safety and efficacy of pimitespib in Japanese patients with advanced GIST.

METHODS

This multicenter, open-label, single-arm study was conducted in patients (≥ 20 years) with histologically confirmed GIST who had been previously treated with imatinib, sunitinib and regorafenib and had an Eastern Cooperative Oncology Group performance status of 0-1. Patients received pimitespib 160 mg/day for five days, followed by a 2-day rest, in 21-day cycles.

RESULTS

Between February and August 2022, 23 patients were enrolled (median age 59.0 years). Over a median pimitespib treatment duration of 81.0 days, adverse events occurred in 22 patients (95.7%). The most common adverse events were diarrhea (73.9%), nausea (39.1%) and increased blood creatinine (30.4%). Serious adverse events occurred in two patients (tumor hemorrhage and tumor pain); neither was related to pimitespib. One patient had grade 3 diarrhea that was considered treatment-related. Four patients (17.4%) had eye disorders, all of which were grade 1 and treatment-related. The median progression-free survival was 4.2 months (95% confidence interval [CI] 1.9-6.2), the overall response rate was 0% (95% CI 0-16.1) and the disease control rate was 66.7% (95% CI 43.0-85.4).

CONCLUSIONS

Pimitespib was well tolerated and effective in patients with advanced GIST in real-world practice in Japan. No new safety signals were identified.

TRIAL REGISTRATION

jRCT2031210526 registered 1 February 2022.

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.

Traction-assisted endoscopic ultrasound-guided fine-needle biopsy using the clip-with-thread method for small gastric subepithelial lesions: Randomized controlled trial (with video)

OBJECTIVES

Endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS-FNA/B) is the gold standard for diagnosing gastric subepithelial lesions (SELs), but diagnosing lesions smaller than 20 mm remains challenging. We developed traction-assisted EUS-FNB (TA-EUS-FNB) using the clip-with-thread method to enhance diagnostic accuracy by stabilizing the lesion and providing counter-traction for easier needle access. This study evaluates the effectiveness of TA-EUS-FNB in diagnosing small gastric SELs.

METHODS

In this prospective, randomized, controlled cross-over trial (August 2019-November 2022), 30 patients with gastric SELs <20 mm were randomized to undergo TA-EUS-FNB or conventional EUS-FNB. Each patient underwent four punctures, two per method. The primary end-point was the adequate tissue sampling rate for both techniques. Secondary end-points included diagnostic yield and performance (sensitivity and specificity) in distinguishing gastrointestinal stromal tumors (GISTs) from non-GISTs.

RESULTS

The mean tumor size was 15.0 mm, with diagnoses comprising GISTs (n = 15, 50%), leiomyomas (n = 8, 26.7%), schwannomas (n = 2, 6.7%), aberrant pancreas (n = 3, 10%), and inflammation (n = 2, 6.7%). TA-EUS-FNB demonstrated a significantly higher adequate-tissue sampling rate (90% vs. 66.7%, P = 0.035) and diagnostic yield (86.7% vs. 63.3%, P = 0.037) than conventional EUS-FNB. Sensitivity (86.7%, 95% confidence interval [CI] 62.1-96.3% vs. 66.7%, 95% CI 41.7-84.8%; P = 0.20) and specificity (100%, 95% CI 79.6-100% vs. 100%, 95% CI 79.6-100%) were comparable between the methods. No adverse events were observed in the study.

CONCLUSION

TA-EUS-FNB demonstrated superior tissue sampling rates and diagnostic yield for SELs <20 mm compared to conventional EUS-FNB, making it a viable option. Controlling lesion mobility is essential for successful EUS-FNB in small SELs.

The role for pancreatic preserving surgery for duodenal (D2) gastrointestinal stromal tumours

INTRODUCTION

A variety of surgical options are available to achieve a complete oncological resection for duodenal gastrointestinal stromal tumours (GISTs). The most common location of such tumours is the second portion (D2) of the duodenum. The key step in assessing the feasibility of localised duodenal resection is the relationship between the GIST and ampulla. We present our surgical approach and results for patients with D2 GISTs undergoing surgical resection at our tertiary oncology centre.

METHODS

Patients diagnosed with duodenal GIST involving D2 who underwent surgical resection at The Royal Marsden NHS Foundation Trust between March 2018 and May 2024 were included in this study.

RESULTS

11 patients with D2 GISTs were included in the study. The mean age was 60 ± 11.2 years. The majority (n = 9) of patients presented with gastrointestinal haemorrhage. The locations of duodenal GIST were D1/2 (n = 1), D2 (n = 8), and D2/3 (n = 2). 9 patients received neoadjuvant Imatinib treatment. 10 patients had peri-ampullary D2 GISTs resected with pancreatic preservation. There were no anastomotic or duodenotomy leaks. One patient developed delayed gastric emptying (DGE). One patient who underwent segmental D2/3 resection and duodeno-jejunostomy developed biliary obstruction and required PTC and biliary stent. One patient who presented with biliary obstruction underwent pancreaticoduodenectomy developed a Grade A post-operative pancreatic fistula. The median study follow-up was 38 months (range 3-72 months) and at the end of the study period only one patient had developed recurrence. All patients remain disease free and under active follow-up.

CONCLUSION

In summary, we demonstrate that for D2 GISTs presenting without biliary obstruction, localised D2 resection should be considered, and this approach is associated with low patient morbidity and good long-term patient outcomes.

Clinical Use of Liquid-Based Comprehensive Genomic Profiling in Gastrointestinal Stromal Tumors

Treatment for gastrointestinal stromal tumor (GIST) focuses on tyrosine kinase inhibitors, the selection of which depends on specific mutations. We sought to determine the clinical use of liquid biopsy in advanced GIST. Liquid (n = 181) (FoundationOne Liquid CDx) and tissue (n = 2198) (FoundationOne and FoundationOne CDx) comprehensive genomic profiling of GIST were evaluated. The presence of circulating tumor DNA in liquid was determined via tumor fraction (TF), with an elevated TF defined as TF ≥ 1%. Liquid comprehensive genomic profiling revealed 30% (54/181) of samples had an elevated TF, among which the prevalence of KIT and PDGFRA alterations were 89% (48/54) and 2% (1/54), respectively. In patient-matched tissue/liquid samples (n = 49), the positive percent agreement of driver alterations in liquid with an elevated TF relative to tissue was 100%. Fifty-five percent (42/77) of liquid samples with a KIT driver mutation had a co-occurring imatinib-resistant alteration; a minority of cases harbored non-KIT mechanisms of resistance such as FGFR2 fusions and BRAF or EGFR alterations. The relative prevalence of imatinib resistance KIT exon 13 and 17 mutations was enriched in liquid compared with tissue. Finally, in the liquid cohort, 2.2%, 1.7%, and 1.1% of patients were predicted to harbor germline KIT, SDHx, or NF1 mutations, respectively. In conclusion, known driver and tyrosine kinase inhibitor--resistant mutations were identified in liquid biopsies of patients with GIST with high concordance to tissue in the presence of an elevated TF. Liquid biopsy may be valuable in the molecular classification and medical management of GIST.

CT feature of irregular extensive ulceration as a predictor of liver metastasis in gastric gastrointestinal stromal tumours

OBJECTIVES

This study aimed to investigate whether the computed tomography (CT) finding of irregular extensive ulceration (IEU) can serve as a predictor of liver metastasis (LIM) in patients with gastric gastrointestinal stromal tumours (GISTs).

METHODS

This study retrospectively collected clinical and imaging data from 286 patients diagnosed with low-, intermediate-, or high-risk gastric GISTs, or primary lesions with LIM from three medical institutions. The patients were categorised into non-LIM and LIM groups according to whether they had synchronous or metachronous LIM. Multivariate logistic regression analyses were performed to identify significant predictors of LIM. Additionally, receiver operating characteristic (ROC) curve, subgroup, and pathologic-radiologic correlation analyses were conducted.

RESULTS

A total of 124 patients were ultimately enroled. There were significant differences in sex, site, growth pattern, size, shape, ulceration and Ki-67 expression between LIM and non-LIM groups. ROC curve analysis demonstrated that IEU had the highest area under the curve for predicting LIM (AUC = 0.842; 95% CI: 0.760-0.924; p < 0.001). Multivariate analysis indicated that IEU was the most significant independent predictor of high LIM risk (OR = 88.62; 95% CI: 2.80-2803.54; p = 0.011). Subgroup analysis showed that IEU was more frequently associated with male sex, age ≤ 55 years, proximal sites, irregular shapes, mixed growth patterns, and a high Ki-67 expression.

CONCLUSIONS

The CT feature of IEU serves as an independent predictor of LIM in gastric GISTs and is strongly associated with high Ki-67 expression.

KEY POINTS

Question Accurate assessment of LIM risk in patients with gastric GISTs is crucial, yet current non-invasive predictors remain inadequate. Findings IEU on CT is an independent predictor of LIM, with high diagnostic accuracy and a significant association with elevated Ki-67 expression. Clinical relevance IEU on CT scans enables non-invasive risk stratification for LIM in gastric GISTs. Our study refined the assessment of ulceration types, highlighting significant heterogeneity, which may guide personalised treatment strategies.

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.

Genetic predisposition in sarcomas: clinical implications and management

Recent studies indicate up to 20% of sarcomas may be associated with predisposition genes, and this number will probably increase as genetic testing becomes more available. Evidence on the management of patients with sarcoma and genetic predisposition remains, however, scarce. This review compiles available research on genetic predisposition syndromes associated with sarcoma and sarcoma treatment within such syndromes, addressing key gaps in knowledge. We explore the current evidence on how genetic predisposition may influence treatment decisions and clinical management, focusing on surgery, radiotherapy, systemic treatment, and surveillance. Evidence-based recommendations are currently not available for most syndromes, and we have therefore included pragmatic advice for clinicians. Unanswered questions and unmet needs are also identified, underscoring the importance of multidisciplinary input from specialists such as geneticists, radiologists, surgeons and oncologists. The review stresses the need for future research to improve clinical outcomes for patients with sarcoma and genetic predisposition.

Funding

No funding has been provided for this work.

Asymptomatic small gastric subepithelial lesions arising from the muscularis propria: outcomes and surveillance in a medical center

BACKGROUND AND AIMS

Gastric subepithelial lesions (SELs) are frequently identified incidentally during endoscopy, with those originating from the muscularis propria (MP) layer posing diagnostic and management challenges. The optimal surveillance duration for these lesions remains debated. This study aimed to assess size changes in SELs from the MP layer and recommend appropriate surveillance intervals.

METHODS

We retrospectively reviewed asymptomatic gastric SELs (≤2 cm) diagnosed via endoscopic ultrasound (EUS) from 2013 to 2018, with follow-up data and no excision within 1 year. Significant progression was defined as a > 20% increase in diameter during EUS surveillance. Lesion-related adverse outcomes, size changes, and histological findings were analyzed.

RESULTS

A total of 561 patients (median surveillance duration: 80 months) were included. One lesion-related adverse outcome (0.2%), liver metastasis from a gastrointestinal stromal tumor, occurred after 62 months. Among the EUS subgroup (n = 313), no differences were observed in progression rates (22.6% vs. 25%) or size increase rates (0.3 mm/year vs. 0.9 mm/year) between micro-SELs (<10 mm) and mini-SELs (10-20 mm). Progressive lesions exhibited faster growth (2.6 mm/year) and more heterogeneous echotexture (43.8%). Most excised lesions were gastrointestinal stromal tumors or leiomyomas.

CONCLUSIONS

Over a mean surveillance period of 25.5 months, 13 lesions grew beyond 20 mm. No lesion-related adverse outcomes occurred within the first three years. Histological diagnosis remains the gold standard, but when tissue acquisition is unfeasible, EUS surveillance may be an alternative. Our findings suggest that for asymptomatic micro-SELs (<10 mm) from the MP layer without high-risk features, the surveillance interval can be safely extended to two years.

Robotic-assisted gastrointestinal stromal tumor (GIST) resection with endoscopic transoral specimen retrieval (Gastrointestinal Cancer-NOSES Type IX): a case report and literature review

Objective

To investigate the methodology and outcomes of Da Vinci robotic-assisted resection of gastrointestinal stromal tumors (GISTs) combined with endoscopic transoral specimen retrieval (GC-NOSES type IX), establishing a benchmark for minimally invasive treatment of GISTs.

Methods

This manuscript details a case involving a GIST situated on the posterior wall of the distal gastric body, adjacent to the lesser curvature, with a size of approximately 2.7 cm and exhibiting an intraluminal growth pattern. The tumor was effectively excised through robot-assisted GIST resection, complemented by endoscopic transoral specimen extraction (GC-NOSES type IX). The case is analyzed alongside pertinent literature and surgical perspectives.

Results

The patient was admitted with "persistent abdominal discomfort persisting for over two months." Preoperative enhanced abdominal CT reveals a gastric body lesion measuring approximately 2.7 centimeters, suggestive of a GIST. The patient underwent a successful robot-assisted resection of the GIST, with endoscopic transoral specimen extraction (GC-NOSES type IX). Postoperative histopathological analysis confirmed a GIST measuring 4.0 cm × 3.0 cm × 3.0 cm, classified as low-risk, with clear resection margins. Immunohistochemical profiling showed CD117 (+), CD34 (+), Desmin (-), DOG-1 (+), Ki67 (approximately 5% positive tumor cells), S-100 (-), SDHB (+), SMA (a few cells +), and SOX-10 (-).

Conclusion

GISTs are the most common mesenchymal tumors found in the gastrointestinal tract, with a predominant occurrence in the stomach. The primary treatment approach is R0 resection. There is a clear trend towards minimally invasive techniques. Robotic-assisted gastric GIST resection with endoscopic transoral specimen extraction (GC-NOSES type IX) has shown significant advantages in minimally invasive surgery. However, the esophagus's unique anatomical structure necessitates careful selection of surgical indications, mastery of operative techniques, and excellent team coordination. Ensuring surgical safety is crucial to fully harness the minimally invasive benefits of this technique, thereby optimizing patient outcomes.

The Prediagnostic General Practitioners' Pathway of Gastrointestinal Stromal Tumor Patients: A Real-World Data Study

Background/Objectives: Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors of the gastrointestinal (GI) tract, predominantly driven by KIT or PDGFRα oncogene mutations. Nonspecific symptoms contribute to diagnostic delays, with general practitioners (GPs) playing a pivotal role in early detection. However, studies on GIST-specific primary care pathways are limited. This study examines GP contacts, diagnoses, and prescribed drugs in primary care during the 12 months preceding GIST diagnosis. Methods: This case-control study utilized data from the Netherlands Cancer Registry and Nivel Primary Care Database. It included 294 GIST patients diagnosed between 2010 and 2020 and 576 matched cancer-free controls. GP contacts, diagnoses, and newly prescribed drugs were analyzed across two time intervals: 0-4 and 5-12 months prediagnosis. Statistical comparisons were conducted using the Wilcoxon rank-sum test and descriptive analyses. Results: GIST cases had a median of six GP contacts (IQR 4-11) in the 12 months prediagnosis versus three (IQR 2-6) for controls (p < 0.05). Contacts increased 4 months before diagnosis, peaking 1 month prior. Common diagnoses in the 4-month interval included malignant neoplasms of the stomach (27.9%) and other digestive sites (27.6% and 11.2%), abdominal pain (9.5%), and iron deficiency anemia (9.5%). Newly prescribed drugs included proton pump inhibitors (13.9%) and osmotically acting laxatives (15.0%). Conclusions: This study highlights increased GP visits and specific reasons for these visits before GIST diagnosis. Future research should further examine GP records, not only through coded data but also unstructured data, and incorporate patient and GP perspectives to explore potential improvements in the diagnostic process.

Rectovaginal Extra-Gastrointestinal Stromal Tumors (EGISTs): A Systematic Review of the Literature and a Pooled Survival Analysis

Background/Objectives: Extra-gastrointestinal stromal tumors (EGISTs) are rare mesenchymal tumors arising outside the gastrointestinal tract, making up <5% of all GISTs. Rectovaginal EGISTs are particularly uncommon, with limited available data. This study systematically reviews the clinicopathological features, management, and outcomes of rectovaginal EGISTs. Methods: A systematic review of the English-language literature was conducted for studies on rectovaginal EGISTs (search date: 15 January 2025). Results: Thirty-one studies, including 40 female patients (mean age: 55.2 ± 15.4 years), met the inclusion criteria. Presenting symptoms included vaginal bleeding (24.3%), palpable mass (13.5%), constipation (10.8%), and abdominal pain (8.1%); however, the majority of patients (45.9%) were asymptomatic. Surgical excision was undertaken in 95% of patients, more often via local resection (61.1%). A high-grade mitotic index (>5/50 HPF) was noted in 63.2%. CD117, DOG-1, and vimentin was expressed in all cases, while CD34 was positive in 97.1%. Adjuvant therapy with tyrosine kinase inhibitors (TKIs) was administered in 57.5%, and neoadjuvant therapy was rare (8.6%). Recurrence occurred in 39.4% over a median follow-up of 40 ± 61.5 months, with a median disease-free survival (DFS) of 48 months. One death occurred 13 months postoperatively. Conclusions: Rectovaginal EGISTs are exceedingly rare and often asymptomatic, complicating preoperative diagnosis. Surgical resection remains the cornerstone of treatment, complemented by stage-specific neoadjuvant or adjuvant TKI therapy. The challenging location predisposes to recurrence, underscoring the need for further studies to optimize management and improve outcomes.

Nanomotor-driven precision therapy for peritoneal metastasis

Peritoneal metastasis (PM) is a terminal stage of gastrointestinal cancers, often resulting in poor survival outcomes. Traditional treatments like cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have shown some effectiveness but are associated with significant risks. This study presents a novel nanomotor-based drug delivery system (M@MnO2-Au-mSiO2@CDDP) designed to enhance the efficacy of PM treatment. By utilizing an oxygen-driven heterojunction nanomotor (MnO2-Au-mSiO2), coated with membrane of M1-type macrophages, the system targets PM tumors with high precision through intraperitoneal perfusion. These biomimetic NMs promote deep tumor penetration, enhance reactive oxygen species (ROS) generation, and activate the STING pathway, a critical component in immune regulation. The catalytic properties of MnO2 within the nanomotors enhance drug permeability and retention, enabling targeted and controlled drug release. Both in vitro and in vivo experiments demonstrated the system's ability to significantly inhibit tumor growth, induce apoptosis, and activate immune responses. In addition, the synergistic effect of targeted drug delivery, catalytic therapy and immunotherapy of this system was further confirmed by constructing an in vitro gastric cancer organoid model, showing great clinical application potential. The study also confirmed excellent biocompatibility and stability, making these NMs a promising clinical tool for the treatment of PM. This research underscores the potential of nanotechnology to revolutionize cancer treatment by overcoming the limitations of traditional therapies and paving the way for future innovations in targeted cancer therapies.

Hepatic hemangiomas mimicking gastrointestinal stromal tumors: A case report

BACKGROUND

Hepatic hemangiomas can be challenging to diagnose, particularly when they present with atypical features that mimic other conditions, such as gastrointestinal stromal tumors (GISTs). This case highlights the diagnostic difficulties encountered when imaging subepithelial lesions, especially when conventional methods such as computed tomography (CT) and endoscopic ultrasound (EUS) are used.

CASE SUMMARY

A 44-year-old woman presented with intermittent abdominal distension and heartburn for three months. Her medical history included iron deficiency anemia, menorrhagia, and previous cholecystectomy. One week prior to admission, an endoscopy suggested a bulging gastric fundus, which was likely a GIST, along with chronic nonatrophic gastritis and bile reflux. CT and EUS revealed nodules in the gastric fundus, which were initially considered benign tumors with a differential diagnosis of stromal tumor or leiomyoma. During surgery, unexpected lesions were found in the liver pressing against the gastric fundus, leading to laparoscopic liver resection. Postoperative pathology confirmed the diagnosis of hepatic cavernous hemangiomas. The patient recovered well and was discharged five days later, with normal follow-up results at three months.

CONCLUSION

This case underscores the challenges in the preoperative diagnosis of GISTs, particularly the limitations of the use of CT and EUS for the evaluation of subepithelial lesions. While CT is the primary tool for visualizing abdominal tumors, it is difficult to detect smaller lesions and assess the layers of the gastrointestinal wall on CT. EUS is recommended for the evaluation of nodules smaller than 2 cm and is useful for distinguishing GISTs from other lesions; however, its accuracy with regard to the differential diagnosis is relatively low. In this case, the gastric distension observed on imaging led to the compression of a liver tumor against the stomach, resulting in the misinterpretation of the tumor as a gastric wall lesion.

An artificial intelligence model utilizing endoscopic ultrasonography for differentiating small and micro gastric stromal tumors from gastric leiomyomas

BACKGROUND

Gastric stromal tumors (GSTs) and gastric leiomyomas (GLs) represent the primary subtypes of gastric submucosal tumors (SMTs) characterized by distinct biological characteristics and treatment modalities. The accurate differentiation between GSTs and GLs poses a significant clinical challenge. Recent advancements in artificial intelligence (AI) leveraging endoscopic ultrasonography (EUS) have demonstrated promising results in the categorization of larger-diameter SMTs (> 2.0 cm). However, the diagnostic capacity of AI models for micro-diameter SMTs (< 1.0 cm) remains uncertain due to limited imaging features. This study seeks to develop a specialized diagnostic model utilizing EUS images to differentiate small and micro GSTs from GLs effectively.

METHODS

In this study, a dataset comprising 358 EUS images of GSTs or GLs was utilized for training the EUS-AI model. Subsequently, 216 EUS images were allocated for validation purposes, with 159 images in validation set 1 (micro SMTs: tumor diameter < 1.0 cm) and 216 images in validation set 2 (small SMTs: tumor diameter < 2.0 cm). The diagnostic performance of the EUS-AI model for individual tumors was assessed by consolidating the diagnostic outcomes of the corresponding images. Comparative analyses were conducted between the diagnostic outcomes of endoscopists, clinical signatures, and those of the EUS-AI models.

RESULTS

The EUS-AI models were developed using DenseNet201, ResNet50, and VGG19 architectures. Among the three models, the ResNet50 model demonstrated superior performance on EUS images, achieving area under the curve (AUC) values of 0.938, 0.832, and 0.841 in the training set, validation set 1, and validation set 2, respectively. By combining predictions from multiple images for each tumor, the diagnostic efficacy of ResNet50 was further enhanced, resulting in AUCs of 0.994, 0.911, and 0.915 in the aforementioned sets. In comparison, both clinical signatures and endoscopists exhibited notably lower AUC values than those obtained with the EUS-AI model.

CONCLUSIONS

The EUS-AI model utilizing ResNet50 architecture effectively discriminates between micro GSTs and GLs from both image-centric and tumor-centric perspectives. Demonstrating superior diagnostic efficiency compared to clinical models and assessments by endoscopists, the EUS-AI model serves as a valuable tool for clinicians in precisely distinguishing small and micro GSTs from GLs before surgery.

Next questions on gastrointestinal stromal tumors: unresolved challenges and future directions

PURPOSE OF REVIEW

Despite remarkable progress in the management of gastrointestinal stromal tumors (GISTs), critical challenges persist. Key aspects such as risk stratification, the optimal duration of adjuvant therapy, and strategies to enhance the efficacy of first-line treatment remain subjects of ongoing debate. This review explores emerging concepts and innovative approaches aimed at refining patient selection and optimizing therapeutic decision-making to further improve clinical outcomes.

RECENT FINDINGS

Molecular and genomic parameters have the potential to enhance traditional risk models, enabling more precise stratification of high-risk patients. Innovations in artificial intelligence and liquid biopsy are emerging as powerful tools for refining predictions of recurrence and treatment response. Meanwhile, the definition and prognostic significance of tumor rupture remain pivotal challenges that influence both risk assessment and adjuvant therapy decisions. Furthermore, transcriptomic and multiomic analyses have unveiled distinct GIST subtypes with significant prognostic and therapeutic implications, paving the way for more tailored treatment strategies.

SUMMARY

Integrating molecular features into clinical decision making may refine risk assessment and personalize the treatment in patients with GIST. Future research should focus on validating these tools and redefine clinical trial designs to accelerate drug development for this rare disease.

Identifying and managing rare subtypes of gastrointestinal stromal tumors

INTRODUCTION

A subset of gastrointestinal stromal tumors (GISTs) lacks the common mutations in KIT/PDGFRa genes. This is a rare and heterogeneous group of challenging GISTs due to their diversity and absence of sensitivity to the tyrosine kinase inhibitor (TKI) imatinib.

AREAS COVERED

In this manscript, we review the pathogenesis, natural history, diagnostic features and management of KIT/PDGFRa wild-type (WT) GISTs, including SDH-deficient GISTs, GISTs with mutations in the RAS/RAF pathway, and quadruple WT GISTs which lack mutations in either KIT/PDGFRa and SDH genes or components of the RAS/RAF pathway, and syndromic GISTs as well as GISTs with rare KIT/PDGFRa mutations.

EXPERT OPINION

Patients should be managed in reference centers. There has been progress in the understanding of the biology of these GISTs, and promising therapeutic targets have been identified. In SDH-deficient GISTs, the TKI olverembatinib has shown encouraging clinical activity but requires further clinical validation, while the HIF2a inhibitor bezultifan and temozolomide alone or in combination with the death receptor agonist 5 are under clinical investigation. Targeting the RAS/RAF pathway in RAS/RAF-mutated GISTs warrants evaluation in clinical trials. Rare molecular alterations in quadruple WT GISTs require investigation for their oncogenic potential. Collaborative research and patient advocacy is critical for these extremely rare tumors.

A deep-learning model for predicting tyrosine kinase inhibitor response from histology in gastrointestinal stromal tumor

Over 90% of gastrointestinal stromal tumors (GISTs) harbor mutations in KIT or PDGFRA that can predict response to tyrosine kinase inhibitor (TKI) therapies, as recommended by NCCN (National Comprehensive Cancer Network) guidelines. However, gene sequencing for mutation testing is expensive and time-consuming and is susceptible to a variety of preanalytical factors. To overcome the challenges associated with genetic screening by sequencing, in the current study we developed an artificial intelligence-based deep-learning （DL） model that uses convolutional neural networks (CNN) to analyze digitized hematoxylin and eosin staining in tumor histological sections to predict potential response to imatinib or avapritinib treatment in GIST patients. Assessment with an independent testing set showed that our DL  model could predict imatinib sensitivity with an area under the curve (AUC) of 0.902 in case-wise analysis and 0.807 in slide-wise analysis. Case-level AUCs for predicting imatinib-dose-adjustment cases, avapritinib-sensitive cases, and wildtype GISTs were 0.920, 0.958, and 0.776, respectively, while slide-level AUCs for these respective groups were 0.714, 0.922, and 0.886, respectively. Our model showed comparable or better prediction of actual response to TKI than sequencing-based screening (accuracy 0.9286 versus 0.8929; DL model versus sequencing), while predictions of nonresponse to imatinib/avapritinib showed markedly higher accuracy than sequencing (0.7143 versus 0.4286). These results demonstrate the potential of a DL model to improve predictions of treatment response to TKI therapy from histology in GIST patients. © 2025 The Pathological Society of Great Britain and Ireland.

Gastrointestinal Stromal Tumors in the Stomach With Tumor Growth and Hemorrhage During Conservative Management: A Report of Two Cases

Gastrointestinal stromal tumors (GISTs) are often detected incidentally during esophagogastroduodenoscopy. Although surgical resection is the standard treatment for GISTs, patients with significant comorbidities may not be eligible for surgery and are managed conservatively. Herein, we report two cases of gastric GISTs that were initially observed during the management of other comorbidities but subsequently became enlarged, resulting in gastrointestinal bleeding. These cases highlight the potential risks of tumor progression and bleeding in patients undergoing conservative management.

Localized Excision of Gastrointestinal Stromal Tumor (GIST) After Sleeve Gastrectomy: Highlighting a Sleeve-Preserving Surgical Approach

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are relatively rare, accounting for approximately 0.1-3% of all gastrointestinal tumors. Their incidence is higher in individuals aged 50 to 70 years, with an equal gender distribution. Due to their diverse clinical presentations, including upper gastrointestinal (GI) bleeding and gastric discomfort, along with an indolent growth pattern, GISTs can remain undetected for extended periods. This delay in diagnosis can lead to complications. Diagnosis involves upper GI endoscopy, computed tomography (CT) scan, biopsy with histologic grading, and immunohistochemical testing for CD-117 and CD34. The higher incidence of GISTs in patients with obesity underscores the need for preoperative upper GI endoscopic screening.

CASE PRESENTATION

A 31-year-old female with a history of sleeve gastrectomy (SG) for obesity (BMI 38 kg/m2) presented 13 months postoperatively with recurrent hematemesis, epigastric fullness, and pain radiating to the back. Despite medical management, including proton pump inhibitors (PPIs), her symptoms persisted. Upper GI endoscopy revealed a polypoidal mass at the gastroesophageal junction (GEJ). Endoscopic ultrasound (EUS) indicated that the lesion originated from the muscularis propria. A contrast-enhanced CT scan confirmed the presence of a polypoid mass without extra-luminal extension, raising suspicion of GIST. The patient underwent laparoscopic resection of the tumor using a sleeve-preserving approach. The tumor was excised with a 1-cm margin of normal tissue, ensuring complete resection with negative margins confirmed by the frozen section. The gastric defect was closed with interrupted sutures, and a 38-Fr gastric tube was placed to maintain luminal patency. The patient had an uneventful recovery, with minimal drain output, and was discharged on postoperative day 3 with continued PPI therapy. Histopathological examination confirmed a low-risk GIST. At 1-year follow-up, the patient remained asymptomatic with no recurrence.

CONCLUSION

Early detection and sleeve-preserving resection of GISTs in post-sleeve gastrectomy patients ensure effective tumor management while maintaining gastric integrity. This case highlights the importance of preoperative evaluation and long-term follow-up in these patients.

Reopenable clip over-the-line method in endoscopic full-thickness resection of gastric submucosal tumors: A historical control study

OBJECTIVES

Endoscopic full-thickness resection for gastric submucosal tumors is gradually gaining popularity, and secure and amenable closure is key to its success. This study aimed to compare the reopenable clip over-the-line method with the purse-string method for defect closure after endoscopic full-thickness resection for gastric submucosal tumors.

METHODS

This historical control trial included 37 consecutive patients with 37 gastric submucosal tumors, who underwent endoscopic full-thickness resection between January 2021 and July 2024. All lesions were resected en bloc. After excluding three patients who underwent non-full-thickness resection, 34 patients were analyzed. Post-endoscopic full-thickness resection defects were closed using the purse-string method (n = 18) until 2022 and the reopenable clip over-the-line method (n = 16) from 2023.

RESULTS

The median (interquartile range) time for defect closure was longer in the reopenable clip over-the-line method group of 33 (31-57) min than in the purse-string method group of 26 (24-35) min (p = 0.013). The visual analog scale pain score at the umbilical region was lower (p = 0.048) after the reopenable clip over-the-line method than after the purse-string method. In the reopenable clip over-the-line method group, post-procedural abdominal pain was confined to the epigastrium, whereas it extended to the umbilical or left lateral regions in the purse-string method group. The reopenable clip over-the-line method group commenced the diet (p = 0.001) and discharged (p = 0.024) earlier than the purse-string method group.

CONCLUSIONS

Reopenable clip over-the-line method facilitated secure post-endoscopic full-thickness resection defect closure, reduced post-procedural abdominal pain, and shortened the fasting and hospitalization periods after endoscopic full-thickness resection in gastric submucosal tumors.

Transanal endoscopic local resection versus radical excision in the treatment of massive rectal gastrointestinal stromal tumors: striving for therapeutic advantages

Objectives

To compare the therapeutic advantages of transanal endoscopic local resection (taLR) and transabdominal radical resection (tbRR) in the treatment of massive gastrointestinal stromal tumors (GIST).

Design

Single-center retrospective study.

Methods

From October 2012 to October 2022, the clinical, surgical, pathological, and prognostic data of patients with rectal GIST who underwent surgery were retrospectively collected. The patients were divided into the taLR group and the tbRR group according to the surgical methods, and the research indicators were compared.

Results

Thirty-five patients with rectal GIST larger than 5 cm were enrolled, including 17 cases in the taLR group and 18 cases in the tbRR group. The taLR group showed shorter intraoperative time (p = 0.006), shorter postoperative hospital days (p = 0.035), earlier postoperative drainage tube removal (p = 0.007), and a higher anus preservation rate (p = 0.011). There was no significant survival difference in the 5-year disease-free survival between the taLR group and the tbRR group (94.1% vs 100%, p = 0.405).

Conclusion

In conclusion, there were no significant differences in survival between taLR and laparoscopic radical resection for massive rectal GIST. Moreover, compared with transabdominal radical excision technique, the transanal endoscopy surgery provides a new method of anal preservation, thereby improving the patient's quality of life.

Endoscopic full-thickness resection vs surgical resection for gastric stromal tumors: Efficacy and safety using propensity score matching

BACKGROUND

Endoscopic full-thickness resection (EFTR) is increasingly used for treating gastrointestinal stromal tumors (GISTs) in the stomach.

AIM

To compare the efficacy, tolerability, and clinical outcomes of EFTR vs surgical resection (SR) for gastric GISTs.

METHODS

We collected clinical data from patients diagnosed with GISTs who underwent either EFTR or SR at our hospital from October 2011 to July 2024. Patients were matched in a 1:1 ratio based on baseline characteristics and tumor clinical-pathological features using propensity score matching. We analyzed perioperative outcomes and follow-up data. The primary outcome measure was progression-free survival (PFS).

RESULTS

Out of 912 patients, 573 met the inclusion criteria. After matching, each group included 95 patients. The EFTR group demonstrated statistically significant advantages over the SR group in average operative time (P < 0.001), length of hospital stay (P < 0.001), time to resume liquid diet (P < 0.001), incidence of adverse events (P = 0.031), and hospitalization costs (P < 0.001). The en bloc resection rate was significantly different, with SR group at 100% and EFTR group at 93.7% (P = 0.038). The median follow-up was 2451.50 days. Recurrence occurred in 3 patients in the EFTR group and 4 patients in the SR group, with no statistically significant difference (P = 1.000). Factors associated with PFS included age, tumor size, high-risk category in the modified National Institutes of Health (NIH) risk score, and resection status. Resection status was identified as an independent prognostic factor for PFS (P = 0.0173, hazard ratios = 0.0179, 95%CI: 0.000655-0.491). Notably, there was no statistically significant difference in PFS between the two groups.

CONCLUSION

This study is a non-inferiority design. The EFTR group significantly outperformed the SR group in terms of operative time, length of hospital stay, time to resume a liquid diet, incidence of adverse events, and hospitalization costs, demonstrating its higher economic efficiency and better tolerability. Additionally, although the en bloc resection rate was lower in the EFTR group compared to the SR group, there were no significant differences in tumor recurrence rates and progression-free survival between the two groups. This study found no statistical difference in the primary endpoint of postoperative recurrence rates between the two groups. However, due to sample size limitations, this result requires further validation in larger-scale studies. The current results should be viewed as exploratory evidence.

Surgical resection for small (≤2 cm) gastric gastrointestinal stromal tumor

BACKGROUND

It is unclear whether surgical excision is the best course of treatment for small gastric gastrointestinal stromal tumor (GIST) ≤2 cm. The aim of this study was to evaluate the long-term survival results of surgical and non-surgical treatment for small gastric GIST.

METHODS

Between 2000 and 2021, patients with small gastric GIST were chosen from the Surveillance, Epidemiology, and End Results (SEER) database. Propensity score matching (PSM) was used to mitigate selection bias in the comparison process. Kaplan-Meier analysis and multivariate Cox model were used to assess the effects of demographic and clinical characteristics on overall survival (OS) and cancer-specific survival (CSS).

RESULTS

A total of 1229 patients with gastric GIST (≤2 cm) were included, including 1004 (81.69 %) patients who underwent operative management and 225 (18.31 %) who received non-operative management. The 5-year OS and CSS rates were compared between the two groups before PSM [5-year OS (83.51 % vs. 79.53 %, P < 0.001), 5-year CSS (96.96 % vs. 91.81 %, P = 0.017)]; after PSM [5-year OS (82.79 % vs. 80.00 %, P = 0.039), and 5-year CSS (94.88 % vs. 94.42 %, P = 0.398)]. Furthermore, after correcting for covariates, operative management was associated with a significant improvement in OS (HR = 0.62, 95 % CI 0.40-0.97, P = 0.037), while no significant effect on CSS was observed (HR = 0.85, 95 % CI 0.43-1.70, P = 0.643).

CONCLUSIONS

Our analysis demonstrated a statistically significant association between operative management and improved OS for small gastric GIST (≤2 cm).

Significance of monitoring imatinib plasma concentration in second-line treatment decisions for c-kit 11 gene-mutated gastrointestinal stromal tumors

BACKGROUND

For patients with advanced gastrointestinal stromal tumors (GISTs) carrying the c-kit exon 11 mutation, imatinib (IM) at a standard dosage of 400 mg per day is the preferred first-line treatment. In cases where treatment with IM fails, there is an urgent need for a more precise assessment method to determine whether to switch therapies or escalate the IM dosage. This approach will enhance clinical decision-making and optimize patient outcomes.

AIM

To investigate IM plasma concentration's role in second-line treatment decisions for c-kit 11-mutated advanced GISTs post-IM failure.

METHODS

Patients with advanced GIST harboring c-kit 11 mutation who experienced failure with IM 400 mg per day as first-line treatment at our hospital were retrospectively analyzed. Patients were categorized into a low plasma (LP) concentration group (LP group, < 1100 ng/mL) and high plasma (HP) concentration group (HP group, ≥ 1100 ng/mL). Each group was further subdivided into Group A (dose-escalation group) and Group B (drug-switch group). Baseline characteristics were compared and Kaplan-Meier curves were used to analyze the survival of patients.

RESULTS

Seventy-five patients were included in the analysis. For the LP group (n = 28), Group A (n = 14) had longer overall survival (OS) than Group B (n = 14) (P = 0.02). No differences were observed between the two subgroups in disease control rate (DCR), objective response rate, and progression-free survival (PFS) (P > 0.05). For the HP group (n = 47), Group B (n = 18) had a higher DCR and longer PFS than Group A (n = 29) (P = 0.008 and P = 0.03, respectively). No difference in OS was observed between the two subgroups (P > 0.05).

CONCLUSION

Increasing IM dosage for c-kit 11-mutated advanced GISTs post-IM failure may prolong OS if plasma concentration is < 1100 ng/mL. Switching tyrosine kinase inhibitors may improve DCR and PFS if ≥ 1100 ng/mL.

Study on the predictive value of preoperative CT features for the mitotic index of GIST based on the nomogram

This study aimed to construct a Nomogram based on preoperative CT features to predict the mitotic index in gastrointestinal stromal tumors and to establish preoperative risk stratification. The constructed nomogram prediction model is targeted towards guiding preoperative risk stratification, facilitating the provision of rational drug administration regimens, and tailoring appropriate surgical plans for personalized treatment. The imaging and pathological data of 250 patients with gastrointestinal stromal tumors in Shanxi Provincial hospital from January 2019 to January 2024 were retrospectively analyzed. According to the pathological data, the patients were divided into high mitotic index and low mitotic index, and were divided into a training group (n = 176) and a validation group (n = 74) according to a stratified sampling ratio of 7:3. In the training group, statistically significant variables were screened out by univariate analysis for multivariate logistic regression analysis, and independent risk factors were screened out and a Nomogram prediction model was constructed. The receiver operating characteristic (ROC) was used to evaluate the model discrimination, and the predicted probability risk was stratified by the optimal cutoff value. The Hosmer-Lemeshow test (HL test) was performed, and the calibration curve was drawn by Bootstrap repeated sampling 1000 times to evaluate the model consistency. Finally, the clinical application value of the prediction model was evaluated by the decision curve analysis (DCA). There were no significant differences in the distribution of clinical characteristics and CT features between the training group and the validation group ( P>0.05). Univariate analysis showed that the differences in tumor size, tumor site, boundary, calcification, liquefaction/necrosis, morphological characteristics, growth pattern, and ulceration were statistically significant (P<0.05). Multivariate logistic regression analysis screened out tumor size (GIST ≤ 2 cm, P = 0.018; GIST 2-5 cm, p = 0.009; GIST 5-10 cm, P = 0.017), liquefaction/necrosis (P = 0.002), and morphological characteristics (P = 0.002) as independent risk factors for high mitotic index. The Nomogram was established based on these three factors. The area under the curve (AUC) of the training group and the validation group of the model were 0.851 (95%CI: 0.793-0.91) and 0.836 (95%CI: 0.735-0.937), the specificity was 0.696 and 0.735, and the sensitivity was 0.869 and 0.760, respectively. The HL test had good calibration (training group P = 0.461, validation group P = 0.822), indicating that the predicted risk was consistent with the actual risk. The DCA also showed good clinical practicality. The Nomogram prediction model that incorporates preoperative CT features of tumor size, liquefaction/necrosis, and morphological characteristics can effectively predict the number of mitotic figures in gastrointestinal stromal tumors, and can perform effective preoperative risk stratification to guide clinical decision-making and personalized treatment.

Management of subepithelial esophageal tumors

Subepithelial esophageal tumors (SET) are normally benign intramural esophageal lesions of mesenchymal origin. Although rare, the incidence of SET has increased in recent decades due to the more widespread use of endoscopy and diagnostic imaging. The current review aims to provide an overview of the histopathologic spectrum and the most frequent entities including leiomyoma and gastrointestinal stromal tumor (GIST), diagnostic workup, and multidisciplinary treatment options. Staging for SET should include endoscopy, endoscopic ultrasonography (EUS), and tissue sampling. Current consensus guidelines recommend that SET suggestive of gastrointestinal stromal tumor (GIST) larger than 20 mm or lesions with high-risk stigmata should undergo tissue sampling. Most SET have an excellent long-term outcome, but malignancy may be present in certain subtypes. Asymptomatic SET without high-risk stigmata discovered incidentally usually do not require specific treatment. However, depending on the size and location of the lesion symptoms may occur. Therapeutic interventions range from endoscopic interventional resections to major surgical procedures. Enucleation via minimally invasive or robotic-assisted access remains the standard of care for most SET sub-entities.

YAP acts as an independent prognostic marker and regulates growth and metastasis of gastrointestinal stromal tumors via FBXW7-YAP pathway

BACKGROUND

Although imatinib (IM) and subsequent tyrosine kinase inhibitors (TKIs) significantly improve the prognosis of GIST patients by delaying metastasis and recurrence, most patients experience limited efficacy due to toxicity and secondary resistance. We evaluated Yes-associated protein (YAP), a coactivator of the Hippo pathway accounting for IM resistance and aggressive GIST phenotypes, in GISTs. The degradation of YAP is mediated by FBXW7, and FBXW7 predicts recurrence and IM efficacy for GIST patients. Here, we aimed to identify the potential of YAP as a prognostic marker for patients with GISTs, and the molecular mechanism of FBXW7-YAP pathway in GIST cells.

METHODS

We measured YAP expression in 167 GIST cases using immunohistochemical staining, correlated its expression levels with clinicopathological features, and the molecular mechanism underlying the FBXW7-YAP pathway was further examined in vitro and in vivo.

RESULTS

Compared to 80 (47.9%) cases in the low YAP expression group, 87 (52.1%) cases with high YAP expression associated with a poorer prognosis in terms of overall survival (P = 0.004) and recurrence-free survival (P = 0.003). YAP expression was identified as a significant independent factor affecting the 5-year overall survival (P = 0.005) and recurrence-free survival rates (P = 0.007). Moreover, YAP was directly targeted by FBXW7 to affect proliferation, invasion, and migration in GIST cells. High YAP expression correlated with FBXW7 deficiency, as shown in xenograft and metastasis mouse models.

CONCLUSIONS

YAP expression serves as a predictive marker of recurrence for GIST patients with curative resection, highlighting its potential as a novel therapeutic target that warrants further investigation.

Clinical description and development of a prognostic score for neurofibromatosis type 1 (NF1)-associated GISTs: a retrospective study from the NETSARC

BACKGROUND

Gastrointestinal stromal tumors (GISTs) occur in ∼7% of neurofibromatosis type 1 (NF1) patients. Data about their natural history remain scarce and neither risk classifications, prognosis model nor adjuvant treatment have been validated in this population.

METHODS

This national retrospective study included consecutive operated NF1-GIST cases from 31 reference centers in France, mostly from the NETSARC+ network. Factors associated with relapse were used to build a new prognostic score (RECKGIST). To address potential bias between adjuvant group and follow-up group, a propensity score was used.

RESULTS

A total of 119 patients were included between 2008 and 2023, of whom 61% were women. Median age was 53 years (range 20-78 years). The main primary location was the small bowel (86%) and the stomach (11%). Median size and mitotic count (mit) were 45 mm [95% confidence interval (CI) 45-58 mm] and 2 mit/5 mm2 (95% CI 3-9 mit/5 mm2), respectively. The vast majority were KIT/PDGFRA wild type (mutation KIT 2%, PDGFRA 3%). The median follow-up was 6 years. For GISTs <30 mm (n = 35), none relapsed. For GISTS >30 mm (n = 84), 18 developed metastases (21%). There was no difference in relapse according to tumor location (P = 0.45) or tumor rupture (P = 0.11), whereas KIT/PDGFRA-mutated GISTs were at higher risk of relapse [recurrence-free survival (RFS) at 10 years of 30% versus 82.5% for wild type, P = 0.03]. Miettinen and Joensuu classification did not predict relapse accurately. For the RECKGIST score A (size ≤30 mm, n = 34) group, 10-year RFS was 100%; it was 78.5% in the RECKGIST B group (size >30 mm and 0 < mit ≤ 5, n = 60), and 45.5% in the RECKGIST C group (size >30 mm and mit >5, n = 20) (P < 0.0001). After matching, 10-year RFS was similar between adjuvant and surveillance groups (P = 0.34).

CONCLUSIONS

For NF1-GISTs <30 mm, prognosis without relapse is excellent. RECKGIST score accurately predicts recurrence and needs to be validated in an external cohort, but it may help treatment decision making. No efficacy of adjuvant treatment was observed.

Gastrointestinal stromal tumours (GIST) in children: An update of this orphan disease

BACKGROUND

Gastrointestinal stromal tumours (GIST) are tumours of the digestive tract that mainly develop in adults. Recommendations for the management of GIST in pediatrics are limited.

MATERIAL AND METHODS

We performed an updated review of the literature serving as a basis for the development of diagnostic and therapeutic recommendations for GIST in children and young adults (YA).

RESULTS

GIST in pediatric population can have a sporadic presentation but occur more often in a syndromic and/or familial context. Currently more than 170 cases of sporadic GIST or in association with Carney-Stratakis syndrome or Carney's triad family cases of familial GIST have been described in children and YA. These syndromes are frequently associated with germline or somatic alterations in a sub-unit of Succinate Dehydrogenase (SDH). In contrast, the frequency of somatic KIT and PDGFRα oncogene mutations (±15%) is significantly lower as compared to adults with GIST. The recommendations for the management of children with GIST are generally comparable to those used for adult patients, although certain biological differences influence the therapeutic attitude.

CONCLUSIONS

International collaborations have been deployed in order to increase the clinical and biological knowledge of this orphan pathology in pediatrics.

Racial Disparities and Trends in Outcomes of Patients with Gastrointestinal Stromal Tumors

BACKGROUND

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the gastrointestinal tract. However, there are limited studies on the latest survival trends and the impact of racial disparities on GIST patients' outcomes.

METHODS

We obtained 12,808 GIST patients between 2001 and 2020 from the Surveillance, Epidemiology, and End Results (SEER) database in 17 original sites. Analysis utilizing the Kaplan-Meier method explored survival disparities and Cox regression was employed to assess the impact of prognostic factors.

RESULTS

Our study revealed an increase in the GIST incidence per 100,000 people over the past two decades, along with a rise in relative survival rate (RSR). Age, gender, social groups, tumor site, size, stage, socioeconomic status, marital status, surgery, and systemic therapy are prognostic factors. Subgroup analysis indicated higher incidence and poorer survival trends among Non-Hispanic Blacks (NHB) (Incidence, 1.88 per 100,000 people; 120 Mo RSR, 61.6%, 2001 to 2020). Colonic GIST has the worst prognosis among different locations, while rectal and anal GIST has the best. Within these groups, Non-Hispanic White (NHW) with colonic GIST have the poorest prognosis (HR, 2.032; 95% CI, 1.476-2.798), whereas NHB with rectal and anal GIST have the best prognosis.

CONCLUSION

The incidence and RSR of GIST both increased during 2001-2020. NHW with colonic GIST showed poorer survival, while NHB with rectal and anal GIST revealed better survival, highlighting the importance of targeted clinical management for GIST.

Inflammatory biomarker correlations and prognosis in high-risk gastrointestinal stromal tumor patients: a multicenter retrospective analysis

BACKGROUND

The accurate prognosis of gastrointestinal stromal tumors (GISTs) has garnered substantial attention, yet a gap persists in understanding the influence of inflammatory markers on the prognosis of high-risk GIST patients. This study investigated the relationship between various factors and the prognosis of high-risk GIST patients, with a specific focus on first recurrence-free survival (RFS) and overall survival (OS) as crucial prognostic indicators.

METHODS

A comprehensive collection of clinical data was conducted on 145 high-risk GIST patients meeting specific inclusion and exclusion criteria at 17 medical centers in Ningxia Hui Autonomous Region, China, covering the period from January 2013 to December 2019. Single-factor analysis and survival curves were used to analyze the variables, while the Cox regression model evaluated independent prognostic factors.

RESULTS

Within the cohort, a balanced male-to-female ratio of 1:1.1 was observed. Univariate analysis revealed compelling associations between RFS and age, preoperative neutrophil-to-lymphocyte ratio (NLR), preoperative platelet-to-lymphocyte ratio (PLR), preoperative systemic immune-inflammatory index (SII), preoperative prognostic nutritional index (PNI), mitotic index, and whether or not imatinib (IM) was taken regularly in high-risk GIST patients (P < 0.05). Except age, these other variables were also significantly correlated with OS (P < 0.05). Cox regression analysis showed that age, preoperative PNI, mitotic index and postoperative IM adjuvant therapy independently affected RFS (P < 0.05). In addition, preoperative PNI and postoperative IM adjuvant therapy were also independent factors of OS, with statistical significance (P < 0.05). Age was negatively correlated with RFS, and early routine IM treatment after operation significantly reduced the risk of recurrence and death. Higher mitotic index is closely related to poor RFS, and higher preoperative PNI indicates a better prognosis.

CONCLUSION

A close correlation between young age, low preoperative PNI, high mitotic index, and lack of IM treatment had an unfavorable prognosis in high-risk GIST patients. Notably, the PNI was identified as a potential additional prognostic factor, enhancing the accuracy of predicting treatment efficacy and patient outcomes in high-risk patients with GISTs. Therefore, we advocate for the serious consideration of the PNI as a valuable addition to standard clinical practice for managing high-risk GIST patients.

Feasibility study of synchronously increasing dose of multi-shell structure to improve stereotactic ablation radiotherapy central dose of large volume locally advanced gastrointestinal stromal tumors using cyberKnife

Purpose. Increasing the central dose for large, locally advanced, drug-resistant gastrointestinal stromal tumors (LADR-GISTs) has consistently been a significant challenge. This study explores the feasibility of using multiple shell structures within the tumor to enhance the central ablation dose of large LADR-GIST by increasing the shell doses.Methods and Materials. This study involved five patients with large LADR-GIST who were treated with CyberKnife. The gross tumor volume (GTV) was delineated as a multi-shell structure. Five dose escalation plans (SIB-SBRT) were created for each patient, varying the dose escalation ratios. The radiation doses for the center of the GTV (GTV center) in these plans ranged from 49 Gy to 70 Gy. Parameter evaluations were conducted comparing the SIB-SBRT plans with conventional SBRT plans (Con-SBRT), focusing on equivalent uniform dose (EUD), relative equivalent uniform dose (rEUD), dose volume parameters, conformal index (CI), new conformal index (nCI), gradient index (GI), and monitor unit (MU). The Friedman Test was employed to determine statistical differences (P< 0.05), followed by pairwise comparisons.Results. When the dose escalation ratios reached 25% of the prescribed dose, the average rEUD increased to 6.92, and the proportion of the GTV volume with Biologically Equivalent Dose (BED)> 100 Gy increased to 30.69%. At dose escalation ratios of 30% of the prescribed dose, the rEUD stabilized, but the radiation dose received by the bladder, colon, and duodenum significantly increased. Except for the SIB25-SBRT and SIB30-SBRT groups, no statistically significant differences were observed between the other SIB-SBRT groups and the Con-SBRT group across various evaluation metrics.Conclusions. The method of synchronously increasing the dose using a multi-shell structure is feasible for stereotactic ablation in the treatment of LADR-GISTs using CyberKnife. The results indicate that dose escalation ratios of 25% of the prescribed dose can provide a satisfactory ablation dose (BED > 100 Gy), covering 31% of the large tumor volume.

Endoscopic calabash technique for gastric mesenchymal tumours: A low hanging fruit or a novel endoscopic technique?

The term subepithelial lesions encompasses a wide array of pathology of which numerous benign and malignant pathologies are grouped. A subset of these lesions are termed gastric mesenchymal tumours of which some have innate malignant potential. Currently there is various guidance on the recommended approach to the investigation and management of these lesions and there exists multiple methods of resection. Lin et al have developed and proposed a new method of resection of these gastric mesenchymal tumours within the field of endoscopy, a procedure they have termed endoscopic calabash ligation and resection. This editorial aims to outlay the current landscape for gastric mesenchymal tumours with regards to the various guidelines and resection techniques while comparing Lin et al's new technique to those that are already established in the field of endoscopy. Advancements in endoscopy that maintain or improve patient outcomes compared to the gold standard approach are exciting developments. Lin et al's study suggests that their technique is comparable in regard to patient outcomes while simultaneously being more efficient in its use of hospital resources including procedural time. Whilst the data and analysis proposed in the study is promising, there are areas that need to be addressed before advocating the procedure for widespread use. However, with further studies and analysis this may be foreseeable in the future.

Incidentally Discovered Duodenal Gastrointestinal Stromal Tumour (GIST): Operative Treatment and Problems After Surgery-A Case Report and Literature Review

Background: Gastrointestinal stromal tumours (GISTs) are mesenchymal tumours of the digestive tract that can involve any part of the tract. The tumours can be harmless or life-threatening. Materials and Methods: A case report of a surgeon who fell in a Finnish sauna, and he immediately felt that some ribs were broken. Magnetic resonance imaging and ultrasound showed three fractured ribs and an intrasplenic haematoma. Contrast-enhanced computed tomography (CT) demonstrated a small intrasplenic anomaly but no haematoma. Incidentally, an incidentaloma in the left adrenal gland was diagnosed. Three months later, a control CT scan was performed. The radiological findings on the adrenal gland and laboratory examinations matched those of a benign adenoma. Incidentally, a small duodenal tumour was diagnosed. At the same time, anaemia (haemoglobin: 104 g/L) and iron deficiency (ferritin: 8 μg/L) were noticed. An esophagogastroduodenoscopy showed an intramural tumour localised after the bulb-descending junction. Because the tumour was submucosal, the pathological diagnosis failed. Three months later, a radical surgical resection of the tumour with a resection margin of 2 mm and primary closing of the duodenum was performed. Pathological examination showed a well-circumscribed submucosal mesenchymal tumour with spindle cells. A tumour-free margin was uncertain. Immunohistochemistry findings showed a GIST. Due to the uncertain margin, an esophagogastroduodenoscopy control was planned at 2 years postoperatively. The patient disagreed with the decision and ordered a private control CT 3 months after the operation. The new CT found no local recurrence or metastasis. The patient contacted the head surgeon of the clinic, who ordered a 1-year postoperative CT. The 1-year follow-up CT finding agreed with the previous findings. Conclusion: The aftertreatment of a radical-operated GIST is extremely important if histologic examination of the tumour-free margin is uncertain. In that case, CT controls should be considered once a year for at least 3 years.