Medical Oncological Treatment for Patients with Gastrointestinal Stromal Tumour (GIST) - a Systematic Review

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.

Long-term outcomes of endoscopic treatment versus surgical resection for 0-2 cm gastrointestinal stromal tumor: A SEER database study

BACKGROUND

The optimal management of gastrointestinal stromal tumor (GIST) ≤ 2 cm in diameter remains debated. This study aimed to compare long-term survival outcomes between patients with small GIST undergoing endoscopic treatment (ET) and those treated with surgical resection (SR).

METHODS

Between 2000 and 2021, patients with small GIST were selected from the Surveillance, Epidemiology, and End Results (SEER) database. Propensity score matching (PSM) was employed to minimize selection bias in the comparison process. Kaplan-Meier analysis and multivariate Cox proportional hazards models were applied to evaluate the effects of demographic and clinical characteristics on overall survival (OS) and cancer-specific survival (CSS).

RESULTS

A total of 1400 patients with small GIST were included, comprising 470 (33.57%) undergoing ET and 930 (66.43%) receiving SR. The 5-year OS and CSS rates were compared between the ET and SR groups both before and after PSM. Before PSM, the 5-year OS rates were 75.28% vs. 83.96% (P = 0.878), and CSS rates were 94.38% vs. 95.09% (P = 0.284). After PSM, the corresponding rates were 85.81% vs. 86.45% (P = 0.393) for OS and 96.77% vs. 95.48% (P = 0.075) for CSS. Multivariable analysis adjusting for covariates demonstrated comparable risks of OS (HR = 0.96, 95% CI 0.74-1.24, P = 0.737) and CSS (HR = 1.26, 95% CI 0.72-2.20, P = 0.426) between the two treatment groups. No significant differences were observed between the groups after PSM.

CONCLUSIONS

Our findings demonstrate comparable long-term OS and CSS outcomes between endoscopic and surgical treatment groups in patients with GIST ≤ 2 cm in diameter.

Huaier inhibits the proliferation and migration of gastrointestinal stromal tumors by regulating the JAK2 / STAT3 signaling pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the digestive tract, often accompanied by a high risk of recurrence and drug resistance. Huaier (Trametes robiniophila Murr), a traditional Chinese medicinal fungus, has demonstrated potent anticancer properties and is widely used as an adjuvant treatment for liver, breast, gastric, colon, and non-small cell lung cancers. However, its effects and molecular mechanisms in GIST remain unclear.

AIM

This study aims to explore the inhibitory effects and underlying mechanisms of Huaier on GIST through network pharmacology and experimental validation.

MATERIALS AND METHODS

Initially, we utilized a publicly accessible database to identify the core targets and principal pathways associated with Huaier's therapeutic effects on gastrointestinal stromal tumors. To further evaluate its biological impact, cell viability, proliferation, migration, and invasion were assessed through CCK-8 and EdU assays, wound healing tests, and Transwell experiments. Apoptotic cell death was quantified using flow cytometry analysis. Additionally, the influence of Huaier extract on the expression levels of JAK2 and STAT3 proteins was examined via Western blotting. Finally, a subcutaneous xenograft mouse model was employed to investigate the anti-tumor efficacy of Huaier in vivo.

RESULTS

In this study, GAPDH, TNF, STAT3, ESR1, EGFR, IL6, CCND1, PTGS2, BCL2L1, and MAPK3 were identified as shared molecular targets, with the JAK/STAT signaling pathway recognized as the pivotal regulatory mechanism. Experimental findings demonstrated that Huaier exerted inhibitory effects on the proliferation, migration, and invasion of GIST-T1 and GIST-882 cells, exhibiting both dose- and time-dependent responses. Furthermore, Huaier was found to promote apoptosis in these cells. Western blot analysis revealed that treatment with Huaier extract significantly decreased the phosphorylation levels of JAK2 and STAT3, thereby suppressing the activation of the JAK2/STAT3 signaling cascade. In vivo experiments further substantiated these findings, showing that Huaier treatment markedly reduced tumor size and inhibited tumor progression.

CONCLUSIONS

Our results suggest that Huaier may inhibit the growth of GIST cells by inhibiting the JAK2/STAT3 signaling pathway, reduce cell proliferation, induce apoptosis, reduce cell migration and invasion, and show anti-tumor effects in vivo and in vitro.

A nomogram for predicting survival in patients with gastrointestinal stromal tumor: a study based on the surveillance, epidemiology, and end results database

PURPOSE

The objective of this investigation was to construct and validate a nomogram for prognosticating cancer-specific survival (CSS) in patients afflicted with gastrointestinal stromal tumor (GIST) at 3-, 5-, and 8-years post-diagnosis.

METHODS

Data pertaining to patients diagnosed with GIST were acquired from the Surveillance, Epidemiology, and End Results (SEER) database. Through random selection, a training cohort (70%) and a validation cohort (30%) were established from the patient population. Employing a backward stepwise Cox regression model, independent prognostic factors were identified. Subsequently, these factors were incorporated into the nomogram to forecast CSS rates at 3-, 5-, and 8-years following diagnosis. The nomogram's performance was assessed using indicators such as the consistency index (C-index), the area under the time-dependent receiver operating characteristic curve (AUC), the net reclassification improvement (NRI), the integrated discrimination improvement (IDI), calibration curves, and decision-curve analysis (DCA).

RESULTS

This investigation encompassed a cohort of 3,062 GIST patients. By analyzing the Cox regression model within the training cohort, nine prognostic factors were identified: age, sex, race, marital status, AJCC (American Joint Committee on Cancer) stage, surgical status, chemotherapy status, radiation status, and income status. The nomogram was subsequently developed and subjected to both internal and external validation. The nomogram exhibited favorable discrimination abilities, as evidenced by notably high C-indices and AUC values. Calibration curves confirmed the nomogram's reliability. Moreover, the nomogram outperformed the AJCC model, as demonstrated by enhanced NRI and IDI values. The DCA curves validated the clinical utility of the nomogram.

CONCLUSION

The present study has successfully constructed and validated the initial nomogram for predicting prognosis in GIST patients. The nomogram's performance and practicality suggest its potential utility in clinical settings. Nevertheless, further external validation is warranted.

The Role of Neoadjuvant Therapy in a Giant Gastric Gastrointestinal Stromal Tumour: A Case Report and Review of the Literature

Gastric gastrointestinal stromal tumour (GIST) is a rare disease with an annual incidence of 10 cases per million. Herein, we present the case of a 45-year-old man who visited our clinic with complaints of weight loss and anorexia, without changes in bowel habits or vomiting, for four months. On physical examination, all vital signs were normal. The abdomen was distended without tenderness and had a giant upper abdominal mass. Tumour marker investigation revealed high levels of cancer antigen 125 with normal levels of alpha-1-fetoprotein, carcinoembryonic antigen, and carbohydrate antigen. A computed tomography (CT) scan showed a mass measuring 35 × 25 × 20 cm, likely originating from the fundus of the stomach. Upper gastrointestinal endoscopy indicated external compression of the stomach and a fundal submucosal mass. Ultrasound-guided biopsy demonstrated the presence of a GIST. There was a severe danger of both the tumour rupturing during surgery and the combined excision of adjacent organs if the surgery was performed with the massive tumour. Therefore, daily neoadjuvant therapy with imatinib 400 mg was administered for three months. Post-therapeutic CT indicated a significant reduction in the size of the mass, which now measured 17 × 14 × 21 cm. The patient underwent surgical resection a month after the completion of neoadjuvant therapy, and the post-operative period was uneventful. He was followed up regularly at the general surgery department for 24 months without recurrence. This case asserts the benefit of neoadjuvant therapy in reducing the tumour size pre-operatively, which enhances the complete resection rate, prevents the need for multi-organ resection, and lowers the risk of surgery.

KIT and PDGFRA Variants and the Survival of Patients with Gastrointestinal Stromal Tumor Treated with Adjuvant Imatinib

Adjuvant imatinib improves the recurrence-free survival and overall survival (OS) of patients with gastrointestinal stromal tumors (GISTs) who have a high risk of recurrence after surgery and is now considered standard treatment. Yet, OS benefit has been demonstrated in only one randomized study, the Scandinavian Sarcoma Group XVIII/AIO trial, where patients with high-risk GISTs were allocated to either 1 year or 3 years of adjuvant imatinib. SSGXVIII/AIO is also the only randomized trial in which adjuvant imatinib duration exceeding 2 years was evaluated. In this trial, the 3-year treatment led to a 45% reduction in the risk of death during the first 10 years that followed random allocation even though some of the patients did not have GISTs at tumor histology review, had mutations now known to be imatinib-resistant or had non-localized disease at study entry. In the subgroup of patients who had KIT exon 11 deletion/indel mutation, the reduction in the risk of death was 66% in favor of the longer treatment. Proper patient selection is of crucial importance since many patients are cured with surgery. Little evidence for OS benefit is available from randomized trials for patients whose GIST harbors KIT exon 9 mutation, KIT insertion mutation, PDGFRA D842V mutation, or lacks KIT and PDGFRA mutations. Adjuvant imatinib improves OS substantially if high-risk GISTs can be identified, treatment duration is long enough, and GISTs harbor an imatinib-sensitive mutation.

Efficacy of post-first-line agents for advanced gastrointestinal stromal tumors following imatinib failure: A network meta-analysis

BACKGROUND

Imatinib is the standard first-line treatment for advanced gastrointestinal stromal tumors (GISTs); however, most patients eventually develop imatinib resistance, leading to considerable clinical challenges. Few direct comparisons have been made between different post-first-line therapies on clinical efficacy in advanced GIST following imatinib failure.

METHODS

Databases including PubMed, Embase, Scopus, Google Scholars, and Cochrane Library from inception to February 2023 were retrieved for randomized controlled trials evaluating the clinical efficacy of different post-first-line agents for advanced GIST following imatinib failure. Network and conventional meta-analysis were carried out using Stata/MP 16.0.

RESULTS

Ripretinib showed significant improvement in progression-free survival (PFS) rates from the 2nd to the 12th month compared to placebo, while there was virtually no evidence that the rest active agents had a significant benefit at the 12th month. Masitinib, ripretinib, sunitinib, regorafenib, and pimitespib exhibited significantly longer median PFS than placebo, and pairwise comparisons indicated there were no significant differences among masitinib, ripretinib, and sunitinib. These post-first-line agents decreased the risk of disease progression or death by 65% (HR = 0.35, 95% CI: 0.26-0.47) compared to placebo. Ripretinib and sunitinib came into effect earlier and exhibited more consistent overall survival (OS) rate improvements than masitinib and pimitespib, while pairwise comparisons revealed no significant differences in these four active agents concerning the improvement in OS rate. These post-first-line agents decreased the risk of death by 39% (HR = 0.61, 95% CI: 0.44-0.83) over placebo for advanced GIST following imatinib failure.

CONCLUSION

The active agents in our analysis as post-first-line therapies are able to provide superior clinical efficacy, with improved PFS rate and OS rate at certain time points, as well as absolute values of PFS and OS for advanced GIST. Ripretinib might be the optimal recommendation as a post-first-line treatment for advanced GIST following imatinib failure.

Targeted Treatment of Soft-Tissue Sarcoma

Background: Soft-tissue sarcoma (STS) is a heterogeneous group of sarcomas with a low incidence. The treatment of advanced disease is poor, and mortality is high. We aimed to generate an overview of the clinical experiences with targeted treatments based on a pre-specified target in patients with STS. Methods: A systematic literature search was conducted in PubMed and Embase databases. The programs ENDNOTE and COVIDENCE were used for data management. The literature was screened to assess the article's eligibility for inclusion. Results: Twenty-eight targeted agents were used to treat 80 patients with advanced STS and a known pre-specified genetic alteration. MDM2 inhibitors were the most-studied drug (n = 19), followed by crizotinib (n = 9), ceritinib (n = 8), and ⁹⁰Y-OTSA (n = 8). All patients treated with the MDM2 inhibitor achieved a treatment response of stable disease (SD) or better with a treatment duration of 4 to 83 months. For the remaining drugs, a more mixed response was observed. The evidence is low because most studies were case reports or cohort studies, where only a few STS patients were included. Conclusions: Many targeted agents can precisely target specific genetic alterations in advanced STS. The MDM2 inhibitor has shown promising results.