Advanced gastrointestinal stromal tumor patients benefit from palliative surgery after tyrosine kinase inhibitors therapy

Giant exophytic gastrointestinal stromal tumor (GIST) causing gastric outlet obstruction: case report and review of literature

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors, mostly located within the stomach. About 30% of GISTs are incidentally diagnosed and as they become symptomatic may be associated with bleeding, bowel obstruction or spontaneous rupture.

CASE PRESENTATION

We present the case of a middle-aged patient diagnosed with a giant gastric GIST, which presented for intermittent gastric outlet obstruction symptoms, and emphasize the major imagistic, histopathological, and therapeutic challenges that may be encountered. There are only several cases of gastric exophytic gastric GIST provoking intermittent gastric outlet obstruction. Tumor resection should be adapted to every patient's status, focused on en bloc extraction, with preservation of invaded organs as much as possible.

Liver resection for metastatic GIST tumor improves survival in the era of tyrosine kinase inhibitors: a systematic review and meta-analysis

INTRODUCTION

Survival for gastrointestinal stromal tumor (GIST) has been increasing over the years after the introduction of tyrosine kinase inhibitors. However, the role of metastasectomy for GIST is still controversial. Patients are currently treated with imatinib or sunitinib in case of imatinib failures as optimal medical therapy for metastatic GIST.

METHODS

The Pubmed, EMBASE, and Cochrane Library were systematically searched. Overall survival following liver resection ± tyrosine kinase inhibitor treatment for metastatic GIST was compared to treatment with tyrosine kinase inhibitors alone.

RESULTS

Eleven studies including both randomized control trials and retrospective cohort studies were included in the final analysis with a total of 988 patients. Seven studies encompassed data on 556 patients with isolated liver metastases (219 surgery ± drug groups and 337 drug-only groups) were included. Overall survival was significantly improved in patients undergoing liver resection ± drug therapy in comparison to drug therapy alone. [HR (95%CI) = 2.10 (1.58, 2.79); p<0.00001]. Subgroup analysis showed that patients also had improved progression free survival based on 4 studies. [HR (95%CI) = 1.92 (1.43, 2.56); p<0.00001]. In case of concurrent liver and peritoneal metastases, patients showed improved overall survival with aggressive surgical approaches based on 10 studies. [HR (95%CI) = 1.90 (1.56, 2.31); p<0.00001].

CONCLUSION

This meta-analysis found that liver resection for patients with metastatic GIST regardless of peritoneal metastases improved progression free and overall survival in conjunction with tyrosine kinase inhibitors as compared with medical therapy alone. Furthermore, liver resections did not have any immediate detrimental impact on survival in the group of patients selected.

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

OBJECTIVES

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

DESIGN

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

SETTING AND PARTICIPANTS

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

PRIMARY OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Debulking of Advanced Gastrointestinal Stromal Tumor With Peritoneal Carcinomatosis Refractory to Imatinib and Sunitinib: A Case Report

Gastrointestinal stromal tumors (GISTs) are non-epithelial stromal tumors that arise in the gastrointestinal tract. Pharmacological treatments for GIST are tyrosine kinase inhibitors. For metastatic disease, debulking may be helpful in reducing the tumor burden, thus increasing the effectiveness of tyrosine kinase inhibitors. Debate on whether resection would benefit the patient is still present. Here is a case of a 52-year-old African American male presenting with metastatic malignant GIST with peritoneal carcinomatosis refractory to imatinib and sunitinib. Since this patient had stage IV metastasis it was ultimately decided to proceed with a therapeutic debulking procedure. For this patient, the procedure increased the effectiveness of the medication and reduced mass effect symptoms, improving quality of life.

Giant hepatic extra-gastrointestinal stromal tumor treated with cytoreductive surgery and adjuvant systemic therapy: A case report and review of literature

BACKGROUND

Primary extra-gastrointestinal stromal tumors (E-GIST) of the liver are rare. The clinical presentation may range from asymptomatic to bleeding or manifestations of mass effect. Oncologic surgery followed by adjuvant therapy with imatinib is the standard of care. However, under specific circumstances, a cytoreductive approach may represent a therapeutic option. We describe herein the case of an 84-year-old woman who presented with a tender, protruding epigastric mass. Abdominal computed tomography scan revealed a large, heterogeneous mass located across segments III, IV, V, and VIII of the liver. The initial approach was transarterial embolization of the tumor, which elicited no appreciable response. Considering the large size and central location of the tumor and the advanced age of the patient, non-anatomic complete resection was indicated. Due to substantial intraoperative bleeding and hemodynamic instability, only a near-complete resection could be achieved. Histopathology and immunohistochemical staining confirmed the diagnosis of primary E-GIST of the liver. Considering the risk/benefit ratio for therapeutic options, debulking surgery may represent a strategy to control pain and prolong survival.

CASE SUMMARY

Here, we present a case report of a patient diagnosed with E-GIST primary of the liver, which was indicated a cytoreductive surgery and adjuvant therapy with imatinib.

CONCLUSION

E-GIST primary of the liver is a rare conditional, the treatment is with systemic therapy and total resection surgery. However, a cytoreductive surgery will be necessary when a complete resection is no possible.

Rectovaginal extragastrointestinal stromal tumour (EGIST): an additional entity to be considered in the differential diagnosis of tumours of the rectovaginal septum

Gastrointestinal stromal tumours (GISTs) are rare - and rectovaginal extragastrointestinal stromal tumours (RV-EGISTs) even rarer. We share a case of RV-EGIST, complemented by high-quality radiological and surgical images. A review of current literature pertaining to RV-EGIST is also included. Our case report highlights the diagnostic challenge presented by extragastrointestinal stromal tumours. Differentiated from overlapping pathologies only by targeted application of immunohistopathology and cytogenetics, the inclusion of RV-EGIST in the differential diagnosis of a rectovaginal tumour is essential to making this correct diagnosis. Primary surgery is the treatment of choice for RV-EGIST if complete cytoreduction can be achieved, combined with adjuvant tyrosine kinase inhibitor (TKI) therapy for those with high-risk features to further reduce rates of future recurrence.

Case report: multiple gastrointestinal stroma tumors in the background of neurofibromatosis type 1

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal malignancies of the gastrointestinal tract. GISTs can occur in the background of neurofibromatosis 1 (NF-1), where chemotherapeutic treatment is not optimal and surgical intervention is the only management option. In this case report, we present a case involving a 61-year-old gentleman with NF-1. The patient presented with acute blood loss anemia that was initially controlled with embolization of a hyper-vascular mass abutting the distal jejunum. The patient was taken to the operating room for excision of the mass. All macroscopic disease was excised and the pathology noted GISTs. Surgical decision making is not clearly delineated in the literature for GISTs in patients with NF-1, where targeted therapy is not a treatment option. Resection of all disease should be considered, since NF-1 associated GISTs generally do not have harbor mutations that can be targeted.

Primary Tumor Resection Improves Survival in Patients With Metastatic Gastrointestinal Stromal Tumors: A Preliminary Population-Based Analysis

Background: Surgery has been the primary treatment in patients with localized gastrointestinal stromal tumors (GISTs) for many decades, whereas it remains controversial regarding the efficacy of primary tumor resection for metastatic GISTs treated with chemotherapy, and likewise it is unclear who would benefit from the surgical resection.

Methods: GISTs patients with distant metastases were identified from the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2016. Cox proportional hazards regression models were used to identify prognostic factors of overall survival (OS) and cancer-specific survival (CSS). Kaplan-Meier analyses and log-rank tests were conducted to assess the effectiveness of surgery on survival.

Results: In total, of 455 patients with metastatic GISTs, 235 patients (51.6%) underwent primary tumor resection and 220 patients (48.4%) did not. Median survival of patients in resection group was 72 (95% CI: 62.90–81.10) months vs. 40 (95% CI: 29.53–50.47) months for those in non-resection group (p < 0.001). Similarly, surgery in conjunction with chemotherapy led to a favorable impact on survival than chemotherapy alone (OS: 72 vs. 40 months, p < 0.001; CSS: 74 vs. 44 months, p < 0.001). Multivariable analysis showed that both OS (HR: 0.581, 95% CI: 0.386–0.874, p = 0.009) and CSS (HR: 0.663, 95% CI: 0.439–0.912, p = 0.042] were dramatically improved in patients with surgical removal of primary site, as well as primary tumor size between 5 and 10 cm, while increasing age was predictive of poorer survival. Stratified analysis revealed that patients with tumor locations in the stomach demonstrated a prolonged survival after surgery, with no significant differential surgical effect between the stomach and small intestine.

Conclusions: Our study preliminarily suggests that carefully selected patients with metastatic GISTs might prolong survival after treatment of surgery, especially those with a primary tumor between 5 and 10 cm and a tumor located in the stomach.

Decreasing the burden: An unusual GIST presentation, a case report

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GIST may be refractory to treatment with only Imatinib and Sunitinib.

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Surgical debulking in addition to molecular therapy for patients with severely extensive GISTs.

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Debulking promotes an improved response to chemotherapy, decreases symptoms of obstruction and improves pain, and increases the patient’s ability in activities of daily living.

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Debulking this large mass significantly reduced tumor burden and thus promoted to an overall increase in chemotherapy effectivity.

Introduction

Gastrointestinal stromal tumours (GIST) are notoriously one of the most common mesenchymal tumours of the alimentary canal. Most commonly originating from the gastric stroma, they are recognized by their mass effects on the abdominal cavity. Recurrence frequently occurs with GIST and these tumours may become refractory to tyrosine kinase inhibitors (TKIs). Therefore, resection may be indicated for improved outcomes.

Presentation of case

We present a 52-year-old African American male with a surgical history of GIST resection with recurrence that came to the emergency room with worsening diffuse abdominal pain. The tumour was refractory to two TKIs, Imatinib and Sunitinib. Computed tomography (CT) of the abdomen and pelvis was done which showed severe metastatic disease with carcinomatosis, multiple dilated loops of small bowel in the left hemiabdomen without discrete transition point. After seventeen days on nasogastric tube, antiemetics, the patient worsened, and it was decided to go to surgery. In this report, attention is focused on the surgical approach of tumour debulking with subsequent Regorafenib therapy for decreased obstructive symptoms and improved quality of life.

Conclusion

This case serves as an example of the importance of surgical debulking in addition to molecular therapy for patients with severely extensive GISTs. Tumour debulking is important to decrease tumour burden, improve chemotherapeutic response and improve quality of life especially in persons refractory to pharmacological therapy.

The Role of Surgical Resection Following Tyrosine Kinase Inhibitors Treatment in Patients with Advanced Gastrointestinal Stromal Tumors: A Systematic Review and Meta-analysis

Background The benefit of surgical resection for advanced gastrointestinal stromal tumors (GISTs) following tyrosine kinase inhibitors (TKIs) treatment was still under debate. The present meta-analysis was designed to assess the value of surgical resection for the prognosis of patients with metastatic, recurrence and unresectable GISTs. Methods A systematic search of PubMed Central, PubMed, EMBASE and the Cochrane Library database was performed. Relevant studies of the role of surgery in advanced GISTs published before 1 May 2019 were identified. The quality of studies was assessed by the Newcastle-Ottawa Quality Assessment Scale. The progression-free survival (PFS) and overall survival (OS) were assessed through software Stata 15.0. Results A total of 6 retrospective studies including 655 patients were analyzed. The pooled result revealed that surgical resection group was associated with better PFS (HR = 2.08; 95% CI: 1.58 to 2.76; P<0.001) and better OS (HR = 2.13; 95% CI: 1.59 to 2.85; P<0.001) compared with TKIs treatment alone group. Conclusions Surgical resection following TKIs treatment could significantly improve the prognosis of patients with advanced GISTs.

Gastrointestinal stromal tumor presenting as a rectovaginal septal mass: A case report and review of literature

INTRODUCTION

Gastrointestinal stromal tumors (GISTs) arising from the gynecological tract are extremely rare. A case of GIST with an unusual presentation as a vaginal mass is presented with comprehensive literature review, aiming to gain a better understanding of the diagnostic and treatment strategy of the disease.

PATIENT CONCERNS

A 78-year-old woman presented with persistent vaginal bleeding and difficulty in micturition. Although the tumor mass was diagnosed, the results of preoperative evaluations are uncertain.

DIAGNOSIS

Preoperative evaluation included the computed tomography examination (a 6.3×5.3 cm cervical mass lesion with rectal and vaginal invasion), colonoscopy (an external compression with an intact mucosa), tumor markers, and biopsy (spindle cell tumor). Postoperative histopathology confirmed the diagnosis of GIST.

INTERVENTIONS

Posterior exenteration with complete resection was performed. The patient received postoperative adjuvant imatinib therapy.

OUTCOMES

The patient has survived without the disease for more than 3 years.

CONCLUSION

It is still a challenge to diagnose GISTs in women with rectovaginal mass preoperatively. Efforts should be made, including a high suspicion and an assistance of immunohistochemistry. A precise diagnosis may offer a better surgical and treatment plan, especially on the preservation of reproductive organs and accessibility of targeted therapy.