Is Lymph Node Metastasis a Common Feature of Gastrointestinal Stromal Tumor?: PET/CT Correlation

Clinical characteristics of gastrointestinal stromal tumors with lymph node metastasis: a retrospective single-center study

BACKGROUND

Lymph node metastasis (LNM) of gastrointestinal stromal tumors (GISTs) rarely occurs, and lymphadenectomy is not routinely performed in GIST resection. To date, the relevant characteristics and prognosis of GIST patients with LNM are not well known.

METHODS

From January 2010 to December 2021, GIST patients who underwent lymph node resection were enrolled from a GIST referral center. All patients were divided into either the LN- group (GISTs without LNM) or the LN+ group (GISTs with LNM). The clinicopathological features and follow-up data were analyzed. Propensity score matching (PSM) was conducted to reduce bias caused by confounders.

RESULTS

Out of 1024 surgical patients, 198 patients (age, 52.23 ± 13.54 years; 56.6% males) underwent GIST resection with lymph node dissection for lymphadenopathy, and 17 patients had lymph node metastases (17/1024, 1.66%; 17/198, 8.59%). The LN+ group had a higher mitotic count (p = 0.012) and a higher proportion of distant metastasis (p < 0.001) than the LN- group. After PSM, 28 patients were included (18 in LN- group and 10 in LN+ group). The LN- group had both longer postoperative progression-free survival (PFS, not reached vs. 15.0 months, p = 0.002) and overall survival (OS) than the LN+ group, but the difference in OS was not statistically significant (not reached vs. 35.0 months, p = 0.069).

CONCLUSIONS

The rate of LNM in GISTs is low. LNM may be a less common form of distant metastasis. Moreover, GIST with LNM has an unfavorable prognosis. Further studies are warranted to identify GISTs with lymph node involvement and the potential involved mechanism.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Lymph node metastases in young patients with gastrointestinal stromal tumor: A nationwide analysis

BACKGROUND

Children, adolescents, and young adults (CAYA) (age ≤39 years) with GIST have high rates of LNM, but their clinical relevance is undefined. This study analyzed the impact of LNM on overall survival (OS) for CAYA with GIST.

METHODS

The National Cancer Database was queried for patients with resected GIST and pathologic nodal staging data from 2004-2019. Factors associated with LNM were identified. Survival was assessed stratified by presence of LNM.

RESULTS

Of 4420 patients with GIST, 238 were CAYA (5.4%). When compared to older adults, CAYA more often had small intestine primaries (51.8% vs. 36.6%, p < 0.0001), T4 tumors (30.7% vs. 24.5%, p = 0.0275) and pN1 disease (11.3% vs. 4.7%, p < 0.0001). Within a multivariable Cox proportional hazards regression model adjusting for age, comorbid disease, mitotic rate, tumor size, and primary site, LNM were associated with increased hazard of death for older adults (hazard ratio [HR]: 1.83; confidence interval [CI]: 1.35-2.42; p < 0.0001), but not CAYA (HR: 3.38; CI: 0.50-14.08; p = 0.13). For CAYA, only high mitotic rate predicted mortality (HR: 4.68; CI: 1.41-18.37: p = 0.02).

CONCLUSIONS

LNM are more commonly identified among CAYA with resected GIST who undergo lymph node evaluations, but do not appear to impact OS as observed in older adults. High mitotic rate remains a predictor of poor outcomes for CAYA with GIST.

Lymph Node Metastases in Gastrointestinal Stromal Tumors: an Uncommon Event

BACKGROUND

Lymph node (LN) metastases are uncommon among gastrointestinal stromal tumors (GISTs), and their presence has not been utilized in disease prognostication. This study was designed to examine factors associated with GIST nodal metastases and their impact on survival.

PATIENTS AND METHODS

Patients undergoing surgical resection of GIST with nodal evaluation were selected from the National Cancer Database. Logistic regression was utilized to evaluate factors associated with LN metastases. Survival was assessed for patients with and without nodal involvement and Cox regression was used to evaluate the impact of LN metastases while adjusting for other prognostic factors.

RESULTS

Out of 5018 patients, 301 (6.0%) had LN involvement. Nodal metastases occurred most frequently among tumors of the stomach (49.5%), followed by the small bowel (43.2%), colorectum (6.0%), and esophagus (1.3%). On multivariable analysis, male sex (OR 1.34), high mitotic rate (OR 2.10), tumor size (OR 1.02), and a primary tumor located in the small bowel (OR 1.36) were all significantly associated with nodal metastases. LN metastases were significantly associated with decreased overall survival (OS) for tumors arising in the small bowel (log-rank p < 0.01) and the colorectum (log-rank p < 0.01). Within a multivariable model adjusting for established prognostic factors, LN metastases remained independently associated with decreased survival (HR 1.60, p < 0.001).

CONCLUSIONS

For GISTs, LN metastases occur more often in males and were associated with tumor size and mitotic activity. Nodal involvement is associated with decreased survival, independent of other well-established prognostic factors.

Tumor-Derived Exosomes Modulate Primary Site Tumor Metastasis

Tumor-derived exosomes (TDEs) are actively produced and released by tumor cells and carry messages from tumor cells to healthy cells or abnormal cells, and they participate in tumor metastasis. In this review, we explore the underlying mechanism of action of TDEs in tumor metastasis. TDEs transport tumor-derived proteins and non-coding RNA to tumor cells and promote migration. Transport to normal cells, such as vascular endothelial cells and immune cells, promotes angiogenesis, inhibits immune cell activation, and improves chances of tumor implantation. Thus, TDEs contribute to tumor metastasis. We summarize the function of TDEs and their components in tumor metastasis and illuminate shortcomings for advancing research on TDEs in tumor metastasis.

Gastrointestinal stromal tumors (GIST): a proposal of a "CT-based predictive model of Miettinen index" in predicting the risk of malignancy

PURPOSE

To identify the predictors of malignancy on CT for the evaluation of gastrointestinal stromal tumors (GIST) by correlating CT findings with the mitotic index in order to propose a "CT-based predictive model of Miettinen index."

METHODS

One radiologist and one resident in radiology with 14- and 4-year experience in oncological field reviewed the CT findings of 42 patients by consensus, with respect to lesion site, size, contour, tumor growth pattern, enhancing pattern, degree of enhancement of tumor, percentage of tumor necrosis, mesenteric fat infiltration, ulceration, calcification, regional lymphadenopathy, direct invasion to adjacent organs, and distant metastasis. All parameters were correlated with the mitotic index evaluated at histopathological analysis following surgery. Normality of variables was evaluated using Shapiro-Wilk test. Pearson's correlation test was used to assess the interaction between variables. The diagnostic accuracy percentage of tumor necrosis was measured by receiver operating characteristic (ROC) analysis for detecting whether the number of mitosis per 50 high-power fields was > 5.

RESULTS

A significant statistical correlation was found between percentage of tumor necrosis and the mitotic index (p < 0.005), dimension, and location of the tumor.

CONCLUSION

CT could be an accurate technique in the prediction of malignancy of GIST in a CT risk assessment system, based on the location of the tumor, its size, and the percentage of tumor necrosis.

Radical excision versus local resection for primary rectal gastrointestinal stromal tumors. Cohort Study

BACKGROUND

Rectal gastrointestinal stromal tumor (GIST) is a rare digestive disease that originates in mesenchymal tissues and has malignant tendencies. At present, no standard treatment has been developed, and surgical approaches and the resection scope for rectal GISTs are controversial.

METHODS

The clinical, surgical, pathological and prognosis data of patients with primary rectal GIST in our center from January 2008 to January 2019 were retrospectively collected. The patients were divided into the radical excision (RE) and local resection (LR) groups.

RESULTS

A total of 537 GIST cases were collected, and 64 patients with primary rectal GIST were included in this study, including 25 cases in the RE group and 39 cases in the LR group. Tumor size (p = 0.013), distance from the anus (p = 0.038), National Institutes of Health (NIH) criteria (p = 0.001), preoperative adjuvant therapy (p = 0.016), postoperative adjuvant therapy (p = 0.028), blood loss (p = 0.048), operative time (p = 0.020) and the duration of hospitalization (p = 0.021) were statistically different between these 2 groups. The mean overall follow-up time was 46 months (range, 1-122 months). Disease recurrence was observed in 12 patients. No statistical differences were observed in 5-year disease-free survival (DFS) (93.3% vs 92.6%, p = 0.952) or overall survival (OS) (90.0% vs 91.6%, p = 0.832) between the RE group and the LR group.

CONCLUSION

Our study showed that LR has a similar prognosis to that of RE with respect to DFS and OS. For appropriate cases, LR has the advantages of a short operative time, less bleeding, and a quick recovery. Especially when combined with neoadjuvant therapy, LR can also achieve better perioperative efficacy. Therefore, LR is an effective method for resection of rectal GISTs and warrants clinical endorsement.

Radiotherapy for Gastrointestinal Stromal Tumors

OBJECTIVE

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors of the gastrointestinal tract, which frequently cause intraabdominal metastases. The current standard of care is surgery for localized cases, and adjuvant imatinib is recommended for tumors with a high risk of recurrence. To date, radiotherapy has not been commonly accepted as a part of multimodality treatment approach other than palliation. However, recently published case reports and some small series suggest that radiotherapy is a valuable option for controlling locally progressive, drug-resistant disease. The aim of this review is to provide a viewpoint from a radiation oncologist concerning the management of GISTs, especially rectal GIST, and clarify the role and technical aspects of radiotherapy in the treatment approach.

DATA SOURCES

A comprehensive search in PubMed using the keywords "radiotherapy for rectal GIST" and "rectal GIST" was undertaken. The literature search included the related articles after 1995.

STUDY SELECTION

The main articles including rectal GIST case reports and GIST series containing rectal cases were the primary references.

RESULTS

Surgery is the mainstay of treatment. However, to date, radiotherapy is included in the multidisciplinary treatment strategy of rectal GISTs in some circumstances with palliative, adjuvant, or definitive intent using different treatment doses and fields.

CONCLUSIONS

Recently reported long-term local control rates indicate that GIST is a radiosensitive disease. This makes radiotherapy a valuable alternative in GIST management with curative intent, especially in patients who (1) cannot tolerate or are resistant to chemotherapy agents, (2) have an unresectable disease, (3) have a gross or microscopic residual disease after surgery, and (4) have a recurrent disease.

Predictors of lymph node metastasis in patients with gastrointestinal stromal tumors (GISTs)

BACKGROUND

Lymph node metastasis is not common among patients with gastrointestinal stromal tumors (GISTs) and its prognostic value is controversial. The purposes of this study are to identify predictors of lymph node metastasis and determine its prognostic associations.

METHODS

A retrospective analysis of the surveillance, epidemiology and end results (SEER) database was performed. Patients with GISTs that underwent surgery and pathologic nodal staging were identified. Logistic regression and Cox regression were performed to identify independent predictors and prognostic factors, respectively.

RESULTS

Of 1430 patients (age: 61.5 ± 14.5 years, 52% males), 140 (9.8%) had lymph node metastasis. On multivariable analysis, distant metastasis was the only independent predictor of lymph node metastasis (OR 4.95, 95% CI: 2.43-10.08, p < 0.001). In the entire cohort, lymph node metastasis did not reflect a worse overall survival (OS, HR 1.12, 95% CI: 0.49-2.58, p = 0.794) or disease-specific survival (DSS, HR 0.95, 95% CI: 0.31-2.88, p = 0.924), but was an independent predictor of worse OS in 51 patients (25.4% of 201 patients) who presented with both lymph node metastasis and synchronous distant metastasis (HR 2, 95% CI: 1.25-3.21, p = 0.004). Lymph node metastasis was also independently associated with worse survival among patients with small intestinal (OS: HR 1.88, 95% CI: 1.15-3.1, p = 0.013) and colorectal tumors (OS: HR 3.41, 95% CI: 1.56-7.46, p = 0.002, DSS: HR 3.58, 95% CI: 1.27-10.06, p = 0.016).

CONCLUSIONS

Metastatic disease is an independent predictor of lymph node metastasis in patients with GISTs. Lymph node metastasis is also associated with worse overall survival in patients with metastatic GISTs.

An innovative procedure of laparoscope combined with endoscopy for gastrointestinal stromal tumor resection and cholecystectomy: A case report and literature review

The present study reports a novel approach to laparoscopic and endoscopic cooperative surgery for gastric gastrointestinal stromal tumor (GIST) resection and cholecystectomy, and conducts a review of the associated literature. The novel surgical procedure was performed on one patient who was diagnosed with a GIST and cholecystic polypus. The GIST was resected using an insulation-tipped diathermic electrosurgical knife under the guide of an endoscope. Subsequently, a cholecystectomy was performed by inserting two more 5-mm trocars and instruments transumbilically, guided using an endoscope. The tumor and the gallbladder were exteriorized using a peroral approach and the incision lining of the stomach was sutured laparoscopically. The procedure was successfully performed and the patient experienced no discomfort during the 5-year follow-up. In conclusion, the present study demonstrates that laparoscopic and endoscopic cooperative surgery is feasible and would be an ideal choice for invisible abdominal scar surgery, in particular for multi-visceral resection.

Clinico-pathological characteristics and prognostic factors of gastrointestinal stromal tumors among a Chinese population

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms in the gastrointestinal tract, exhibiting wide variability in their biological behavior. The aim of the present study was to investigate the clinicopathological characteristics and prognostic factors of GISTs in Chinese patients. All GIST cases (n=182) retrieved from the pathology database and the archived files in Shanghai Changzheng Hospital between January 2011 and December 2014 were reviewed. The clinical symptoms, preoperative investigations, treatments, pathological characteristics and follow-up data of these patients were reviewed, and univariate and multivariate survival analyses were performed. A total of 73.1% of the GISTs were located in the stomach, and the most common three symptoms included abdominal pain (30.2%), dyspepsia (23.1%) and gastrointestinal bleeding (21.4%). Univariate analysis revealed that larger tumor size (P<0.001), higher mitotic rate (P<0.001), aggressive behavior (P<0.001), negative smooth muscle actin expression (P=0.009) and palliative resection (P<0.001) contributed toward poor overall survival (OS). In addition, non-gastric disease location (P<0.001), larger tumor size (P<0.001), higher mitotic rate (P=0.004), aggressive behavior (P<0.001) and palliative resection (P<0.001) were associated with poor relapse-free survival (RFS). Multivariate analysis indicated that mitotic rate [hazard ratio (HR=3.761, P=0.015)] and aggressive behavior (HR=3.916, P=0.010) were independent risk factors for OS, while non-gastric location (HR=4.740, P=0.002) and aggressive behavior (HR=4.009, P=0.004) were independent risk factors for RFS. The present study provided information on the clinicopathological characteristics and epidemiology of GISTs in the Chinese population. Non-gastric disease location, higher mitotic rate and tumor metastasis or local invasion prior to treatment were identified as predictors of a poor prognosis.

Gastrointestinal stromal tumor: 15-years' experience in a single center

Background

Gastrointestinal stromal tumor (GIST) is known for its wide variability in biological behaviors and it is difficult to predict its malignant potential. The aim of this study is to explore the characteristics and prognostic factors of GIST.

Methods

Clinical and pathological data of 497 GIST patients in our center between 1997 and 2012 were reviewed.

Results

Patients were categorized into very low-, low-, intermediate- and high-risk groups according to modified National Institutes of Health (NIH) consensus classification system. Among the 401 patients untreated with imatinib mesylate (IM), 5-year overall survival (OS) in very low-, low-, intermediate- and high-risk groups was 100%, 100%, 89.6% and 65.9%; and 5-year relapse-free survival (RFS) was 100%, 98.1%, 90.9% and 44.5%, respectively. Univariate analysis revealed that sex, tumor size, mitotic rate, risk grade, CD34 expression, and adjacent involvement were predictors of OS or RFS. COX hazard proportional model (Forward LR) showed that large tumor size, high mitotic rate, and high risk grade were independent risk factors to OS, whereas high mitotic rate, high risk grade and adjacent organ involvement were independent risk factors to RFS. The intermediate-high risk patients who received IM adjuvant therapy (n = 87) had better 5-year OS and RFS than those who did not (n = 188) (94.9% vs. 72.1; 82.3% vs. 56.3%, respectively). Similarly, advanced GIST patients underwent IM therapy (n = 45) had better 3-year OS and 1-year progression-free survival (PFS) than those who didn’t (n = 42) (75.6% vs. 6.8%; 87.6% vs. 12.4%, respectively).

Conclusions

Very low- and low-risk GISTs can be treated with surgery alone. Large tumor size, high mitotic rate, high risk grade, and adjacent organ involvement contribute to the poor outcome. IM therapy significantly improves the survival of intermediate-high risk or advanced GIST patients.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2482-14-93) contains supplementary material, which is available to authorized users.