Novel Prognostic Nomogram for Recurrence-Free Survival of Patients With Primary Gastrointestinal Stromal Tumors After Surgical Resection: Combination of Prognostic Nutritional Index and Basic Variables

Prognostic Nutritional Index is a valuable preoperative prognostic biomarker in Mexican patients surgically intervened on gastrointestinal stromal tumors: a retrospective cohort study

PURPOSE

The immunonutritional status of cancer patients has a profound impact on lifespan. Prognostic Nutritional Index (PNI) evaluates prognosis in operated patients with both neoplastic and non-neoplastic conditions. This study estimates the overall survival (OS) of Mexican patients operated on gastrointestinal stromal tumors (GIST) based on PNI.

METHODS

Immune-nutritional status was retrospectively analyzed in a cohort of 104 patients operated on GIST. Receiver operating characteristic (ROC) curves and X-tile software were used to estimate the optimal cutoff point and predict OS stratifying patients by PNI. Survival curves were obtained through Kaplan-Meier and log-rank methods. Multivariate analysis of survival was performed by Cox regression.

RESULTS

PNI (≥ 36.5) (p = 0.024) and mitotic index (≥ 5) (p = 0.013) were the only independent prognostic scores; the PNI-high group had better survival with 81.5% less risk of death (HR = 0.185). High PNI was correlated with favorable characteristics, i.e., low/intermediate risk (p = 0.046), reduced mitotic index (< 5) (p = 0.001), and younger age (< 55 years, p = 0.047).

CONCLUSIONS

PNI ≥ 36.5 entails a better prognosis for Mexican patients with surgically resected GIST. PNI represents a simple, reliable, and cost-effective prognostic tool, besides the pathological approach.

Prognostic Role of Preoperative Onodera's Prognostic Nutritional Index (OPNI) in Gastrointestinal Stromal Tumors: a Systematic Review and Meta-analysis

PURPOSE

The inflammatory parameters of peripheral blood are related to the prognosis of various cancers. The aim of this meta-analysis is to explore the prognostic value of preoperative OPNI in gastrointestinal stromal tumors (GIST).

METHODS

The following search strategies were used to locate all literature published up to May 1, 2022: PubMed, Web of Science, CBM, EMBASE, and Cochrane, using the keywords "Prognosis," "survival," "Nutritional Assessment," "Nutrition Index," and "PNI," "OPNI," "Gastrointestinal stromal tumor," and "GIST." Studies that did not report an associated cumulative hazard ratio (HR) of recurrence-free survival (RFS) were excluded. The pooled hazard ratio (HR) and corresponding 95% confidence intervals (CI) were calculated by a fixed-effects model. Subgroups were analyzed for heterogeneity of studies, and Egger's test was applied to assess the risk of publication bias.

RESULTS

Through the inclusion and exclusion criteria, 8 articles with a total of 2462 patients with gastrointestinal stromal tumors were selected for analysis. The HR summary of univariate analysis of RFS was 2.73 (95% CI: 2.17-3.43, P < 0.0001), and there was no heterogeneity, which indicated that the prognosis of gastrointestinal stromal tumors with low OPNI before operation was poor. Except for one article that did not give the HR of RFS under the condition of multi-factor analysis, the other 7 articles gave the HR of RFS and summarized it to 1.81 (95% CI: 1.40-3.83, P < 0.0001). Although there was slight heterogeneity in the multifactorial analysis, the publication bias risk and sensitivity assessment showed that the results were still reliable (p > 0.05).

CONCLUSION

The results of this systematic review and meta-analysis show that decreased preoperative OPNI is closely associated with poor long-term survival (RFS) in GIST patients. Monitoring OPNI in GIST patients may help with risk stratification and individualized treatment.

TATA-box-binding protein-associated factor 15 is a novel biomarker that promotes cell proliferation and migration in gastrointestinal stromal tumor

BACKGROUND

Gastrointestinal stromal tumor (GIST) is a common neoplasm with high rates of recurrence and metastasis, and its therapeutic efficacy is still not ideal. There is an unmet need to find new molecular therapeutic targets for GIST. TATA-box-binding protein-associated factor 15 (TAF15) contributes to the progress of various tumors, while the role and molecular mechanism of TAF15 in GIST progression are still unknown.

AIM

To explore new molecular therapeutic targets for GIST and understand the biological role and underlying mechanisms of TAF15 in GIST progression.

METHODS

Proteomic analysis was performed to explore the differentially expressed proteins in GIST. Western blotting and immunohistochemical analysis were used to verify the expression level of TAF15 in GIST tissues and cell lines. Cell counting kit-8, colony formation, wound-healing and transwell assay were executed to detect the ability of TAF15 on cell proliferation, migration and invasion. A xenograft mouse model was applied to explore the role of TAF15 in the progression of GIST. Western blotting was used to detect the phosphorylation level and total level of RAF1, MEK and ERK1/2.

RESULTS

A total of 1669 proteins were identified as differentially expressed proteins with 762 upregulated and 907 downregulated in GIST. TAF15 was selected for the further study because of its important role in cell proliferation and migration. TAF15 was significantly over expressed in GIST tissues and cell lines. Overexpression of TAF15 was associated with larger tumor size and higher risk stage of GIST. TAF15 knockdown significantly inhibited the cell proliferation and migration of GIST in vitro and suppressed tumor growth in vivo. Moreover, the inhibition of TAF15 expression significantly decreased the phosphorylation level of RAF1, MEK and ERK1/2 in GIST cells and xenograft tissues, while the total RAF1, MEK and ERK1/2 had no significant change.

CONCLUSION

TAF15 is over expressed in GIST tissues and cell lines. Overexpression of TAF15 was associated with a poor prognosis of GIST patients. TAF15 promotes cell proliferation and migration in GIST via the activation of the RAF1/MEK/ERK signaling pathway. Thus, TAF15 is expected to be a novel latent molecular biomarker or therapeutic target of GIST.

Advances in immunology and immunotherapy for mesenchymal gastrointestinal cancers

Mesenchymal gastrointestinal cancers are represented by the gastrointestinal stromal tumors (GISTs) which occur throughout the whole gastrointestinal tract, and affect human health and economy globally. Curative surgical resections and tyrosine kinase inhibitors (TKIs) are the main managements for localized GISTs and recurrent/metastatic GISTs, respectively. Despite multi-lines of TKIs treatments prolonged the survival time of recurrent/metastatic GISTs by delaying the relapse and metastasis of the tumor, drug resistance developed quickly and inevitably, and became the huge obstacle for stopping disease progression. Immunotherapy, which is typically represented by immune checkpoint inhibitors (ICIs), has achieved great success in several solid tumors by reactivating the host immune system, and been proposed as an alternative choice for GIST treatment. Substantial efforts have been devoted to the research of immunology and immunotherapy for GIST, and great achievements have been made. Generally, the intratumoral immune cell level and the immune-related gene expressions are influenced by metastasis status, anatomical locations, driver gene mutations of the tumor, and modulated by imatinib therapy. Systemic inflammatory biomarkers are regarded as prognostic indicators of GIST and closely associated with its clinicopathological features. The efficacy of immunotherapy strategies for GIST has been widely explored in pre-clinical cell and mouse models and clinical experiments in human, and some patients did benefit from ICIs. This review comprehensively summarizes the up-to-date advancements of immunology, immunotherapy and research models for GIST, and provides new insights and perspectives for future studies.

Nomogram for Predicting Recurrence-Free Survival of Primary Localized Gastrointestinal Stromal Tumor

PURPOSE

This study aimed to establish a new nomogram that predicts recurrence-free survival (RFS) after a complete surgical resection of primary localized gastrointestinal stromal tumors (GISTs); it also aimed to evaluate the discrimination, calibration, and clinical utility of the decision-making nomogram.

METHODS

The clinicopathological data of patients with primary localized GISTs at the First Affiliated Hospital of Chongqing Medical University from January 2000 to June 2022 were retrospectively analyzed. The clinicopathological data were randomly split into two sets (7:3 ratio) for training and validation. Suitable variables for the construction of a nomogram for the 1-, 3-, and 5-year RFS were selected using univariate and multivariate Cox regression analyses. Receiver operating characteristic (ROC) analysis and a concordance index (C-index) were used to quantify the discrimination of the nomogram and were compared with four commonly used prognostic scoring systems: Memorial Sloan Kettering Cancer Center prognostic nomogram, National Institutes of Health-Fletcher staging system, Chen's prognostic nomogram, and Air Forces Institute of Pathology risk criteria-Miettinen staging system. The calibration and clinical utility for the decision-making nomogram were validated using calibration curves and decision curves, respectively.

RESULTS

In total, 641 patients were screened and analyzed in this retrospective, observational study. RFS was significantly related to tumor size, mitotic count, gender, DOG-1, and adjuvant therapy with imatinib according to the results of the multivariate and univariate Cox analyses. The nomogram was constructed using the above variables (all p < 0.05) for the 1-, 3-, and 5-year RFS. In the training set, the 1-, 3-, and 5-year ROC and C-index values of the nomogram were 0.868, 0.838, 0.816, and 0.830, respectively. For internal validation, we performed model fitting on the validation set, and the 1-, 3-, and 5-year ROC and C-indices were 0.977, 0.845, 0.869, and 0.849, respectively. Among the five GIST prognostic scoring systems, our nomogram had almost all the largest area under these decision curves and had a good calibration capability.

CONCLUSIONS

The newly constructed nomogram based on tumor size, gender, mitotic count, DOG-1, and adjuvant treatment with imatinib exhibited an excellent performance and may serve as a prognostic scoring system to support therapeutic decision-making and individualized treatment for GISTs in China.

The prognostic significance of prognostic nutritional index in gastrointestinal stromal tumors: A systematic review and meta-analysis

BACKGROUND

Risk assessment before treatment is important for gastrointestinal stromal tumors (GISTs), which will determine the priority of surgery or preoperative treatment. The prognostic nutritional index (PNI) is an integrated parameter consisting of serum albumin and lymphocyte count. Immunonutritional status defined in this manner is well-known to be closely linked to the prognosis of several other cancers. Nevertheless, the prognostic value of PNI specifically in GISTs has not been well-established. This study aimed to verify the prognostic role of PNI in patients with GISTs.

METHODS

A comprehensive literature search was conducted on medical databases up to June, 2022, and the raw data (hazard ratios and 95% confidence intervals [CIs]) focusing on the prognostic value of PNI in patients with GISTs regarding recurrence-free survival were extracted and synthesized adopting the random-effects model. This review was registered in the PROSPERO database (CRD42022345440).

RESULTS

A total of 8 eligible studies including 2627 patients with GISTs was analyzed and the pooled results confirmed that an elevated PNI was associated with a better recurrence-free survival (hazard ratio: 0.52, 95% CI: 0.40-0.68), with a moderate heterogeneity (I-square, 38%). The findings from subgroup analysis were consistent with the overall pooled results, and a sensitivity analysis, not the subgroup analysis, identified the source of heterogeneity.

CONCLUSION

Elevated pretreatment PNI may be a useful indicator for assessing risk of recurrence in patients from China with GISTs. Studies in other countries and regions are needed to further verify the prognostic value of PNI in GISTs.

Development and validation of a prognostic model to predict the prognosis of patients with colorectal gastrointestinal stromal tumor: A large international population-based cohort study

Background

Colorectal gastrointestinal stromal tumors (GISTs), mesenchymal malignancy, only accounts for about 6% of GISTs, but prognosis is generally poor. Given the rarity of colorectal GISTs, the prognostic values of clinicopathological features in the patients remain unclear. Nomograms can provide a visual interface to help calculate the predicted probability of a patient meeting a specific clinical endpoint and communicate it to the patient.

Methods

We included a total of 448 patients with colorectal GISTs diagnosed between 2000 and 2019 from the Surveillance, Epidemiology, and End Results (SEER) database. For nomogram construction and validation, patients in the SEER database were divided randomly into the training cohort and internal validation cohort at a ratio of 7:3, while 44 patients with colorectal GISTs from our hospital patient data set between 2010 to 2016 served as the external validation cohort. The OS curves were drawn using the Kaplan–Meier method and assessed using the log-rank test. And, Fine and Gray’s competing-risks regression models were conducted to assess CSS. We performed univariate and multivariate analyses to select prognostic factors for survival time and constructed a predictive nomogram based on the results of the multivariate analysis.

Results

Through univariate and multivariate analyses, it is found that age, primary site, SEER stage, surgery, and tumor size constitute significant risk factors for OS, and age, primary site, histological grade, SEER stage, American Joint Committee for Cancer (AJCC) stage, surgery, and tumor size constitute risk factors for CSS. We found that the nomogram provided a good assessment of OS and CSS at 1-, 3- and 5- year in patients with colorectal GISTs. The calibration plots for the training, internal validation and external validation cohorts at 1-, 3- and 5- year OS and CSS indicated that the predicted survival rates closely correspond to the actual survival rates.

Conclusion

We constructed and validated an unprecedented nomogram to predict OS and CSS in patients with colorectal GISTs. The nomogram had the potential as a clinically predictive tool for colorectal GISTs prognosis, and can be used as a potential, objective and additional tool for clinicians in predicting the prognosis of colorectal GISTs patients worldwide. Clinicians could wield the nomogram to accurately evaluate patients’ OS and CSS, identify high-risk patients, and provide a baseline to optimize treatment plans.

Delayed adjuvant imatinib in patients with high risk of recurrence of gastrointestinal stromal tumor after radical surgery: a retrospective cohort study

PURPOSE

To investigate the impact of delayed adjuvant imatinib on GIST patients with high risk of recurrence.

METHOD

Adult GIST patients were retrospectively collected from our hospital between 2011 and 2018, and patients having high risk of recurrence were included for subsequent analyses. The primary endpoint was recurrence-free survival (RFS).

RESULTS

According to the interval between the radical surgery and the beginning of adjuvant imatinib, 222 patients were divided into three groups: group A (≤ 2 months, n = 41), group B (2-≤ 4 months, n = 113), and group C (4-≤ 6 months, n = 68). Univariate, multivariate, and survival analyses all showed that patients in group A had significantly more favorable RFS than those in group C but not group B, and patients taking adjuvant imatinib for over 12 months were also associated with longer RFS comparing to adjuvant imatinib of ≤ 12 months. When stratified by the duration of adjuvant imatinib, no significant differences were found in RFS among groups A, B, and C for adjuvant imatinib of ≤ 12 months. While for adjuvant imatinib of over 12 months, both groups A and B had significantly more favorable RFS than group C, and no significant difference in RFS was found between group A and B.

CONCLUSION

Delayed postoperative adjuvant imatinib for over 4 months in patients with high risk of recurrence of GIST may lead to worse RFS, and longer treatment with shorter delay has best results.