Abstract
The response of gastrointestinal stromal tumors (GISTs) to tyrosine kinase receptor inhibitors (TKR-I) has been a breakthrough for small molecular therapy. We report here on the very different long-term outcome of a synchronous metastatic GIST with complete remission of the primary tumor and progressive liver metastases under TKR-I therapy. In 2003, a 52-year-old patient was diagnosed with gastric GIST and synchronous multiple liver metastases. Therapy with imatinib, 400 mg daily, was started immediately. Fifteen months later, the primary was no longer detectable by endoscopy. In 2006, progression of the liver metastases was observed. Mutation analysis of the initial biopsy specimen from the primary, as well as the biopsy from the three main liver metastases after 3 years of imatinib treatment, revealed the common KIT exon 11 deletion (W557_K558del) in all tumor samples. Two of the metastases had a separate secondary mutation in KIT exon 14 and 17, respectively, while the largest cystic metastatic lesion had no other mutation. Imatinib was then increased to a daily dose of 800 mg, and in April 2007 the treatment was changed to sunitinib. Fifty-two months after initial diagnosis, the patient died of liver failure. At no time point, relapse of the gastric primary tumor was observed. Whilst TKR-Is are commonly very effective in treating GISTs, the present case illustrates their varying effects regarding the clinical behavior and genetic variations within different tumors of the same patient after long-term treatment.
Similar content being viewed by others
References
Miettinen M, Lasotta J. Gastrointestinal stromal tumors—definition, clinical, histological, immunohistochemical, and molecular genetic features and differential diagnosis. Virchows Arch. 2001;438:1–12. doi:10.1007/s004280000338.
Kindblom LG, et al. Incidence, prevalence, phenotype and biologic spectrum of gastrointestinal stromal cell tumors (GIST)—A population based study of 600 cases. Ann Oncol. 2002;13(Suppl 5):157. doi:10.1093/annonc/mdf012.
Hirota S, et al. Gain-of-function mutations of c-Kit in human gastrointestinal stromal tumors. Science. 1998;279:577–80. doi:10.1126/science.279.5350.577.
Heinrich MC, et al. PDGFRA activating mutations in gastrointestinal stromal tumors. Science. 2003;299:708–10. doi:10.1126/science.1079666.
Hirota S, Isozaki K. Pathology of gastrointestinal stromal tumors. Pathol Int. 2006;56:1–9. doi:10.1111/j.1440-1827.2006.02036.x.
DeMatteo RP, et al. Two hundred gastrointestinal stromal tumors: recurrence patterns and prognostic factors for survival. Ann Surg. 2000;231:51–8. doi:10.1097/00000658-200001000-00008.
Pidhorecky I, Cheney RT, Kraybill WG, Gibbs JF. Gastrointestinal stromal tumors: current diagnosis, biologic behavior, and management. Ann Surg Oncol. 2000;7:705–12. doi:10.1007/s10434-000-0705-6.
Pierie JP, et al. The effect of surgery and grade on outcome of gastrointestinal stromal tumors. Arch Surg. 2001;136:383–9. doi:10.1001/archsurg.136.4.383.
DeMatteo RP, Heinrich MC, El-Rifai WM, Demetri G. Clinical management of gastrointestinal stromal tumors: before and after STI-571. Hum Pathol. 2002;33:466–77. doi:10.1053/hupa.2002.124122.
Joensuu H, et al. Effect of the tyrosine kinase inhibitor STI571 in a patient with a metastatic gastrointestinal stromal tumor. N Engl J Med. 2001;344:1052–6. doi:10.1056/NEJM200104053441404.
DeMatteo RP, et al. Results of tyrosine kinase inhibitor therapy followed by surgical resection for metastatic gastrointestinal stromal tumor. Ann Surg. 2007;245:347–52. doi:10.1097/01.sla.0000236630.93587.59.
Haller F, et al. Surgical management after neoadjuvant imatinib therapy in gastrointestinal stromal tumours (GISTs) with respect to imatinib resistance caused by secondary KIT Mutations. Ann Surg Oncol. 2006;14:526–32. doi:10.1245/s10434-006-9228-0.
Joensuu H. Gastrointestinal stromal tumor (GIST). Ann Oncol. 2006;17(Suppl 10):280–6. doi:10.1093/annonc/mdl274.
Bümming P, et al. Neoadjuvant, adjuvant and palliative treatment of gastrointestinal stromal tumours (GIST) with imatinib: a centre-based study of 17 patients. Br J Cancer. 2003;89:460–4. doi:10.1038/sj.bjc.6600965.
Salazar M, et al. First report of a complete pathological response of a pelvic GIST treated with imatinib as neoadjuvant therapy. GUT. 2006;55:585–6. doi:10.1136/gut.2005.086744.
Bauer S, Lang H, Schütte J, Hartman JT. Complete remission with imatinib in metastatic gastrointestinal stromal tumors. J Clin Oncol. 2005;23:6800–1. doi:10.1200/JCO.2005.02.1063.
Chacon M, Roca E, Huertas E, Sanchez Loria F, Domenechini E. Pathologic complete remission of metastatic gastrointestinal stromal tumor after imatinib mesylate. J Clin Oncol. 2005;23:1580–2. doi:10.1200/JCO.2005.03.194.
Bauer S, et al. Resection of residual disease in patients with metastatic gastrointestinal stromal tumors responding to treatment with imatinib. Int J Cancer. 2005;117:316–25. doi:10.1002/ijc.21164.
Heinrich MC, et al. Primary and secondary kinase genotypes correlate with the biological and clinical activity of sunitinib in imatinib-resistant gastrointestinal stromal tumor. J Clin Oncol. 2008;26:5352–9. doi:10.1200/JCO.2007.15.7461.
van der Zwan S, DeMatteo RP. Gastrointestinal stromal tumor: 5 years later. Cancer. 2005;104:1781–8. doi:10.1002/cncr.21419.
Lim K-H, et al. Molecular analysis of secondary kinase mutations in imatinib-resistant gastrointestinal stromal tumors. Med Oncol. 2008;25:207–13. doi:10.1007/s12032-007-9014-2.
Rubin BP. Gastrointestinal stromal tumours: an update. Histopathol. 2006;48:83–96. doi:10.1111/j.1365-2559.2005.02291.x.
Heinrich MC, et al. Molecular correlates of imatinib resistance in gastrointestinal stromal tumors. JCO. 2006;24:4764–74. doi:10.1200/JCO.2006.06.2265.
Fletcher CDM, et al. Diagnosis of gastrointestinal stromal tumors: a consensus approach. Hum Pathol. 2002;33:459–65. doi:10.1053/hupa.2002.123545.
Miettinen M, El-Rifai W, Sobin LH, Lasota J. Evaluation of malignancy and prognosis of gastrointestinal stromal tumors: a review. Hum Pathol. 2002;33:478–83. doi:10.1053/hupa.2002.124123.
Joensuu H. Risk stratification of patients diagnosed with gastrointestinal stromal tumor. Hum Pathol. 2008;39:1411–9. doi:10.1016/j.humpath.2008.06.025.
Judson IR. Prognosis, imatinib dose, and benefit of sunitinib in GIST: knowing the genotype. J Clin Oncol. 2008;26:5322–5. doi:10.1200/JCO.2008.17.7725.
Ryu M-H, et al. Patterns of progression in gastrointestinal stromal tumor treated with imatinib mesylate. Jpn J Clin Oncol. 2006;36:17–24. doi:10.1093/jjco/hyi212.
Liegl B, et al. Heterogeneity of kinase inhibitor resistance mechanisms in GIST. J Pathol. 2008;216:64–74. doi:10.1002/path.2382.
Acknowledgment
We are thankful to all our colleagues who participated in the treatment of the patient.
Author information
Authors and Affiliations
Corresponding author
Additional information
Dedicated to Prof. Dr. Dr. h.c. Karl-Hermann Meyer zum Büschenfelde on the occasion of his 80th birthday.
Rights and permissions
About this article
Cite this article
Cameron, S., Savvoukidis, T., Armbrust, T. et al. Analysis of a case with disappearance of the primary gastrointestinal stromal tumor and progressive liver metastases under long-term treatment with tyrosine kinase inhibitors. Med Oncol 27, 213–218 (2010). https://doi.org/10.1007/s12032-009-9193-0
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12032-009-9193-0