An audit of surgical management of gastrointestinal stromal tumours (GIST)

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Abstract

Aim

To analyze GIST outcome after primary resection and to determine if a new grading system could adequately predict there prognosis.

Methods

A retrospective review (1993–2002) identified 80 patients who underwent primary surgical resection for, c-KIT positive, GIST. Follow-up was complete for all patients (median follow-up 42, range 1–132, months). GIST were classified as low or high grade according to the following parameters: size, mitotic rate, mitotic index (MiB1), presence of necrosis, invasion of adjacent structure and presence of metastasis.

Results

GIST originated from the stomach (46), small bowel (30), colon and rectum two and mesentery two. At surgery, 94% of cases presented with localized disease and 6% blood born metastasis with or without lymph node invasion. Resections were complete (R0) in 72 cases. R0 resection correlated with prognosis (p<0.01). Sixty GIST were classified as low grade (median follow-up 60 months) and 20 as high grade (median follow-up 27 months). Five-year actuarial survival of patients with low or high grade GIST were of 95 and 21%, respectively, (p<0.001).

Conclusion

Prognosis of GIST after surgical treatment is influenced by completeness of primary resection and tumour malignant potential. Low grade GIST have an excellent prognosis after surgery alone, while high grade GIST have a high rate of recurrence after primary resection. Adjuvant treatment should be advocated for patient with either high grade GIST or after incomplete primary resection. The presented grading system can reliably predict GIST outcome after primary surgical treatment.

Complete surgical resection offers good chance of cure for low grade GIST, while for high grade GIST surgery alone is not sufficient. The presented grading system could be used to identify patients who may benefit of adjuvant treatment with imatinib mesylate after GIST resection.

Introduction

Gastrointestinal stromal tumours (GIST) are the most common mesenchymal tumours of the digestive tract.1 Their incidence is estimated between 10 and 20/106 people per year.2, 3 Most gastrointestinal soft tissue neoplasm, previously referred as leiomyomas, schwannomas, leiomyoblastomas or leiomyosarcomas, are today classified as GIST on the basis of molecular and immunohistological features.1, 2, 4 GIST are characterized by over expression of the tyrosine kinase receptor KIT2, 5 and gain of function mutations of the tyrosine-kinase c-Kit have been related to GIST oncogenesis as well as PDGFRA mutations.2, 6 Recently, the development of imatinib mesylate, a tyrosine kinase inhibitor, has dramatically improved metastatic or unresectable GIST prognosis.7, 8, 9

Surgery has been and is still the mainstay of GIST treatment.4, 10, 11, 12, 13 However, GIST span a wide clinical spectrum from benign to highly malignant tumours.4, 14, 15 Five years survival rates after resection range from 50 to 70%.4 As prognostic scales to detect high risk or malignant GIST, who would benefit of adjuvant imatinib mesylate,16, 17 are still under investigation.2, 4, 14, 18 The role of primary surgical resection parameters, i.e. completeness and extension of resection, is still discussed.11, 19, 20, 21, 22

We report our experience with 80 GIST patients who underwent primary surgical resection. This study was undertaken to evaluate the prognostic factors after primary surgical treatment of GIST and to develop a clinically reliable prognosis grading system.

Section snippets

Materials and methods

Eighty-seven patients with gastrointestinal stromal tumour (GIST) were retrieved from the archives of our Division of Clinical Pathology and Department of Surgery in, between January 1993 and September 2003. Only patients with primary presentation and treatment of GIST were included. Among these 87 cases collected, seven were only diagnosed at autopsy and were excluded.

All tumours were reviewed by experienced pathologists for confirmation of true GIST nature and evaluation of the morphological

Clinical data

Eighty patients were considered for analysis. The median age was of 61 (range 29–88) years and the male:female ratio of 1:1. Localization of GIST were as follow: stomach 46 (58%), duodenum two (2.5%), small bowel 28 (35%), colon and rectum two (2.5%) and mesentery two cases (2.5%).

Clinical manifestations were related in 36 cases (45%) to digestive bleeding. Twenty patients presented tumour related pain while another 20 were discovered incidentally either through radiological examination or

Discussion

This study reviews the long-term outcome of GIST patients in relation with surgical resection status and tumour malignant potential. According to our data, GIST prognosis is influenced by completeness of surgical resection and depends on GIST malignant potential. The staging system presented here strongly correlates with GIST disease free survival and patient survival after primary surgery.

In this series, GIST localizations as well as clinical and pathological features were similar to those of

Conclusion

Clinical outcome of GIST after surgery is influenced by completeness of resection and dependant on tumour malignant potential. The presented staging system provides additional prognostic information and could be used to determine which patients would benefit of adjuvant treatment. While, low grade GIST could be cured by surgery, high grade GIST have a high rate of recurrence even after R0 resection. Adjuvant treatment would be of benefit for patient either with high grade GIST or after

References (40)

  • T. Aparicio et al.

    Prognostic factors after surgery of primary resectable gastrointestinal stromal tumours

    Eur J Surg Oncol

    (2004)
  • P. Bucher et al.

    For small intestinal stromal tumors are there prognostic factors

    Am J Surg

    (2004)
  • M. Miettinen et al.

    Gastrointestinal stromal tumours: recent advances in understanding of their biology

    Hum Pathol

    (1999)
  • C. Corless et al.

    Biology of gastrointestinal stromal tumours

    J Clin Oncol

    (2004)
  • M. Miettinen et al.

    Gastrointestinal stromal tumours-definition, clinical, histological, immunohistochemical, and molecular genetic features and differential diagnosis

    Virchows Arch

    (2001)
  • P. Bucher et al.

    Management of gastrointestinal stromal tumours: from diagnosis to treatment

    Swiss Med Wkly

    (2004)
  • L. Wang et al.

    Cellular origin of gastrointestinal stromal tumours

    Arch Pathol Lab Med

    (2000)
  • G.D. Demetri et al.

    Efficacy and safety of imatinib mesylate in advanced gastrointestinal stromal tumours

    N Engl J Med

    (2002)
  • E. Connolly et al.

    Gastrointestinal stromal tumours

    Br J Surg

    (2003)
  • M. Miettinen et al.

    Gastrointestinal stromal tumours

    Ann Chir Gynaecol

    (1998)
  • Cited by (0)

    This work has been presented and awarded at the 12th United European Gastroenterology Week in Prague (25th–29th September 2004). Moreover, it received the 2nd prize for best scientific work at the 14th World Congress of the International Association of Surgeon and Gastroenterologist in Zurich (8th–11th September 2004).

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