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