prof sm chandramohan professor and hod department of surgical gastroenterology center of excellence...
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GIST -CURRENT TRENDS
Prof SM ChandramohanProfessor and HOD
Department of Surgical GastroenterologyCenter of Excellence for Upper GI Surgery
Rajiv Gandhi Government General HospitalMadras Medical College
Chennai
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Epidemiology
• Most common mesenchymal neoplasm of the GI tract.
• 0.1%-3% of all GI malignant tumors
• Median age of 60 years (40-80)
No predilection for either gender (Miettinen M, Eur J Cancer 2002,
Rossi CR, Int J Cancer 2003; )
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Unique
Biologic behavior,
Clinicopathological features,
Molecular mechanisms
Treatment implications.
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Clinical Spectrum
Benign
Intermediate
Malignant
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History
1960
•Smooth muscle neoplasm of GIT
1980
•Immunohistochemistry
•Smooth muscle & neuronal differentiation and null
1983
•MAZUR &CLARK
•Coined the term GIST
1998
•c-KIT proto-oncogene
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<Location
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• Multicentric GISTs - <5%
• “Extra” GISTsSites Other than GIT,
- genito urinary,portal vein, pancreas
“Micro” GISTs - Size <2 cm “Giant” GISTs - ? 5 cm ? 10 cm
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CELL OF ORIGIN
Interstitial” cells of CAJAL
Santiago ramon y cajal -1893 • Interposed between smooth
muscle and nerve endings.
• Pacemaker—propagates intrinsic peristalsis
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CELL OF ORIGIN –Nobel laureate
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Biomarkers in GIST
C KIT
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KIT is a 145-kDa glycoprotein
CD117
-epitope on the extra-cellular domain of the KIT receptor.
Steel factor (SLF)
stem-cell factor ligand for KIT.
Binding of SLF to KIT
-activation of KIT tyrosine kinase activity
-downstream signaling pathways
-uncontrolled cell proliferation
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KIT Mutations
20 mutations
Exon 11
Most common
Better response to imatinib
Exon 9
Common in small bowel
Poor response to imatinib.
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Wild-type GIST (WT-GIST)
GISTs that have no detectable KIT or PDGFRA mutations- (10%-15%)
DOG gene
Discovered On GIST-1 gene in CH 11q13
DOG1 is a calcium dependent, receptor activated chloride channel protein expressed in GIST-independent of mutation type
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Immunohistochemistry
Gastrointestinal Mesenchymal Tumor
C-kit (+) or CD 34 (+)
GIST (80%)
C-kit (-) or CD 34 (-)
SMA (+) or Desmin (+)
Leiomyoma (15%)
S-100 (+)
Neurinoma (5%)
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GIST
CD 117 - >95%
CD 34 – 60-70%
Vimentin
Actin - 15-30%
Lymphoma
B-cell- CD 20,CD 79
T-Cell- CD 3,CD 5
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D/D
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Pathology
Few millimeters to more than 30 cm,
(median size -5 and 8 cm.)
Muscularis propria layer of GI wall
Exophytic growth.
Mucosal ulceration-50% cases.
Mass attached to the stomach, projecting into the abdominal cavity and displacing other organs.
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Pathological types
Exophytic Endophytic Combined
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Smooth
Gray and white tumors
Well circumscribed
Pseudocapsule
Small areas of hemorrhage
Cystic degeneration
Necrosis
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HistoPathology
• Nuclear palisading or prominent perinuclear vacuolization patternSpindle cell
• Solid pattern or a myxoid pattern, with a possible compartmental patternEpitheloid
• Both spindle cell and epitheloid patternMixed
pattern
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Histology
Spindle pattern
Epitheliod pattern
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CLINICAL PRESENTATION…
Asymptomatic, Especially early in
tumor development, Discovered
incidentally by CT or endoscopy
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Symptomatic GISTs
Vague abdominal discomfort (60%-70%).
Bleeding (30%-40%).
Perforation (20%)
Anorexia, weight loss, nausea, anemia, and additional GI complaints
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Site specfic symptoms
Esophageal GISTs -dysphagia, Gastric and small intestinal GISTs
- Bleeding &Intestinal obstruction.
Duodenal GISTs
- Biliary Obstruction Colorectal GISTs –
-pain and GI obstruction, and lower intestinal bleeding.
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Acute Presentation
Bleeding
peritoneal cavity- Ruptured Gist
GI tract lumen-
hematemesis, melena or anemia
Obstruction
Over growth
Intussusception
Volvulus
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Syndromes linked to GISTs
(i) Carney triad
Gastric GISTs,
Paraganglioma,
Pulmonary chondromas.
(ii) Type-1 neurofibromatosis
Generally wild-type
Predominantly located at the small bowel
Possibly multicentric .
(iii) Carney-Stratakis syndrome
Germ-line mutations of succinate dehydrogenase Dyad of GIST and paraganglioma
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UGI Scopy
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EUS- Management process
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Contrast enhanced computed tomography (CECT)
Modality of choice.
To characterize the lesion&evaluate its extent.
To assess the presence or absence of metastasis at the initial staging workup.
Monitoring response to therapy
Performing follow-up surveillance of recurrence
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Magnetic Resonance Imaging
Provides better soft-tissue contrast resolution and direct multiplanar imaging
Helps to localise the tumour
Delineate the relationships of the tumour and adjacent organs.
Particularly of benefit in anorectal disease.
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MRI
Axial T2-weighted MR image
Extraluminal mass arising from the greater curvature of the stomach.
The mass shows high signal intensity
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Benign gastric fundal GIST- MRI
Axial T1-weighted Axial enhanced T1-weightedAxial T2-weighted
Homogeneous iso-intensity
Homogeneous medium lintensity
Homogeneous moderate enhancement
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CT or MRI
large exophytic tumor with heterogeneous contrast enhancement, arising from the stomach or small bowel.
Metastases, if present, are usually to the liver or peritoneum.
Lymph node enlargement is uncommon.
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CT&MRI-D/D
Lymphomas
Circumferential with homogeneous enhancement
Lymph node enlargement.
Carcinoid tumors
Found in the distal ileum,or root of the mesentery,
Desmoplastic reaction with calcifications.
Large carcinomas
More likely to cause visceral obstruction.
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FDG-PET
Reveals small metastases
Establish baseline metabolic activity
Assess therapy response
Helps to clarify ambiguous findings seen on CT or MRI
To assess complex metastatic disease in patients who are being considered for surgery
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Changes in the metabolic activity of tumors precede anatomic changes on CECT.
used to assess the response to Imatinib therapy.
Routine use of PET for surveillance after resection is not yet recommended
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FNAC/BIOPSY
FNA- controversial
-risk of rupture and dissemination
Resectable lesion in the absence of metastatic disease
“Preoperative diagnosis may be unnecessary”
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Biopsy-Indications
If diagnosis would impact the extent of resection
Prior to Neoadjuant therapy
Unresectable GISTs
Metastatic GISTs
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Fletcher 2002
Size Mitotic count
Very Low risk <2 cm <5/50 HPF
Low risk 2-5 cm <5/50 HPF
Intermediate risk <5 cm5-10 cm
6-10/50 HPF<5/50 HPF
High risk >5 cm>10 cmAny size
>5/50 HPF Any count>10/50 HPF
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UICC 2010 TNM 7th Edition
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Management Guidelines
ESOINDIA GUIDELINESInternational Conference and Workshop,
Jan 2014,Chennai.
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Management strategies
Surgery Surgery + adjuvant Imatinib Neoadjuvant Imatinib + surgery
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Site specific surgery
Esophagus:
Esophagectomy
Esophageal sparing wide local excision
Stomach
Small-wedge resection
Large-subtotal/total gastrectomy
(BlumMG et al,AnnThoracSurg2007; WinfieldRDetal.AmSurg2006;
WayneJD et al SurgClinNorthAm2005).
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Duodenum:
Partial duodenal resection
Whipple’s Procedure
Small Intestine:
Segmental resection
Colon:
Colectomy
Rectum:
Anterior resection/
Abdominoperineal resection
(Blay JY et ai.Ann Oncology 2005;16:566-57 )
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Principles of surgery
AIM:
To obtain complete resection with maximal organ preservation with macroscopic negative margin.
Great care should be taken to avoid rupture of pseudocapsule
Re resection is generally not indicated for microscopically positive margins on final pathology
Lymphadenectomy is not required
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Irregular borderCystic spaces
UlcerationEchogenic fociHeterogeneity
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Resection margin
1-2 cm margin is necessary for an adequate resection
Tumor size Main determining factor for survival
Complete resection with gross negative margin is acceptable.
De Matteo et al,Ann Surg 2000
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Esophageal GISTs
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Gastric GIST- CECT- Coronal multiple planar reformation
Exophtic-growth
Heterogeneous enhancement.
Intact mucosa
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Laparoscopic Approach-NCCN Guidelines
Select GISTs in favorable anatomic locations
-Greater curvature or Anterior wall of stomach
-Jejunum or ileum
Preservation of pseudo capsule
Specimen retrieval through Plastic bag
-Avoidance of tumor spillage & port site seeding
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Minimally invasive (Privette et all-2008)
Type1: Lap. Stapled partial gastrectomy
Type2: lap.distal gastrectomy
Type3: lap.transgastric resection.
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Lap. Transgastric ….
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LEGGS-Laparoscopic endoscopically-guided gastric surgery
LECS-Laparoscopic and endoscopic cooperative surgery
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Laparoscopic and endoscopic cooperative surgery (LECS).
Mucosal&submucosal dissection – Endoscopy
Seromuscular resection by laparoscopy
Enables tumor resection with minimal surgical Margin.
Useful in esophagogastric junction or pyloric ring GISTs
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Small bowel GISTs
May occur throughout the small intestine
Signs and symptoms of
obstruction or rarely with hemorrhage .
They may appear as intramural masses or intraluminal polyps, and may show extension into adjacent mesentery
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Small bowel Vs Gastric GISTs
More commonly associated with Neurofibromatosis 1
More frequent exon 9 mutations
More frequently malignant
Intestinal obstruction more common than bleeding
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Small bowel GIST-CT-exophytic mass with an irregular
margin, heterogeneous contrast enhancement,
Central gas within the tumor with a gas-fluid level (arrow).
Central calcifications (arrow).
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Extension into the adjacent small bowel colon, bladder, ureter, and abdominal wall may occur.
D/D Adenocarcinoma
annular lesion in the proximal small intestine
Lymphoma.
similar features
associated lymphadenopathy
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Anorectal GISTs
Well-defined, eccentric mural masses that expand the rectal wall and may contain mucosal ulceration.
The mass spreads via extension into the ischiorectal fossa, prostate, or vagina.
As in GISTs at other locations, central areas of hemorrhage can be seen
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Rectal GIST
MRI should be used in rectal GIST as it provides better preoperative staging information
Endoscopic ultrasound and MRI assessment followed by biopsy and wide excision is the standard approach, regardless of tumor size.
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Colonic GISTs
Transmural tumors that involve the intraluminal and extraserosal surfaces of the colon.
Cystic change, hemorrhage, necrosis, or calcification are common
Circumferential growth with secondary
dilatation of the affected colonic segment.
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Imatinib Therapy
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Neoadjuvant imatinib
GIST that is resectable with negative margins but with significant morbidity
A multivisceral resection is indicated
To optimize timing of surgery
To facilitate organ function-sparing resections.
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Imatinib-Dosage
Initial dose
400 mg daily
Dose escalation
Pts with Progressive disease
Pts with KIT mutation in exon 9
Upto 800mg daily(400 mg BD) depending upon the tolerance
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Imatinib- Duration of Threapy
Preop
6–12 months until max.response is reached
Periop
stopped 2–3 days before surgery
resumed promptly when the patient recovers from surgery.
Post op
High Risk of relapse- 3 years (Level 1 a)
Low Risk - Adjuvant therapy not recommended.
Intermediate Risk- Controversial
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PET-Response to imatinib
Decreases the tumour avidity for 18F-FDG
PET imaging could detect the biological activity of imatinib far earlier than changes in anatomic measures on CT scanning.
PET changes as early as 24 hours following a single dose of imatinib.
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Sunitinib
-second-line drug treatment.
-For patients whose GIST tumors become resistant to imatinib.
Regorafenib
-FDA-2013 approved as a third-line drug for patients whose tumors are not responding to imatinib or sunitinib.
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Metastatic GISTs
Distant metastases most commonly involve liver (50-65%) & peritoneum (21-43%)
Only 10% of metastatic lesions occur in the lungs or bones
GISTs rarely spread to regional lymph nodes (<10%)
On presentation, 41-47% of malignant GISTs are metastatic.
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Metastatic GISTs
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Prognostic factors for RFS
Large tumor size, High mitotic count, Nongastric location, Presence of rupture, Male sex
(H. Joensuu et al, The Lancet 2011.)
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Prognosis…
The 5-year survival for malignant GIST
28 to 80%.
Median survival after incomplete surgery 10–23 months.
The median survival for metastatic or recurrent disease
12 to 19 months.
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FOLLOW UP-ESMO Guidelines
High-risk patients
CT scan or MRI
Every 3–6 months for first 3 years
Every 3 months for next 2 years,
Every 6 months for next 3 years
Annually for an additional 5 years.
For low-risk tumors,
CT scan or MRI every 6–12 months for 5 years.
Very low-risk GISTs
-probably do not deserve routine followup, although one must be aware that the risk is not nil.
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