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Gastric Gastrointestinal Stromal Tumors Follow-up

  • Author: Michael A Choti, MD, MBA, FACS; Chief Editor: N Joseph Espat, MD, MS, FACS  more...
 
Updated: Sep 15, 2015
 

Further Outpatient Care

Follow-up care after curative operations is important because certain patients with recurrent disease may benefit from second surgical intervention and from systemic therapy with tyrosine kinase inhibitors for unresectable and/or metastatic disease. Follow-up includes physical examination and computed tomography (CT) scanning, and possibly periodical gastroscopies, as well.

For followup of gastric GISTs < 2 cm that have been completely resected, the National Comprehensive Cancer Network (NCCN) recommendations vary according to the presence or absence of high-risk features (eg, irregular border, cystic spaces, ulceration, echogenic foci, heterogeneity). For GISTs with high-risk features, the NCCN recommends considering abdominal/pelvic CT with contrast every 3-6 months for 3-5 years, then annually. For those without high-risk features, endoscopic surveillance at 6-12 month intervals may be considered.[17]

For followup of patients with metastic or persistent gross residual disease, the NCCN recommends followup with history and physical examination and abdominal/pelvic CT every 3-6 months. For patients with completely resected GISTs, the NCCN recommends history and physical examination every 3-6 months for 5 years, then annually, plus abdominal/pelvic CT every 3-6 months for 35 years, then annually.[17]

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Prognosis

In general, long-term survival for malignant GIST after a curative-intent surgery is strongly related to tumor size, mitotic rate, and tumor location.[50, 51, 52] Gastric GISTs tend to act less aggressively than small bowel GISTs of comparable size and mitotic rate.

Because no standardized staging system exists for stromal tumors of the GI tract and most series are small and heterogenous, comparison of the different published survival rates is difficult. However, various reports of 5-year survival rates after R0 resection for gastrointestinal stromal tumors range from 32-93%. In large series, this rate is about 50-60%. The median survival after palliative resection is about 10 months, with a 5-year survival rate as high as 10%. These rates improve with the addition of imatinib.

The NCCN criteria for risk stratification of primary GIST have not been incorporated into the AJCC staging but may be more helpful in determining individual risk for progressive disease, after margin-negative resection.[17] The stratification is by mitotic index (5 or less or more than 5 per 50 HPF) and then further divided by tumor size (2 cm or less or more than 2 cm; 5 cm or less or more than 5 cm; 10 cm or less or more than 10 cm) and tumor location (gastric, duodenum, jejunum-ileum, and rectum). Gastric GISTs greater than 10 cm but less than or equal to 5 per 50 HPF mitotic index have only a 10% risk of progressive disease despite 34-57% risk of progressive disease in the other tumor locations. Gastric GISTs greater than 10 cm and a high mitotic index (>5 per 50 HPF), however, have an equally high risk of progressive disease (86%) as the other tumor locations.

Ng et al in 1992 have reported the long-term survival of 139 patients with gastrointestinal malignant stromal tumors from different sites—40% gastric tumors. The overall 5-year survival rates by stage for GI stromal tumors is as follows:[53]

  • Stage I - 75%
  • Stage II - 52%
  • Stage III - 28%
  • Stage IVa - 12%
  • Stage IVb - 7%

In another large series of patients after resection of malignant GISTs published by Koga et al in 1995, survival was studied according to a classification combining tumor size and mitotic index. A very high survival rate was found in patients with tumors smaller than 6 cm and low mitotic index.[51]

Table 2. Five-Year Survival According to Size and Number of Mitoses (Open Table in a new window)

Size,



cm



Mitoses per 20 HPF 5-Year Survival Rate
< 6 < 4 97.5%
>6 < 4 91.5%
< 6 >4 80.0%
>6 >4 17.7%

 

Histologic grade alone is a strong prognostic factor. In 1982, Shiu et al reported a 5-year survival rate of 80% in patients after resection of low-grade tumors (low mitotic index, no necrosis). The 5-year survival rate dropped to 32% in patients with high-grade tumors (high mitotic index, regions of necrosis).[54]

Other factors found to have a negative impact on prognosis are as follows:

  • Tumor rupture during operation
  • Involvement of histologic margins
  • Lymph node involvement

The liver and the peritoneal cavity represent the predominant sites of recurrence after attempted curative surgery. Extra-abdominal sites (eg, lungs) are less common. Evaluate patients with recurrent disease for possible second resection if feasible. Survival prolongation is reported for resected local recurrences and even for resected isolated hepatic or peritoneal recurrent lesions.

In an analysis of 4,694 patients with localized GISTs from the National Cancer Data Base, Sineshaw and colleagues found that patients treated with adjuvant therapy had a 46% lower risk of death than patients treated with surgery alone, This survival benefit was significant for patients with GISTs larger than 10 cm.[84]

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Contributor Information and Disclosures
Author

Michael A Choti, MD, MBA, FACS Hall and Mary Lucile Shannon Professor and Chair, Department of Surgery, University of Texas Southwestern Medical Center

Michael A Choti, MD, MBA, FACS is a member of the following medical societies: American Association for the Study of Liver Diseases, American Surgical Association, International Hepato-Pancreato-Biliary Association, Americas Hepato-Pancreato-Biliary Association, American Society of Clinical Oncology, American College of Surgeons, Association for Academic Surgery, Society for Surgery of the Alimentary Tract, Society of Surgical Oncology, Society of University Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Fabian M Johnston, MD, MHS, FACS Assistant Professor, Department of Surgery, Johns Hopkins University School of Medicine

Fabian M Johnston, MD, MHS, FACS is a member of the following medical societies: American Medical Association, National Medical Association, Society of Black Academic Surgeons, Society of Surgical Oncology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

N Joseph Espat, MD, MS, FACS Harold J Wanebo Professor of Surgery, Assistant Dean of Clinical Affairs, Boston University School of Medicine; Chairman, Department of Surgery, Director, Adele R Decof Cancer Center, Roger Williams Medical Center

N Joseph Espat, MD, MS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American College of Surgeons, American Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Clinical Oncology, Americas Hepato-Pancreato-Biliary Association, Association for Academic Surgery, Central Surgical Association, Chicago Medical Society, International Hepato-Pancreato-Biliary Association, Pancreas Club, Sigma Xi, Society for Leukocyte Biology, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Surgical Oncology, Society of University Surgeons, Southeastern Surgical Congress, Southern Medical Association, Surgical Infection Society

Disclosure: Nothing to disclose.

Additional Contributors

Robert C Shepard, MD, FACP Associate Professor of Medicine in Hematology and Oncology at University of North Carolina at Chapel Hill; Vice President of Scientific Affairs, Therapeutic Expertise, Oncology, at PRA International

Robert C Shepard, MD, FACP is a member of the following medical societies: American Association for Cancer Research, American Association for Physician Leadership, European Society for Medical Oncology, Association of Clinical Research Professionals, American Federation for Clinical Research, Eastern Cooperative Oncology Group, Society for Immunotherapy of Cancer, American Medical Informatics Association, American College of Physicians, American Federation for Medical Research, American Medical Association, American Society of Hematology, Massachusetts Medical Society

Disclosure: Nothing to disclose.

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Shown here is a gastric gastrointestinal stromal tumor (GIST). This is a gross specimen following partial gastrectomy. Note the submucosal tumor mass with the classic features of central umbilication and ulceration.
CT scan of the abdomen with oral contrast in a 60-year-old woman with a gastric gastrointestinal stromal tumor (GIST). A huge mass with central necrosis is observed originating from the gastric wall and narrowing its lumen. An ulcer crater can be identified within the mass (arrow).
Photomicrograph of gastrointestinal stromal tumor (GIST) stained with hematoxylin and eosin (H&E) and magnified 40X. Note the solid sheet of spindle cells.
Photomicrograph of gastric gastrointestinal stromal tumor (GIST) stained with hematoxylin and eosin (H&E) and magnified 400X. This stromal tumor demonstrates spindle cells with epithelioid features.
Photomicrograph of gastrointestinal stromal tumor (GIST) with immunohistochemical staining for CD117. Note the strong positive staining of tumor cells with negative staining of the adjacent vessel. Positive stain for CD117 is diagnostic of GIST.
Table 1. Staging System for Malignant Gastrointestinal Stromal Tumors
Group Tumor Size Regional Lymph Node Metastasis Mitosis
Stage IA T1 or T2 N0 M0 Low
Stage IB T3 N0 M0 High
  T1 N0 N0 High
Stage II T2 N0 M0 High
  T4 N0 M0 Low
Stage IIIA T3 N0 M0 High
Stage IIIB T4 N0 M0 High
  Any T N1 M0 Any rate
Stage IV Any T Any N M1 Any rate
Table 2. Five-Year Survival According to Size and Number of Mitoses
Size,



cm



Mitoses per 20 HPF 5-Year Survival Rate
< 6 < 4 97.5%
>6 < 4 91.5%
< 6 >4 80.0%
>6 >4 17.7%
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