Intestinal Stromal Tumors Follow-up

  • Author: Michael A Choti, MD, MBA, FACS; Chief Editor: Jules E Harris, MD, FACP, FRCPC  more...
 
Updated: Apr 28, 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 imatinib mesylate or chemotherapy for unresectable and metastatic disease. Follow-up includes physical examination and periodical gastroscopies and CT scans. Time intervals for performing these studies are not defined.

These tumors metastasize to the lungs in only about 2% of cases. Therefore, if findings are negative on an initial staging CT scan of the chest, additional evaluation for lung metastases may be obtained with chest X-rays alone.

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Further Inpatient Care

Postoperative and other inpatient care for GIST patients is similar to that for other GI surgery patients. Care is individualized to each patient.

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Complications

In patients who undergo surgery for their GISTs, postoperative complications depend on the nature of the surgery, the extent of resection, and the malignant potential of the tumor, as well as patient comorbidities. In the immediate postoperative period, the list of complications is no different from those for other GI surgeries.

In patients undergoing medical intervention, the risk profile is similar to that seen with the use of these chemotherapeutic drugs for other types of tumors.

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Prognosis

For malignant GIST In general, tumor size and histological grade correlate strongly with long-term survival after curative-intent surgery. The 3 primary prognostic factors are (1) whether the tumor is completely resectable, (2) tumor size, and (3) tumor grade.

Comparison of the different published survival rates is difficult because no standardized staging system exists for stromal tumors of the GI tract and most series are small and heterogeneous. In gastric sarcoma, however, reported 5-year survival rates after complete resection with negative margins (R0) range from 32-93%. In large series, this rate is about 60% (see Table 1 in Mortality/Morbidity). The median survival after palliative resection is about 10 months, with a 5-year survival rate as high as 10%.

Histopathology and clinical features of GISTs affect prognosis. Median survival is 5 years for primary disease, but only 10-20 months for metastatic or recurrent disease. The grade on histology also strongly correlates with prognosis. In one study, median survival in patients with GISTs was 98 months for those whose tumors had fewer than 5 mitoses per 50 cells on HPF, versus 25 months for those whose tumors had more than 10 mitoses. Other factors that have a negative impact on prognosis are tumor rupture during operation, involvement of margins, and lymph node involvement.

The liver, as shown in the image below, and peritoneal cavity represent the predominant sites of recurrence after attempted curative surgery. Compared with other soft tissue sarcomas, metastasis to extra-abdominal sites (eg, lungs) is infrequent. Patients with recurrent disease should be evaluated for a possible second resection. Survival prolongation is reported for patients with resected local recurrences and even for those with resected isolated hepatic or peritoneal recurrent lesions.

Liver resection specimen demonstrating 2 hepatic m Liver resection specimen demonstrating 2 hepatic metastases from a gastrointestinal stromal tumor. Image courtesy of Michael Choti, MD.
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Patient Education

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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.

Marcel E Conrad, MD Distinguished Professor of Medicine (Retired), University of South Alabama College of Medicine

Marcel E Conrad, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for the Advancement of Science, American Association of Blood Banks, American Chemical Society, American College of Physicians, American Physiological Society, American Society for Clinical Investigation, American Society of Hematology, Association of American Physicians, Association of Military Surgeons of the US, International Society of Hematology, Society for Experimental Biology and Medicine, SWOG

Disclosure: Partner received none from No financial interests for none.

Chief Editor

Jules E Harris, MD, FACP, FRCPC Clinical Professor of Medicine, Section of Hematology/Oncology, University of Arizona College of Medicine, Arizona Cancer Center

Jules E Harris, MD, FACP, FRCPC is a member of the following medical societies: American Association for the Advancement of Science, American Society of Hematology, Central Society for Clinical and Translational Research, American Society of Clinical Oncology

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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Gastric stromal tumor: Gross specimen following partial gastrectomy. Note the submucosal tumor mass with the classic features of central umbilication and ulceration. Image courtesy of Michael Choti, MD.
CT scan of the abdomen with oral contrast in a 60-year-old woman with gastric stromal tumor. 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). Image courtesy of Michael Choti, MD.
Gastric stromal tumor. Photomicrograph of gastrointestinal stromal tumor (GIST) stained with hematoxylin and eosin (H&E) and magnified 40 times. Note the solid sheet of spindle cells. Image courtesy of Michael Choti, MD.
Photomicrograph of a gastric stromal tumor stained with hematoxylin and eosin (H&E) and magnified 400 times. This stromal tumor demonstrates spindle cells with epithelioid features. Image courtesy of Michael Choti, MD.
Gastric stromal tumor: 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. Image courtesy of Michael Choti, MD.
Liver resection specimen demonstrating 2 hepatic metastases from a gastrointestinal stromal tumor. Image courtesy of Michael Choti, MD.
Table 1. Survival in Patients Undergoing Resection of GISTs [12, 13, 14, 15, 16, 17]
Reference Period Patients, No. Complete Resections, No. 5-y Survival Rate After Complete Resection, %
Caterino et al 1999-2009 47 46 65
DeMatteo et al 1982-1998 200 80 54
Ng et al 1957-1997 191 99 48
McGrath et al 1951-1984 51 30 63
Shiu et al 1949-1973 38 20 65
Akwari et al 1950-1974 108 52 50
Table 2. Risk Classification for Primary GIST by Mitotic Index, Size, and Tumor Site. Adapted from AJCC.
Tumor Parameters Risk of Progressive Disease*
Mitotic



Index



Size Stomach Duodenum Jejunum



or ileum



Rectum
 



≤5 per 50 HPF



≤2cm None None None None
>2 to ≤5 cm Very low (1.9%) Low (8.3%) Low (4.3%) Low (8.5%)
>5 to ≤10 cm Low (3.6%) Insufficient data Moderate (24%) Insufficient data
>10 cm Moderate (10%) High (34%) High (52%) High (57%)
 



>5 per 50 HPF



≤2 cm None* Insufficient data High † High (54%)
>2 to ≤5 cm Moderate (16%) High (50%) High (73%) High (52%)
>5 to ≤10 cm High (55%) Insufficient data High (85%) Insufficient data
>10 cm High (86%) High (86%) High (90%) High (71%)
*Defined as metastasis or tumor-related death.



† Denotes small number of cases.



Data based on long-term follow up of 1055 gastric, 629 small intestinal, 144 duodenal, and 111 rectal GISTs.
Table 3. Proposed Staging System for Malignant Gastrointestinal Stromal Tumors [24]
Group T N M Mitosis
Stage I T1 or T2 N0 M0 Low
Stage II T3 N0 M0 Low
Stage IIIA T1 N0 M0 High
  T4 N0 M0 Low
Stage IIIB T2 N0 M0 High
  T3 N0 M0 High
  T4 N0 M0 High
Stage IV Any T N1 M0 Any Rate
  Any T Any N M1 Any Rate
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