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Gastrointestinal Stromal Tumors: A clinicopathologic study of 67 cases.

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Amr H. Sleema MD; Ihab S. Fayeka MD; Hany F. Habashyb MD;Amany Saberc MD;Alfred E. Namourd MD;Nevine F. Habashye MD
a: Surgical Oncology Department – National Cancer Institute – Cairo University – Egypt.
b: Surgery Department – Fayoum teaching hospital – Fayoum University – Egypt.
c: Medical Oncology Department – Minia Cancer Center – Egypt.
d: Medical Oncology Department – National Cancer Institute – Cairo University – Egypt.
e: Surgical Pathology Department - National Cancer Institute – Cairo University – Egypt.
Kasr el-aini journal of surgery Volume 15, No.2, May 2014

Published in: Health & Medicine
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Gastrointestinal Stromal Tumors: A clinicopathologic study of 67 cases.

  1. 1. 1 Gastrointestinal Stromal Tumors: A clinicopathologic study of 67 cases. Amr H. Sleema MD; Ihab S. Fayeka MD; Hany F. Habashyb MD;Amany Saberc MD;Alfred E. Namourd MD;Nevine F. Habashye MD a: Surgical Oncology Department – National Cancer Institute – Cairo University – Egypt. b: Surgery Department – Fayoum teaching hospital – Fayoum University – Egypt. c: Medical Oncology Department – Minia Cancer Center – Egypt. d: Medical Oncology Department – National Cancer Institute – Cairo University – Egypt. e: Surgical Pathology Department - National Cancer Institute – Cairo University – Egypt. Abstract Aim: Is to study the clinicopathologic aspects of Gastrointestinal Stromal Tumors (GISTs) with correlation between surgical resection, pathological characterestics; disease free survival (DFS) and overall survival (OS) for all cases in a combined retrospective and prospective study. Patient and methods: A retrospective study for 33 patients with GISTs at the National Cancer Institute , Minia Oncology Center and Fayoum Teaching hospital between January 2001- December 2006 and a prospective study for 34 patients at the National Cancer Institute , Minia oncology center and Fayoum Teaching hospital between January 2007 - January 2011. All patients were evaluated pre-operatively and underwent exploratory laparotomy with surgical resection for curative intent; they were followed up for a period ranging from 24 to 60 Months. Results: Among the 67 patients, there were 25 males and 42 females; 77.61% of patients were above 40 years. Abdominal pain (40.3%), abdominal mass (38.8%) and GIT bleeding (34.8 %) were the main presentations. The stomach was the most common site of origin of the disease (49.3%) followed by small intestine (28.4%). Tumors were high
  2. 2. 2 grade in (70.1%) and low grade in (29.9%). Complete resection of all gross disease was accomplished in 53 patients (79.1%) and residual disease in 14 patients (20.9%).Overall survival and disease free survival were statistically significant in relation to the size of the tumor, the grade of the tumor, and the resection status. Conclusion:Complete surgical resection, including en block resection of locally advanced tumors, remains the only curative treatment for GISTs. The overall survival and disease free survival were significantly affected by size of the tumor, grade of the tumor and the resection status. Keywords Gastrointestinal stromal tumor – Sarcoma - CD117 - CD34 – Imatinib - surgical resection. Introduction Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract (1). They account for 1% of all GI tumors. Their origin was at first attributed to interstitial cells of Cajal, in mesodermal tissue but it has nowadays been recognized that GISTs arise from multipotential mesenchymal stem cells (2). GISTs are defined as pleomorphic mesenchymal tumors of the GI tract that express the KIT protein (CD117-Protooncogene that encodes the transmembrane tyrosine kinase receptor CD117 and in some gastrointestinal stromal tumors often also CD34 on immunohistochemistry (3). GISTs demonstrate a fairly equal distribution between men and woman although some literature suggests that GIST has a slight male predominance (4). Although GIST has been documented in patients of all ages, most of the people affected by GIST are between 40 and 80 years old at the time of
  3. 3. 3 diagnosis with the median age of 60 years (5).The proportion of overtly malignant or high-risk GISTs is considered to be 20-45% of all GISTs (6), which suggests that the annual incidence of GISTs with a high malignancy potential is about 5 - 6.8 per million (7). GISTs present as well circumscribed, highly vascular tumors in the wall of subserosa of the gastrointestinal tract. On gross examination, these tumors appear fleshy, pink or tan-white, and may show hemorrhage. Large tumors frequently show cystic degeneration or necrosis even in the absence of prior treatment (8). Most GlSTs (60% to 70%) arise in the stomach, 20% to 30% originate in the small intestine, and less than 10% in the esophagus, colon, and rectum. GISTs can also occur in extra intestinal sites in the abdomen or pelvis such as the omentum, mesentery or retroperitoneum (9). The vast majority of studies on GISTs suggest that the two most important prognostic features to assess the risk of aggressive behavior in a primary GIST are mitotic activity and tumor size. These two features were the foundation of the consensus approach for risk assessment in GISTs (10). According to the new guidelines (11) GISTs smaller than 2 cm without significant mitotic activity (<5 per 50 high-power fields) can be regarded as essentially benign. The next strongest parameter in these studies was tumor location, small intestinal and rectal GlSTs were more aggressive than gastric GlSTs of similar size (12). The clinical presentation of GIST varies widely, approximately 70% of patients with GIST were symptomatic, 20% were asymptomatic, and 10% were detected at autopsy. GISTs that caused symptoms tended to be larger with an average size of 6 cm. versus 2 cm. for asymptomatic GISTs and 1.5 cm. for GISTs detected at autopsy (13). Total surgical resection still constitutes the standard treatment for non-metastatic GISTs, since it is the only modality of treatment capable of being curative. The complete R0 resection (absence of residual disease) represents one of the most
  4. 4. 4 important determinant factors in the treatment outcome (disease-free interval and survival); RO resection is achieved in approximately 40% to 60% of all cases of GIST and in over 70% of the non-metastatic case (14). The primary goal of surgery is the total resection of the tumor. The type of resection to be performed is dependent on tumor location and size. Lesions suspected of having invaded adjacent organs must be treated by radical surgery through an en bloc resection of the organs involved. It is mandatory that the resection achieves negative margins verified by intraoperative frozen section examination, since the presence of residual disease negatively influences survival (15). The presence of lymph node metastasis has not been recognized as a prognostic factor (16); in fact, no data can be found in the literature to support routine lymphadenectomy. Therefore, lymphadenectomy should be performed when gross examination suggests lymph node involvement. For patients presenting with metastatic or recurrent GIST, the exact place of surgery in the Imatinib era remains to be determined. Surgery is generally not indicated if a patient presents with generalized disease progression under treatment. In such situation, the outcomes appear to be marginal: one study reported no patients free of recurrence at 12 months (17) and another reported a median time to progression of 3 months (18). The aim of this study is to correlate the clinicopathologic aspects of Gastrointestinal Stromal Tumors (GISTs) with surgical resection, pathological characterestics; disease free survival (DFS) and overall survival (OS) for all cases in a combined retrospective and prospective study. Patient and methods A retrospective study of 33 patients (January 2001- December 2006), and
  5. 5. 5 a prospective study of 34 patients (January 2007 - January 2011) at the National Cancer Institute, Minia Oncology Center and Fayoum Teaching Hospital. All patients were evaluated pre-operatively with complete laboratory investigations, chest radiograph and CT abdomen and pelvis with oral and IV contrast. Upper and lower GIT endoscopies were performed when indicated while an endoscopic biopsy done when the later was feasible. All patients underwent exploratory laparotomy aiming at complete surgical resection with a curative intent; they were followed up for periods ranging between 24 – 60 Months. All specimens were examined in relation to the risk factors, namely size, and histopathological grade and safety margin "R status". All specimens were also subjected to immunohistochemistry staining including CD34 cent CD117, tumors exhibiting mitotic rate 5/50 per high-power field (HPF) or less were defined as low grade and those exhibiting mitotic rate > 5/50 HPF as high grade tumors. Results Among the 67 patients in the studied population female predominance was obvious where 25 patients were men (37.3%) and 42 patients were women (62.7%). The median age was 49.7 years. 15 patients (22.4%) were under age of 40, 27 patients (40.3%) in the range between 40 and 60 years and 25 patients (37.3%) were above 60 concluding that 77.6% of the patients were above 40 years old. All patients were symptomatic on presentation, the most common symptom was pain in 27 patients (40.3%),other clinical manifestations included palpable mass in 24 patients (35.8%), GIT bleeding in 22
  6. 6. 6 patients (32.8%), Nausea & vomiting in 8 patients (11.9%), Anemia in 17 patients (25.4%) weight loss in 6 patients (9%) and constipation in 5 patients (7.5%). Computed tomography (CT) of the abdomen and pelvis was the most commonly used investigation (Figures 1 and 2), being done for 65 patients (97.6%). The other investigations used included upper GI endoscopy in 17 patients (25%) and lower GI endoscopy used in 11 patients (16.4%). Endoscopic abnormalities were demonstrated in 14 of 17 patients who underwent upper GIT endoscopy (82.3%). Those abnormalities were: extra gastric mass in 10 patients (71%) and ulcerative mass in 4 patients (29%).As for lower GIT endoscopy, abnormalities were detected in 9 of the 12 patients in whom it was performed (75%), Detected abnormalities were: ulcerating and extra luminal mass in 7 patients (77.7%) and 2 patients (22.2%) respectively. FNAC was done in 8 patients only and was positive diagnosis only in 6 of 8 patients. Anatomic distribution of the tumors is listed in (Table 1). The most common site of origin was the stomach (Figure 3) 33 patients (49.3%), followed by the small intestine (Figure 4 & 5) 19 patients (28.4%), the colon and rectum 9 patients (13.4%), Mesentery 5 patients (7.5%) and least frequently abdominal wall 1 patient (1.5%). Postoperative pathology revealed tumor size more than 5 cm. in 56 patients (83.6%) and less than 5 cm. in 11 patients (16.4%). Tumors exhibited high histopathologic grade in 47 patients (70.1%) and low Grade in 20 patients (29.9%). Microscopic examination revealed spindle cell appearance in 55 patients (82.1%), epithelioid in 5 patients (7.5%) and mixed in 7 patients (10.4%). Receptor status was studied in most of cases, CD117 was positive (Figure 7) in 28 cases (41.8 %) and negative in 12 cases (17.9%), CD34 was positive in 25 cases (37.3%) and negative
  7. 7. 7 in 10 cases (14.9%). Actin was done in 20 cases (29.9%) and Desmin in 5 cases (7.5%) all of them were negative (Table 2). The incidence of lymph node involvement in our series was 0%. The different operative procedures (Figure 6) performed during this study are listed in (Table 3). Complete resection with final negative pathologic margins (R0) was accomplished in 53patients (79.1%) and incomplete resection either microscopic (R1) or gross (R2) was documented in 14 patients (20.9%). Intra-operatively 3 complications (4.4%) were reported in the form of 2 minor bladder injuries (2.9%) due to extensive adhesions and repaired primarily in 2 layers and a single case (14.9%) of major vascular injury (aorta) which was repaired. Post-operatively 4 morbidities and 2 mortalities, two cases with wound sepsis, one cysto-cutaneous urinary fistula, and the fourth patient suffered from malnutrition all cases were managed conservatively. Disease free survival (DFS) was calculated from the date of primary tumor resection to the date of recurrence or the last follow-up date. DFS and Overall survival (OS) were assessed in relation to the following variables: size of the tumor (Table 4), grade of the tumor (Table 5) and completeness of resection (Table 6). Statistical analysis revealed a better DFS and OS with tumors <5 cm. in diameter, low grade and completely resected tumors. Cases with tumor size 5 < cm (11 cases) had disease free survival 45.63+13.46 and overall survival 46.18+12.32 while tumors > 5cm (56 cases) had DFS 25.96+13.29 OS 27.46+11.99. And this difference was statistically significant (P-Value > 001). Twenty patients had low-grade tumors whose DFS was 43.55+8.49 and OS 43.95+7.83 while 47 patients had high-grade tumors with a DFS 23.08+13.05 and OS 24.82+11.75 (P-Value < 001). DFS was 33.35+ 13.93 and OS
  8. 8. 8 33.77+13.46 in tumors completely resected, while tumors incompletely resected or with positive margins DFS was 13.42+6.79 and OS 18.28+6.61 (P value <001). In the prospectively studied 34 patients only 16 patients (47.1%) received adjuvant therapy 14 patients of them received Imatinib myselate and 2 patients received other chemotherapeutic regimens due to the high cost and unavailability of Imatinib myselate. Discussion GIST represents the most common mesenchymal tumor of the gastro- intestinal tract, a female predominance in this study representing 62.7% of patients, however a fairly equal distribution between men and woman in the literature (19). About 77.6% of patients in our study were above 40 years with a median age of 49.7 years. In comparison to Kim KM et al. 2005, who reported over 90% of GISTs occur in adults over 40 years, with a median age of 63 years (5). The symptoms associated with primary gastro-intestinal stromal tumors are usually vague and nonspecific which is a contributing factor in the delayed diagnosis associated with GIST (20). Despite the fact that most patients in our study were symptomatic either with pain, abdominal mass and/or GIT bleeding .Previous studies report that only 70% of patients are symptomatic, while 20% are asymptomatic and 10% detected in autopsy (21). This was explained by the large size of tumors in this study in comparison to the small size (< 2 cm) of asymptomatic tumors in others (22). By analysis of the utility of the frequently ordered diagnostic studies that
  9. 9. 9 were performed before surgical exploration, the most frequently ordered diagnostic test in our series was the CT scan (97.1%) which demonstrated the mass, determined its size and its relation to contiguous organs and it confirmed the presence or absence of distant metastases. A primary tumor is typically a well- circumscribed and often highly vascular mass closely associated with stomach or intestine .GISTs usually appear heterogeneous due to necrosis or intramural hemorrhage. Upper GIT endoscopy to evaluate a patient with upper gastrointestinal bleeding seems a reasonable first test to detect a benign source but it was our general impression that these studies added little in terms of planning the extent and the type of the operation because most of the endoscopically detected lesions were extra-luminal with an intact mucosa. Needle biopsy was performed infrequently and, when performed, was not helpful in the establishment of a definitive diagnosis. No other imaging tests (including upper gastrointestinal contrast study or abdominal ultrasound scanning) were found to be more sensitive than CT for the detection and staging of a primary GIST. In this study, tumors originated most frequently from the stomach 49.3%, these finding are similar to other reports in which the stomach was involved in 38% to 65% of cases (4, 23, 24). The small intestine was the second most common site of origin representing 28.4% correlating with other reports in which the small intestine represents about 30% of tumor origin (4). Regarding the size of the primary GISTs in this study, 83.6% of patients had tumors greater than 5 cm and 16.4% had tumors less than 5 cm. This was explained by the latent period between the start of disease and initiation of symptoms and delay for seeking a medical advice. Small tumors (< 5 cm.) had a significantly better DFS and OS. Similarly,
  10. 10. 10 several studies demonstrated that tumor size more than 5 cm significantly affect survival (24) where the 5 –years DFS rate for patients with primary tumor < 5 cm was 95% (52.1-100) ,5-10 cm 31.2% (16.6-42.8) and > 10 cm 22.5% (11.5-33.6). As with sarcomas elsewhere, histological grade is a powerful prognostic characteristic. Previous Reports have shown that low grade lesions are associated with improved overall 5-year survival in the 40% to 80% range compared with high-grade lesions with overall survival rates between 16% and 28% (25), and this correlates with our study where significant better DFS and OS were detected in low grade tumors. In the current study, Spindle cell tumors represented 82.1% of all cases, epithelioid cell type 7.5 % and Mixed type 10.5 % which are close to percentages to many studies (26), however Miettinen et al 2006 stated that spindle cell GISTs represent approximately 70%, epithelioid GISTs 20% and mixed spindle and epithelioid cyto-morphology approximately 10% (8). Characteristically stain positively for CD117 and CD34, but less commonly for Actin and Desmin which are expressed typically by leiomyosarcoma and shwanomas, respectively (20). In our study, about 79% of patients were positive for CD117 and CD34 Compared to other studies which reported positive CD 117 in 85-94% (27) and positive CD34 in 52-72% of cases (28). Complete surgical resection emerged as the most important prognostic variable in this study. Complete resection were achieved in 79.1% of patients and residual disease either microscopic or gross were in 20.9%; similarly Jason S et al 2006 achieved complete resection in 80% of cases
  11. 11. 11 (29). In a recent report, Langer et al., 2003 reported the outcome of 39 patients following surgery. Complete (R0) resection was achieved in 35 of 39 patients and from whom only five died from recurrent disease, compared with 3 of 4 patients with involved margins (30). Incomplete resection should only be performed for palliation of pain, bleeding or symptoms due to mass effect. Univariate analysis of different studies of GIST found that tumor size of less than 5cm, low histological grade, presence of localized disease, and complete surgical resection without tumor spillage were all favor-able prognostic factors (31). The incidence of lymph node involvement in our series was 0%, which is consistent with a low incidence of lymph node metastases seen in other reports (less than 2%) (32). In conclusion complete resection with an aggressive attempt to remove all gross disease and achieve negative margins remains the fundamental surgical principle in the management of GIST. Extensive preoperative testing and biopsy do little and not recommended; still CT is the best modality for evaluation of GIST. For localized gastric tumors, wedge resection with negative margins appears adequate. More extensive gastric lesions may require total gastrectomy or en bloc resection of adjacent organs. Small bowel and colon lesions are removed with segmental resections and, when indicated, may require the removal of involved contiguous organs. As the incidence of lymph node involvement is low, extended lymph node dissections are not warranted.
  12. 12. 12 References 1) Gina D; Dejka MS; John CM; Jonathan CT. Update on the biology and therapy of gastrointestinal stromal tumors, cancer control. 2005; 12(1): 44-56. 2) Joensuu H: Gastrointestinal Stromal tumor (GIST). Annals of oncology 2006, 17 (10):280 -286. 3) Heinrich MC, Corless CL, Duensing A,et al: PDGFRA activating mutations in gastrointestinal stromal tumors. Science 2003, 299:708-710. 4) Dematteo RP, Lewis JJ, Leung D, et al. Two hundred gastrointestinal stromal tumors: recurrence patterns and prognostic factors for survival. Ann Surg 2000:231 (1):51-8. 5) Kim KM, Kang DW, Moon WS: Gastrointestinal stromal tumor committee; The Korean Gastrointestinal pathology study Group. Gastrointestinal stromal Tumors in Koreans: incidence and the clinical, pathologic and immune-histochemical findings. J Korean Med sci 2005, 20:977-984. 6) Nilsson B, Bumming P, Meis- Kindblom JM, et al. Gastrointestinal stromal tumors: The incidence, prevalence, clinical course, and prognostication in the pre-imatinib mesylate era, Cancer 2005, 103(4) 821-29. 7) Tran T, Davila JA, EL-Serag HB. The epidemiology of malignant gastrointestinal stromal tumors: an analysis of 1,458 cases from1992 to 2000.AM J Gastroenterol 2005, 100(1), 162-8. 8) Miettinen M, Lasota J. Gastrointestinal stromal tumors: review on morphology, molecular pathology, prognosis, and differential diagnosis, Arch Pathol Lab Med 2006; 130(10):1466-78. 9) De silva CM, Reid R. Gastrointestinal stromal tumours (GIST): C- kit mutations, CD117 expression, differential diagnosis and
  13. 13. 13 targeted cancer therapy with imatinib. Pathol Oncol Res.2003; 9:13-19. 10) Fletcher CD, Berman JJ, Corless C, Gorstein F, Lasota J, Longley BJ et al. Diagnosis of gastrointestinal stromal tumors: A consensus approach. Hum Pathol. 2002 May; 33(5):459-65. 11) Demetri GD, Benjamin RS, Blanke CD, et al. NCCN Task Force report: management of patients with gastrointestinal stromal tumor (GIST) update of the NCCN clinical practice guidelines. J Natl Compr Canc Netw 2007; 5(Suppl2): S1-29(quiz S30). 12) Miettinen M, Makhlout H, Sobin LH, et al. Gastroll iteslinal stromal tumors of the jejunum and ileum: a clinicopathologic, immunohistochemical, and molecular genetic study of 906cases before Imatinib with long – term follow-up. Am J surg Pathol 2006; 30(4):477-89. 13) Kindblom LG. Gastrointestinal stromal Tumors; Diagnosis, Epidemiology, Prognosis. ASCO Annual Meeting Chicago II, 2003. 14) Roberts PJ, Eisenberg B. Clinical presentation of gastrointestinal stromal tumors and treatment of operable disease. Eur J Cancer. 2002; 38 suppl 5:537-8. 15) Singer S, Rubin BP, Lux ML, et al. Prognostic value of KIT mutation type, mitotic activity, and histologic subtype in gastrointestinal stromal tumors. J Clin oncol. 2002; 20(18):3898- 905. 16) Valadao M, de Mello EL, Lourenco L, et al. What is the prognificance of metastatic lymph nodes in GIST? Hepatogastroenterology. 2008; 55(82-83):471-4. 17) Raut C, Posner M, Desai J, et al. Surgical management of advanced gastrointestinal stromal tumors after treatment with
  14. 14. 14 targeted systemic therapy using kinase inhibitors. J Clin Oncol.2006; 24(15):2325-2331. 18) Dematteo R, Maki R, Singer S, Gonen M, Brennan M, Antonescu CR. Results of tyrosine kinase inhibitor therapy followed by surgical resection for metastatic gastrointestinal stromal tumor. Ann Surg. 2007; 245(3):347-352. 19) Goettsch WG, Bos SD, Breekveldt-Postma et al. Incidence of gastrointestinal stromal tumours is underestimated: Results of a nation – wide study. Eur J Cancer, 2005, 14(18), 2868-72. 20) Hasegawa T, Matsuno Y, Shimoda T, Hirohashi S. Gastrointestinal stromal tumor: consistent CD117 immunostaining for diagnosis, and prognostic classification based on tumor size and MIB-1 grade. Hum Pathol. 2002 33:669-76. 21) Heinrich MC, Corless CL, Demetri GD, et al. kinase mutations and Imatinib response in patients with metastatic gastrointestinal stromal tumor. J clin oncol 2003:21(23):4342-9. 22) Nilsson B, Bumming P, Meis- Kindblom JM, et al. Gastrointestinal stromal tumors: The incidence, prevalence, clinical course, and prognostication in the pre-imatinib mesylate era, Cancer 2005, 103(4) 821-29. 23) McGrath PC, Neifeld JP, Lawerence w, Kay S, Horsley Js, paker GA, Gastrointestinal sarcomas: Analysis of prognostics . Ann Surg. 1987, 206: 706-10. 24) Dougherty MJ, Compton C, Talbert M, wood WC. Sarcomas of the gastrointestinal tract: separation into favourable and unfavourable prognostic groups by mitotic count, Ann Surg. 1991. 214: 569- 74. 25) Meijer S. Peretz T. Gaynor JJ, Tan C, Hajdu St, brennan MF. Primary colorectal sarcoma. Arch Surg. 1990, 125: 1163-68.
  15. 15. 15 26) Ting WU, LI YU, Chun NE et al :Surgical and treatment and prognostic analysis for ( GISTs) of small intestine ; before the era of Imatinib ;B M Gastroenterolgy 2006,6 :29. 27) Hirota S; Isozaki K. Pathology of gastrointestinal stromal tumors. Pathol int. 2006; 56 (1): 1-9. 28) Miettinen M, Monihan JM, Sarlomo-Rikala M, et al. Gastrointestinal stromal tumors/smooth muscle tumors (GISTs) primary in the omentum and mesentery: clinicopathologic and immunohistochemical study of 26 cases. Am J Surg Pathol 1999; 23:1109-1118. 29) Jason S, Ronald P, DeMatteo et al: Combined surgical and Molecular Therapy; Ann Surg; 2006 August; 244(2):176-184. 30) Langer C, Gunawan B, Schulter P, Huber W, Fuzesi L, Becker H. Prognostic factors influencing surgical management and outcome of gastrointestinal stromal tumors. Br J surg.2003, 90:332-39. 31) Heikki Joensuu. Risk stratification of patients with gastrointestinal stromal tumors .Human Patholgy 2008: volume 39, Issue 10, pages 1411-1419. 32) Burkill GJ, Badran M, Al-Muderis O, Thomas JM, Judson IR, Fisher C, et al, Malignant gastrointestinal stromal tumor: Distribution, imaging features and pattern of metastatic spread. Radiology. 2003,226:527-32.
  16. 16. 16 Figure (1): CT abdomen axial cut for gastric GIST Figure (2): CT abdomen sagittal cut for jejunal GIST Figure (3): Small exophytic gastric GIST from the anterior wall of the stomach.
  17. 17. 17 Figure (4): Small jejunal GIST. Figure (5): A large lobulated Jejunal GIST
  18. 18. 18 Figure (6): Sleeve resection of the stomach using GIA-90 stapler. Figure (7): C Kit + ve Slides
  19. 19. 19 Table (1): Anatomic distribution of GISTs Origin: Frequency (N=67) Percentage Stomach. Small intestine. Colon / rectum. Mesentery. Abdominal wall. 33 19 9 4 1 49.3 28.4 13.4 6 1.5 Table (2): Receptors' Status Receptors +ve -ve Frequency Percent Frequency Percent CD117. CD34. Actin. Desmin. 28 25 0 0 41.8 37.3 0 0 12 10 20 5 17.9 14.9 29.9 7.5
  20. 20. 20 Table (3): operative procedures Type of operation. Frequency (N=67) Percentage Sleeve Gastrectomy. 15 22.4 Partial Gastrectomy. 9 13.4 Partial Gastrectomy + omentectomy. 1 1.5 Partial Gastrectomy + omentectomy + splenectomy. 2 3 Partial Gastrectomy + splenectomy + distal pancreatectomy. 2 3 Partial Gastrectomy + splenectomy + segmental colonic resection. 1 1.5 En block resection of mesenteric mass. 4 6 Extended RT. hemicolectomy. 3 4.5 LT. Hemicolectomy. 1 1.5 Sigmoid colectomy. 2 3 Abdomino-Perineal Resection 1 1.5 Partial Gastrectomy + splenectomy. 2 3 Total Gastrectomy + subtotal colectomy + splenectomy + omentectomy. 1 1.5 Small intestine resection anastomosis. 15 22.4 Intra-abdominal abscess drainage + resection of jejunal mass. 1 1.5
  21. 21. 21 Right hemicolectomy. 2 3 Transverse colectomy. 1 1.5 Cystic mass excision + pancreatectomy. 1 1.5 Huge mass excision + partial cystectomy. 1 1.5 Excision of mass of abdominal wall + prolene mesh 1 1.5 Mesenteric mass en block resection with transverse colectomy. 1 1.5 Table (4): Effect of size on DFS and OS Less than 5 cm More than 5 cm P value Disease free survival 45.63 ± 13.46 25.96 ± 13.29 <0.001 Overall survival 46.18 ± 12.32 27.46 ± 11.99 <0.001 Table (5): Effect of tumor grade on DFS and OS Low grade High grade P value Disease free survival 43.55 ± 8.49 23.08 ± 13.05 <0.001 Overall survival 43.95 ± 7.83 24.82 ± 11.75 <0.001
  22. 22. 22 Table (6): Effect of completeness of resection on DFS and OS R0 R1&2 P value Disease free survival 33.35 ± 13.93 13.42 ± 6.79 <0.001 Overall survival 33.77 ± 13.46 18.28 ± 6.61 <0.001

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