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Review
. 2022 Apr:42:1-15.
doi: 10.1200/EDBK_351231.

The GIST of Advances in Treatment of Advanced Gastrointestinal Stromal Tumor

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Review

"V体育安卓版" The GIST of Advances in Treatment of Advanced Gastrointestinal Stromal Tumor

Inga-Marie Schaefer et al. Am Soc Clin Oncol Educ Book. 2022 Apr.

Abstract

Gastrointestinal stromal tumor (GIST) is the most common malignant neoplasm of mesenchymal origin and a compelling clinical and biologic model for the rational development of molecularly targeted agents. This is because the majority of GISTs are driven by gain-of-function mutations in KIT or PDGFRA receptor tyrosine kinases. Specific GIST mutations circumscribe well-defined molecular subgroups that must be determined during the diagnostic work-up to guide clinical management, including therapeutic decisions. Surgery is the cornerstone treatment in localized disease and can also be clinically relevant in the metastatic setting. The correct combination and sequence of targeted agents and surgical procedures improves outcomes for patients with GIST and should be discussed individually within multidisciplinary expert teams. All currently approved agents for the treatment of GIST are based on orally available tyrosine kinase inhibitors targeting KIT and PDGFRA oncogenic activation VSports手机版. Although first-line imatinib achieves remarkable prolonged disease control, the benefit of subsequent lines of treatment is more modest. Novel therapeutic strategies focus on overcoming the heterogeneity of KIT or PDGFRA secondary mutations and providing more potent inhibition of specific challenging mutations. This article reviews the current understanding and treatment of GIST, with an emphasis on recent advances. .

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Figures

FIGURE 1.
FIGURE 1.. Frequency of Gastrointestinal Stromal Tumor Molecular Subtypes
Abbreviation: SDH, succinate dehydrogenase. Adapted from Schaefer et al.
FIGURE 2.
FIGURE 2.. Immunohistochemical Markers in the Diagnostic Work-Up of Gastrointestinal Stromal Tumor
(A–C) Example of a KIT-mutant GIST with typical spindle-cell morphology (A) and strong and diffuse expression of KIT (B) and DOG-1 (C). (D–F) In contrast, a PDGFRA-mutant GIST displays epithelioid morphology (D) and weak expression of KIT (E), but strong and diffuse staining for PDGFRA (F). (G–I) Example of an SDH-deficient GIST characterized by epithelioid morphology (G), strong expression of KIT (H), and loss of SDHB expression in tumor cells (I), whereas SDHA expression is retained (I, inset), suggestive of an underlying mutation inactivating SDHB, SDHC, or SDHD. Abbreviations: GIST, gastrointestinal stromal tumor; SDH, succinate dehydrogenase.
FIGURE 3.
FIGURE 3.. Targeted Next-Generation Sequencing in Clinical Cases of Gastrointestinal Stromal Tumor
(A) An exon 11 KIT mutation (c.1667_1672delAGTGGA; p.W557_K558del; allele fraction 0.29) (arrow) is detected in a low-risk gastric GIST. (B) Atypical PDGFRA exon 18 mutation (c.2525A> T; p.D842; allele fraction 0.4) (arrow) is found in a low-risk gastric GIST. (C) An inactivating SDHC mutation (c.43C> T; p.R15*; allele fraction; 0.44; additional copy loss of the remaining allele) (arrow) is identified for a young patient with gastric GIST. Abbreviations: GIST, gastrointestinal stromal tumor; SDH, succinate dehydrogenase.
FIGURE 4.
FIGURE 4.. Treatment Algorithm to Guide the Management of Primary Gastrointestinal Stromal Tumor
Abbreviations: GIST, gastrointestinal stromal tumor; IM, imatinib mesylate; SDH, succinate dehydrogenase; TKI, tyrosine kinase inhibitor. *Complex-extensive tumor or multivisceral resection is required. **Complex but resectable tumors that are unresponsive to neoadjuvant IM can also be treated directly with surgery. Adapted from Etherington and DeMatteo and Joensuu and DeMatteo with permission.
FIGURE 5.
FIGURE 5.. Impact of Surgical Resection in Metastatic Gastrointestinal Stromal Tumor
Abbreviation: PFS, progression-free survival. Based on Etherington and DeMatteo and Joensuu and DeMatteo.
FIGURE 6.
FIGURE 6.. Sensitivity Profile of the Five Drugs With Regulatory Approval for Gastrointestinal Stromal Tumor
Green indicates sensitivity and red indicates resistance. The red and green boxes in D816 indicate the differences in sensitivities depending on the amino acid change (these drugs are resistant to the D816V substitution). These profiles have been established based on literature research from in vitro and in vivo studies and clinical data if available. Future research with patients’ correlative studies will further confirm or redefine laboratory findings. Abbreviations: AV, avapritinib; Ex, exon; GIST, gastrointestinal stromal tumor; IM, imatinib mesylate; RE, regorafenib; RI, ripretinib; SU, sunitinib.

References

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