The effect of surgery and grade on outcome of gastrointestinal stromal tumors

Hypothesis: Gastrointestinal stromal tumors (GIST) are aggressive, rare, an d difficult-to-curt gastrointestinal turners. We believe that the clinical behavior of these tumors can be predicted by reproducible prognostic factor s. Design and Setting: A retrospective review of all patients (N = 70) with GI ST treated at a tertiary care center from 1973 to 1998. Patients: Adequate data for evaluation were available for 69 patients. Male -female distribution was 40:29. Median age was 60 years. Median follow-up d uration was 38 months. Main Outcome Measures: Tumor grade, stage, and histologic subtype at presen tation; effect of grade, surgery and adjuvant therapy on recurrence, salvag e, and survival. Results: Tumor distribution included 61% in the upper, 23%;, in the middle, and 16% in the lower digestive tract, with a median tumor size of 7.9 cm ( range, 1.8-25 cm). Tumors with more than 1 mitosis per 10 high-power fields constituted 57% of neoplasia in the series. Distant disease at initial vis it occurred in 49% of patients. Complete gross resection occurred in 59% of patients. After complete resection, the 5-year survival rate was 42%, comp ared with 9% after incomplete resection (hazard ratio=0.27, P<.001). Neithe r radiation nor chemotherapy demonstrated any significant benefit. Among 39 patients who were disease free after complete resection, 2% develo ped lymph node recurrence, 25% developed local recurrence, and 33% develope d distant recurrences (54% liver, 20% peritoneum). By multivariate analysis the risk of local and/or distant metastases was significantly increased fo r tumors with more than 1 mitosis and size larger than 5 cm (P<.05). Multiv ariate analysis in all 69 patients revealed that incomplete resection, age greater than 50 years, non-smooth muscle histological feature, tumor with m ore than 1 mitosis, and tumor size larger than 5 cm significantly decreased survival. Conclusion: Complete gross surgical resection is presently the only means o f cure for GIST. Tumors with more than 1 mitosis and a size larger than 5 c m have an especially poor prognosis, with decreased survival, and increased local and/or distant recurrence.