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Gist For Hyderabad
Gist For Hyderabad
1
H:
• 59 y ,Postmenopausal, Dysphagia, &
bleeding p/v, (year 2005 at AIIMS)
• ANA +, Arthritis, Malar pigmentation
Ca ® Breast pT2N0M0 (July ‘ 02)
• BCS
• Breast RT + electron boost
• Adjuvant CMF 6#
• ER, PR & HER 2-neu +
• Tamoxifen 20 mg OD 2
Investigations
• Chest X Ray
• USG
• CECT
• EUS
• Ba Swallow
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Dermatomyosisits ► GI &
Breast CA
Maoz CR, Langevitz P, Livnch A,
Blumstein Z, Sadeh M, bank I, et al.
High incidece of malignancies in
patients with dermatomyositis and
polymyositis: an 11-yr analysis. Semin
Arthritis Rheum. 1998 Apr;27(5):319-
24
Dermatomyosisits ~ Malignancies
• No
– Obedian E, JClin Oncol 2000
Jun;18(12):2406-12
• Yes 16%
– Hanlon FB, Freedman G., Nicolaou N.,
Anderson P. Int J Radiat Oncol Biol Phys..
2001 nov 1;51(3):679-90
GIST + Neurogenic
• No relation to RT, CT
• Her 2 neu +
• Dermatomysositis
Diagnosis
♠ Submucosal ≡ ►
►GIST = first diagnosis
GIST
• Case history- • CT
submucosal • Surgery
• Cajal Cell • Chemoresistance
• Gene KIT • Imatininb
• PGDRF • Sumanitib
• Diagnosis • Prognosis
• CT • Predictor factors
• PET
30
GIST…??
• Uncommon
• Mesenchymal tumors
• Origin in the wall of G-I tract
• Intestinal pacemaker cell called the
interstitial cell of Cajal.
31
History of GIST…
• late1960’s smooth muscle neoplasms
of the gastrointestinal tract
• Immuno-histochemistry in the 1980’s
some lacked features of smooth muscle
differentiation
• Mazur and Clark
– “Gastrointestinal stromal tumors” =
Neurogenic or Myogenic differentiation
32
• Mutations c-kit gene can cause
constitutive activation of the tyrosine
kinase function of c-kit
• These mutations result in:
– Auto-phosphorylation of c-kit
– Ligand-independent tyrosine kinase activity
– Uncontrolled cell proliferation
– Stimulation of downstream signaling
pathways
33
Cajal cell
34
GIST
• Case history- • CT
submucosal • Surgery
• Cajal Cell • Chemoresistance
• Gene KIT • Imatininb
• PGDRF • Sumanitib
• Diagnosis • Prognosis
• CT • Predictor factors
• PET
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KIT
• role of the KIT and platelet-derived growth
factor receptor (PDGFR) tyrosine kinase
receptors
• KIT receptor tyrosine kinase (KIT RTK)
37
KIT
• approximately 5% of GIST cells show not
activation and aberrant signaling of the
KIT receptor, but rather mutational
activation of a structurally related kinase,
PDGFR- (PDGFRA).
• 90% rate of mutations seen in a more
recent series searching for potential
mutations in each of exons 11, 9, 13, and
17
38
Survival & KIT
• Exon 11 worse than PDGFR
• Exon 9 worse than Exon 11
• Small intestine worse than stomach or
colon
• Exon 11 not dose dependent (Imatinib)
• Exon 9 dose dependent (Imatinib)
• ( EORTC, NA Swog S0033, B2222 phase
II)
39
KIT & other markers
• KIT
• PDGFRA
• Protein kinase C Theta ( PKCTheta)
• DOG-1
• Wild type = KIT negative GIST
40
PDGFR
Platelet derived growth receptor
alpha (PDGFR-a)
• Tyrosine kinase activator
• Similar to c-kit
• Helps define GIST
41
Pediatric
• - KIT
• - PDGFRA
• Wild type
• + CD117
• ▲ Local recurrence
• Slow growing
42
CD117 CD34 Actin & S-100
Desmin
GIST + + - -
Desmoid - + - -
tumor
True - - + -
leiomyosarc
oma
Schwanoma - - - +
43
GIST
• Case history- • CT
submucosal • Surgery
• Cajal Cell • Chemoresistance
• Gene KIT • Imatininb
• PGDRF • Sumanitib
• Diagnosis • Prognosis
• CT • Predictor factors
• PET
44
GIST
• Case history- • CT
submucosal • Surgery
• Cajal Cell • Chemoresistance
• Gene KIT • Imatininb
• PGDRF • Sumanitib
• Diagnosis • Prognosis
• CT • Predictor factors
• PET
45
Diagnosis
• FDG PET = mandatory
►FDG-PET CT scan is ideal
• MD-CE-CT = image modality of choice for
abdomen (if FDG-PET-CT is not available)
• MR
• Evaluate by Chol or RECIST criterion
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47
GIST & chemoresistance
• ▲ P-glycoprotein [the product of the
multidrug resistance-1 (MDR-1) gene]
• ▲ MDR protein
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▼ active tyrosine kinase enzymatic function
of the BCR-ABL oncoprotein ► critical to
the pathogenesis of chronic myeloid
leukemia (CML)
49
Definition…
• GI submucosal mesenchymal tumor
that is not myogenic (eg,
leiomyosarcoma) or neurogenic (eg,
schwannoma) in origin.
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Distribution…
• Stomach 50-60%
• Small bowel 20-30%
• Large bowel 10%
• Esophagus 5%
• Else where in abdomen 5%
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Symptoms…
Abdominal pain
Dysphagia
Gastrointestinal bleeding
Symptoms of bowel obstruction
Small tumors may be asymptomatic
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Cytologically…
58
Malignant Versus Benign
60
GIST
• Case history- • CT
submucosal • Surgery
• Cajal Cell • Chemoresistance
• Gene KIT • Imatininb
• PGDRF • Sumanitib
• Diagnosis • Prognosis
• CT • Predictor factors
• PET
61
Treatment…
• Surgical excision is primary treatment
option but recurrence rates are high
• Resistant to standard chemotherapy
regimens due to over-expression of
efflux pumps
• Radiation therapy limited by large tumor
sizes and sensitivity of adjacent bowel
62
GIST
• Case history- • CT
submucosal • Surgery
• Cajal Cell • Chemoresistance
• Gene KIT • Imatininb
• PGDRF • Sumanitib
• Diagnosis • Prognosis
• CT • Predictor factors
• PET
63
IMATINIB
• Since activation of Kit played a crucial
role in the pathogenesis of GIST,
inhibition of Kit would be therapeutic
64
IMATINIB
• Orally bioactive tyrosine kinase
inhibitor
• Shown to be effective against GIST
tumors in two trials in the US and
Europe reported in 2001 & 2002
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Sunitinb
• Oral TK 1
• ▼ KIT & PDGFR
• ▼ VEGFR, RET
• Anti-Angoiogenic + Antitumour
• Indication: Imatinib resistant, Wild type
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Neoadjuvant
• For unresectable tumours
(NCI-RTOG 2007)
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Adjuvant ???
• For high risk of recurrence only
(ACS-OG Z9000, Z 9001)
(Scandinavian-German SSG VIII/AIO)
(EORTC 62024)
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Recurrence or Metastaic
• Imanitib is MUST
• (Univ of Texas MD A)
• (MGH Boston)
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GIST: Summary
• All have malignant potential
• CD 34 , CD 117, PET for Diagnosis
• Complete surgical resection important
• Metastatic disease responds to Imatinib
• Role of Imtanib
• No role of chemo or radiation
70
Prognosis…
• The overall survival rate 35% at 5
years
• complete resection 54% at 5 years
• Incomplete resection 12 months
• Metastasis 19 months
• Local recurrence 12 months
71
Survival & KIT
• Exon 11 of KIT worse than PDGFR
• Exon 9 of KIT worse than Exon 11
• Small intestine worse than stomach or
colon
• Exon 11 not dose dependent (Imatinib)
• Exon 9 dose dependent (Imatinib)
( EORTC, NA Swog S0033, B2222 phase II)
72
Predictors of survival
• Male sex,
significant
• Tumor size > 5cm on
• Incomplete resection multivariate
analysis
• Mitotic index
73
GIST
• Case history- • Rx
submucosal • Surgery
• Cajal Cell • Chemoresistance
• Gene KIT • Imatininb
• PGDRF • Sumanitib
• Diagnosis • Prognosis
• CT • Predictor factors
• PET 74
Present Complaints
• Bleeding P/V x 2 months (July
2005)
• Hematemesis, Wt loss -
• GPE N
H:
• 59 y ,Postmenopausal
Ca ® Breast pT2N0M0 (July ‘ 02)
• BCS
• Breast RT + electron boost
• Adjuvant CMF 6#
• ER, PR & HER 2-neu +
• Tamoxifen 20 mg OD
CMF vs CAF
• Lancet 19988 Early Trialist Group
Her 2 Neu Rx
• Her 2 +ve indicates a more severe
disease
• Another reason not to use the CMF and
rather use Anthracycline
• Aggressive tumors in presence of
Dermatomyositis
• Rx by Herceptin
Tx
• 10 mg bd vs 20mg OD
• Current recommendations are 10mg BD
Tamoxifen ► Endometrial polyps,
hyperplasia & adenocarcinoma
• Hysteroscopy: pretreatment and
annual
• Endoscopic myomectmy
Nomikos IN, Elemenoglou J, Papatheophanis
J. Tamoxifen-induced endometrial polyp. A
case report and review of literature. Eur J
Gynaecol Oncol. 1998;19(5):476-8
Tamoxifen ► Endometrial polyps,
hyperplasia & adenocarcinoma
• Hysteroscopy: pre-Rx & annual
• Endometrial resection
• Goldenberg, Nezhat C, Mashiach S., Seidman
DS. J AM Assoc Gynecol Laparosc. 1999
Aug:6(3):285-8.
Bleeding PV
• All causes +
• Tamoxifen induced hyperplasia, polyp,
carcinoma,
• Mets from Metastatic Lobular breast
CA
Tx►Polyps► hyperplastic or
metstatic
• Hysteroscopy is mandatory
Tamoxifen ► Post M Bleed P/V
►Hysteroscopy mandatory
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