From the Guidelines
The standard treatment of localized GISTs is complete surgical excision of the lesion, with no dissection of clinically negative lymph nodes, and adjuvant therapy with imatinib for 3 years is recommended for patients with a significant risk of relapse. The management of GISTs involves a multidisciplinary approach, including surgery, medical therapy, and management of complications.
Diagnosis and Treatment
- The diagnosis of GIST relies on morphological assessment and immunohistochemistry, with CD117 and/or DOG1 immunopositivity supporting the diagnosis 1.
- Molecular analysis, including KIT and PDGFRA genotyping, is highly recommended to predict sensitivity to molecular-targeted therapy and to determine the prognosis 1.
- For localized GISTs, complete surgical excision is the standard treatment, with sparing surgery recommended whenever possible 1.
- Adjuvant therapy with imatinib for 3 years is recommended for patients with a significant risk of relapse, with the exception of PDGFRA D842V-mutated GISTs, which should not be treated with adjuvant imatinib 1.
Medical Therapy
- Imatinib is the standard upfront treatment for locally advanced inoperable and metastatic disease, at a dose of 400 mg daily, with the option to increase to 800 mg daily in case of progression 1.
- Sunitinib is the standard second-line treatment, at a dose of 50 mg/d, 4 weeks of therapy/2 weeks off, or continuous dosing of 37.5 mg/d 1.
- Regorafenib is the standard third-line therapy, at a dose of 160 mg daily for 3 out of every 4 weeks, with the option to adapt the treatment schedule to patient tolerability 1.
Monitoring and Follow-up
- Regular monitoring with imaging studies, endoscopy, and molecular analysis is essential to assess treatment response and disease progression 1.
- The mitotic count has prognostic value and should be expressed as the number of mitoses in a total area of 5 mm2 1. The treatment of GISTs should be individualized, taking into account the patient's specific characteristics, tumor genotype, and risk of relapse, with the goal of improving morbidity, mortality, and quality of life.
From the Research
Gastrinoma Treatment Options
- Surgical treatment is considered the first line of treatment for gastrinomas, especially if the liver is not involved 2, 3
- Surgery can provide a cure for localized gastrinomas, and debulking of metastatic tumor may improve symptoms and survival 3
- Medical therapy for tumor control includes biotherapy with alpha-interferon and somatostatin analogs, chemotherapy, or targeted radiotherapy 2, 4
- Proton pump inhibitors offer symptomatic relief by suppressing hypersecretion of gastric acid and improving quality of life in patients with Zollinger-Ellison syndrome 4, 5
- Somatostatin analogs, such as Sandostatin LAR, may be an alternative treatment option for patients with metastatic gastrinomas not suitable for chemotherapy, interferon, or targeted radiotherapy 2
Diagnosis and Treatment Approaches
- Diagnosis of gastrinoma is based on clinical history, gastroscopy, and measurement of serum gastrin, gastric juice pH, CT scan, endoscopic ultrasonography, and somatostatin receptor scintigraphy 2, 5
- Treatment approaches have evolved over time, with a focus on surgical and medical management being complementary 6
- The role of adjuvant therapies for gastrinoma remains limited, but novel somatostatin analogues, angiogenesis inhibitors, and kinase inhibitors may be potential future therapeutic strategies 4
Specific Treatment Considerations
- For patients with gastrinoma and multiple endocrine neoplasia type 1, the treatment approach remains controversial, with some advocating for aggressive surgical approaches and others suggesting less aggressive or nonoperative approaches 3, 6
- The use of proton pump inhibitors is recommended to control symptoms and inhibit gastric acid hypersecretion, with a therapeutic target of elevating gastric pH > 4 5