GIST risk stratification (mitotic count, size, site; Miettinen and modified NIH criteria)
Whether a gastrointestinal stromal tumour will come back after surgery is read from three things on the pathology report, its size, how many cells are dividing in a 5 square millimetre field, and where it started (stomach is safer than small bowel or rectum), plus whether it ruptured; high-risk patients get three years of imatinib and the others get none.
Overview
What is measured: the probability that a resected GIST will recur. How: tumour size in centimetres, mitotic count per 5 mm² (about 50 high-power fields; 5 or fewer against more than 5), the site of origin and rupture before or during surgery, read against the Miettinen and Lasota (AFIP, 2006) tables (a gastric tumour of 5 cm or less with 5 or fewer mitoses has a 0 to 2 percent risk; a small-bowel tumour over 10 cm or with more than 5 mitoses a 50 to 90 percent risk), the modified NIH criteria (Joensuu 2008) that add rupture as high risk, and nomograms and contour maps. The genotype is read alongside: KIT exon 11 deletions involving codons 557 and 558 are worse, PDGFRA D842V tumours are indolent and imatinib-insensitive, SDH-deficient tumours follow their own course; KIT (CD117) and DOG1 immunohistochemistry make the diagnosis. What a result changes: high risk or rupture means three years of adjuvant imatinib (SSG XVIII: five-year survival 92 against 82 percent with one year; five years against three is being tested), with the dose and the decision informed by genotype (no adjuvant imatinib for D842V); intermediate risk is discussed case by case; low and very low risk get follow-up only, with imaging intensity set by risk. Where it matters: GIST and its KIT exon 11, PDGFRA D842V and imatinib-resistant pages.
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