INTESTINAL GIST ANAMNESIS Laki-laki 44 tahun, 12 bulan perut merasa tidak enak,kadang-kadang mules, pernah berak kehitaman. Hanya diobatkan ke dokter puskesmas 3 bulan teraba benjolan yang makin lama makin membesar, perut terasa sebah dan mules sekali dan berak hitam makin jelas Nafsu makan kurang dan berat badan menurun Riwayat family dengan tumor abdomen disangkal PEMERIKSAAN FISIK Laki-laki berat badan: 42 Kg, TB 165 cm, BMI : 15,44 Kurus, nampak pucat Abdomen kembung ringan, terlihat bulging perut dibagian tengah, gambaran dan gerakan usus tidak terlihat. Palpasi teraba tumor diameter sekitar 12 cm, bulat dengan permukaan tidak rata, konsistensi keras, nyeri tekan (-), relatif mobile Auscultasi: Peristaltik normal, tidak terdengar bising diatas tumor LABORATORIUM Hb 7,8 Mg%, Ht 24, Lekosit 6500 Alb 2,8 mg%, Glob 2,3 mg% Na 134, K 3,2, Cl 98, Ca 2,10 Lain-lain baik.
SEVERE MALNUTRITION PRE-OPERATIVE NUTRITIONAL SUPPORT LAPARATOMI TUMOR USUS HALUS PERTENGAHAN (PERBATASAN ILEUM-JEJENUM) SEKITAR 14 CM, KERAS, LN MESENTERIKA (-), PERITONEAL SEEDING (-), METASTASE HEPAR (-) TANDA PARTIAL OBSTRUKSI USUS (+) DILAKUKAN RESEKSI USUS HALUS ISTAL DAN PROKSIMAL TUMOR, ANASTOMOSIS END TO END PASCA BEDAH PASIEN BAIK PULANG TANPA KOMPLIKASI
PA SPINDEL CELL TUMOR CURIGA GIST, BATAS RESEKSI BEBAS TUMOR, MITOSIS(?) IHC CD 117 (+)
NO NEED DIRECT LAPARATOMY & RESECTION OR BIOPSY. GRADING POLSKIE ARCHIWUM MEDYCYNY WEWNTRZNEJ 2008; 118 (4) HUMAN PATHOLOGY Volume33, No. 5 (May 2002) NIH Classification for Risk of Recurrence Very Low Risk Low Risk Intermediate Risk High Risk NIH consensus criteria 1
Tumor size < 2 cm Mitotic index < 5
Tumor size 2-5 cm Mitotic index < 5
Tumor size 5-10 cm Mitotic index < 5 OR Tumor size < 5 cm Mitotic index 6-10 Tumor size > 5 cm Mitotic index > 5 OR Tumor size > 10 cm Mitotic index, any OR Tumor size, any Mitotic index > 10 Modified NIH consensus classification 2
Any location: Tumor size < 2 cm Mitotic index 5
Any location: Tumor size 2.1-5 cm Mitotic index 5
Any location: Tumor size < 5 cm Mitotic index 6-10
Gastric: Tumor size 2.1-5 cm Mitotic index > 5 OR Tumor size 5.1-10 cm Mitotic index 5 Any location: Tumor rupture OR Tumor size > 10 cm OR Mitotic index > 10 OR Tumor size > 5 cm Mitotic index > 5
Nongastric: Tumor size 2.1-5 cm Mitotic index > 5 OR Tumor size 5.1-10 cm Mitotic index 5 Abbreviations: Mitotic index, number of mitoses per 50 high-power fields; NIH, National Institutes of health. 1. Fletcher CD, et al. Hum Pathol. 2002;33(5):459-465; 2. Joensuu H. Hum Pathol. 2008;39(10):1411-1419. 24 GRADE TUMOR > 10 CM MITOTIC INDEX: NOT REPORTED NEGATIVE MARGIN LOCATION: NON GASTRIC
HIGH RISK GROUP FOR RECCURRENCE
SURGERY Surgical treatment of gist The radical surgical treatment is the most effective treatment The 5-year survival rate after surgery amounts to 2865% It is not necessary to resect the regional lymph nodes because GIST do not metastasize to the regional lymphatic system 2040% of the surgery patients have intra-abdominal dissemination or liver metastasis paliatif surgery (sympotomatic treatment) endoscopic dissection (submucosal-mucosal resection) allows a radical therapy of small tumors without malignancy features and limited to the submucosal layer.
POLSKIE ARCHIWUM MEDYCYNY WEWNTRZNEJ 2008; 118 (4)
CHEMOTHERAPY Preoperative : need histological diagnosis PROGNOSIS The 5-year survival rate after surgery of GIST amounts to 2865%
778 patients 18 y Localized and primary GIST KIT-positive tumors 3 cm Complete surgical resection Placebo for 1 y Imatinib 400 mg/d for 1 y Imatinib 400/800 mg/d 713 patients randomized Imatinib 400 mg/d DeMatteo RP, et al. Lancet. 2009;37(9669)3:1097-1104. Phase 3 ACOSOG Z9001: Trial Schema
33 At time of recurrence At time of recurrence Abbreviations: CI, confidence interval; HR, hazard ratio. a All randomized patients were included in the analysis; recurrence-free survival was defined as the time from patient registration to the development of tumor recurrence or death from any cause. Intention-to-treat analyses were done for recurrence-free survival (ie, analyzed patients by randomized group). Adapted from DeMatteo RP, et al. Lancet. 2009;373(9669):1097-1104. Recurrence-Free Survival a HR = 0.35 (95% CI = 0.22, 0.53); P < .0001 100 90 80 70 60 50 40 30 20 10 0 R e c u r r e n c e - F r e e
a n d
A l i v e ,
%
0 6 12 18 24 30 Time, mo 36 42 48 Imatinib Placebo 359 354 30 70 Total Events Median follow-up: 19.7 mo 34 Size 10 cm Size 3 and < 6 cm Size 6 and < 10 cm Recurrence-Free Survival (Tumor Size) Imatinib adjuvant therapy results in significantly longer RFS in each of the tumor size categories compared with placebo 100 90 80 70 60 50 40 30 20 10 0 R e c u r r e n c e - F r e e
a n d
A l i v e ,
%
0 6 12 18 24 30 36 42 48 100 90 80 70 60 50 40 30 20 10 0 R e c u r r e n c e - F r e e
a n d
A l i v e ,
%
0 6 12 18 24 30 36 42 48 Imatinib, n = 143 Placebo, n = 149 HR = 0.23 (95% CI = 0.07, 0.79); P = .011 Imatinib, n = 93 Placebo, n = 86 HR = 0.29 (95% CI = 0.16, 0.55); P < .001 Time, mo Time, mo 100 90 80 70 60 50 40 30 20 10 0 R e c u r r e n c e - F r e e
a n d
A l i v e ,
%
0 6 12 18 24 30 36 42 48 Time, mo Imatinib, n = 123 Placebo, n = 119 HR = 0.50 (95% CI = 0.25, 0.98); P = .041 Abbreviations: CI, confidence interval; HR, hazard ratio; RFS, recurrence-free survival. Adapted from DeMatteo RP, et al. Lancet. 2009;373(9669):1097-1104. 35 Follow-up Follow-up Phase 3 SSGXVIII: Study Design Randomized 1:1 Imatinib 12 mo 400 patients KIT-positive histologically confirmed GIST High recurrence risk according to modified NIH consensus criteria
Imatinib 36 mo Abbreviation: NIH, National Institutes of Health. Data from Joensuu H, et al. JAMA. 2012;307(12):1265-1272.
Key Elements:
Patient stratification: R0 resection, no tumor rupture R1 resection OR tumor rupture
36 HR = 0.46 (95% CI = 0.32, 0.65); P < .0001 SSGXVIII: Recurrence-Free Survival (ITT) Abbreviations: CI, confidence interval; HR, hazard ratio; ITT, intent to treat. Adapted from Joensuu H, et al. JAMA. 2012;307(12):1265-1272. 60.1% 47.9% 86.6% 65.6% 36 mo, n = 198 12 mo, n = 199 0 1 2 3 4 5 6 0 20 40 60 80 100 Median follow-up, 54 mo Time, y R e c u r r e n c e - F r e e
Charles Catton, Brian O'Sullivan, Robert Dinniwell, Anthony Griffin, Peter C Ferguson, Rebecca Gladdy, David Mccready, Martin Blackstein, Abha Gupta, Lisa W Le, Peter Chung