GASTRIC GASTROINTESTINAL STROMAL TUMORS PRESENTING IN THE CARDIA
Leslie Blackshear*3, Theresa W. Gillespie1, Ambreen Merchant2, Rosemary Nustas3, Vaishali Patel2, Saurabh Chawla3, Steven Keilin2, Qiang Cai3, Shishir K. Maithel2, Field F. Willingham3
1Winship Cancer Institute, Emory University, Atlanta, GA; 2Emory University Hospital, Atlanta, GA; 3Emory University, School of Medicine, Atlanta, GA
Background: While many gastric Gastrointestinal Stromal Tumors (GISTs) may be indolent, surgical management for GISTs presenting in the cardia may involve major organ resection. This study examined the distribution of surgeries performed for patients with gastric GISTs comparing cardia tumors to more distal locations. Short and long-term outcomes were then examined by tumor location and type of resection.
Methods: Cases were identified in the National Cancer Database (NCDB) from 2004-2015. Exclusion criteria included missing data, presence of other cancers, ambiguous or unknown surgical approach, no surgery, and nonspecific tumor site. Surgical approach was categorized into major surgery (near total or total gastrectomy, or gastrectomy involving a portion of the esophagus) and non-major surgery (local tumor excision, antrectomy, or lower gastrectomy involving less than 40% of the stomach). Tumors were stratified by size and tumor site (cardia compared to all other sites) to assess the percentage of patients undergoing major compared to non-major surgeries for tumors in the same size categories. Univariate analysis and multivariate analysis were utilized to characterize the associations between tumor size, site, surgical approach, and 90-day survival. Kaplan Meier survival estimates were utilized to assess the relationship between surgical approach and tumor site with overall survival (OS).
Results: 14,979 patients with gastric GISTs were initially abstracted from the NCDB, and 1,377 remained in the analysis cohort after exclusions. Cardia GISTs were managed with major surgery 65.1% of the time, compared to 35.0% for tumors in other sites P<.0001. For cardia GISTs ≤5 cm, 41.9% underwent major surgery compared to 22.7% for gastric GISTs ≤5 cm in other sites P=.0002. For cardia GISTs >5 cm, 76.24% underwent major surgery compared to 44.30% of other gastric GISTs >5 cm P<.0001 (Fig. 1). On multivariate analysis, tumor size >5 cm and tumor site (cardia compared to all other sites) were independently associated with major surgery (OR 2.90: CI 2.29-3.66 [P<.0001]) and (OR 3.16: CI .776-1.24 [P<.0001]), respectively. For gastric GISTs undergoing major surgery, 3.39% died in the first 90 days, compared to 1.38% of patients undergoing a non-major surgery P=.0141. Major surgery compared to non-major surgery, and cardia compared to non-cardia gastric GISTs were associated with significantly worse OS (Fig. 2).
Conclusions: Patients with GISTs of the cardia undergo major surgery more frequently than patients with gastric GISTs of similar size presenting in other sites, and have worse OS. Major surgery compared to non-major surgery was associated with a significantly increased 90-day mortality, and worse OS. GISTs presenting in the cardia represent a unique surgical challenge and may warrant greater consideration for minimally invasive or hybrid type resections.
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