Miami Report 2015

New Horizons GIST 2015 was held in Miami from 15-17^th May 2015. The aim of the meet is to improve Global understanding of GIST ,its treatment and Advocacy.

I was fortunate to be part of the group of people across the world from various organizations. There were 2 parts of the meet:
1st Part was Clinical Presentations and 2nd Part was Advocacy and Group building.

Amongst the Doctors attending the meet were Dr Reichardt , Dr Matia, Dr Trent, Dr Livingstone, Dr Pablo.

The key points of the meets were as follows:

GIST is a rare cancer.
Imatinib is termed as the Magic Bullet and the first choice for most of cases of GIST.
Mutational analysis revealed 67% were KIT ,12 % were PDGFRA and 21 % were Wild type.

4 Aspects to GIST treatment

Clinical and Pathological diagnosis
Molecular testing
Surgical treatment
Systemic treatment

Surgeon is the most important supported by Oncologist and Clinician.

Aims of Surgery :

Complete Resection
Negative margins
Explore peritoneal cavity
Non mutilated surgery
Non tumour rupture
No routine Lymphadenectomy

Important Pathological Information :

T cms (size)
IM (N/50 HPF)Mitosis
C-Kit
Mutational Analysis

Prognostic Classification :
Size + Mitosis + Site + Rupture + Mutation

Neo Adjuvant Therapy
Helps patients with potentially morbid surgery

Organ Preservation
Minimal invasive surgery
Reduces mortality and morbidity

Adjuvant Therapy :

Objective :
– To cure
– To delay recurrence
– To decrease Local /Sytemic recurrence
– Benefits immediate and high risk patients and may continue lifelong in patients with initial Metastatic disease

Imatinib In GIST :

1st Line is Imatinib
85% Disease control

Scenario in Clinical Resistance to Imatinib :

False :Image interpretation –Radiology
False : Lack Of Adherence to taking the drug
False : Low dose –Exon 9 Mutation
True : Imatinib resistant mutation
True : Other Kinase activation

Drug Therapy in GIST

2nd Line Drug : Sunitinib
3rd Line Drug : Regorafenib

Multidisciplinary Team Approach for GIST :

Pathologist
Oncologist
Gastroenterologist
Clinician/Researcher
Surgeon
Imagenologist
Radiotherapist
Genetic Expert

Newer Treatment Modalities:

Hepatic Artery Embolization
RFA
SIRT (Selective Internal Radiation Therapy)
Immunotherapy trials beginning in Miami ,Immunotherapy helps in removing protective cover on the cancer and attacks Cancer cells directly.

Axitinib +Pembrolizumab Immunotherapy

Combination Therapy
Additional drugs to cause cell death of GIST along with Imatinib by mechanism of Apoptosis (Drug ABT 737)
Autophagy( Drug Antimalarial Primaquine)
Radiation Therapy (Oesophageal + Rectal) Bone metastasis
Individual treatment.

Key Points

Challenges : may present as an acute abdominal bleeding resulting in emergency surgery –Surgeon has to be well informed of operating on such cases.