By The Life Raft Group

An Introduction toGASTROINTESTINAL STROMAL TUMORS

What is cancer?• Cancer consists of over 100 diseases.• Cancer begins when there is an abnormal growth

of cells that cannot be controlled.• Because different types of cancers behave

differently, it is important to get treated according to the specific diagnosis.

2Diagnosis: a medical decision that determines the nature of a disease.

What are Gastrointestinal Stromal Tumors or GISTs?

esophagus

liver

gallbladderstomach

small intestine

colon

rectum

The Gastrointestinal System

• The GI tract or the digestive system consists of all organs located between the esophagus and the rectum.

• This organ system’s role is to absorb the needed water and nutrients from ingested food.

• GIST’s can occur all along the GI tract, most commonly found in the stomach and small intestine. 4

• Gastrointestinal stromal tumors

(GISTs) belong to a group of

cancers called sarcomas.

• Sarcomas are a rare type of

cancer that can occur in bones,

muscles, fat, nerves, blood

vessels, connective tissues, and

cartilage.

• GIST cancers arise from unique

cells called Interstitial Cells of

Cajal due to mutations in these

cells. These special cells move

digested food throughout the GI

tract. 5

What is GIST?

What are Interstitial Cells of Cajal or ICCs?

• ICCs are found in the muscles that line the digestive system.

• Their role is to gently contract to propel ingested food along the GI tract.

• Similar to the cells that make your heart beat, the ICCs are also called “pacemaker” cells, as they rhythmically coordinate digestion.

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Santiago Ramón y Cajal(1852-1934)

A pathologist, histologist, neuroscientist and Nobel

laureate.

• 40-70% of GISTs arise from the stomach.

• 20-40% arise from the small intestine.

• 5-15% arise from the colon and rectum.

• Less than 5% can also be found in the esophagus or elsewhere in the GI tract.

• The original GIST site is called the Primary.

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Where does GIST start?

What is Metastatic GIST?

• When GIST spreads to additional locations beyond the primary tumor site it is called a metastasis (mets).

• Some common sites for GIST mets are the liver and elsewhere in the abdomen.

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• GIST is assessed by its risk of recurrence, sometimes referred to as staging in other cancers.

• Staging is commonly used in other cancers but it typically is not used with GIST.

• Four important criteria in risk of recurrence:

• Tumor size (measured in centimeters)• Mitotic index (or mitotic count, mitotic rate)• Tumor location• Whether or not the tumor has ruptured

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Risk Assessment

Risk of recurrence: the chances of GIST returning after surgery.Staging: the process of determining how far a cancer has spread in the body, often helping to select treatment options and predicting the patient’s outcome.

Risk of Recurrence Chart

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* Nilsson, Bengt, Per Bümming, Jeanne M Meis-Kindblom, Anders Odén, Aydin Dortok, Bengt Gustavsson, Katarzyna Sablinska, and Lars-Gunnar Kindblom. "Gastrointestinal Stromal Tumors: The Incidence, Prevalence, Clinical Course, and Prognostication in the Preimatinib Mesylate Era--a Population-based Study in Western Sweden." Cancer 103, no. 4 (February 15, 2005): 821-829. doi:10.1002/cncr.20862.

These numbers are based on a group of patients from Western Sweden* but give a good representation of GIST patients as a whole. Some other series have shown slightly different numbers.

Mitotic Index• Mitotic index is the measurement of

how quickly the cancer cells are growing and dividing (a low mitotic index predicts a better outcome).

• Based on tumor size and location, mitotic index and whether or not the tumor has ruptured, the doctor determines the risk of recurrence of the cancer.

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Risk of recurrence: the chances of GIST returning after surgery.

Survival Rate

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With the advent of a drug called Gleevec and other treatments the

survival rate has increased dramatically.

The five-year survival rate is about 80%.

Most GISTs are not inherited and have no clear cause, but rare cases have found members of the same family to have GIST – this is called familial or hereditary GIST.

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Is GIST hereditary?

• The exact number of people diagnosed with GIST every year is unknown.

• In the United States, it is estimated that there are about 4,000 to 5,000 new cases of GIST each year.

• Most people diagnosed with GIST are older than 50, but it can occur at any age. 14

Statistics

How is GIST diagnosed and monitored?

*A diagnosis is a medical decision that determines the nature of a disease.

• At this time, no effective screening, such as blood tests, is available for GIST

• Some GISTs are found incidentally during an exam or surgery for another problem

• Most are found because of symptoms or signs

• Not all tumors may cause symptoms

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Screening

• Black and tarry stool• Abdominal/belly discomfort• Mass/swelling in the abdomen• Loss of appetite• Weight loss/gain• Feeling full after eating a small amount of food• However, many cases are asymptomatic and

these symptoms can also describe other diseases.

Possible GIST Symptoms and Signs

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How is GIST Diagnosed?

• Accurate diagnosis of GIST is determined by a pathologist who views a tissue sample obtained from surgery or a biopsy under a microscope.

• The pathologist examines the unique features of the cells using stains that detect the presence of a specific protein called KIT.

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Chris Corless, M.D.LRG Research Team

Pathologist Oregon Health & Science

University

There Are Different Types of GIST

• GISTs can also be caused by the mutation of PDGFRA gene. KIT and PDGFRA have a similar structure, and belong to the same sub-family of proteins (tyrosine kinases).

• GIST tumors that do not have a mutation in KIT or PDGFRA are called "wild-type" GIST, whose mutation is in one of the succinate dehydrogenase genes.

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Why is a Biopsy Important?

• When masses are found, small pieces removed by surgery, endoscopy, or needle biopsy are prepared for identification under a microscope. This process is called a biopsy.

• A biopsy is read by a pathologist.

• This is how a GIST is diagnosed.

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What is Mutational Testing?

• Mutational testing is done using a tissue sample from surgery or the biopsy to identify the specific GIST mutation.

• This is essential because targeted treatments are available that can maximize outcomes based on specific mutations.

• One way to get mutational testing is to join the Life Raft Group’s GIST Collaborative Tissue Bank, which also makes the tissue available to researchers working to find a cure for GIST.

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Endoscopy• Performed by a gastroenterologist, this procedure

uses a slim, flexible tube to view inside the body.• An endoscope is equipped with micro tools that

can view, film, remove or take biopsies of any masses inside the body

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Imaging TestsImaging tests create pictures of the inside of the body and are used to monitor GIST. They include:

o X-rayso Computed tomography or CT scanso Magnetic resonance imaging or MRI scanso Positron emissions topography or PET scans

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I have GIST. What do I do?

• Doctors appointments, lab results, insurance forms and invoices can accumulate quickly. Organize each in a simple file or binder.

• Write down any questions and bring them with you when you visit the doctor or call the office.

• Read and learn about GIST in reputable information sources. The Life Raft Group can help identify these.

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Preparing for Treatment

• Ideally, a patient should seek treatment from a GIST specialist. If there is not one locally, it is advised that one be consulted and seen at least once.

• Frequently a GIST patient will have a local oncologist who works in concert with the specialist at another institution. This method maximizes treatment outcome for the patient.

Finding the Right Doctors

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Your Treatment Team

It is common to have different types of doctors who work together to diagnose and manage your care. They may include:

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o An oncologist: choose someone with experience in GIST

o A gastroenterologist: treats diseases in the digestive tract.

o A gastrointestinal surgeon: removal of your GIST tumor is imperative to your wellness goals.

Other Knowledgeable Professionals

• Physician assistants, nurse practitioners, nutrition specialists and social workers may also play a role in your treatment.

• Support groups and connecting with others living with GIST can help navigate the emotional issues that arise from a cancer diagnosis.

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Treatment options include surgery and medication

Initial Treatment

Initial treatment will depend on several factors including:

• Whether GIST has spread or metastasized

• The expected difficulty of the surgery

• The size of the original tumor• The general health of the patient

Metastasize: The spread of a tumor to a distant location from the original tumor.

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Surgery

• Surgery is typically the first treatment for GIST to remove resectable tumors.

• The goal is to remove the tumor entirely and achieve clear margins.

• If the tumor cannot be removed, the doctor may treat the patient with medication first to shrink the tumor enough to remove it.

31Resectable: Removable

Can GIST return after surgery?

• Tumor size (measured in centimeters)• Mitotic Index• Location of the tumor• Tumor rupture before or during surgery• Failure to obtain clear margins during

surgery• Your KIT mutation (preliminary data)

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Risk of Recurrence

The following data are obtained from your surgeon and pathologist to evaluate your GIST risk of recurrence:

• Recurrences that occur while a patient is taking Gleevec can mean that the tumors might have become resistant to this drug.

• Sutent is considered a second line drug and can be used to treat GIST patients who have become resistant to Gleevec.

• If a patient has stopped taking Gleevec before the recurrence, chances are good that they could be responsive to Gleevec again.

• Stivarga is a third line drug that is given when the tumor is not responding to Gleevec or Sutent.

Recurrence Variables

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Gleevec

Also known as “imatinib” or Glivec, Gleevec is a pill that is taken daily.

Gleevec targets the specific protein that is causing the tumor to grow.

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Gleevec (continued)

• Gleevec is sometimes given before surgery with the goal of shrinking the size of the tumor(s). This makes surgical removal of the GIST more successful. This is called neoadjuvant treatment.

• Gleevec can be given as adjuvant treatment to help to prevent GIST recurrence and increase overall survival.

• Gleevec is given to patients whose tumors are unresectable or metastatic.

Neoadjuvant: treatment given before surgery.

Adjuvant: additional treatment usually given after surgery. 36

Edema: abnormal accumulation of fluid beneath the skin that produces swelling.

Fatigue: a feeling of tiredness, exhaustion, or lack of energy.

Reflux: regurgitated gastric content.

Possible Gleevec Side Effects

NOTE: In the beginning of treatment, patients may feel side effects but over time they subside. For more information, visit the Side Effects section at www.liferaftgroup.org

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• Cramping• Reflux • Muscle or Joint

Aches/Pain• Weight change• Skin problems (such as rashes)

• Nausea• Edema• Fatigue • Diarrhea• Eye puffiness• Cramping

Sutent

Sutent is taken as a pill and its most common side effects are:

• Sutent is also called sunitinib. It is given after failure or intolerance to Gleevec.

• Like Gleevec, Sutent works against GIST by inhibiting the KIT protein.

• Diarrhea• Mouth irritation• Fatigue

• High blood pressure• Hand and foot syndrome• Increased risk of bleeding• Hypothyroidism

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Stivarga

• Stivarga is also known as regorafenib.

• Newly approved in the United States for GIST patients who do not respond to Gleevec and Sutent.

• Side effects may include hand and foot syndrome, hypertension and diarrhea.

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Clinical Trials

Clinical Trials

• Clinical trials are available for all stages of GIST.

• Clinical trials are carefully conducted research studies that determine reactions and effects of promising drugs and therapy methods.

• Volunteer patients are chosen based on the criteria set by the trial. If a patient is interested in learning more about volunteering, he/she should look into the facilities doing trials for GIST.

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The LRG Clinical Trial Database

To access the database, visit the Clinical Trials

section on the LRG website:

www.liferaftgroup.org42

The LRG website offers information about all trials ongoing or completed that are relevant

to GIST

Living with GIST

• Make regular follow-up appointments with doctors to keep a close watch on any new growth or side effects.

• It is usually recommended that patients get CT scans every 3 to 6 months for at least several years after treatment.

• Patients should never hesitate to contact their doctors about any questions or concerns.

Regular Visits to the Doctor

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Lifestyle Changes

Consider making simple lifestyle changes to feel your best and promote wellness:

• Make healthy diet choices

• Exercise• Cut down on alcohol• Give up tobacco

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Support Groups

• Several U.S. cities and many regions throughout the world have GIST support groups.

• Attending a support group has shown to increase the ability to cope, both for the person with cancer and their caregiver.

• For more information, visit the Find a Support Group section under the Get Support section of the LRG website: www.liferaftgroup.org

• If there is no support group listed for your area, please consider starting one. We can help—email us for details: liferaft@liferaftgroup.org

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FOR MORE INFORMATION, VISIT:WWW.LIFERAFTGROUP.ORG

EMAIL US AT:LIFERAFT@LIFERAFTGROUP.ORG

OR CALL US AT:973.837.9092

The Life Raft Group

The Life Raft Group (LRG) recognizes that coping with GIST can be very stressful and no one should be without the right support and educational resources.

The Life Raft Group has a simple focus: to cure a form of cancer –GIST- and to help those living with it until then.

Our mission is to ensure the survival of GIST patients through a comprehensive approach connecting individual patients’ needs, the worldwide community of GIST advocates and the global health and research environment.

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At Life Fest 2010, a few of our Life Raft Group members who are 10-year survivors were

honored. 49