Prognostic impact of positive microscopic margins (R1 resection) in patients with GIST (gastrointestinal stromal tumours): Results of a multicenter European study.

BACKGROUND: Although several prognostic factors in GIST have been well studied such as tumour size, mitotic rate, or localization, the influence of microscopic margins or R1 resection remains controversial. The aim of this study was to evaluate the influence of R1 resection on the prognosis of GIST in a large multicentre retrospective series of patients. METHODS: From 2001 to 2013, 1413 patients who underwent surgery for any site of GIST were identified from 61 European centers. 1098 patients were included, excluding synchronous metastases, concurrent malignancies, R2 resection or GIST recurrence. Tumour rupture (TR) was reclassified according to the Oslo sarcoma classification. Cox proportional hazards ratio and Kaplan-Meier survival estimates were used to analyse 5-year recurrence-free survival (RFS). RESULTS: Of 1098 patients, 38 (3%) underwent R1 resection with a risk of TR of 11%. The 5-year RFS was 89.6% with a median follow-up of 81 months [range: 31.2-152 months]. On univariate analysis, lower RFS was significantly associated with R1 resection [HR = 2.13; p = 0.04], high risk score according to the modified NIH classification, administration of adjuvant therapy [HR = 2.24; p < 0.001] and intraoperative complications [HR = 2.82; p < 0.001]. Only intraoperative complications [HR = 1.79; p = 0.02] and high risk according to the modified NIH classification including the updated definition of TR [HR = 3.43; p = 0.04] remained significant on multivariate analysis. CONCLUSION: This study shows that positive microscopic margins are not an independent predictive factor for RFS in GIST when taking into account the up-dated classification of TR. R1 resection may be considered a reasonable alternative to avoid major functional sequelae and should not lead to reoperation.

Esofago "mecano" y "quimio sensible": investigacion del dolor toracico no cardiogenico con el test de balon intraesofagico y la perfusion acida / \"Mechano and chemosensitive\" esophagus: investigation of non-cardiac chest pain by intraesophageal balloon test and acid perfusion

Se investigó la mecano y quimio-sensibilidad del esófago en 20 sujetos control y en 73 pacientes con purisus, D.T.N.C. y la combinación simultánea de dolor y pirosis. Se utilizó la prueba de distensión de un balón hasta 15 ml., en escalas de 2 cm. desde los 38 hasta los 22 cm. de la A.D.S. Se registró el número de pacientes que respondieron, volúmenes de distensión necesarios para evocar el sintoma, sitio de aparición y propagación del mismo. Las zonas de propagación fueron ubicadas en 13 zonas frontales y 10 dorsales. Se consideró como número de respuestas a la suma de las zonas de propagación para cada nivel estimulado (9 en total). En la misma sesión se realizó la prueba de perfusión ácida y el clearance ácido de es£fago. Se consideró como prueba positivo cuando se reprodujo el síntoma espontáneo. Se realizó endoscopía previa en todos los pacintes. RESULTADOS: La prueba de balón reprodujo el síntoma dolor en el 77.5 por ciento, cifra alcanzada estimulando los 9 niveles. De haberse estimulado un solo nivel la proporción no hubiera superado el 51 por ciento. Existen zonas "mudas" con relativa frecuencia. El 66.6 por ciento respondió con volúmenes < de 7 ml. La endoscopía fue normal en todos ellos. El test de perfusión ácida reprodujo la pirosis en el 62.5 por ciento. La presencia de esofagitis determinó una tendencia a aumentar la probabilidad de prueba positiva. Los pacientes con la combinación pirosis-dolor respondieron por separado ante cada prueba en el 60 por ciento. La perfusión ácida reprodujo el D.T.N.C. en el 6 por ciento. La prueba del balón reprodujo la pirosis en el 6.1 por ciento. CONCLUSIONES: 1) La prueba del balón sería la más útil en el estudio de la mecano-sensibilidad con altos porcentajes de reproducción cuando se estimulan al menos 9 niveles. 2) el test de perfusión sería útil para investigar quimio-sensibilida. La esofagitis aumentaria la posibilidad de test positivo. 3) Los pacientes con síntomas combinados se comportarían ante los tests de provocación como una disfunción sensorial mixta . 4) Una subpoblación de pacientes mostraría comportamientos atípicos ante los tests de...

Esófago [quot ]Mecano[quot ] y [quot ]Quimio Sensible[quot ]. Investigación del dolor toracico no cardiogenico con el test de balón intraesofágico y la perfusión ácida / [[quot ]Mechano-[quot ] and [quot ]chemo-sensitive[quot ] esophagus. Investigation of non-cardiac chest pain using intraesophageal balloon test and acid perfusion]

Mechano--and chemo--sensitivity were studied in 20 normal control patients and 73 patients suffering from pirosis, chest pain or both symptoms. Upper endoscopy, balloon and acid perfussion tests were performed. Balloon was inflated up to 15 ml. and deflated, in 2 cm. steps from 38 to 22 cm. from S.D.A. The number of patients with response, volume of balloon distension that evoked symptoms, place and irradiation of pain or discomfort were registered and plotted on 13 frontal and 10 dorsal zones. The total number of areas involved in pain irradiation was considered as [quot ]number of responses[quot ]. Nine levels were stimulated. Acid perfusion and clearance tests were performed at the same session. Test positivity was accepted when some test evoked spontaneous patient’s symptoms. RESULTS: When 9 levels were stimulated, balloon reproduced symptoms in 77.5

. If only one level was considered, the maximal rate was 51

, responses with volumes of + < 7 ml. were obtained. In all patients with chest pain upper endoscopy was normal. In 70

of the total group and in 62.5

of patients with pirosis the acid perfusion test was [quot ]positive[quot ]. Esophagitis increased the probability of a positive test. In sixty per cent, patients with combined pirosis and chest pain responded separately with each test. In 6

balloon evoked pirosis. CONCLUSION: 1) Balloon test could be considered the most useful test in mechano-sensitivity investigation. 2) acid perfussion was useful for chemo-sensitivity investigation. As esophagitis increases chemosensitivity, it could be a conditionant factor in some patients. 3) Patients with combined symptoms responded as a mixed sensorial dysfunction with each test. 4) sub-population of patients had atypical responses to the provocative tests.