Evolving patterns of gastrointestinal stromal tumor presentation, management, and outcome over three decades: A Middle Eastern retrospective study

Abstract

BACKGROUND

Gastrointestinal stromal tumor (GIST) represent the most common mesenchymal neoplasms of the gastrointestinal tract, with evolving management driven by advances in molecular profiling, targeted therapy, and minimally invasive surgical techniques. However, longitudinal regional data describing real-world outcomes remain limited.

AIM

To evaluate trends in presentation, surgical management, risk stratification, and outcomes of GIST over three decades in a Middle Eastern tertiary referral center.

METHODS

A retrospective cohort study included patients with GIST who were managed between 1995 and 2024. We analyzed demographic, clinicopathological, radiological, and treatment-related variables. We compared clinicopathological characteristics across risk stratification groups (low-, intermediate-, and high-risk) and by surgical approach (open vs minimally invasive). Survival outcomes were evaluated using Kaplan-Meier analysis.

RESULTS

A total of 282 patients were included. The mean age was 53.4 ± 13.5 years, and 64.9% were male. Gastric tumors predominated (67.7%), followed by small-bowel GIST (21.3%). Most tumors were localized at presentation (64.5%), while 12.8% had distant metastases. The median tumor size was 5.5 cm (range 0.3-29.0). Mitotic count was ≤ 5 per 50 high-power field in 66.2%, 6-10 in 19.7%, and > 10 in 14.1%. Risk categories included low (57.1%), intermediate (14.2%), and high (28.7%). Resection was performed in 94.3% of cases (open 46.6%, laparoscopic 42.9%, robotic 10.5%), and R0 margins were achieved in 85.5% of cases. Minimally invasive surgery (MIS) made up 53.4% of resections. It was associated with smaller tumors, more localized disease, fewer positive margins, and shorter hospital stay compared with open surgery. Adjuvant or systemic therapy was given in 51.4% of patients, predominantly imatinib. Median hospital stay was 8 days (1-60). Over a median follow-up of 35.5 months, disease-free survival (DFS) was 82.3%. A total of 10.6% were alive with recurrence or metastases, and 7.1% died. Incidental GIST detection during bariatric surgery occurred in 8.9% of cases. The surgical approach, both laparoscopic [hazard ratio (HR) 2.454, 95% confidence interval (CI): 1.604-3.754, P < 0.001] and robotic resections (HR 2.936, 95%CI: 1.682-5.124, P < 0.001), were significantly associated with improved DFS compared with open surgery.

CONCLUSION

This study found that most GISTs were gastric in origin. Over three decades, the region showed a shift toward MIS, more molecularly guided and risk-adapted therapy, and improved outcomes. High rates of complete resection and favorable DFS underscore the effectiveness of multidisciplinary care. These region-specific findings provide important benchmarks to shape practice and future collaboration across centers.

Keywords: Gastrointestinal stromal tumor; Epidemiology; Minimally invasive surgical procedures; Imatinib mesylate; Recurrence

Core Tip: Gastrointestinal stromal tumors (GIST) represent the most common mesenchymal neoplasms of the gastrointestinal tract, with evolving management driven by advances in molecular profiling, targeted therapy, and minimally invasive surgical techniques. However, longitudinal regional data describing real-world outcomes remain limited. This study aimed to evaluate trends in presentation, surgical management, risk stratification, and outcomes of GIST over three decades in a Middle Eastern country. Gastric primary tumors were the most common GIST. Over three decades, the management of GIST in this regional cohort has evolved toward increased adoption of minimally invasive surgery, molecularly guided therapy, and risk-adapted treatment strategies. High rates of complete resection and favorable disease-free survival highlight the effectiveness of multidisciplinary care. These findings provide region-specific benchmarks to inform clinical practices and future collaborations across multiple centers.