Conditional Disease-Free Survival After Surgical Resection of Gastrointestinal Stromal Tumors: A Multi-institutional Analysis of 502 Patients | Clinical Decision Support | JAMA Surgery | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
Miettinen  M, Lasota  J.  Gastrointestinal stromal tumors--definition, clinical, histological, immunohistochemical, and molecular genetic features and differential diagnosis.  Virchows Arch. 2001;438(1):1-12.PubMedGoogle ScholarCrossref
Nilsson  B, Bümming  P, Meis-Kindblom  JM,  et al.  Gastrointestinal stromal tumors: the incidence, prevalence, clinical course, and prognostication in the preimatinib mesylate era: a population-based study in western Sweden.  Cancer. 2005;103(4):821-829.PubMedGoogle ScholarCrossref
Tryggvason  G, Gíslason  HG, Magnússon  MK, Jónasson  JG.  Gastrointestinal stromal tumors in Iceland, 1990-2003: the icelandic GIST study, a population-based incidence and pathologic risk stratification study.  Int J Cancer. 2005;117(2):289-293.PubMedGoogle ScholarCrossref
 National Comprehensive Cancer Network.von Mehren  MG, Meyer C, Riedel R, Van Tine B. Soft tissue sarcoma. In: NCCN Clinical Practice Guidelines in Oncology.2013. Accessed 2013.
Dematteo  RP, Gold  JS, Saran  L,  et al.  Tumor mitotic rate, size, and location independently predict recurrence after resection of primary gastrointestinal stromal tumor (GIST).  Cancer. 2008;112(3):608-615.PubMedGoogle ScholarCrossref
Joensuu  H.  Risk stratification of patients diagnosed with gastrointestinal stromal tumor.  Hum Pathol. 2008;39(10):1411-1419.PubMedGoogle ScholarCrossref
Miettinen  M, Makhlouf  H, Sobin  LH, Lasota  J.  Gastrointestinal stromal tumors of the jejunum and ileum: a clinicopathologic, immunohistochemical, and molecular genetic study of 906 cases before imatinib with long-term follow-up.  Am J Surg Pathol. 2006;30(4):477-489.PubMedGoogle ScholarCrossref
Miettinen  M, Sobin  LH, Lasota  J.  Gastrointestinal stromal tumors of the stomach: a clinicopathologic, immunohistochemical, and molecular genetic study of 1765 cases with long-term follow-up.  Am J Surg Pathol. 2005;29(1):52-68.PubMedGoogle ScholarCrossref
Fletcher  CD, Berman  JJ, Corless  C,  et al.  Diagnosis of gastrointestinal stromal tumors: a consensus approach.  Hum Pathol. 2002;33(5):459-465.PubMedGoogle ScholarCrossref
Gold  JS, Gönen  M, Gutiérrez  A,  et al.  Development and validation of a prognostic nomogram for recurrence-free survival after complete surgical resection of localised primary gastrointestinal stromal tumour: a retrospective analysis.  Lancet Oncol. 2009;10(11):1045-1052.PubMedGoogle ScholarCrossref
American Joint Committee on Cancer.  Cancer Staging Atlas: A Companion to the Seventh Editions of the AJCC Cancer Staging Manual and Handbook. 2nd ed. New York, NY: Springer; 2012.
Merrill  RM, Henson  DE, Ries  LA.  Conditional survival estimates in 34,963 patients with invasive carcinoma of the colon.  Dis Colon Rectum. 1998;41(9):1097-1106.PubMedGoogle ScholarCrossref
Henson  DE, Ries  LA, Carriaga  MT.  Conditional survival of 56,268 patients with breast cancer.  Cancer. 1995;76(2):237-242.PubMedGoogle ScholarCrossref
Nathan  H, de Jong  MC, Pulitano  C,  et al.  Conditional survival after surgical resection of colorectal liver metastasis: an international multi-institutional analysis of 949 patients.  J Am Coll Surg. 2010;210(5):755-764, 764-766.PubMedGoogle ScholarCrossref
Kaplan  EL, Meier  P.  Nonparametric estimation from incomplete observations.  J Am Stat Assoc. 1958;53(282):457-481.Google ScholarCrossref
Cox  DR.  Regression models and life-tables.  J R Stat Soc B. 1972;34(2):187-220. Google Scholar
Harrell  FE  Jr, Lee  KL, Mark  DB.  Multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors.  Stat Med. 1996;15(4):361-387.PubMedGoogle ScholarCrossref
Bouvier  AM, Remontet  L, Hédelin  G,  et al; Association of the French Cancer Registries (FRANCIM).  Conditional relative survival of cancer patients and conditional probability of death: a French national database analysis.  Cancer. 2009;115(19):4616-4624.PubMedGoogle ScholarCrossref
Joensuu  H, Vehtari  A, Riihimäki  J,  et al.  Risk of recurrence of gastrointestinal stromal tumour after surgery: an analysis of pooled population-based cohorts.  Lancet Oncol. 2012;13(3):265-274.PubMedGoogle ScholarCrossref
Mayo  SC, Nathan  H, Cameron  JL,  et al.  Conditional survival in patients with pancreatic ductal adenocarcinoma resected with curative intent.  Cancer. 2012;118(10):2674-2681.PubMedGoogle ScholarCrossref
Choi  M, Fuller  CD, Thomas  CR  Jr, Wang  SJ.  Conditional survival in ovarian cancer: results from the SEER dataset 1988-2001.  Gynecol Oncol. 2008;109(2):203-209.PubMedGoogle ScholarCrossref
Kato  I, Severson  RK, Schwartz  AG.  Conditional median survival of patients with advanced carcinoma: surveillance, epidemiology, and end results data.  Cancer. 2001;92(8):2211-2219.PubMedGoogle ScholarCrossref
Original Investigation
April 2015

Conditional Disease-Free Survival After Surgical Resection of Gastrointestinal Stromal Tumors: A Multi-institutional Analysis of 502 Patients

Author Affiliations
  • 1Department of Surgery, The Johns Hopkins University, Baltimore, Maryland
  • 2University Health Network, Toronto, Ontario, Canada
  • 3Department of Surgery, University of Toronto, Toronto, Ontario, Canada
  • 4Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  • 5Department of Surgery, Duke University, Durham, North Carolina
  • 6Department of Surgery, Emory University, Atlanta, Georgia
  • 7Department of Surgery, Medical College of Wisconsin, Milwaukee
  • 8Department of Surgery, University of Virginia, Charlottesville
JAMA Surg. 2015;150(4):299-306. doi:10.1001/jamasurg.2014.2881

Importance  Gastrointestinal stromal tumors (GISTs) are the most commonly diagnosed mesenchymal tumors of the gastrointestinal tract. The risk of recurrence following surgical resection of GISTs is typically reported from the date of surgery. However, disease-free survival (DFS) over time is dynamic and changes based on disease-free time already accumulated following surgery.

Objectives  To assess the comparative performance of established GIST recurrence risk prognostic scoring systems and to characterize conditional DFS following surgical resection of GISTs.

Design, Setting, and Participants  A retrospective cohort study of 502 patients who underwent surgery for a primary, nonmetastatic GIST between January 1, 1998, and December 31, 2012, at 7 major academic cancer centers in the United States and Canada.

Main Outcomes and Measures  Disease-free survival of the patients was classified according to 5 prognostic scoring systems, including the National Institutes of Health criteria, modified National Institutes of Health criteria, Memorial Sloan Kettering Cancer Center GIST nomogram, and American Joint Committee on Cancer gastric and nongastric categories. The concordance index (also known as the C statistic or the area under the receiver operating curve) of established GIST recurrence risk prognostic scoring systems. Conditional DFS estimates were calculated.

Results  Overall 1-year, 3-year, and 5-year DFS following resection of GISTs was 95%, 83%, and 74%, respectively. All the prognostic scoring systems had fair prognostic ability. For all tumor sites, the American Joint Committee on Cancer gastric category demonstrated the best discrimination (C = 0.79). Using conditional DFS, the probability of remaining disease free for an additional 3 years given that a patient was disease free at 1 year, 3 years, and 5 years was 82%, 89%, and 92%, respectively. Patients with the highest initial recurrence risk demonstrated the greatest increase in conditional survival as time elapsed.

Conclusions and Relevance  Conditional DFS improves over time following resection of GISTs. This is valuable information about long-term prognosis to communicate to patients who are disease free after a period following surgery.