KIT Exon 9-Mutated Gastrointestinal Stromal Tumours: Biology and Treatment

Abstract

<b><i>Background:</i></b> The majority of gastroinstestinal stromal tumours (GISTs) harbour oncogenic mutations in the gene encoding for the tyrosine kinase (TK) KIT. The most common mutations are found in exon 11, followed by mutations in exon 9. The latter mutations are associated more frequently with GISTs in extra-gastric locations and with a more aggressive clinical behaviour. <b><i>Summary:</i></b> Here, we review the unique and often poorly recognized molecular, biological, and clinical characteristics that differentiate <i>KIT</i> exon 9-mutant GISTs from other GIST subtypes. In particular, <i>KIT</i> exon 9 mutations are associated to KIT mutants with retained sensitivity to stimulation by stem cell factor and localization to the cell membrane. Moreover, <i>KIT</i> exon 9-mutant GISTs display significant activation of KIT-independent oncogenic pathways. These characteristics may explain the limited activity of the TK inhibitor imatinib in the adjuvant setting in <i>KIT</i> exon 9-mutant GISTs, as well as their lower sensitivity to standard dose imatinib in the advanced setting. In contrast, the multi-TK inhibitor sunitinib displays better activity in <i>KIT</i> exon 9-mutant GISTs compared to others. <b><i>Key Messages:</i></b> <i>KIT</i> exon 9-mutant GISTs represent a subtype of GIST distinct from other GISTs, including the more common <i>KIT</i> exon 11-mutant GISTs. A better understanding of the molecular biology and clinical behaviour of <i>KIT</i> exon 9-mutant GISTs may help identify more improved treatment options.