Ripretinib as second-line treatment for imatinib-resistant advanced gastrointestinal stromal tumors: a case report
Case Report

Ripretinib as second-line treatment for imatinib-resistant advanced gastrointestinal stromal tumors: a case report

Junzhao You1, Nengyi Hou2, Song Yu2, Jiang Gao3, Wei Xie4, Xingmei Yuan1, Hongtao Tang5, Shun Jiang6, Minghui Pang2

1School of Medicine, University of Electronic Science and Technology of China, Chengdu, China; 2Department of Geriatric General Surgery, Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China; 3Department of General Surgery, Yucheng District People’s Hospital of Ya’an & Second People’s Hospital of Ya’an City, Ya’an, China; 4General Surgery Department One, Dazhu County People’s Hospital, Dazhou, China; 5School of Clinical Medicine, North Sichuan Medical College, Nanchong, China; 6School of Clinical Medicine, Southwest Medical University, Luzhou, China

Contributions: (I) Conception and design: J You; (II) Administrative support: N Hou; (III) Provision of study materials or patients: S Yu, J Gao, W Xie; (IV) Collection and assembly of data: H Tang, S Jiang; (V) Data analysis and interpretation: X Yuan; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Minghui Pang, MD. Department of Geriatric General Surgery, Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, No. 32, West Section 2, First Ring Road, Qingyang District, Chengdu 610072, China. Email: mhpang@uestc.edu.cn.

Background: Gastrointestinal stromal tumors (GISTs) are driven by KIT/PDGFRA mutations. While imatinib improves outcomes, resistance often occurs. The Chinese Society of Clinical Oncology (CSCO) guidelines recommend ripretinib as second-line therapy for imatinib-resistant GISTs, particularly with KIT exon 17 mutations. Notably, Food and Drug Administration/European Medicines Agency (FDA/EMA) approvals and other guidelines restrict ripretinib to later-line use, highlighting this case’s relevance for exploring its earlier application.

Case Description: A 59-year-old female with an advanced gastric GIST (KIT exon 11 mutations) and liver metastasis was on long-term imatinib (400 mg/d) after surgical resection in 2011. After 9 years, her liver metastasis progressed, with a secondary KIT exon 17 mutation identified by genetic testing. The dose of imatinib was increased to 600 mg/day, and the liver metastases were resected. One year later, multiple peritoneal and abdominal metastases were detected, and the treatment was switched to ripretinib 150 mg/day, which resulted in lesion shrinkage with good tolerance (with toxicities including only mild hair loss and myalgia). Progressive disease (PD) was noted after 16 months, and stable disease (SD) was achieved after dose escalation to 150 mg bid. The patient is currently under regular follow-up.

Conclusions: Dynamic gene testing is valuable for guiding targeted therapy. Switching to ripretinib in imatinib-resistant GIST patients can remarkably prolong progression-free survival. Although dose escalation may temporarily control drug resistance, the risk of double mutation-conferred resistance must be heeded. Our present case provides a practical reference for second-line strategies in imatinib-resistant GISTs, highlighting the importance of genetic testing and personalized treatment.

Keywords: Gastrointestinal stromal tumor (GIST); imatinib; ripretinib; secondary resistant mutations; case report

Received: 13 July 2025; Accepted: 12 August 2025; Published online: 29 August 2025.

doi: 10.21037/gist-2025-10

Highlight box

Key findings

• This study demonstrates: (I) successful 16-month progression-free survival with ripretinib (150 mg qd) in imatinib-resistant gastrointestinal stromal tumors (GISTs) harboring KIT exon 17 mutation; (II) secondary disease stabilization (8+ months) following dose escalation to 150 mg bid; (III) clinical utility of continued imatinib (600 mg) despite exon 17 mutation during treatment transition; (IV) tolerability of ripretinib with only grade 1–2 toxicities (hair loss/myalgia); and (V) the critical role of serial genetic testing in detecting resistance mutations and guiding therapeutic decisions.

What is known and what is new?

• Imatinib resistance often involves secondary KIT mutations (exon 17). Ripretinib shows efficacy in later-line settings per Food and Drug Administration/European Medicines Agency, while Chinese Society of Clinical Oncology guidelines support second-line use.

• This case provides: (I) real-world evidence of ripretinib’s extended efficacy (16+ months) as second-line therapy; (II) documentation of successful dose escalation strategy; (III) practical insights into managing exon 17-mutated GISTs during therapeutic transitions; and (IV) longitudinal data on resistance patterns, highlighting the emergence of dual mutations after prolonged ripretinib use.

What is the implication, and what should change now?

• The findings suggest: (I) wider adoption of ripretinib in second-line settings warrants consideration, particularly for exon 17-mutated GISTs; (II) dynamic genetic testing should be standardized to detect emerging resistance; (III) dose escalation protocols require further validation in real-world settings; and (IV) research into combination therapies is urgently needed to address dual-mutation resistance. Clinicians should prioritize genetic profiling at progression and consider early transition to ripretinib when exon 17 mutations are detected.

Introduction

Gastrointestinal stromal tumors (GISTs) are the most common soft tissue sarcomas of the digestive tract, potentially affecting the entire gastrointestinal tract from the esophagus to the rectum. The pathogenesis and progression of GISTs are closely related to specific genetic mutations, particularly the oncogenic mutations of the c-KIT gene and the PDGFRA gene (1), which are crucial for the proliferation and survival of tumor cells. Imatinib, a highly specific tyrosine kinase inhibitor (TKI), can effectively block the growth and spread of GIST cells by accurately targeting c-Kit and PDGFRA and suppressing their activities. Imatinib has been widely used in treating GIST, with notable efficacy. It is currently the standard adjuvant treatment for primary (2), resectable GISTs and those with moderate or high recurrence risk. However, subsequent treatment options for GISTs are limited due to their unique biology, high tumor heterogeneity, imatinib resistance, and complex secondary mutations in advanced disease following imatinib resistance. Addressing these challenges to find effective subsequent treatments remains a major issue in GIST treatment. This case uniquely demonstrates prolonged response to imatinib before secondary resistance, highlighting dynamic management challenges. We present this case in accordance with the CARE reporting checklist (available at https://gist.amegroups.com/article/view/10.21037/gist-2025-10/rc).

Case presentation

In 2011, a 59-year-old woman was admitted to Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital due to “hematemesis and upper abdominal pain for over a month”. Abdominal computed tomography (CT) revealed significant thickening of the walls at the greater curvature of gastric fundus, with a 3.7 cm × 4.9 cm homogeneously enhancing lobulated soft-tissue mass protruding into the abdomen and a 6.0 cm × 4.4 cm mass in the right upper abdomen. Multiple irregular, variably sized, slightly hypodense liver lesions, some with a “target sign”, were observed. Endoscopic ultrasound indicated a mucosal elevation with ulcer at the fundus-body junction. The possibility of a GIST was considered.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Treatments

The patients had significant hematemesis, with a hemoglobin (Hb) level of only 65 g/L, necessitating urgent surgery. After the preoperative examinations were completed and all the surgical contraindications were excluded, an emergency surgery was performed on 7 April 2011, during which a laparotomy for malignant gastric stromal tumor resection and omental nodule resection was conducted under general anesthesia. A firm mass measuring 7 cm × 6 cm × 5 cm was located at the posterior wall of the gastric fundus, presenting a dumbbell-shaped exophytic growth. It infiltrated the pancreatic capsule and the anterior leaf of the splenic flexure of the transverse colon, but was able to be separated. The fundic mass was locally resected during the surgery. Multiple nodules were visible on the liver surface, with the largest two in the right lobe measuring 8 cm × 8 cm and 6 cm × 6 cm, respectively. Nodules were distributed diffusely in the abdomen but without obvious ascites. Morphological examination of the surgical specimen revealed that the mass had a fish meat-like appearance with cystic changes and bleeding, and the tumor mucosa showed ulcerative changes. Intraoperative frozen section histopathology showed negative margins, and the fundic mass was confirmed to be a spindle cell tumor. Postoperative pathology indicated a high-risk “gastric” GIST of 5 cm × 3.5 cm × 2 cm. The immunohistochemical (IHC) findings included: CD34(+), CD117 (focally +), DOG-1(+), S100(−), SMA(−), and Ki67 positivity 5–10%. Genetic testing identified a KIT exon 11 mutation. Accordingly, the diagnosis was adjusted as “advanced gastric GIST with liver metastasis”. Imatinib 400 mg daily with regular abdominal CT follow-up was prescribed.

After 9 years on imatinib, an abdominal CT at a local hospital in March 2020 indicated a soft-tissue mass in the right anterior lobe of liver, suggesting the presence of liver metastasis. In August 2020, a contrast-enhanced abdominal CT scan at another hospital showed a 5.6 cm × 5.7 cm soft tissue mass in the right anterior upper sector of the liver, with liquefactive necrosis in its center. In addition, a constantly enhanced nodule measuring 2.5 cm × 2.3 cm was observed beneath it. Compared with the findings in March 2020, the lesion had enlarged with multiple metastases. A multidisciplinary team (MDT) concluded that there was progressive disease (PD) despite targeted treatment with imatinib; the lesion was surgically resectable, and there was no recurrence at the primary gastric lesion or elsewhere in the abdomen. The treatment advice given by the MDT comprised imatinib 600 mg daily and elective resection of liver metastases. On 3 September 2020, resection of complex liver cancer in the right liver + partial resection and repair of the diaphragm + cholecystectomy + radiofrequency ablation (RFA) for liver cancer was performed under general anesthesia. Intraoperatively, a 5 cm × 4.5 cm mass that protruded through the liver capsule and invaded the right diaphragm was seen in the right liver. The IHC findings were as follows: spindle cells CD34(+), CD117(+), DOG-1(+), PCK(−), desmin(−), SMA (−), SDHB (±), and Ki67 positivity ~10%. The mitotic count was 8–9/50 high power field (HPF). Accordingly, a diagnosis of metastatic GISTs was considered. Genetic testing revealed KIT exon 11 and 17 mutations. Thus, imatinib 600 mg daily was continued as maintenance treatment. While secondary KIT exon 17 mutations typically confer resistance to imatinib, the dose escalation to 600 mg/day was implemented as an interim measure for several reasons: first, partial suppression of the original exon 11 mutation was maintained while transitioning to second-line therapy. The second had been well tolerated to imatinib. Third, immediate surgical treatment is prioritized for liver metastases. This approach is consistent with clinical experience showing that some patients may have limited benefit from continued imatinib therapy despite secondary mutations.

One year after imatinib dose escalation, a follow-up abdominal contrast-enhanced CT conducted on 4 November 2021 demonstrated patchy slightly hypodense shadows and multiple slightly hypodense nodules in the peritoneum around the liver, including a dominant nodule measuring 52 mm × 72 mm × 78 mm in the right suprahepatic space. Multiple soft tissue masses with obvious enhancement were seen in the greater omentum, intraperitoneal (above the bladder) and pelvic (posterior to the bladder) cavities, and right inguinal area, with the largest measuring 55 mm in diameter. The stomach showed postoperative changes, whereas no tumor recurrence was observed in the surgical area. Multiple space-occupying lesions were seen in abdominal (including the perihepatic space) and right inguinal areas, which were believed to be GIST metastases, with possible local recurrence in the right suprahepatic space. PD was noted after surgery and imatinib treatment, along with the occurrence of secondary resistant mutation (KIT exon 17 mutation). It has been reported that sunitinib has limited efficacy as second-line treatment for advanced GIST with KIT exon 17 mutation (3). Meanwhile, the 2021 Chinese Society of Clinical Oncology (CSCO) guidelines (4) recommended ripretinib as a second-line drug for advanced GIST. After providing informed consent, the patient commenced ripretinib 150 mg daily on 11 November 12021. During her ripretinib administration, the main toxicity was hair loss, followed by mild myalgia, fatigue, and constipation, which were alleviated after symptomatic management. Despite the observation of continued lesion shrinkage on abdominal CT scans conducted every 2 months following second-line ripretinib 150 mg qd, R0 resection remained unachievable. Due to two prior surgeries and patient preference, ripretinib was continued with regular follow-up, and her condition remained stable.

After 16 months of ripretinib treatment, a follow-up abdominal contrast-enhanced CT on 10 March 2023 showed patchy slightly hypodense shadows and multiple slightly hypodense nodules in the peritoneum around the liver, including a dominant nodule measuring 47 mm × 56 mm × 73 mm in the right suprahepatic space. Multiple soft tissue masses with obvious enhancement were seen in the greater omentum, intraperitoneal (above the bladder) and pelvic (posterior to the bladder) cavities, and right inguinal area, with the largest measuring 31 mm × 44 mm. The stomach showed postoperative changes, yet no tumor recurrence was observed in the surgical area. Multiple space-occupying lesions were seen in abdominal (including the perihepatic space) and right inguinal areas. GIST metastases were considered, and their number and size increased. PD was considered, and the ripretinib dose was increased to 150 mg bid in April 2023. The patient is currently tolerating the treatment well, with no worsening of toxicities such as hair loss, mild myalgia, and fatigue. She continues to be closely followed-up (see Table 1 for a complete course of treatment).

Table 1

The diagnosis and treatment timeline of the case

Time Key events and treatment measures   Gene testing/drug resistance mutations   Treatment adjustment
April 2011 Patient presented with “hematemesis and upper abdominal pain for over a month”; she underwent a laparotomy for gastric malignant stromal tumor resection and omental nodule resection in the emergency setting; postoperative pathology confirmed advanced GIST with liver metastases (KIT exon 11 mutation)   KIT exon 11 mutation   Started imatinib 400 mg qd orally
2011–2020 Long-term imatinib 400 mg qd, with regular follow-up visits; stable disease   No new mutations found   Continued the current dosage
March 2020 Abdominal CT showed PD (liver metastases in the right anterior lobe)   Genetic testing identified a secondary KIT exon 17 mutation   Imatinib dose escalated to 600 mg qd
September 2020 Resection of complex liver cancer in right liver + partial resection and repair of the diaphragm + cholecystectomy + RFA for liver cancer was performed; postoperative pathology confirmed metastatic GIST (KIT exon 11 and 17 mutations)   KIT exon 11 and 17 double mutations   Continued imatinib 600 mg qd for maintenance therapy
November 2021 Abdominal CT revealed multiple peritoneal and abdominal metastases; MDT confirmed imatinib resistance   Dominant KIT exon 17 mutation   Switched to ripretinib 150 mg qd as second-line therapy
2021–2023 Ripretinib treatment resulted in continued lesion shrinkage with good tolerance (mild hair loss and myalgia); regular follow-ups showed SD   No new mutations reported   Maintained ripretinib 150 mg qd
2023–present Dose-escalated imatinib maintained disease control during transition planning, despite exon 17 mutation   Dynamic monitoring of secondary mutations   Continued ripretinib 150 mg bid

CT, computed tomography; GIST, gastrointestinal stromal tumor; MDT, multidisciplinary team; PD, progressive disease; RFA, radiofrequency ablation; SD, stable disease.

Discussion

The incidence of GISTs is rising, with 10–15 cases per million worldwide, especially in China, South Korea, and Norway (5). However, due to the lack of any characteristic symptoms in its early stage, timely detection of GISTs is particularly difficult. Patients typically experience mild abdominal discomfort, indigestion, or non-specific pain related to the digestive tract when GISTs grow to 3–4 cm, complicating early diagnosis. Most patients present with an advanced GIST or its metastasis at diagnosis.

The timing of surgery for advanced metastatic GISTs needs to be chosen with caution. Although surgery is the mainstay of treatment for GISTs and remains the only strategy to achieve permanent cure of primary localized GISTs, there is a significant risk of recurrence and PD after a surgical treatment (6-8). Therefore, neoadjuvant therapy is preferred for deeply located, large (>10 cm in diameter), and/or diffuse GISTs (9). In this case, two R0-resection surgeries provided effective local disease control and symptom relief, though their impact on long-term survival remains uncertain. Furthermore, genetic testing of the resected specimens offered valuable information for subsequent treatments.

Genetic testing on postoperative specimens is highly valued in GIST cases. First, detailed genetic testing is essential prior to initiating targeted therapy. The in-depth analysis of the genetic profile of specific patients offers critical information, enabling clinicians to select the most appropriate first-line treatment. Second, some GIST patients may exhibit primary resistance to first-line imatinib, featured by non-response to imatinib therapy or tumor progression within 3–6 months after the initiation of imatinib treatment. Secondary resistance, which is defined as PD at least 6 months after initial response to imatinib therapy, may also occur (10). The imatinib therapy failures in GISTs are primarily due to heterogeneous secondary KIT resistance mutations, which can occur in up to 90% of GIST patients (11,12). Therefore, careful post-surgical genetic testing of tissue specimens is essential and crucial for monitoring potential drug resistance caused by secondary mutations, which enables personalized treatment plans that optimize efficacy and minimize side effects, ensuring a safer and more effective treatment experience.

A phase III clinical trial compared the efficacy of ripretinib versus sunitinib as a second-line treatment for GISTs and found that ripretinib had comparable progression-free survival to sunitinib but with superior tolerability; furthermore, such a therapeutic advantage was even greater in patients with primary KIT exon 11 mutations (13). The 2024 European Society for Medical Oncology (ESMO) and National Comprehensive Cancer Network (NCCN) guidelines (14,15) also recommend ripretinib as a second-line treatment for advanced GIST. In our present case, the therapeutic drug was switched to second-line ripretinib after the patient developed imatinib resistance, resulting in significant efficacy and mild toxicities after 4 months of treatment (as shown in abdominal CT images in Figure 1). The patient’s compliance was good, and regular follow-ups were conducted. The patient remained stable for 16 months on treatment with good compliance and regular follow-ups, until disease progression in March 2023. According to Zalcberg et al. (16), escalating ripretinib dose from 150 mg qd to 150 mg bid after PD in advanced GISTs may offer further clinical benefits with an acceptable safety profile. Similarly, our patient had good tolerance after dose escalation, although dynamic monitoring for secondary mutations is still necessary. Nevertheless, ripretinib resistance remains a clinical concern. In 2024, Mühlenberg et al. (17) found dual mutations [ATP-binding pocket and activation loop mutations (AP/AL)] in 50% of patients with tumors resistant to ripretinib. Patients with such mutations generally do not respond to the currently available TKIs, necessitating exploration of combination therapies or next-generation inhibitors.

Figure 1 Abdominal CT images after the initiation of ripretinib treatment reveal the shrinkage of perihepatic lesions. Red arrows indicate the changes in CT images of liver metastases and inguinal metastases before and after the administration of ripretinib. CT, computed tomography.

Given the long-term survival of GIST-bearing patients, standardized patient management is required throughout the entire disease course. Since most GIST patients receive follow-up care in outpatient settings, establishing comprehensive follow-up records at the initial visit is crucial for monitoring disease progression and adjusting treatment plans.

Conclusions

We have presented a case of advanced metastatic GIST, in whom the secondary KIT mutations following imatinib treatment underscored the critical need for close follow-up. Genetic testing is crucial for identifying the specific mutation types. Our patient developed imatinib resistance after 9 years of oral imatinib administration, after drug switch to ripretinib, ripretinib demonstrated its therapeutic potential, the initial response was significant, although PD was noted again in 2023. However, this case has limitations, including its single-patient nature and potential non-generalizability to other populations where ripretinib is used in later lines, which may affect treatment response patterns. Continued follow-up is essential to evaluate the impact of ripretinib dose escalation on the disease course.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://gist.amegroups.com/article/view/10.21037/gist-2025-10/rc

Peer Review File: Available at https://gist.amegroups.com/article/view/10.21037/gist-2025-10/prf

Funding: This article was supported by the horizontal project “Intelligent Assessment of Postoperative Recurrence Status in Gastrointestinal Stromal Tumors Based on Multimodal Fusion” from the social organization—Sichuan Science and Education Xingchuan Promotion Association (Project No. KJXC24-0303) and the provincial-level project “Construction of an intelligent prediction and individualized screening model for the efficacy of neoadjuvant therapy for gastrointestinal stromal tumors” from Sichuan Provincial Department of Science and Technology-Key Research and Development Project (Project No. 2023YFS0197).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gist.amegroups.com/article/view/10.21037/gist-2025-10/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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(English Language Editor: J. Jones)

doi: 10.21037/gist-2025-10
Cite this article as: You J, Hou N, Yu S, Gao J, Xie W, Yuan X, Tang H, Jiang S, Pang M. Ripretinib as second-line treatment for imatinib-resistant advanced gastrointestinal stromal tumors: a case report. Gastrointest Stromal Tumor 2025;8:3.

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