54,55 The reported frequency of mutations in exon 11 varies from 20% to 92%, depending on the type of material (frozen or formalin fixed) and the technique used.8,14,18,31,32,33,51,56,57 Most of the mutations are located between codons 556 and 560, next with deletions and insertions prevalently affecting codons 557�C559 and point mutations affecting codons 559 and 560.8,24,49,51,52,53,58,59,60 Internal tandem duplications are prevalently found towards the end of the exon (codons 576�C580).52 The type of mutation is apparently related to the prognosis, with deletions behaving more aggressively in comparison with insertions and point mutations,8,18,29,58,61,62,63 and to the risk classification. Exon 9 (extracellular domain) The frequency of this mutation is described in 5�C18% of cases, depending on the series.
18,24,28,49,53,64,65,66,67,68,69,70,71,72 It occurs mainly at codons 501�C502 and is represented by duplication�Cinsertion. It is associated with small intestinal localization and aggressive behaviour.18,24 Its mechanism probably affects an antidimerisation motif in the extracellular domain. Exon 13 (kinase I domain) This rare mutation, affecting codon 642, occurs in 0.8�C4.1% of cases.1,3,35,49,64,65,66,70,71,73,74 It is associated with resistance to treatment with imatinib. Exon 17 (activation loop) The activating mechanism of these rare mutations (0.6% of cases)18,33 affecting codons 820 and 822, is unclear. A mutation occuring at codon 817, highly activating and frequently observed in other tumours (mastocytosis, acute myelogenous leukaemia), was never observed in GISTs, implying that the transforming mechanisms in the genesis of GIST are different from those of other tumours.
18,23 Mutation in the pdgfra gene They are observed in 7�C12% of cases,18,20,29,45,49,50,51 occurring more often in exon 18 (activation loop) and rarely in exons 12 (juxtamembrane domain) and 14 (kinase I domain). pdgfra Mutants are prevalently epithelioid, located in the stomach and show weak or no immunohistochemical reactivity for KIT,18,20,29,45,49,50,51,75,76 but are functionally similar to kit mutants. The mutations occur in homologous domains, and activation of the downstream signalling pathways seem to be largely similar in the two mutant subtypes.77 Some degree of difference in gene expression may exist, but these data need confirmation in larger series.
78 Exon 18 (activation loop) Mutations occur at codons 842�C849. Some of them (D842V, RD841�C842KI and Carfilzomib DI842�C843IM) have shown considerable resistance to treatment with imatinib.45,48,49,79 Exon 12 (juxtamembrane domain) Mutations occur at codons 561�C571 and are associated with good response to imatinib.18,48,49,50 Exon 14 (kinase I domain) A single rare mutation is described (N659K). It showed in vitro sensitivity to imatinib that is comparable to that observed in kit exon 13 mutants.