Disease Progression Following Imatinib Failure in Gastrointestinal Stromal Tumors: Role of Surgical Therapy

Abstract

Gastrointestinal stromal tumors (GISTs) represent the most common mesenchymal neoplasms of the GI tract. The optimal management of GISTs has been evolving rapidly over the past 5 years and depends on proper histopathologic and radiologic diagnosis as well as appropriate multidisciplinary medical and surgical treatments. Complete surgical resection of primary localized GIST with negative margins remains the best therapeutic option today. In the setting of locally advanced or metastatic disease, imatinib mesylate has emerged as the initial treatment of choice, administered either as cytoreductive or as definitive treatment. Surgery or ablative modalities in this setting are becoming increasingly employed, particularly when all disease becomes amenable to gross resection or destruction, or to manage complications arising from the disease following imatinib failure.We report on the surgical management of an unusual and clinically significant complication following progression of disease secondary to imatinib resistance. The role of surgical therapy in the management of GIST complications following resistance to imatinib and the integration of surgical and molecular therapy of locally advanced or metastatic GISTs are discussed. The Oncologist 2007;12:438 -442 Disclosure of potential conflicts of interest is found at the end of this article. CASE PRESENTATIONA 49-year-old female patient presented with a severalmonth history of progressive fatigue, upper abdominal discomfort, and weight loss. On physical examination, she was noted to have a palpable mass in the epigastric area. She underwent evaluation with a computed tomography (CT) scan of the abdomen and pelvis which revealed a large solid mass occupying most of the upper abdomen and the lesser sac, most likely of gastric origin, though the exact source could not be well defined. There were no separation planes seen on the CT scan between the mass and the pancreatic tissue in the body and tail area. In addition, multiple hypodense lesions were noted in segments II, IV, V, and VII of the liver (Fig. 1A, 1B).Upper endoscopy revealed a raised 5-cm ϫ 6-cm hard, submucosal mass extending from the cardia/fundus into the lesser curve. Endoscopic ultrasonography (EUS) was performed, revealing that the hypoechoic mass was arising from the fourth layer of the gastric wall (corresponding to the muscularis propria), highly suggestive of gastrointestinal stromal tumor (GIST). Deep well endoscopic biopsies were obtained and showed a stromal cell tumor with high

Gastrointestinal Stromal Tumor in Sigmoid Colon at a Tertiary Care Hospital: A Case Report

“…The significance of endoscopic ultra-sound guided fine needle aspiration has been pointed out in several studies 13 and the reported accuracy is 80.0 o %-85.0 o %. However the present case report section from core biopy has shown fibrofatty tissue containing a few chronic inflammatory cells with no gastrointestinal stromal tumor or malignancy which is inconsistent with other findings 11,12 .…”

“…This is consistent with the present case report. The preoperative percutaneous biopsy should not be used because it is associated with a significant risk of tumor rupture or dissemination 12 . The significance of endoscopic ultra-sound guided fine needle aspiration has been pointed out in several studies 13 and the reported accuracy is 80.0 o %-85.0 o %.…”

Gastrointestinal stromal tumor

“…Although, the diagnostic procedure includes several examinations, like barium examination of the GI tract, computer tomography and angiography, none of them can establish the diagnosis. The preoperative percutaneous biopsy should not be used because it is associated with a significant risk of tumor rupture or dissemination [ 20 ]. The significance of endoscopic ultra-sound guided fine needle aspiration has been pointed out in several studies and the reported accuracy is 80% - 85% [ 21 ].…”

Surgical debulking of gastrointestinal stromal tumors: Is it a reasonable option after second-line treatment with sunitinib?

“…The role of surgery for patients aVected by GIST has changed due to the neo-adjuvant use of imatinib Andtbacka et al 2007;Gronchi et al 2007;Raut et al 2006;DeMatteo et al 2007;Scaife et al 2003;Wu et al 2003;Rutkowski et al 2006;Haller et al 2007;Jamali et al 2007). Imatinib may reduce the tumor size and increase the rate of complete resection of a large tumor mass, which was unresectable before systemic therapy (Andtbacka et al 2007).…”