Is multivisceral resection in locally advanced gastrointestinal stromal tumours an acceptable strategy?

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Excerpt

Gastrointestinal stromal tumours (GISTs) represent the most common sarcoma of the gastrointestinal (GI) tract, developing from interstitial cells of cajal (ICC), the pacemaker cells of the GI tract.1 Up to 75–80% of GIST harbour activating KIT (CD117) or PDGFR‐α mutations, the target of tyrosine kinase inhibitors (TKIs).4 Imatinib Mesylate (Gleevec; Novartis Pharma AG, Basel, Switzerland), a selective TKI of KIT and PDGFR‐α, has since been approved as a first line therapy for locally unresectable and metastatic GISTs;6 its use may also be considered in the adjuvant setting in the management of GISTs with a high risk of recurrence.6
Although the use of TKIs represents a major advancement in the treatment of GISTs, surgical resection remains the only chance of cure. In studies evaluating the role of imatinib in advanced or metastatic GISTs, complete pathological response was rarely achieved.6 It is likely that TKIs control but fail to eradicate all tumour cells. Complete resection (R0) of disease is possible in low volume disease and confers good survival outcomes even in the absence of adjuvant TKI therapy.14 However, when GISTs are large, they have a tendency to involve multiple viscera, and carry a higher risk of tumour rupture. In addition, size has been shown to be an independent predictor of poor outcome.15
Multivisceral resection (MVR) to achieve complete cytoreduction is an acceptable strategy in the management of large gastric, colo‐rectal and various gastrointestinal tumours.16 In the pre‐imatinib era, locally advanced GISTs were primarily resected, MVR was common, and majority were removed with clear margins.14 Given the tremendous success of imatinib in unresectable or metastatic GISTs with up to 80% of patients achieving partial response or stable disease,6 some authors proposed the use of neoadjuvant TKI to downsize locally advanced GISTs as a strategy to decrease the morbidity of MVR and reduce the risk of tumour rupture or positive margins.11 However, there are no randomized trials comparing the efficacy of neoadjuvant TKI therapy followed by surgery with upfront surgery for locally advanced GIST. Therefore, we sought to determine if upfront MVR is a reasonable strategy for the management of locally advanced GIST in our population.
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