Downstaging of a gastric GIST by neoadjuvant imatinib and endoscopic assisted laparoscopic resection

Neoadjuvant therapy for gastrointestinal stromal tumor

Molecular-targeting therapy using tyrosine kinase inhibitor imatinib mesylate is effective for metastasis/recurrent gastrointestinal stromal tumors (GISTs). Likewise, imatinib would be effective in the neoadjuvant therapy for high-risk GIST. Neoadjuvant therapy may have the potential to increase the complete resection rate and to avoid the surgical rupture by decreasing the tumor size. Thereby, it is expected that improvement of recurrence rate and survival rate can be obtained by neoadjuvant therapy. Neoadjuvant therapy is also expected to be favored from the viewpoint of organ/function preservation by tumor shrinkage. The existing results of clinical trials established the feasibility of neoadjuvant imatinib therapy. However, proof of the survival effectiveness of neoadjuvant imatinib therapy has not been sufficiently demonstrated. The aim of this article is to introduce previous evidence and strategies regarding neoadjuvant therapy for GIST.

Laparoscopic resection of gastrointestinal stromal tumors: Does laparoscopic surgery provide an adequate oncologic resection?

Gastrointestinal stromal tumors (GISTs) are rare tumors of the GI tract. Surgical resection remains the mainstay of non-metastatic disease. However, the ability to provide an adequate oncologic resection using laparoscopic surgery is still an area of debate. This is a thorough review of the current literature, looking particularly at the use of laparoscopic surgery for larger GISTs and the long-term oncologic outcomes compared to the results of open surgery. Laparoscopic resections provide an adequate oncologic result for GISTs of all sizes, including those greater than 5 cm in size.

Endoscopic dissection of large endogenous myogenic tumors in the esophagus and stomach is safe and feasible: a report of 42 cases

OBJECTIVE

Submucosal myogenic tumors, including leiomyoma and stromal tumors, are currently treated primarily by open surgery or laparoscopic excision. The aim of this retrospective study was to evaluate the feasibility of endoscopic dissection (ED) for resecting endogenous esophageal leiomyoma (EL) and gastric stromal tumors (GSTs) with diameters of 5 cm.

METHODS

We enrolled 42 patients with endogenous EL and GST who had undergone endoscopic surgery (endoscopic group). These cases were compared retrospectively with 22 patients who had undergone thoracotomy or laparotomy (control group). Endoscopic group (n = 42) received ED for EL and GST resection, including circumferential removal of superficial mucosa of targeted tumor. Control group (n = 22) received thoracotomy or laparotomy for resection of esophageal and gastric myogenic tumors. Main outcome measures were operative time, intraoperative bleeding and perforation, postoperative complications, and hospital stays and costs were compared between groups.

RESULTS

Endogenous EL and GST were successfully removed from all patients. Bleeding and perforation occurred in seven and five EL and GST patients, respectively. Bleeding was corrected with argon plasma coagulation (APC). Perforation was endoscopically repaired with clips. Mean operative time was 49 min for endoscopic EL and 55 min for GST resection. No major bleeding or perforation occurred postoperatively. Endoscopic treatment had shorter length of stay and lower hospital costs than conventional procedures.

CONCLUSIONS

ED is safe and feasible for resection of endogenous EL and GST in selected cases.

Full-thickness endoscopic resection of nonintracavitary gastric stromal tumors: a novel approach

BACKGROUND

Until now, the conventional treatment of stromal tumors has been primarily open surgery or laparoscopic excision. The use of combined laparoscopic/endoscopic surgeries has been investigated, but endoscopic therapy alone has been limited to en bloc resection or nucleus removal of intracavitary tumors with diameters<2 cm. Nonintracavitary and intramural gastric stromal tumors preclude the use of endoscopic resection due to the risk of gastric perforation. This study was designed to show the safety and effectiveness of full-thickness endoscopic resection of nonintracavitary stromal tumors based on our direct experience.

METHODS

A total of 109 consecutive patients with nonintracavitary gastric stromal tumors<4 cm in diameter underwent surgical treatment; 66 patients received endoscopic surgery and 43 patients received laparoscopic surgery.

RESULTS

No significant differences existed between the two groups in terms of demographics and clinical characteristics, and no tumor exceeded 3.5 cm in size. Median operation times (endoscopic group, 53.6 min; laparoscopic group, 139 min) and hospitalization fees of the endoscopic group were significantly lower than those of the laparoscopic group with significant median hospital stays (8 days for endoscopic group; 6 days for laparoscopic group). No intraoperative complications occurred in the laparoscopic group and complete removal of tumors was achieved in the endoscopic group. Postoperative complications occurred in 6 patients of 43 who underwent laparoscopic surgery and 17 patients of 66 who underwent endoscopic surgery, representing a significant difference; the size of the lesion correlated positively with the occurrence of complications.

CONCLUSIONS

Endoscopic resection is safe and effective for treating nonintracavitary stromal tumors. The endoscopic natural-cavity technique produced less surgical injury to the patients and preserved the anatomy of intra-abdominal structures. In addition, the endoscopic technique reduced operative times, postoperative bleeding, and costs.

Management of gastrointestinal stromal tumours in the Imatinib era: a surgeon's perspective

BACKGROUND

Surgical resection has remained the mainstay of treatment of GIST with a 5-year-survival of 28-35%. Tyrosine kinase inhibitor (Imatinib) has revolutionised the treatment of these tumours. The current research is directed towards expanding the role of this drug in the treatment of GIST. We present our experience of managing GIST in this institute.

METHODS

This is a case note study of patients identified from a prospectively kept database from January 2000 to August 2007.

RESULTS

16 patients were diagnosed with GIST. The median age was 66 years (range 46 to 82) and the male to female ratio was 9:7. Eleven patients underwent surgery, 9 of which had R0 resection (2 laparoscopic, 1 converted to open), one had an open biopsy and one had a debulking procedure. 3 patients were inoperable and 2 were found to be unfit for surgery. Five patients received Imatinib (2 postoperatively). The risk assessment based on morphological criteria showed that 4 patients had low, 4 had intermediate and 8 had high malignant potential. The median follow up was for 12 months (range 3-72); 2 patients died of unrelated causes at 6 and 9 months after diagnosis.

CONCLUSION

Most GISTs can be managed effectively using existing protocols. However currently there is no evidence based guidance available on the management of GIST in the following situations-role of debulking surgery, the follow up of benign tumours not requiring surgical resection and role of laparoscopic surgery. Further research is needed to answer these questions.