title: Surgical debulking of gastrointestinal stromal tumors: is it a reasonable option after second-line treatment with sunitinib?
abstract: BACKGROUND
  After imatinib treatment, the surgical management of patients affected by gastrointestinal stromal tumor (GIST) has been widely reported and often considered by many oncologists in clinical practice. Surgical results are correlated with disease responsiveness to tyrosine kinase inhibitors and with complete extirpation of all tumor sites. By now, no report specifically addressing surgical management after second-line treatment with sunitinib is still available. Most patients have an unresectable disease and do not have any other therapeutical options except for clinical trials.
  
  
  METHODS
  We report two clinical cases of patients with metastatic GISTs, who underwent surgery after sunitinib, and discuss the surgical management option in this clinical setting.
  
  
  RESULTS
  Both our patients had a long, durable stable disease on sunitinib, but one developed a chronic mild bleeding that does not call for emergency surgical interventions and the other one developed chronic heart toxicity. They were proposed to undergo surgery despite the unresectable diseases and received an incomplete resection because of residual metastatic lesions. They restarted sunitinib after surgery.
  
  
  CONCLUSIONS
  The poor prognosis after sunitinib treatment and the absence of alternative validated options open the debate on the assessment of surgical management of metastatic GISTs in this setting. The role of surgery should be investigated in clinical trials; however, the enrollment may be difficult. In clinical practice and after a multidisciplinary case patient discussion, surgery could represent a reasonable choice for advanced GISTs especially if the risk of surgery-related death is not too high.
authors.affiliation: Institute of Hematology and Medical Oncology L. A. Seragnoli, Sant' Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, 40126 Bologna, Italy. pantaleo@med.unibo.it
authors.forename: M A
authors.initials: MA
authors.lastname: Pantaleo
authors.forename: M
authors.initials: M
authors.lastname: Di Battista
authors.forename: F
authors.initials: F
authors.lastname: Catena
authors.forename: M
authors.initials: M
authors.lastname: Astorino
authors.forename: M
authors.initials: M
authors.lastname: Saponara
authors.forename: V
authors.initials: V
authors.lastname: Di Scioscio
authors.forename: D
authors.initials: D
authors.lastname: Santini
authors.forename: G
authors.initials: G
authors.lastname: Piazzi
authors.forename: P
authors.initials: P
authors.lastname: Castellucci
authors.forename: G
authors.initials: G
authors.lastname: Brandi
authors.forename: G
authors.initials: G
authors.lastname: Biasco
mesh_terms: D000328:Adult; D000970:Antineoplastic Agents / Q000627:therapeutic use*; D001549:Benzamides; D003131:Combined Modality Therapy; D013505:Digestive System Surgical Procedures; D005260:Female; D046152:Gastrointestinal Stromal Tumors / Q000188:drug therapy* / Q000473:pathology / Q000601:surgery*; D006801:Humans; D000068877:Imatinib Mesylate; D007211:Indoles / Q000627:therapeutic use*; D008113:Liver Neoplasms / Q000188:drug therapy / Q000556:secondary / Q000601:surgery; D020360:Neoadjuvant Therapy; D009364:Neoplasm Recurrence, Local / Q000188:drug therapy / Q000601:surgery; D010879:Piperazines / Q000627:therapeutic use; D011743:Pyrimidines / Q000627:therapeutic use; D011758:Pyrroles / Q000627:therapeutic use*; D000077210:Sunitinib; D014057:Tomography, X-Ray Computed
chemical_list: D000970:Antineoplastic Agents; D001549:Benzamides; D007211:Indoles; D010879:Piperazines; D011743:Pyrimidines; D011758:Pyrroles; D000068877:Imatinib Mesylate; D000077210:Sunitinib