title: Outcome after curative resection of large (>or=10 cm) gastric gastrointestinal stromal tumors: how frequent is adjacent organ involvement and is concomitant distal pancreatectomy necessary?
abstract: BACKGROUND
  Complete tumor resection with clear margins including adjacent organs is the treatment of choice for gastrointestinal stromal tumors (GISTs). However, true tumor invasion of adjacent organs has been reported to be rare. Concomitant distal pancreatectomy (DP) for suspected tumor infiltration is not infrequently performed during resection of large gastric GISTs. This study aims to determine the true frequency of adjacent organ involvement by large gastric GISTs with particular attention to the pancreas and compares the outcome after curative resection with and without a concomitant DP in order to determine if DP is truly necessary.
  
  
  METHODS
  A retrospective review of 37 patients who underwent curative resection of large (>or=10 cm) gastric GISTs was conducted.
  
  
  RESULTS
  Wedge resections were performed in 22, partial gastectomies in nine, and total gastrectomies in six patients. The median operative time was 180 min (range, 60-330 min), and the patients had a median postoperative stay of 8 days (range, 4-29 days). Overall, there were eight (22%) morbidities including two (5%) mortalities. Nineteen (51%) had concomitant adjacent organ resection, and these included 15 (41%) DPs with splenectomies. Direct organ invasion was demonstrated in 5/19 patients (26%) and 7/30 organs (23%) resected. Only 1/15 (6.7%) DP specimens demonstrated tumor infiltration. Comparison between the patients with and without a concomitant DP demonstrated that performance of a DP was associated with a longer operation time [225 min (range, 105-305 min) vs 158 min (60-330 min), P=.002)], increased postoperative stay [9 days (range, 7-29 days) vs 7.5 days (4-19 days), P=.042], and increased postoperative morbidity [6 (40%) vs 2 (9%), P=.025]. The DP cohort also had a statistically significant poorer 5-year recurrence free survival (22% vs 60%, P=.017).
  
  
  CONCLUSIONS
  Although adjacent organ involvement is not uncommon with large gastric GISTs, concomitant DP is usually unnecessary as direct pancreatic invasion is rare. Furthermore, concomitant DP with splenectomy is associated with an increase in postoperative morbidity.
authors.affiliation: Department of Surgery, Singapore General Hospital, Singapore. bsgkp@hotmail.com
authors.forename: Brian K P
authors.initials: BK
authors.lastname: Goh
authors.forename: Pierce K H
authors.initials: PK
authors.lastname: Chow
authors.forename: Sittampalam M
authors.initials: SM
authors.lastname: Kesavan
authors.forename: Wai-Ming
authors.initials: WM
authors.lastname: Yap
authors.forename: Yaw-Fui A
authors.initials: YF
authors.lastname: Chung
authors.forename: Wai-Keong
authors.initials: WK
authors.lastname: Wong
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016009:Chi-Square Distribution; D005260:Female; D005743:Gastrectomy / Q000379:methods; D046152:Gastrointestinal Stromal Tumors / Q000473:pathology* / Q000601:surgery*; D006801:Humans; D007150:Immunohistochemistry; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D010180:Pancreatectomy; D010182:Pancreatic Diseases / Q000209:etiology / Q000601:surgery*; D011183:Postoperative Complications / Q000209:etiology / Q000601:surgery*; D011379:Prognosis; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018709:Statistics, Nonparametric; D015996:Survival Rate; D016896:Treatment Outcome