title: The Role of Surgery in Metastatic Gastrointestinal Stromal Tumors.
abstract: Gastrointestinal stromal tumors (GISTs) are the most common sarcomas and mesenchymal neoplasms of the gastrointestinal tract. Macroscopically complete (R0/R1) resection is the standard treatment for localized resectable GIST with adjuvant imatinib therapy recommended for patients with intermediate or high-risk disease. In patients with advanced unresectable or metastatic GIST, imatinib has significantly improved outcomes. However, while most patients achieve partial response (PR) or stable disease (SD) on imatinib (with maximal response typically seen by 6 months on treatment), approximately half will develop secondary resistance by 2 years. Available data suggest that cytoreductive surgery may be considered in patients with metastatic GIST who respond to imatinib, particularly if a R0/R1 resection is achieved. The benefit of surgery in patients with focal tumor progression on imatinib is unclear, but may be considered. Patients with multifocal progression undergoing surgery generally have poor outcomes. Thus, surgery should be considered in patients with metastatic GIST whose disease responds to imatinib with a goal of performing R0/R1 resection. Optimal timing of surgery is unclear but should be considered between 6 months and 2 years after starting imatinib. Although surgery in patients with metastatic GIST treated with sunitinib is feasible, incomplete resections are common, complication rates are high, and survival benefit is unclear. Therefore, a careful multidisciplinary consultation is required to determine optimal treatment options on a case-by-case basis. Finally, patients with metastatic GIST should resume tyrosine kinase inhibitor treatment postoperatively.
authors.affiliation: Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.|Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02115, USA.
authors.forename: Emily Z
authors.initials: EZ
authors.lastname: Keung
authors.affiliation: Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.|Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02115, USA.
authors.forename: Mark
authors.initials: M
authors.lastname: Fairweather
authors.affiliation: Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. craut@bwh.harvard.edu.|Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02115, USA. craut@bwh.harvard.edu.
authors.forename: Chandrajit P
authors.initials: CP
authors.lastname: Raut
mesh_terms: D000970:Antineoplastic Agents / Q000627:therapeutic use*; D065426:Cytoreduction Surgical Procedures; D005770:Gastrointestinal Neoplasms / Q000188:drug therapy* / Q000601:surgery*; D046152:Gastrointestinal Stromal Tumors / Q000188:drug therapy* / Q000601:surgery*; D006801:Humans; D000068877:Imatinib Mesylate / Q000627:therapeutic use*; D047428:Protein Kinase Inhibitors / Q000627:therapeutic use
chemical_list: D000970:Antineoplastic Agents; D047428:Protein Kinase Inhibitors; D000068877:Imatinib Mesylate
keywords: Cytoreduction; Debulking; GIST; Gastrointestinal stromal tumor; Imatinib; Metastasectomy; Metastatic; Regorafenib; Sunitinib; Surgery; Tyrosine kinase inhibitor
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