Surgical Oncology net Blog aimed at residents in surgery     e mail surgoncnet@gmail.com

 

Blog aimed at residents in surgery

URL :  www.surgical-oncology.net             e mail surgoncnet@gmail.com

GIST: INVITED COMMENTARY ALFONSO CARLI  PhD Director of the School of General Surgery and Emergency Surgery. University of Siena.  Italy.  email acarli@unisi.it March 2001.     INVITED COMMENTARY To Previous Article about GIST To the first updating To the second updating To the third updating The term GIST has been recently introduced and arouses great controversies in regard to many aspects: definition, diagnosis, prognostic factors and treatment. In comparison with extremity sarcomas this tumors have a much greater local failure rate and an overall 5 years survival rate of 30%, in consequence of their insidious progress and late diagnosis, often suggested at laparotomy. Moreover for the proximity of the tumor to vital structures we can' t often apply neither the principles of sarcoma surgery nor local adjuvant therapies such as external beam radiation therapy and brachytherapy. Consequently diagnostic techniques are very important, in particular CT, Endoscopic Ultrasound, Staging Laparoscopy, Laparoscopic Ultrasonography that are useful for the diagnosis in emergency and for the detection of recurrences in the follow up. The clinical presentation is different between gastric GISTs and small bowel GISTs, the first often presenting with a gastrointestinal bleeding, the second with an insidious and progressive obstruction. In fact the large median tumor size of the small bowel GISTs is 11 cm. And according to Crosby's study the small bowel GISTs have a worse prognosis than gastric. In the recent retrospective and prospective studies the authors sought to include only sarcomas with standard and traditional criteria of malignancy, but the histologic criteria are not well defined. It is not uncommon for lesions of low malignant potential to metastasize decades later. The prognostic factors have been re-examined in time: we concur with Memorial Sloan Kettering Cancer Center studies. They affirm that in the patients without metastases and who undergo complete gross resection size is an important predictor of survival on both univariate and multivariate analysis. But the main problem is that of recurrences. They occur also in patients who had a complete resection of the tumor. The decision to perform a second surgery depends on biological behaviour of the tumor, one clinical manifestation of which is DFI (the interval between the initial surgery for resection of the primary to first pathologic or radiologic evidence of recurrence) and on necessity of symptom control. In patients with a isolated liver metastases and a long DFI there may be benefit for resecting recurrent disease. It is not well defined the management of patients with asymptomatic recurrence detected by surveillance radiologic imaging. Effective adjuvant therapies are on study to diminish the recurrence rate and to treat sarcomatosis (PDT).   References DeMatteo RP, Lewis JJ, Leung D, Mudan S, Woodruff MJ, Brennan MF. Two hundred gastrointestinal stromal tumors : recurrence patterns and prognostic factors for survival. Ann Surg 2000; 231: 51-8. Mudan S, Conlon KC, Woodruff M, Lewis J, Brennan MF. Salvage surgery for patients with recurrent Gastrointestinal sarcoma. Cancer 2000; volume 88 : 66-74. Crosby JA, Catton NC, Davis A,Couture J,O'Sullivan B, Kandel R,Swallow JC. Malignant Gastrointestinal Stromal Tumors of the small intestine: a review of 50 cases from a prospective database. Annals of Surgical Oncology, 2001; 8(1): 50-59. Hendren SK , Hahn SM, Spitz RF, Bauer TW,Rubin CS, Zhu T, Glastsein E, Fraker LD. Phase II trial of debulking surgery and Photodinamic Therapy for disseminated intraperitoneal tumors. Annals of Surgical Oncology,2001; 8(1):65-67. Stein HJ, Sendler A, Fink U, and JR Siewert. Multidisciplinary approach to Esophageal and Gastric Cancer. Surgical Clinics Of North America. 2000; 80:2,659-682. Buyske Jo. Role of videoscopic-assisted techniques in staging malignant disease. Surgical Clinics of North America, 2000;80:2, 495-502. JR Siewert. Staging laparoscopy. Invited Commentary.World J Surg 24, 1135-1136. 2000.   TO HOME PAGE next article Surgical Oncology net