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Surgical Management of Gastrointestinal Stromal Tumors - Color
Surgical Management of Gastrointestinal Stromal Tumors - Color
Kariadi Hospital
GIST
Rare mesenchymal tumors US : 5000-6000 cases per year Affect men and women equally Age 40-80 years old (median age 60)
Biopsy
Prevent rupture of pseudocapsule and intraperitoneal tumor dissemination Fine-needle aspirates / Core-needle biopsy inconclusive because of the submucosal location and the necrotic centers
Chest X-Ray Abdominal-Pelvix CT EUS small lession (<2cm) Percutaneous biopsy should not be used if tumor is considered resectable
Surgery : mainstay treatment of Localized resectable GIST A complete gross resection with preservation of an intact (pseudo) capsule and negative microscopic margins (R0) Wide margins not improve outcomes Lymphadenectomy is not routinly required En bloc resection is needed when adjacent organs appear to be involved
The abdomen should be thoughly explored for evidence of metastatic disease GIST tend to displaced stucture (most sarcomas) rather than invade them Final pathologic examination reveals microscopically positive margins
Contoversy Reoperation and marginal resection ? R0 and R1 long term outcome : similar R2 worst outcome subtotal resection should be avoided
Laparoscopy has emerged as a helpful tool in the treatment of GIST (<5/10 cm)
Safe and feasible Oncologic safety Minimizing tumor manipulation Tumor Rupture Intraperitoneal Spread Wound protecting device (hand port) Endobag
85% of Px with Localised Primary GIST : Complete resection 70-95% : Negative microscopic margins Surgery alone recurrence rate 50% (irrespective of negative margins) 5-year survival : 50%
Greater Curv/Fundus : Sleeve or Wedge gastrectomy Incisura/Antrum : Distal Gastrectomy Lesser Curv/GE junction : Partial Gastrectomy/Total Gastrectomy
Second most common (20%) : Jejunal - Ileal - Duodenal Resection of the involved bowel with Negative Margins Primary Anastomosis Can be performed Laparoscopically either intra- or extracorporeal anastomosis
Rare : 3-5% Increases in the more distal colon, rectum for majority of tumor Rectal GIST : difficult
Involvement of surrounding structure R0 difficult to obtain Average positive margin up to 40%
Operative plan : depends on proximity of the tumor to the internal sphincter Mesorectal excision and wide margin are not needed
LAR APR
Colonic GIST
Marginal resection with primary anastomosis In the setting of perforation and gross contamination colostomy and mucous fistula may be prefered risk of anastomotic dehiscence Formal lymphadenectomy is not necessary
Rare : <5% Operative approach : tumor size and location relation to the GE junction
Small lession (<2cm) : Transmurally resected alonf the longitudinal axis w/ Transverse closure Larger lession/within GE junction : esophagectomy
Treatment options were very limited in the pre-TKI era GIST : respond poorly to chemo-tx or radiation-tx General rule :
R1/R2 resection Debulking Surgery Mutilating Surgery Not recommended
Neoadjuvant Imatinib 2 CT scan evaluation surgical option Incomplete resection/debulking only performed in the setting of palliation for bleeding, obstruction, perforation Timing of resection : imatinib for 6 months
Cytoreductive Surgery :
Stable or responsive to TKI therapy when complete gross resection is possible Emergencies situation : hemorrhage, perforation, obstruction or abscess