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General Surgery
Perspective on Gastrointestinal Stromal Tumors
Built from Maingot's Abdominal Operations
What’s inside
10 sections · 60 slides
Introduction
What changed, and what did not
- Gastrointestinal stromal tumour in outline
- 12 months
- How the treatment paradigm changed
- Resected gastric stromal tumour
- Targeted molecular therapy in other solid tumours
- Relevance of the GIST experience to commoner cancers
- Tyrosine kinase inhibitors do not replace surgery
- Imatinib bound inside a tyrosine kinase
- Imatinib molecule in three dimensions
Handling the tumour at operation
Rupture, bleeding and adherent organs
- Gentle handling and tumour rupture
- Blood supply of a large stromal tumour
- Behaviour towards neighbouring organs
- Stromal tumour bulging from the small bowel wall
The stomach
The commonest site, and the operations it needs
- Regions of the stomach and duodenum
- Site and size determine the surgical approach
- Spindle cells of a stromal tumour
- Tumour growing beneath intact gastric mucosa
- Locating a gastric tumour at operation
- Two growth patterns of a gastric tumour
- Posterior wall tumours and laparoscopic exposure
- Resection margin and use of staplers
- Operating without a preoperative tissue diagnosis
- Tumours at the gastro-oesophageal junction
- Mass at the gastric cardia on computed tomography
- Massive gastric tumours and adjacent structures
- Consequence of an inseparable massive tumour
Neoadjuvant imatinib
Shrinking the tumour before operating
- Imatinib before surgery for large tumours
- Assessing response to imatinib on CT
- Timing of resection after starting a tyrosine kinase inhibitor
- Extent of resection after neoadjuvant therapy
Small intestine and duodenum
The next commonest site, and the hardest
- Small intestine as the next commonest site
- Jejunal stromal tumour on CT and at operation
- Tumours in the second part of the duodenum
- Tumours in the fourth part of the duodenum
- Reconstruction options by duodenal segment
Colon and rectum
Rare sites where sphincter preservation is the issue
- Colonic and rectal stromal tumours
- Local excision of distal rectal tumours
- 1 cm
Perioperative care
Stopping and restarting the drug
- Stopping tyrosine kinase inhibitors before surgery
- Restarting the drug after surgery
Adjuvant therapy
Who benefits after the tumour is out
- Adjuvant imatinib after resection of a localized tumour
- Patients at low risk of recurrence
- Nomogram for recurrence-free survival
- Three inputs to the nomogram
- Duration of adjuvant imatinib therapy
Surgery for metastatic disease
An unproven operation with a plausible rationale
- Standard of care for metastatic GIST
- Recurrent abdominal deposits on computed tomography
- Circled abdominal mass, axial view enlarged
- Limitations of the published evidence
- How bias inflates an apparent surgical benefit
- Rationale for resecting responding metastases
- Two arms under randomised comparison
- Detection of small-volume metastatic disease
- Mass adjacent to the stomach on computed tomography
- Practical position in the absence of randomised data
Summary
What to carry away
- Whole resected stromal tumour of the stomach
- Take-home points on surgical management
- Take-home points on drug therapy and metastases
- References
- Maingot's Abdominal Operations, 12th Edition