A 68-Year-Old Man With Gastrointestinal Stromal Tumor - Episode 3
Margaret von Mehren, MD: For patients with GIST [gastrointestinal stromal tumor], we think very much, especially in the metastatic disease setting, about using systemic therapy. That is very important. When these agents were first available, we thought less and less about the role of surgery. Before tyrosine kinases were available, surgery was really the only effective option that these patients had. With tyrosine kinase inhibitors being so effective, we sort of forgot about use or how to combine them. Over time, however, we’ve really come to understand a couple of things. We do see patients for whom the disease is controlled, for the most part, but maybe there’s 1 lesion that has started to progress. So do you give up on the agent the patient is on that seems to be controlling most of the disease, or can you consider another form of therapy, such as surgery? I think increasingly, we do that based on the benefit to the patient.
Certainly, with imatinib, it is very straightforward. There are no issues in terms of potentially increased risk of bleeding or wound-healing issues. Patients can take their therapy up to the night before surgery—at least that’s our standard practice where I work—and then resume it as soon as they are able to eat and drink normally and the surgeon is comfortable with them doing so.
It’s a bit more complicated in patients who are on Sutent [sunitinib] and regorafenib, because they do have some VEGF targets. And so, there are potentially some issues with wound healing and/or bleeding. So we’re a bit more conservative with these patients. Typically, within 5 to 7 days before surgery, one would have them hold their therapy. And then, most surgeons want to make sure that patients have good wound healing before they resume therapy.
I think the other thing that we think about are other forms of localized therapy, in particular liver-directed therapy. Our interventional radiologists have techniques for embolization, sometimes radiofrequency ablation, and occasionally there is a role for radiation therapy as well. So working with a multidisciplinary team that is thinking about all of these modalities with you is helpful to make sure that we’re giving the best to our patients.
Certainly, when a patient presents and we’re thinking about what the best therapy is, typically when a patient has metastatic disease we will start with systemic therapy and then do surgery. There are certainly times when surgery needs to be the first thing we do, including if a patient is presenting with obstruction. This is not terribly common with GIST, but there are patients who may present with perforation. Certainly, a perforated tumor can be a medical emergency and should be treated as such, even in the setting of metastatic disease.
Transcript edited for clarity.
Case: A 68-Year-Old Man With Gastrointestinal Stromal Tumor