Marginally Resectable Disease

A subgroup of patients with GIST, present with disease best characterized as "marginally resectable." Complete gross resection of these tumors typically requires either radically extensive surgery or highly morbid procedures that severely compromise organ function or quality of life. Common locations for these tumors may be the gastroesophageal junction, first and second portions of the duodenum, or the low rectum (4). Recently, imatinib has been advocated in the neoadjuvant setting with the goals of either allowing function-sparing resections in marginally resectable patients, or converting unresectable tumors. The feasibility of major surgical resection after imatinib was reported in a series of 17 patients. Ninety-four percent underwent complete gross tumor resection after a median of 10 months of imatinib therapy (58). Anecdotally, 12 weeks of preoperative imatinib allowed for a more limited resection in a patient with a previously locally advanced pelvic GIST. After seven months of follow-up, the patient remained free of disease (59). Lastly, neoadjuvant drug therapy is being tested in a phase II trial for patients with potentially resectable primary or recurrent GISTs sponsored by the Radiation

Primary GIST > 3 cm

Complete Gross Resection

Tumor Kit +

Tumor Kit +

Placebo x 1 yr

Imatinib x 1 yr



FIGURE 1 The Intergroup ACOSOG Z 9001 trial: A phase III randomized double-blinded study of adjuvant imatinib mesylate versus placebo in patients following the resection of primary GIST. Patients who develop tumor recurrence on the placebo arm may cross over to imatinib therapy. Abbreviations: ASOCOG, American College of Surgeons Oncology Group; GIST, gastrointestinal stromal tumor.

Therapy Oncology Group (RTOG S0132). Surgical resection is undertaken after 8 weeks of ima-tinib with the goal of improving progression free survival (60). Currently, using imatinib in the neoadjuvant setting for patients with marginally resectable or unresectable disease remains investigational and should be performed in the setting of a clinical trial whenever possible (3).

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