Surgery

Surgical resection is the primary treatment modality for the following types of patients:[2][Level of evidence C2]

Endoscopic surveillance is an option for patients with tumors measuring 2 cm or smaller with a mitotic index of 5 or less per 50 high-power fields. The low rates of progression and metastasis in these tumors make endoscopic surveillance viable in place of surgical resection.[3]

The goal of surgery is complete gross resection with an intact pseudocapsule and negative microscopic margins.[4] Because GISTs are generally encapsulated and relatively less infiltrative than other malignancies, wide excision is not necessary. Lymphadenectomy is typically unnecessary, given that lymph node metastasis is rare with GISTs. However, lymphadenectomy should be considered in patients with SDH-deficient GISTs and pathologically enlarged lymph nodes.

If anatomically feasible, laparoscopic surgery is increasingly performed instead of laparotomy. Reports demonstrate lower rates of recurrence, shorter hospital stays, and lower morbidity.[5-8]

Neoadjuvant imatinib therapy can be given to patients with large tumors or difficult-to-access GISTs that are considered marginally resectable. Significant tumor shrinkage is often seen with targeted therapy, so this approach can potentially avoid major organ resection, or enable organ-sparing surgery. Genetic sequencing may be considered to identify sensitive or resistant variants prior to neoadjuvant imatinib therapy.

For patients with oligometastatic recurrences (e.g., isolated intra-abdominal implants or solitary liver lesions), surgical resection may be used in conjunction with tyrosine kinase inhibitors (TKIs).[9,10][Level of evidence C1] This should only be considered after multidisciplinary consultation.