Recurrent Gastrointestinal Stromal Tumor With Limited Disease Spread: Role of Surgical Resection

Abstract

Gastrointestinal stromal tumor (GIST) occurs mostly in the stomach and presents usually with gastrointestinal bleeding, abdominal pain, and rarely with perforation. It remains asymptomatic, if advanced far enough, liver metastasis is the frequent site of malignancy. A 61 years old male with a history of a large GIST tumor status post en bloc resection together with partial gastrectomy, distal pancreatectomy and splenectomy with the diaphragmatic implant presented for routine follow up after six months. Post-operatively, he was non-compliant to his adjuvant imatinib therapy due to financial restraints. CT scan and MRI at this follow up visit revealed a 2 cm lesion in the liver concerning for metastatic disease. The patient was taken for elective surgery for laparoscopic lysis of adhesions, exploratory laparotomy, and metastasectomy in segment 2/3 of liver for the metastatic liver lesion. Surveillance CT chest showed no metastasis to the lung. Final pathology from metastectomy showed 2.2 cm High-grade GIST tumor with negative margins. Patient has remained asymptomatic pre- and post-op and had only a surgical scar on abdominal examination. GIST is considered the most common gastrointestinal mesenchymal tumor; the age-adjusted incidence in the United States is 6.8 per million in the Surveillance Epidemiology and End Result (SEER) registry data collected from 1992-2000. Very characteristic of GIST is KIT (CD117) positivity, and in 80% of non-KIT positive GISTs, there is a platelet-derived growth factor receptor alpha (PDGFRa) mutation. There was a 61% decrease in relative risk in progression-free survival in the high dose group on imatinib with the KIT/PDGFRa mutation. Surgical resection, on the other hand, remains the mainstay of therapy especially in cases where the lesion is >2 cm or for non-metastatic localized tumors. Complete resection can be achieved only in few of these patients. Our case was unique in which a metastatic lesion was successfully resected using a limited surgical approach. More than half of GIST cases can experience recurrence even after complete resection of primary tumor, however, in our case the patient lost follow ups and it was difficult to determine the long-term success of metastatic GIST resection.2658_A Figure 1. CT scan abdomen showing 2 cm cystic lesion (arrow).2658_B Figure 2. Histology showing spindle cell lesion in the hepatic parenchyma2658_C Figure 3. Immunofluorescent stain positive for CD117.