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The Connective Tissue Oncology Society. Surgical Treatment of GIST post Imatinib. Barry W. Feig, M.D. Robert S. Benjamin, M.D. The SARCOMA Center. Chemotherapy + Surgery CR Chemotherapy CR Partial Response Stable Disease. SOFT TISSUE SARCOMAS 1971-1977

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Barry W. Feig, M.D. Robert S. Benjamin, M.D. The SARCOMA Center

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The Connective Tissue Oncology Society

Surgical Treatment of GIST post Imatinib

Barry W. Feig, M.D.

Robert S. Benjamin, M.D.

The SARCOMA Center


Chemotherapy + Surgery CR

Chemotherapy CR

Partial Response

Stable Disease

SOFT TISSUE SARCOMAS 1971-1977

Time to Progression - Distant Metastases

1.00

TOTAL

FAIL

12

37

66

97

9

32

63

96

0.80

0.60

PROPORTION

p = 0.64

p = 0.002

p = 0.002

vs

vs

0.40

vs

0.20

0.00

0

1

2

3

4

5

6

7

8

9

10

YEARS


GIST: Management of Resistance

  • If the majority of tumor is controlled by imatinib mesylate, then continue therapy

  • Dose escalation up to 800-1000 mg/d as tolerated

  • Surgical resection of progressing sites if possible

  • Other trials

Demetri et al. JNCCN. 2004;21(suppl 1):S1.


RADIOGRAPHIC RESPONSE TO IMATINIB IN RECURRENT / METASTATIC GIST (N=35)


TIME OF SURGERY IN IMATINIB RESPONSIVE RECURRENT / METASTATIC GIST

COMPLETE RESECTION

(N=11)

INCOMPLETE RESECTION

(N=18)

SURGERY

SURGERY

PROGRESSION

Median (months) 10.0 18.0 23.7

P=0.04


FOLLOW-UP RECURRENT / METASTATIC GIST (N=35)


GIST Surgery: Randomized Study

  • Surgery vs No Surgery

  • Surgery at maximum response vs Surgery at first evidence of relapse.


TIME OF SURGERY IN IMATINIB RESPONSIVE RECURRENT / METASTATIC GIST

COMPLETE RESECTION

(N=11)

INCOMPLETE RESECTION

(N=18)

SURGERY

SURGERY

PROGRESSION

Median (months) 10.0 18.0 23.7

P=0.04


TIME OF SURGERY IN IMATINIB RESPONSIVE RECURRENT / METASTATIC GIST

R

A

N

D

O

M

I

Z

E

EARLY SURGERY

PROGRESSION

DELAYEDSURGERY

Months (estimate) 10 18 20


GIST Surgery: Endpoints

  • Time to Progression from start of imatinib

    • If no difference, then surgery does not have a role

    • If TTP longer with early surgery, then surgery is adding

  • Survival

    • If no difference, delayed surgery is preferable (not all will need it).

    • If survival better with early surgery, it is better to do at that time.


The Connective Tissue Oncology Society

Surgical Treatment of GIST post Imatinib

Barry W. Feig, M.D.

Robert S. Benjamin, M.D.

The SARCOMA Center


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