Front. Med. 2015, 9(1): 108–111 DOI 10.1007/s11684-014-0344-0
CASE REPORT
A ruptured recurrent small bowel gastrointestinal stromal tumour causing hemoperitoneum ✉)1
Eric C.H. Lai1,3, Kam Man Chung2, Stephanie H.Y. Lau4, Wan Yee Lau (
1 Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China; 2Dr. K.M. Chung’s Clinic, Rm 807, Hang Seng Tsimshatsui Building, 18 Carnarvon Road, Tsimshatsui, Hong Kong SAR, China; 3Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China; 4Department of Surgery, Queen Elizabeth Hospital, Hong Kong SAR, China
© Higher Education Press and Springer-Verlag Berlin Heidelberg 2014
Abstract Hemoperitoneum is a rare and potentially life-threatening complication of GIST. We reported a 54year-old man who developed disseminated intra-abdominal recurrence from a previously resected gastrointestinal stromal tumour (GIST) of the small bowel, and the patient presented with hemoperitoneum. Emergent debulking surgery was performed. A high dose imatinib was prescribed. Despite the presence of residual disease, the patient was well clinically 8 months after the operation. Even though, there is no evidence to support the routine use of debulking surgery in the management of GIST. In our patient, disease progression after second line targeted therapy and the absence of alternative treatment options for spontaneous rupture and hemoperitoneum prompted us to treat the patient aggressively. Resection of the ruptured GIST was carried out for control of bleeding and to prevent recurrent bleeding in this patient with good surgical risks. During the treatment decision-making, the patient’s general condition, the risk of surgery and the extent of dissemination were taken into consideration. In this patient who presented with spontaneous rupture of a small intestinal GIST, the novel use of targeted therapy and aggressive surgical treatment produced reasonably good survival outcome. Keywords
gastrointestinal stromal tumour; hemoperitoneum; small bowel GIST; small bowel neoplasm; imatinib
Introduction Gastrointestinal stromal tumor (GIST) comprises of < 1% of all gastrointestinal (GI) tumors. However, it is the most common mesenchymal tumor of the GI tract. Primary GIST may manifest anywhere along the GI tract [1], but it occurs most commonly in the stomach (50%–60%), followed by the small intestine (20%–30%), the large intestine and the esophagus ( < 10%). The treatment for localized GIST is surgical resection. GIST has received considerable attention recently because it serves as a model for molecular therapy to treat cancer. GIST is a vascular tumor that primarily presents with GI bleeding (50%), a palpable mass (35%, sometimes with features of intestinal obstruction), pain (20%), and, rarely, as an incidental finding [1]. Hemoperitoneum as a presentation due to GIST rupture is very rare. This is a case report on a patient who developed non-traumatic
Received April 1, 2014; accepted June 6, 2014 Correspondence: [email protected]
hemoperitoneum due to rupture of recurrent small bowel GIST, and the patient required urgent surgical treatment.
Presentation of case A 54-year-old gentleman with a history of small intestinal GIST first presented with acute abdomen in November 2001. He was diagnosed to have acute appendicitis. Laparoscopy revealed hemoperitoneum and subsequent conversion to open surgery showed a 15 cm 20 cm small bowel tumor with bleeding and dense adhesions to the pelvis. Small bowel resection was carried out and the main tumor was removed but residual disease was left in the pelvis. Histopathologic examination confirmed the diagnosis of malignant GIST and the tumor cells showed membrane positivity for CD117 (c-kit). The residual tumor gradually grew in size and the first debulking operation was performed in October 2003. Imatinib mesylate (Gleevec; Novartis Pharmaceuticals, Basel, Switzerland) was started post-operatively and the treatment was continued until June 2010 and was switched to nilotinib
Eric C.H. Lai et al.
(Novartis Pharmaceutical, Switzerland) because of disease progression. Soon after the patient was put on nilotinib, he developed small bowel perforation and a loop ileostomy was carried out. In January 2011, he was switched from nilotinib to sunitinib malate (Pfizer, New York, USA) because of disease progression but the tumor response was minimal. A second debulking operation with closure of the ileostomy was carried out in May 2011 and the patient was immediately restarted on sunitinib malate treatment after the operation. In May 2013, 12 years after the first operation, he presented with a 3 cm subcutaneous mass in the midline scar. Fluoro-deoxyglucose-positron emission tomography (18FDG-PET)-computed tomography (CT) scan showed the mass to be compatible with a wound recurrence (Fig. 1). There were also multiple tumor nodules in the pelvis (Fig. 2) and in the right sub-hepatic space (Fig. 3).
Fig. 1 18FDG-PET-computed tomography showed a 3 cm subcutaneous tumor nodule just beneath the umbilicus.
109
Fig. 3 Tumour nodules in the right subhepatic space.
The patient suddenly presented with acute abdominal pain and fever. He had no history of abdominal trauma. Physical examination revealed pallor with a mildly distended abdomen and bluish discoloration of the umbilicus near the midline scar (Fig. 4). The hemoglobin level was 6.9 g/dl. The clinical picture was compatible with a ruptured GIST with hemoperitoneum. Blood transfusion was given and emergent laparotomy was carried out. A ruptured GIST was found in the pelvis (Fig. 5) and there were 2 L of fresh blood in the peritoneal cavity. Tumour nodules were also found in the right subhepatic and left subphrenic spaces. Debulking operation with small bowel resection was carried out. The patient recovered well and was discharged home 10 days after the operation. Histopathologic examination confirmed the diagnosis of recurrent malignant GIST with a mitotic rate of up to 100/50 high power fields. The spindle cells were immuno-reactive to c-kit and negative for CD34. Representative tumor tissue was sent for KIT and PDGFRA mutation analysis. Two missense mutation of KIT gene were detected at exon 11c.1679 t > A/p.Val560Asp (imatinib sensitive mutation) and exon 13 c. 1961 t > C/p.Val654Gly (imatinib resistant mutation). A high dose imatinib (800 mg daily) was prescribed. Despite the presence of residual disease, the patient was well clinically 8 months after the operation.
Discussion
Fig. 2 Tumour nodules in the pelvis.
The clinical presentations of GIST are variable according to their location and size. The most frequent symptoms are anemia, weight loss, abdominal pain, gastrointestinal bleeding, and mass-related symptoms. Patients may also present with acute abdomen, such as obstruction, perforation or rupture and peritonitis. Prompt diagnosis and treatment would save lives of many patients who presented with GIST-related emergencies. Surgery is still the main
110
Fig. 4 Bluish discoloration of the umbilicus near the midline scar.
Fig. 5 A ruptured GIST in the pelvis.
treatment for these complications and cure of disease. The prognosis is related to the condition of patient, the grade/ size of the GISTs and the completeness of surgical resection. Indeed, after adequate treatment, the outcome is good. In a series of patients having GISTs with emergency presentation (n = 92) [2], Sorour et al. reported 3- and 5-year overall survival rates of 92.1% and 81.4%, respectively, and 3- and 5-year disease-free survival rates of 73.2% and 64.5%, respectively. The most frequent presentation was gastrointestinal bleeding (n = 45), followed by intestinal obstruction (n = 26), intraperitoneal bleeding (n = 14), and rupture and peritonitis (n = 7). Ninety patients received operation. Two patients presented with advanced GIST, and they were not candidates for surgery. Complete macroscopic resection was achieved in 86 patients (95.6%), while 4 patients (4.4%) had incomplete resection. Morano et al. reported 12 patients, with a mean age of 70 years, who presented with proximal
Ruptured recurrent GIST
gastrointestinal obstruction (41.7% of all gastric GIST cases), acute gastrointestinal bleeding (41.7%) and perforation (16.6%) [3]. The mean length of hospital stay was 9.1 days and there were no postoperative complications or mortalities. At a mean follow-up of 21 months, 11 patients (91.6%) were still alive and disease free. Therefore, surgeons should be prepared to treat GISTs with emergency and left-threatening complications. Spontaneous rupture with hemoperitoneum is a very rare clinical presentation of GIST. To the best of our knowledge, only around 30 cases of GIST presenting with hemoperitoneum have been reported in the medical literature [4,5]. The majority of these cases were gastric in origin. The mechanism of non-traumatic hemoperitoneum might be due to bleeding in the tumor leading to hematoma formation followed by frank rupture of the tumor. For spontaneous hemoperitoneum resulting from a ruptured primary GIST, surgical intervention is still the predominant therapeutic method, but the prognosis is poorer than those patients without a rupture. Rupture with hemoperitoneum was considered to have a worse prognosis because of the possibility to produce peritoneal tumor-seeding [1]. However, after a R0 resection, there is still a possible chance of cure. For patients with disseminated disease, the surgical decision is more difficult. Currently, there is no strong evidence to support the use of debulking surgery in the management of GIST. However, debulking surgery may have a role in two situations. In emergency surgery, it has a definite role to play in treating life-threatening tumor-associated bleeding, bowel obstruction, or intestinal perforation for patients with locally advanced GISTs. In elective surgery, based on retrospective studies, surgery may also play a role in the treatment algorithm for metastatic disease in carefully selected patients who have stable disease or limited radiographic progression of disease while they are put on inhibitors of tyrosine kinase receptors [6–8]. In such patients with GISTs having relatively favorable tumor biology, surgery provides the opportunity to remove malignant clones of cells which have become resistant to inhibitors of tyrosine kinase receptors, thus delaying or preventing recurrence. It is reasonable to assume that there is a possible relationship between the volume of tumor and the risk of developing resistance clones to targeted systemic therapy using kinase inhibitors. However, based on the currently available medical evidence, surgery to treat metastatic GIST is still considered as investigational. There have been no medical report which specifically addresses the survival outcome of surgical management with the use of the second-line treatment with sunitinib [9,10]. In our patient, disease progression after sunitinib and the absence of alternative treatment options for spontaneous rupture and hemoperitoneum prompted us to treat the patient aggressively. Resection of the ruptured
Eric C.H. Lai et al.
GIST was carried out for control of bleeding and to prevent recurrent bleeding in this patient with good surgical risks. During the treatment decision-making, the patient’s general condition, the risk of surgery and the extent of dissemination were taken into consideration. This case also supports the role of surgery in patients with multiple, recurrent but limited progression disease. Larger studies are needed to clarify this issue [11].
Conclusions Hemoperitoneum is a rare and potentially life-threatening complication of GIST. In this patient who presented with spontaneous bleeding of a small intestinal GIST, the novel use of targeted therapy and aggressive surgical treatment produced reasonably good survival outcome.
Compliance with ethics guidelines Eric C.H. Lai, Kam Man Chung, Stephanie H.Y. Lau, and Wan Yee Lau declare that they have no conflict of interest. Ethical board approval is not applicable in this case report.
References 1. Lai EC, Lau SH, Lau WY. Current management of gastrointestinal stromal tumors—a comprehensive review. Int J Surg 2012; 10(7): 334–340 2. Sorour MA, Kassem MI, Ghazal AH, El-Riwini MT, Abu Nasr A. Gastrointestinal stromal tumors (GIST) related emergencies. Int J Surg 2014; 12(4): 269–280 3. Marano L, Antonio Arru GM, Piras M, Gemini S. Surgical management of acutely presenting gastrointestinal stromal tumors of the stomach among elderly: Experience of an emergency surgery department. Int J Surg. 2014 May 22. [Epub ahead of print] doi:
111 10.1016/j.ijsu.2014.05.025 4. Hirasaki S, Fujita K, Matsubara M, Kanzaki H, Yamane H, Okuda M, Suzuki S, Shirakawa A, Saeki H. A ruptured large extraluminal ileal gastrointestinal stromal tumor causing hemoperitoneum. World J Gastroenterol 2008; 14(18): 2928–2931 5. Mahmoud A, Fadhel F, Amin M, Wael R, Amin D, Haykel B, Faouzi C, Rachid K, Mohamed J, Montasser K, Zoubeir BS. A ruptured ileal GI stromal tumor causing hemoperitoneum. Gastrointest Endosc 2010; 71(1): 185–186, discussion 186 6. Pantaleo MA, Di Battista M, Catena F, Astorino M, Saponara M, Di Scioscio V, Santini D, Piazzi G, Castellucci P, Brandi G, Biasco G. Surgical debulking of gastrointestinal stromal tumors: is it a reasonable option after second-line treatment with sunitinib? J Cancer Res Clin Oncol 2008; 134(5): 625–630 7. Tielen R, Verhoef C, van Coevorden F, Gelderblom H, Sleijfer S, Hartgrink HH, Bonenkamp JJ, van der Graaf WT, de Wilt JH. Surgical treatment of locally advanced, non-metastatic, gastrointestinal stromal tumours after treatment with imatinib. Eur J Surg Oncol 2013; 39(2): 150–155 8. Bauer S, Rutkowski P, Hohenberger P, Miceli R, Fumagalli E, Siedlecki JA, Nguyen BP, Kerst M, Fiore M, Nyckowski P, Hoiczyk M, Cats A, Casali PG, Treckmann J, van Coevorden F, Gronchi A. Long-term follow-up of patients with GIST undergoing metastasectomy in the era of imatinib — analysis of prognostic factors (EORTC-STBSG collaborative study). Eur J Surg Oncol 2014; 40 (4): 412–419 9. Pantaleo MA, Di Battista M, Catena F, Astorino M, Saponara M, Di Scioscio V, Santini D, Piazzi G, Castellucci P, Brandi G, Biasco G. Surgical debulking of gastrointestinal stromal tumors: is it a reasonable option after second-line treatment with sunitinib? J Cancer Res Clin Oncol 2008; 134(5): 625–630 10. Ruka W, Rutkowski P, Szawłowski A, Nowecki Z, Debiec-Rychter M, Grzesiakowska U, Dziewirski W, Siedlecki JA, Michej W. Surgical resection of residual disease in initially inoperable imatinib-resistant/intolerant gastrointestinal stromal tumor treated with sunitinib. Eur J Surg Oncol 2009; 35(1): 87–91 11. Mullady DK, Tan BR. A multidisciplinary approach to the diagnosis and treatment of gastrointestinal stromal tumor. J Clin Gastroenterol 2013; 47(7): 578–585
CASE REPORT
A ruptured recurrent small bowel gastrointestinal stromal tumour causing hemoperitoneum ✉)1
Eric C.H. Lai1,3, Kam Man Chung2, Stephanie H.Y. Lau4, Wan Yee Lau (
1 Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China; 2Dr. K.M. Chung’s Clinic, Rm 807, Hang Seng Tsimshatsui Building, 18 Carnarvon Road, Tsimshatsui, Hong Kong SAR, China; 3Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China; 4Department of Surgery, Queen Elizabeth Hospital, Hong Kong SAR, China
© Higher Education Press and Springer-Verlag Berlin Heidelberg 2014
Abstract Hemoperitoneum is a rare and potentially life-threatening complication of GIST. We reported a 54year-old man who developed disseminated intra-abdominal recurrence from a previously resected gastrointestinal stromal tumour (GIST) of the small bowel, and the patient presented with hemoperitoneum. Emergent debulking surgery was performed. A high dose imatinib was prescribed. Despite the presence of residual disease, the patient was well clinically 8 months after the operation. Even though, there is no evidence to support the routine use of debulking surgery in the management of GIST. In our patient, disease progression after second line targeted therapy and the absence of alternative treatment options for spontaneous rupture and hemoperitoneum prompted us to treat the patient aggressively. Resection of the ruptured GIST was carried out for control of bleeding and to prevent recurrent bleeding in this patient with good surgical risks. During the treatment decision-making, the patient’s general condition, the risk of surgery and the extent of dissemination were taken into consideration. In this patient who presented with spontaneous rupture of a small intestinal GIST, the novel use of targeted therapy and aggressive surgical treatment produced reasonably good survival outcome. Keywords
gastrointestinal stromal tumour; hemoperitoneum; small bowel GIST; small bowel neoplasm; imatinib
Introduction Gastrointestinal stromal tumor (GIST) comprises of < 1% of all gastrointestinal (GI) tumors. However, it is the most common mesenchymal tumor of the GI tract. Primary GIST may manifest anywhere along the GI tract [1], but it occurs most commonly in the stomach (50%–60%), followed by the small intestine (20%–30%), the large intestine and the esophagus ( < 10%). The treatment for localized GIST is surgical resection. GIST has received considerable attention recently because it serves as a model for molecular therapy to treat cancer. GIST is a vascular tumor that primarily presents with GI bleeding (50%), a palpable mass (35%, sometimes with features of intestinal obstruction), pain (20%), and, rarely, as an incidental finding [1]. Hemoperitoneum as a presentation due to GIST rupture is very rare. This is a case report on a patient who developed non-traumatic
Received April 1, 2014; accepted June 6, 2014 Correspondence: [email protected]
hemoperitoneum due to rupture of recurrent small bowel GIST, and the patient required urgent surgical treatment.
Presentation of case A 54-year-old gentleman with a history of small intestinal GIST first presented with acute abdomen in November 2001. He was diagnosed to have acute appendicitis. Laparoscopy revealed hemoperitoneum and subsequent conversion to open surgery showed a 15 cm 20 cm small bowel tumor with bleeding and dense adhesions to the pelvis. Small bowel resection was carried out and the main tumor was removed but residual disease was left in the pelvis. Histopathologic examination confirmed the diagnosis of malignant GIST and the tumor cells showed membrane positivity for CD117 (c-kit). The residual tumor gradually grew in size and the first debulking operation was performed in October 2003. Imatinib mesylate (Gleevec; Novartis Pharmaceuticals, Basel, Switzerland) was started post-operatively and the treatment was continued until June 2010 and was switched to nilotinib
Eric C.H. Lai et al.
(Novartis Pharmaceutical, Switzerland) because of disease progression. Soon after the patient was put on nilotinib, he developed small bowel perforation and a loop ileostomy was carried out. In January 2011, he was switched from nilotinib to sunitinib malate (Pfizer, New York, USA) because of disease progression but the tumor response was minimal. A second debulking operation with closure of the ileostomy was carried out in May 2011 and the patient was immediately restarted on sunitinib malate treatment after the operation. In May 2013, 12 years after the first operation, he presented with a 3 cm subcutaneous mass in the midline scar. Fluoro-deoxyglucose-positron emission tomography (18FDG-PET)-computed tomography (CT) scan showed the mass to be compatible with a wound recurrence (Fig. 1). There were also multiple tumor nodules in the pelvis (Fig. 2) and in the right sub-hepatic space (Fig. 3).
Fig. 1 18FDG-PET-computed tomography showed a 3 cm subcutaneous tumor nodule just beneath the umbilicus.
109
Fig. 3 Tumour nodules in the right subhepatic space.
The patient suddenly presented with acute abdominal pain and fever. He had no history of abdominal trauma. Physical examination revealed pallor with a mildly distended abdomen and bluish discoloration of the umbilicus near the midline scar (Fig. 4). The hemoglobin level was 6.9 g/dl. The clinical picture was compatible with a ruptured GIST with hemoperitoneum. Blood transfusion was given and emergent laparotomy was carried out. A ruptured GIST was found in the pelvis (Fig. 5) and there were 2 L of fresh blood in the peritoneal cavity. Tumour nodules were also found in the right subhepatic and left subphrenic spaces. Debulking operation with small bowel resection was carried out. The patient recovered well and was discharged home 10 days after the operation. Histopathologic examination confirmed the diagnosis of recurrent malignant GIST with a mitotic rate of up to 100/50 high power fields. The spindle cells were immuno-reactive to c-kit and negative for CD34. Representative tumor tissue was sent for KIT and PDGFRA mutation analysis. Two missense mutation of KIT gene were detected at exon 11c.1679 t > A/p.Val560Asp (imatinib sensitive mutation) and exon 13 c. 1961 t > C/p.Val654Gly (imatinib resistant mutation). A high dose imatinib (800 mg daily) was prescribed. Despite the presence of residual disease, the patient was well clinically 8 months after the operation.
Discussion
Fig. 2 Tumour nodules in the pelvis.
The clinical presentations of GIST are variable according to their location and size. The most frequent symptoms are anemia, weight loss, abdominal pain, gastrointestinal bleeding, and mass-related symptoms. Patients may also present with acute abdomen, such as obstruction, perforation or rupture and peritonitis. Prompt diagnosis and treatment would save lives of many patients who presented with GIST-related emergencies. Surgery is still the main
110
Fig. 4 Bluish discoloration of the umbilicus near the midline scar.
Fig. 5 A ruptured GIST in the pelvis.
treatment for these complications and cure of disease. The prognosis is related to the condition of patient, the grade/ size of the GISTs and the completeness of surgical resection. Indeed, after adequate treatment, the outcome is good. In a series of patients having GISTs with emergency presentation (n = 92) [2], Sorour et al. reported 3- and 5-year overall survival rates of 92.1% and 81.4%, respectively, and 3- and 5-year disease-free survival rates of 73.2% and 64.5%, respectively. The most frequent presentation was gastrointestinal bleeding (n = 45), followed by intestinal obstruction (n = 26), intraperitoneal bleeding (n = 14), and rupture and peritonitis (n = 7). Ninety patients received operation. Two patients presented with advanced GIST, and they were not candidates for surgery. Complete macroscopic resection was achieved in 86 patients (95.6%), while 4 patients (4.4%) had incomplete resection. Morano et al. reported 12 patients, with a mean age of 70 years, who presented with proximal
Ruptured recurrent GIST
gastrointestinal obstruction (41.7% of all gastric GIST cases), acute gastrointestinal bleeding (41.7%) and perforation (16.6%) [3]. The mean length of hospital stay was 9.1 days and there were no postoperative complications or mortalities. At a mean follow-up of 21 months, 11 patients (91.6%) were still alive and disease free. Therefore, surgeons should be prepared to treat GISTs with emergency and left-threatening complications. Spontaneous rupture with hemoperitoneum is a very rare clinical presentation of GIST. To the best of our knowledge, only around 30 cases of GIST presenting with hemoperitoneum have been reported in the medical literature [4,5]. The majority of these cases were gastric in origin. The mechanism of non-traumatic hemoperitoneum might be due to bleeding in the tumor leading to hematoma formation followed by frank rupture of the tumor. For spontaneous hemoperitoneum resulting from a ruptured primary GIST, surgical intervention is still the predominant therapeutic method, but the prognosis is poorer than those patients without a rupture. Rupture with hemoperitoneum was considered to have a worse prognosis because of the possibility to produce peritoneal tumor-seeding [1]. However, after a R0 resection, there is still a possible chance of cure. For patients with disseminated disease, the surgical decision is more difficult. Currently, there is no strong evidence to support the use of debulking surgery in the management of GIST. However, debulking surgery may have a role in two situations. In emergency surgery, it has a definite role to play in treating life-threatening tumor-associated bleeding, bowel obstruction, or intestinal perforation for patients with locally advanced GISTs. In elective surgery, based on retrospective studies, surgery may also play a role in the treatment algorithm for metastatic disease in carefully selected patients who have stable disease or limited radiographic progression of disease while they are put on inhibitors of tyrosine kinase receptors [6–8]. In such patients with GISTs having relatively favorable tumor biology, surgery provides the opportunity to remove malignant clones of cells which have become resistant to inhibitors of tyrosine kinase receptors, thus delaying or preventing recurrence. It is reasonable to assume that there is a possible relationship between the volume of tumor and the risk of developing resistance clones to targeted systemic therapy using kinase inhibitors. However, based on the currently available medical evidence, surgery to treat metastatic GIST is still considered as investigational. There have been no medical report which specifically addresses the survival outcome of surgical management with the use of the second-line treatment with sunitinib [9,10]. In our patient, disease progression after sunitinib and the absence of alternative treatment options for spontaneous rupture and hemoperitoneum prompted us to treat the patient aggressively. Resection of the ruptured
Eric C.H. Lai et al.
GIST was carried out for control of bleeding and to prevent recurrent bleeding in this patient with good surgical risks. During the treatment decision-making, the patient’s general condition, the risk of surgery and the extent of dissemination were taken into consideration. This case also supports the role of surgery in patients with multiple, recurrent but limited progression disease. Larger studies are needed to clarify this issue [11].
Conclusions Hemoperitoneum is a rare and potentially life-threatening complication of GIST. In this patient who presented with spontaneous bleeding of a small intestinal GIST, the novel use of targeted therapy and aggressive surgical treatment produced reasonably good survival outcome.
Compliance with ethics guidelines Eric C.H. Lai, Kam Man Chung, Stephanie H.Y. Lau, and Wan Yee Lau declare that they have no conflict of interest. Ethical board approval is not applicable in this case report.
References 1. Lai EC, Lau SH, Lau WY. Current management of gastrointestinal stromal tumors—a comprehensive review. Int J Surg 2012; 10(7): 334–340 2. Sorour MA, Kassem MI, Ghazal AH, El-Riwini MT, Abu Nasr A. Gastrointestinal stromal tumors (GIST) related emergencies. Int J Surg 2014; 12(4): 269–280 3. Marano L, Antonio Arru GM, Piras M, Gemini S. Surgical management of acutely presenting gastrointestinal stromal tumors of the stomach among elderly: Experience of an emergency surgery department. Int J Surg. 2014 May 22. [Epub ahead of print] doi:
111 10.1016/j.ijsu.2014.05.025 4. Hirasaki S, Fujita K, Matsubara M, Kanzaki H, Yamane H, Okuda M, Suzuki S, Shirakawa A, Saeki H. A ruptured large extraluminal ileal gastrointestinal stromal tumor causing hemoperitoneum. World J Gastroenterol 2008; 14(18): 2928–2931 5. Mahmoud A, Fadhel F, Amin M, Wael R, Amin D, Haykel B, Faouzi C, Rachid K, Mohamed J, Montasser K, Zoubeir BS. A ruptured ileal GI stromal tumor causing hemoperitoneum. Gastrointest Endosc 2010; 71(1): 185–186, discussion 186 6. Pantaleo MA, Di Battista M, Catena F, Astorino M, Saponara M, Di Scioscio V, Santini D, Piazzi G, Castellucci P, Brandi G, Biasco G. Surgical debulking of gastrointestinal stromal tumors: is it a reasonable option after second-line treatment with sunitinib? J Cancer Res Clin Oncol 2008; 134(5): 625–630 7. Tielen R, Verhoef C, van Coevorden F, Gelderblom H, Sleijfer S, Hartgrink HH, Bonenkamp JJ, van der Graaf WT, de Wilt JH. Surgical treatment of locally advanced, non-metastatic, gastrointestinal stromal tumours after treatment with imatinib. Eur J Surg Oncol 2013; 39(2): 150–155 8. Bauer S, Rutkowski P, Hohenberger P, Miceli R, Fumagalli E, Siedlecki JA, Nguyen BP, Kerst M, Fiore M, Nyckowski P, Hoiczyk M, Cats A, Casali PG, Treckmann J, van Coevorden F, Gronchi A. Long-term follow-up of patients with GIST undergoing metastasectomy in the era of imatinib — analysis of prognostic factors (EORTC-STBSG collaborative study). Eur J Surg Oncol 2014; 40 (4): 412–419 9. Pantaleo MA, Di Battista M, Catena F, Astorino M, Saponara M, Di Scioscio V, Santini D, Piazzi G, Castellucci P, Brandi G, Biasco G. Surgical debulking of gastrointestinal stromal tumors: is it a reasonable option after second-line treatment with sunitinib? J Cancer Res Clin Oncol 2008; 134(5): 625–630 10. Ruka W, Rutkowski P, Szawłowski A, Nowecki Z, Debiec-Rychter M, Grzesiakowska U, Dziewirski W, Siedlecki JA, Michej W. Surgical resection of residual disease in initially inoperable imatinib-resistant/intolerant gastrointestinal stromal tumor treated with sunitinib. Eur J Surg Oncol 2009; 35(1): 87–91 11. Mullady DK, Tan BR. A multidisciplinary approach to the diagnosis and treatment of gastrointestinal stromal tumor. J Clin Gastroenterol 2013; 47(7): 578–585
