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February 16, 2009

Open or Laparoscopic Resection of a Large Gastric Gastrointestinal Stromal Tumor

Arch Surg. 2009;144(2):193-197. doi:10.1001/archsurg.2008.538

I read with interest the article by Huguet and colleagues1 on sophisticated laparoscopic operations for gastric gastrointestinal stromal tumors (GISTs) and their outcomes. The authors report their excellent outcomes of attempted laparoscopic surgery for gastric GIST, including a low rate of conversion to open laparotomy (6%), a minimum morbidity rate (9%), no perioperative mortality, a short median hospital stay (3 days), and no evidence for tumor recurrence during a mean follow-up of 13 months in 33 patients. Based on these findings, the authors concluded that almost all gastric GISTs are amenable to laparoscopic resection without compromising oncologic principles. The authors classified 26 small (<5 cm) GISTs as having low malignant potential, 5 GISTs (5-10 cm or having 5-10 mitoses per high power field) as being intermediate-malignant, and 2 GISTs (measuring >10 cm or having >10 mitoses per high power field) as having high malignant potential (as shown in Table 2). This suggests that at least 26 tumors were smaller than 5 cm, whereas Table 1 indicates that 25 tumors were smaller than 5 cm, yielding a confusion. As tumor size is an established independent prognostic factor and correlates with mitotic index, which is also an independent determinant for recurrence, I would like to know the correct distribution of tumor size and ask the authors how long the patients who had gastric GISTs larger than 5 cm were followed up. Approximately half of the patients with primary GISTs who undergo gross complete resection will experience tumor recurrence, and the reported median time to recurrence after radical surgery ranges from 18 to 24 months.2 Gastric GISTs, accounting for 50% to 60% of all GISTs, have a more favorable clinical course than small intestinal GISTs after resection. In a large retrospective study that included 74 gastric GISTs, 35 small intestinal GISTs, 14 colorectal GISTs, and 4 other GISTs, patients with small intestinal GISTs did worse than those with gastric GISTs (hazard ratio, 3.3) on multivariate analysis after adjustment for tumor size and mitotic activity.3 In that study, the authors reported recurrence-free survivals of approximately 90% at 1 year and 80% at 2 years after radical open surgery. Small gastric GISTs with low mitotic activity rarely recur, while up to 86% of gastric GISTs larger than 10 cm with high mitotic activity recur during a long-term follow-up.4 In the current study, I think that a mean follow-up of 13 months is too short to correctly evaluate the oncologic outcomes of laparoscopic surgery, especially in patients with large gastric GISTs.

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