Lesson of the Month Downstaging of a gastric GIST by neoadjuvant imatinib and endoscopic assisted laparoscopic resection D. Cavaliere a, * , A. Vagliasindi a , G. Mura a , M. Framarini a , G. Giorgetti a , G. Solfrini a , F. Tauceri a , F. Padovani b , C. Milandri c , A. Dubini b , L. Ridolfi c , E. Ricci d , G.M. Verdecchia a a Department of Surgery, Chirurgia e Terapie Oncologiche Avanzate, Ospedale ‘‘Morgagni-Pierantoni’’ di Forlı `, Italy b Department of Pathology, Ospedale ‘‘Morgagni-Pierantoni’’ di Forlı `, Italy c Department of Medical Oncology, Ospedale ‘‘Morgagni-Pierantoni’’ di Forlı `, Italy d Gastroenterology and Digestive Endoscopy, Ospedale ‘‘Morgagni-Pierantoni’’ di Forlı `, Italy Accepted 12 March 2007 Available online 30 April 2007 Keywords: Gastrointestinal stromal tumours (GISTs); Gastric neoplasm; Imatinib; Laparoscopic resection Background Gastrointestinal stromal tumours (GISTs) are rare malig- nancies characterized by a specific histological and im- munohistochemical pattern. 1 The management of these tumours has been recently revised by the introduction of im- atinib (Glivec Ò , formerly STI-571; Novartis Pharma AG, Basel, Switzerland), an orally administered tyrosine kinase inhibitor blocking most activated KIT proteins. Up to 85% of the patients respond to the treatment (controlled tumour growth) with a 50% or greater reduction of the tumour mass in 35e53%. 2,3 A planned interim analysis of a random- ized phase III trial comparing two doses of imatinib in patients with advanced GISTs, showed complete tumour responses in 2% and 3% according to the dosage, after a me- dian follow-up of 8.4 months. 4 Promising results of surgery to remove residual GIST masses in patients who had an ob- jective response to initial therapy with imatinib have already been reported 5 and have led to clinical trials of imatinib as an adjuvant or neoadjuvant therapy with surgery. 6 We report a case of a marginally resectable primitive gastric GIST treated with imatinib with a neoadjuvant intent, and late endoscopic assisted laparoscopic radical resection. Case presentation A 64-year-old man presented with a 15  10 cm solid perigastric mass with blurred margins. Gastric endoscopy reported an ab-extrinsic subcardial lesion. Biopsy con- firmed the diagnosis of GIST. The patient was referred for imatinib therapy (400 mg/ day) on a neoadjuvant basis, before subsequent surgical resection. An important morphologic and clinical response was rapidly obtained. The pharmacologic debulking was monitored by means of echography, positron emission to- mography with [18F] fluorodeoxyglucose (FDG-PET) and CT. Restaging was performed after 6 months and revealed a reduction in tumour diameter of approximately 50% with complete metabolic response. The lesion presented central aerial cavitations as with necrotic tissue. The search for hepatic or peritoneal metastatic lesions by means of radio- logical imaging was negative. He continued the treatment with imatimib for 12 months. A surgical operation was per- formed on the residual disease. A laparoscopic approach was attempted. The lesion was located at the gastric fundus, in tight proximity of the cardia; an intra-operative endos- copy was performed and, under laparoscopic and endo- scopic combined control, the linear stapler was placed. * Corresponding author. U.O. Chirurgia e Terapie Oncologiche Avanzate, Dipartimento di Chirurgia, Ospedale ‘‘GB Morgagni-L Pierantoni’’, Via C. Forlanini 34, 47100 Forlı `, Italia. Tel.: þ39 0543 735502; fax: þ39 0543 735760. E-mail address: davidecavaliere@libero.it (D. Cavaliere). 0748-7983/$ - see front matter Ó 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2007.03.011 EJSO 33 (2007) 1044e1046 www.ejso.com