What is changing in the surgical treatment of gastrointestinal stromal tumors after multidisciplinary approach? A comprehensive literature's review.

INTRODUCTION: Gastrointestinal stromal tumors (GIST) represent the most common mesenchymal neoplasms of the gastrointestinal tract. Surgery is the only curative treatment for GIST. The aim of our review was to highlight the changes in the surgical treatment of GIST after the introduction of TKI therapy in a multimodality management (neo-adiuvant or adiuvant setting).

EVIDENCE ACQUISITION: We carried out a review of the recent literature about surgical treatment of GIST according to its anatomical location and size according to PRISMA STATEMENT to systematic review. We searched the Cochrane Library, MEDLINE, and EMBASE, limited to the final search date [31/12/2015], limited to English language publications. We used the search terms "GIST" in combination with the terms "surgery" or "multidisciplinary approach" or "TKI therapy" or "neo-adiuvant - adiuvant treatment".

EVIDENCE SYNTHESIS: The optimal surgical technique to achieve the best results in terms of Overall Survival, Relapse Free Survival and Disease Free Survival is oncological resection with disease free margins. Proper preoperative staging is essential to decide the surgical approach. Data reported in literature showed that laparoscopic approach to GIST obtains the same oncological results as conventional surgery.

CONCLUSIONS: The medical oncologist, radiologist and surgeon must collaborate to determine the appropriateness of primary surgery, with curative intent, after neoadiuvant therapy or as palliative treatment. Laparoscopy is feasible and safe for small GIST, but there is no international consensus for large GIST yet. The introduction of imatinib as neoadjuvant therapy with the goal of reducing tumor size, minimizes surgical morbidity and, in some cases, makes operable the inoperable cases. In addition, the use of imatinib in the adjuvant setting, to eradicate micrometastases and to prevent recurrence, has shown promising results in reducing relapse rates.