eMedicine Specialties > Gastroenterology > Stomach

Gastrointestinal Stromal Tumors: Follow-up

Author: Sandeep Mukherjee, MB, BCh, MPH, FRCPC, Associate Professor, Department of Internal Medicine, Section of Gastroenterology and Hepatology, University of Nebraska Medical Center; Consulting Staff, Section of Gastroenterology and Hepatology, Veteran Affairs Medical Center
Coauthor(s): Michael AJ Sawyer, MD, Director, Videoendoscopic Surgical Institute of Oklahoma, Consulting Staff, Department of Surgery, Comanche County Memorial Hospital; Consulting Staff, Great Plains Surgical Clinic, Lawton, Oklahoma; Robert A Decker, MD, Clinical Assistant Professor, Department of Medicine, University of Hawaii at Manoa: Chief, Gastroenterology Service, Kaiser Permanente Medical Center of Honolulu
Contributor Information and Disclosures

Updated: Mar 4, 2008

Follow-up

Further Inpatient Care

  • Preoperative care focuses on managing the acute complications of GISTs (ie, hemorrhage, bowel obstruction, perforation) or on preparing the patient for surgery. Proper postoperative care helps ensure complete and uneventful patient recovery. Features of preoperative and postoperative care in patients with GISTs include the following:
    • Fluid resuscitation and transfusion
      • Patients with GIST-related hemorrhage require intravenous fluid resuscitation. Those with massive hemorrhage may require transfusion of blood products.
      • Postoperatively, resuscitative and maintenance intravenous fluids are provided. Most commonly, a balanced salt solution such as lactated Ringer is used.
    • Correction of electrolyte abnormalities: Specific electrolyte abnormalities can be directly measured and replaced as appropriate.
    • Activity: Early postoperative activity is encouraged.
    • Diet and nutrition
      • Patients receive nothing by mouth for varying durations, depending on the preference of the operating surgeon.
      • Following nasogastric tube removal, patients can be started on a liquid diet and advanced to a full diet as tolerated. Postgastrectomy diet counseling by a registered dietitian is helpful in patients undergoing subtotal or total gastrectomies.
      • Depending on the patient's preoperative nutritional status, a period of specialized nutritional support might be indicated. This can range from enteral tube feedings to peripheral hyperalimentation to total parenteral nutrition. Multivitamin and iron supplementation may be indicated.
    • Drains
      • Depending on the type of resection, a nasogastric tube is left in place postoperatively. Ensuring that the tube is continuously functional and remains unclogged is crucial. Criteria for removal of a nasogastric tube vary by clinician.
      • A urinary Foley catheter remains in place in the early postoperative period or during the preoperative resuscitative period in patients who have sustained major hemorrhage or other complications. The catheter aids monitoring of hydration status and serves as a guide for fluid resuscitation. Once the patient is stabilized and no additional major fluid shifts are anticipated, the catheter can be removed.
    • Pulmonary toilet
      • Instruct patients to cough and to take frequent deep breaths. The incentive spirometer is an important adjunct for this and should be used by the patient every 1-2 hours while awake.
      • Early mobilization of the patient assists with maintaining good pulmonary toilet.
    • Monitoring
      • Vital signs are monitored per protocol. Intake and output records are kept.
      • Pulse oximetry is used when appropriate to measure oxygen saturation.
    • Antibiotics
      • Unless bowel perforation or other septic complications have occurred, a single dose of intravenous antibiotic prophylaxis against wound infection is usually sufficient.
      • Patients with abdominal catastrophes such as bowel perforation or infarction require a full therapeutic course of intravenous antibiotics that cover the spectrum of gut flora.
    • Pain control, deep venous thrombosis prophylaxis, and aspiration precautions
      • An epidural catheter can be placed by anesthesia personnel for postoperative pain control. Alternately, a patient-controlled anesthesia schedule can be ordered.
      • Prophylaxis against deep venous thrombosis is crucial because it and pulmonary embolism are significant sources of postoperative morbidity and mortality. Available modalities include subcutaneous heparin, subcutaneous fractionated heparin preparations, and sequential compression stockings.
      • The head of the bed can be kept elevated 30-45°, or sometimes higher for elderly patients or during sleep, to help prevent aspiration.

Further Outpatient Care

  • Comprehensive follow-up is extremely important in all but the smallest and lowest-grade tumors. A follow-up plan should include these measures:
    • Periodic office visits and physical examinations are crucial in the follow-up of patients with GISTs.
    • Periodic CT scanning can be ordered to aid in the detection of locally recurrent disease or distant metastasis. The optimal frequency for CT scan follow-up is not known. This is left to the discretion of the attending physician.
    • Positron emission tomography scanning may be indicated in the follow-up of patients with GISTs, especially those receiving imatinib mesylate for incompletely resected, recurrent, or metastatic disease.

Complications

  • Complications can be divided into preoperative and postoperative categories. Preoperative tumor-related complications usually occur with tumors larger than 4 cm.
    • Major preoperative complications include the following:
      • Hemorrhage
      • Bowel obstruction
      • Volvulus
      • Intussusception
      • Bowel perforation with peritonitis
    • The range of postoperative complications is that typical for major abdominal and GI surgery. The following is a representative but not exhaustive list:
      • Wound infection
      • Wound dehiscence with or without evisceration
      • Urinary tract infection
      • Atelectasis
      • Pneumonia
      • Anastomotic disruption
      • Anastomotic stricture
      • Marginal ulceration
      • Intra-abdominal abscess formation
      • Cholangitis
      • Delayed gastric emptying or gastroparesis
      • Internal or enterocutaneous fistula
      • Small bowel obstruction
      • Dumping syndrome
      • Alkaline reflux gastritis
      • Cardiac arrhythmias
      • Myocardial infarction
      • Deep venous thrombosis
      • Pulmonary embolism

Prognosis

  • The predominant prognostic factors in patients with GISTs include the size of the tumor and the mitotic rate. To these may be added the ability or inability to achieve completely negative resection margins.
    • Reported 5-year disease-specific survival rates are 30-60% according to results reported by many studies (eg, DeMatteo et al, 2000 and 2002; Crosby et al 2001; Carney, 1999; Conlon et al 1995).24,21,25,26 The disparity between patients presenting with localized primary disease (median survival of 5 y) and those presenting with metastasis or recurrent disease (median survival of 10-20 mo) is large.
    • Location is also significant. Patients with gastric GISTs tend to fare better than those with extragastric GISTs.
    • The importance of the mitotic count as a prognostic factor and predictor of malignant behavior was illustrated by Dougherty et al in 1991.27 Even after curative resections, patients with a mitotic rate of 10 or greater per 50 high-power fields (HPFs) had a median survival rate of 18 months, compared with an 80%, 8-year disease-free survival rate in patients who had curative resections and tumors with a mitotic rate less than 10/50 HPFs.
    • The 2002 Fletcher et al stratification of the risk of aggressive or malignant behavior in GISTs, based on size and mitotic rate, is as follows:16
      • Very low risk - Smaller than 2 cm and less than 5/50 HPFs
      • Low risk - From 2-5 cm and less than 5/50 HPFs
      • Intermediate risk - Either (1) smaller than 5 cm and 6-10/50 HPFs or (2) 5-10 cm and less than 5/50 HPFs
      • High risk - Includes (1) larger than 5 cm and more than 5/50 HPFs, (2) larger than 10 cm and any mitotic rate, or (3) any size and more than 10/50 HPFs

Patient Education

  • Patients should be educated about as many aspects of the disease as possible, including diagnostic and therapeutic measures and options. Most importantly, they should be apprised of the need for lifelong close clinical follow-up, even after complete resection of disease. Emphasize that GISTs have a propensity to recur.
  • For excellent patient education resources, visit eMedicine's Cancer and Tumors Center. Also, see eMedicine's patient education articles Stomach Cancer and Cancer of the Small Intestine.

Miscellaneous

Medicolegal Pitfalls

  • The standard of care includes resection of the tumor to negative margins whenever possible. Therapy with imatinib mesylate is indicated in many patients, including those with metastatic disease and incomplete resections. Nearly all patients with GISTs, with the potential exception of those with very small low-risk tumors, deserve careful lifelong follow-up with updated histories, physical examinations, and imaging studies. Delayed diagnosis, failure to treat with appropriate adjuvant therapy, and inadequate follow-up are all areas for potential medicolegal pitfalls.
 


More on Gastrointestinal Stromal Tumors

Overview: Gastrointestinal Stromal Tumors
Differential Diagnoses & Workup: Gastrointestinal Stromal Tumors
Treatment & Medication: Gastrointestinal Stromal Tumors
Follow-up: Gastrointestinal Stromal Tumors
References
[ CLOSE WINDOW ]

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Further Reading

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Keywords

GI stromal tumor, GIST, GISTs, gastrointestinal mesenchymal neoplasm, GI mesenchymal neoplasm, leiomyoma, leiomyosarcoma, pacemaker cell tumor, GI pacemaker cell tumor, gastrointestinal pacemaker cell tumor, GI tumor, gut tumor, gastrointestinal neoplasm, GI neoplasm

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Contributor Information and Disclosures

Author

Sandeep Mukherjee, MB, BCh, MPH, FRCPC, Associate Professor, Department of Internal Medicine, Section of Gastroenterology and Hepatology, University of Nebraska Medical Center; Consulting Staff, Section of Gastroenterology and Hepatology, Veteran Affairs Medical Center
Sandeep Mukherjee, MB, BCh, MPH, FRCPC is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Coauthor(s)

Michael AJ Sawyer, MD, Director, Videoendoscopic Surgical Institute of Oklahoma, Consulting Staff, Department of Surgery, Comanche County Memorial Hospital; Consulting Staff, Great Plains Surgical Clinic, Lawton, Oklahoma
Michael AJ Sawyer, MD is a member of the following medical societies: American College of Surgeons, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, and Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.

Robert A Decker, MD, Clinical Assistant Professor, Department of Medicine, University of Hawaii at Manoa: Chief, Gastroenterology Service, Kaiser Permanente Medical Center of Honolulu
Disclosure: Nothing to disclose.

Medical Editor

Sandeep Mukherjee, MB, BCh, MPH, FRCPC, Associate Professor, Department of Internal Medicine, Section of Gastroenterology and Hepatology, University of Nebraska Medical Center; Consulting Staff, Section of Gastroenterology and Hepatology, Veteran Affairs Medical Center
Sandeep Mukherjee, MB, BCh, MPH, FRCPC is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Noel Williams, MD, Professor Emeritus, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Professor, Department of Internal Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
Noel Williams, MD is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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