Metastatic Liver Disease Associated with Gastrointestinal Stromal Tumors: Controversies in Diagnostic and Therapeutic Approach

Aikaterini Mastoraki, Eleftheria Toliaki, Eleni Chrisovergi, Sotiria Mastoraki, Ioannis S Papanikolaou, Nikolaos Danias, Vasilios Smyrniotis, Nikolaos Arkadopoulos

Gastrointestinal stromal tumors (GISTs) are the most frequent mesenchymal lesions of the GI tract. They are considered to originate from neoplastic transformation of either the intestinal pacemaker cells of Cajal or the precursor pluripotential stem cells. The genetic basis of GIST growth is an activating mutation of two receptor tyrosine kinases. Recent epidemiologic studies demonstrate that the GIST prevalence is approximately 20/1000000/year. Although GISTs develop in every part of the GI tract, stomach remains the most common localization. About 80 % of the patients experience tumor recurrence or hepatic metastasis after radical resection. GIST liver metastases are usually multiple, large in diameter, and localized in both lobes. In addition, GISTs are usually completely asymptomatic, discovered incidentally. Symptoms are not typical and depend on the location, size, and aggressiveness of the tumor. Diagnostic evaluation is based on imaging techniques, such as computed tomography, magnetic resonance imaging, positron emission tomography, and endoscopic ultrasound. Despite recent research on the therapeutic strategies against GISTs, surgical resection appears the only potentially curative approach. For the advanced metastatic disease, imatinib, a tyrosine kinase inhibitor, has been proposed neoadjuvantly with the surgery performed after the adequate reduction of tumor burden. The aim of this review was to evaluate the results of surgical treatment for metastatic GIST with special reference to the extent of its histological spread and to present the recent literature in order to provide an update on the current concepts of advanced surgical management of this entity.