The primary treatment of patients with metastatic or recurrent gastrointestinal stromal tumors (GIST) involves medical therapy with a tyrosine kinase inhibitor (TKI); in select cases, surgical therapy may be added. Patients with metastatic or recurrent tumors that do not respond to these measures may be candidates for clinical trials.
Therapy with imatinib is standard for patients with metastatic or recurrent disease. The initial dose may range from 400 mg to 600 mg daily, except for patients...
A combination of surgery with postoperative radiation therapy or postoperative chemoradiation for selected high-risk patients.
Radiation therapy for patients with cancer of the tonsil. Hyperfractionated radiation therapy yields a higher control rate than standard fractionated radiation therapy for patients with stage III cancer of the oropharynx, but this has not resulted in an increase in overall survival.[Level of evidence: 1iiA]
New surgical techniques for resection and reconstruction developed in the last 7 to 10 years that provide access and at least partial function restoration have extended the surgical options. External-beam radiation therapy augmented with interstitial implantation and multiple daily treatment schemes have given new insights into the use of radiation for this group of tumors. All of these patients may be considered for entry into neoadjuvant chemotherapy trials.
In general, the preferred treatment has been to combine surgery with postoperative radiation therapy when possible, as shown in the RTOG-7303 trial, for example. This approach has become the standard in this specific grouping whenever it can be applied. Aggressive radiation therapy alone will give equivalent control rates to surgery for cancers originating in the tonsil or on the base of the tongue.[2,10]
Specific surgical procedures and their modifications are not designated here because of the wide variety of surgical approaches to the area, the variety of opinions about the role of modified neck dissections, and the multiple reconstructive techniques that may give the same results. This group of patients should be managed by surgeons who are skilled in the multiple procedures available and actively and frequently involved in the care of these patients.
Treatment options under clinical evaluation:
Neoadjuvant chemotherapy as given in clinical trials has been used to shrink tumors and thereby render them more definitively treatable with either surgery or radiation. Chemotherapy is given prior to the other modalities, hence the designation neoadjuvant to distinguish it from standard adjuvant therapy, which is given after or during definitive therapy with radiation or after surgery. Many drug combinations have been used in neoadjuvant chemotherapy.[11,12,13,14,15]
Chemotherapy has been combined with radiation therapy in patients who have locally advanced disease that is surgically unresectable, as shown in several trials, including RTOG-9911, EORTC-24971, and NCT00273546.[16,17,18,19,20,21,22,23,24,25] The best chemotherapy to use and the appropriate way to integrate the two modalities is still unresolved.
Radiation clinical trials, such as RTOG-8313, for example, have evaluated hyperfractionation schedules and/or brachytherapy and should be considered.