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SMALL-SIZED GASTROINTESTINAL STROMAL TUMORS: SHOULD EXPECTANT MANAGEMENT BE THE PREFERRED APPROACH TO CARE?
DJ Patel, S. Kulshrestha, C Bunn, C Tonelli, M Littau, P Kim, F Luchette, Z Abdelsattar, MS Baker
Loyola University Medical Center

Background
Small-sized Gastrointestinal Stromal Tumors (GISTs) are often discovered incidentally on endoscopy/imaging done to evaluate unrelated abdominal symptoms. Most of these are low grade tumors with limited potential for aggressive behavior. We evaluate the safety of an expectant approach to management (EM) of these tumors.

Methods
The National Cancer Database was queried to identify patients ?65 years of age presenting with GISTs ?3CM in size between 2004 and 2015. Patients with second primary malignancies and those receiving systemic therapy were excluded. Multivariable logistic regression (MVR) and Cox proportional hazard modeling were used to identify factors associated with EM and overall survival (OS). Patients undergoing EM were then 1:3 propensity score matched for age, demographics, Charlson Comorbidity Index (CCI), facility type, tumor location and size (?2CM vs. 2.1-3.CM) to patients undergoing resection. Kaplan-Meier (KM) analysis was used to compare OS profiles for matched cohorts.

Results
1330 patients met inclusion criteria; 966 (72.6%) had gastric, 304 (22.9%) small bowel and 60 (4.5%) colorectal GIST; 1196 (89.9%) underwent resection; 134 (10.1%) EM. Of those undergoing resection, 884 had a recorded histologic grade with 861 (97.4%) having low-grade tumors. On MVR, gastric location (OR: 2.80; 95% CI [1.46, 5.36]) and tumor size ?2CM (OR: 2.33; 95% CI [1.53, 3.55]) were associated with an increased adjusted odds of EM. On Cox analysis, patients that were male (HR: 2.29, 95% CI [1.20, 4.36]) and under-insured (HR: 3.43, [1.47, 7.99]) had increased adjusted odds risk of mortality. EM was not associated with OS (HR: 1.05, CI [0.37, 2.98]). 117 patients undergoing EM were successfully matched to 356 patients undergoing resection. On KM analysis (Figure 1), there was no difference in 5-year OS between patients undergoing EM and those undergoing resection (92.6% vs 95.7%, p=0.4882).

Conclusion
Small-sized GISTs are generally low-grade tumors with limited potential to impact OS. In patients presenting with small, asymptomatic GIST, EM may be the preferred approach to care.


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