胃腸間質瘤2022.v1（英文）-NCCN腫瘤臨床實踐指南

NCCNClinicalPracticeGuidelinesinOncologyNCCNGuidelines?)GastrointestinalStromalTumors(GISTs)ersionJanuaryNCCNGuidelinesforPatients?availableat/patientsVersion1.2022,01/21/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon1/31/20229:23:49PM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.*MargaretvonMehren,MD/Chair?FoxChaseCancerCenter*JohnM.Kane,III,MD/Vice-Chair?CancerCenterMarkAgulnik,MD?CityofHopeNationalMedicalCenterMarilynM.Bui,MD,PhD≠MoffittCancerCenterJanaiCarr-Ascher,MD,PhD≠UCDavisComprehensiveCancerCenterEdwinChoy,MD,PhD?CancerCenterSarahDry,MD≠UCLAJonssonComprehensiveCancerCenterKristenN.Ganjoo,MD?RicardoJ.Gonzalez,MD?MoffittCancerCenterAshleyHolder,MD?CancerCenteratUABJadeHomsi,MD?CenteresPanelDisclosuresVickiKeedy,MD,MSCI?Vanderbilt-IngramCancerCenterCiaraM.Kelly,MD?EdwardKim,MD§SeattleCancerCareAllianceDavidLiebner,MDT?CancerCenterJamesCancerHospitalMartinMcCarter,MD?UniversityofColoradoCancerCenterSeanV.McGarry,MD?τChristianMeyer,MD,PhD?kinsAlbertoS.Pappo,MD€AmandaM.Parkes,MD??UniversityofWisconsinIvyA.Petersen,MD§SethM.Pollack,MD?MatthewPoppe,MD§RichardF.Riedel,MD?ScottSchuetze,MD,PhD?ofMichiganRogelCancerCenterJacobShabason,MD§nterJasonK.Sicklick,MD?cerCenterMatthewB.Spraker,MD,PhD§SitemanCancerCenteratBarnes-JewishHospitalandWashingtonUniversitySchoolofMedicineMelissaZimel,MDτ?UCSFHelenDillerFamilyCenterangPhD?Hematology/oncologyTInternalmedicine?Medicaloncology§Radiotherapy/Radiationoncology?Surgery/SurgicalPrintedbyMinTangon1/31/20229:23:49PM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexlievesthatthebestmanagementlievesthatthebestmanagementforanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.FindanNCCNMemberInstitution:/home/member-institutions.ofEvidenceanddationsotherwisedNCategoriesofEvidenceandConsensus.NCCNCategoriesofPreference:Allrecommendationsareconsideredappropriate.SeeNCCNCategoriesofPreference.SummaryoftheGuidelinesUpdates?WorkupatPrimaryPresentation?WorkupatPrimaryPresentation(GIST-1)?ResectableGISTwithSignificantMorbidity(GIST-2)?PostoperativeOutcomesandAdjuvantTreatment(GIST-3)?Unresectable,Recurrent,orMetastaticGIST(GIST-4)?TreatmentforProgressiveDisease(GIST-5)?PrinciplesofBiopsyandRiskStratificationforGISTs(GIST-A)?PrinciplesofMutationTesting(GIST-B)?GeneralPrinciplesofSurgeryforGIST(GIST-C)?SystemicTherapyAgentsandRegimensforGISTs(GIST-D)?PrinciplesofImaging(GIST-E)TheNCCNGuidelinesareastatementofevidenceandconsensusoftheauthorsregardingtheirviewsofcurrentlyacceptedapproachestotreatmentAnyclinicianseekingtoapplyorconsulttheNCCNGuidelinesisexpectedtouseindependentmedicaljudgmentinthecontextofindividualstancestodetermineanypatientscareortreatmentTheNationalComprehensiveCancerNetworkNCCNmakesnorepresentationsorwarrantiesofanykindregardingtheircontentuseorapplicationanddisclaimsanyresponsibilityfortheirapplicationoruseinanywayTheNCCNbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.?2022.Version1.2022,01/21/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrimaryTreatmentheaderchangedtoNeoadjuvantTherapy?Column2:"Baselineimaging"changedto"Mutationaltesting"ColumnCategory1designationwasremovedforImatinibpletelyresectedafterpreoperativeimatinibAdjuvantimatinibrecommendationclarifiedasfollowsforpatientsPrimaryTreatmentheaderchangedtoNeoadjuvantTherapy?Column2:"Baselineimaging"changedto"Mutationaltesting"ColumnCategory1designationwasremovedforImatinibpletelyresectedafterpreoperativeimatinibAdjuvantimatinibrecommendationclarifiedasfollowsforpatientswithsignificantriskofenceintermediateorhighriskSeeGISTAModifiedPersistentmicroscopicresidualdisease(R1resection)orGrossldiseaseRresectiony(every3moifhighrisk),thenannuallyyearsThePERSISTstudy...FootnotetSomestratificationschemeshaveincludedtumorrupture,whichhasbeenassociatedwithamuchhigherriskofrecurrence.alAnnSurgOncol8-2027isnewcorrespondingto"adjuvantBulletmodifiedforlimitedprogression:imatiniboravapritinibBullet,modified,Ifpreviouslytreatedwithstandarddoseimatinib:Switchtosunitinibcategory1)orescalatedoseofimatinibastoleratedygeneralizedprogressionmodifiedForperformancestatusPSandprogressiononimatiniboravapritinibBullet:ListoftreatmentoptionswerereplacedwithalinktoGIST-Dperitonealseedingbythetumorislowislowerforthistechnique.Ifconsideringneoadjuvanttherapyisplanned,considerbiopsy.Basedonmoleculartesting,imatiniborkstratificationthsignificantmorbiditydexUpdatesinVersion1.2022oftheNCCNGuidelinesforGastrointestinalStromalTumors(GISTs)fromVersion1.2021include:GIST-1WorkupatPrimaryPresentation?GIST-1WorkupatPrimaryPresentation?Bullet4,modified:Doseescalationofimatinibastolerated(ifpreviouslyhstandarddoseimatinibaspirationbiopsyEUShstandarddoseimatinibaspirationbiopsyEUSFNAB)orEndoscopicultrasound-guidedcoreeedlebiopsyEUSCNBeedlebiopsyEUSCNBonpercutaneoustransperitonealbiopsyifastheriskforavapritinib..pPathologicgradingbymitoticratemaynotbeaccurateinsmallavapritinib..GIST-2?Footnotesremoved.GIST-3OutcomesNeoadjuvantGIST-2?Footnotesremoved.GIST-3Outcomesnotyieldaccuratemitoticinformation.Inthissituation,riskstratificationmayneedtobebasedonclinicalparameters,sizeandanatomiclocationintheabsenceofmitoticrate.GIST-A(2of3)Table1:GastricGISTs:ProposedGuidelinesforAssessingtheMalignant?Newstatement:ThisprognosticassessmentappliesbesttoKITorPDGFRA-Follow-UppositiveGISTswhereassuccinatedehydrogenase(SDH)-deficientGISTsFollow-Upmoreunpredictable.?Newbullet:Riskstratificationisdeterminedwithoutanypriorexposuretotyrosinekinaseinhibitor(TKI)therapy.AlsoforTable2.?RiskPerCAPisanewcolumn:Modified:H&Pandimagingevery3–6moforhighrisk,Modified:H&Pandimagingevery3–6moforhighrisk,every3–6mofor5Footnotes:?Footnotesmodified:Theoptimaldurationofadjuvantimatinibisunknown.Availabledatasupporttheuseofadjuvantimatinibforatleast3p>2cmto≤5cm/≤5isVerylow(1.9%)and>5isModerate(16%)p>5cmto≤10cm/≤5isLow(3.6%)and>5isHigh(55%)p>10cm/≤5isModerate(10%)and>5isHigh(86%)?Reference2modified:DatafromLauriniJA.ProtocolfortheExaminationofResectionSpecimensfromPatientswithGastrointestinalStromalTumors(GIST).Version,June2021.Availableat:/protocols/Stomach.GIST_.REL_CAPCP.pdf.GIST-A(3of3)Table2:Non-GastricGISTs(includessmallbowelandcolorectalGISTs):ProposedGuidelinesforAssessingtheMalignantGIST-4?PrimaryTreatmentheaderchangedtoFirst-LineTherapy.GISTGIST-4?PrimaryTreatmentheaderchangedtoFirst-LineTherapy.GIST-5TreatmentforProgressiveDiseasePDGFRA-positiveGISTswhereasSDH-deficientGISTsaremoreunpredictable.Foranatomicsitesnotlistedinthistable,suchasesophagus,mesentery,andperitoneum,orinthecaseof“insufficientdata,”itisbesttouseriskcriteriaforjejunum/ileum.?RiskPerCAPisanewcolumn:p≤2cm/≤5isNoneand>5isInsufficientdata-High(54%)p>2cmto≤5cm/≤5isLow(4.3%–8.5%)and>5isHigh(50%–73%)p>5cmto≤10cm/≤5isInsufficientdata-Moderate(24%)and>5iswhichoutlinessystemictherapyoptionswhichoutlinessystemictherapyoptionsforprogressiveormetastaticdisease.UPDATESp>10cm/≤5isHigh(34%–57%)and>5isdisease.UPDATESVersion1.2022,01/21/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.UPDATESVersion1.2022,01/21/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon1/31/20229:23:49PM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dextrointestinalStromalTumorsGISTsfromVersionincludePrinciplesofMutationTesting?Bullet4,firstsentencemodified:GISTshavedifferentresponseratestoimatinibbaseduponthetumormutationstatus:KITexon9mutationshavealowerresponserateandprogression-freesurvival(PFS)thanexon11tumorsat400mg,butdosingat400mgBIDhasbeenassociatedwithbetterPFS.?Bullet5modified:pThirdsentencedeleted:Ripretinibisindicatedforpatientswithdiseaseprogressiononimatinib,sunitinib,andregorafenib.Ripretinibisindicatedforpatientswhohavereceivedpriortreatmentwith3ormorekinaseinhibitors,includingimatinib.Anadditionalclinicalbenefitmaybeobtainedwiththeuseofripretinib150mgBIDuponprogressiononripretinib150mgdaily.?Bullet6,lastsentencemodified:AsmallminorityofGISTsthatretainwithlossofSDHexpressionhavealternativedrivermutations.?Bullet7deleted:TestingforalternativedrivermutationsisindicatedfortumorsthatarenegativeforKITorPDGFRAmutations.pFirstsentenceisnew:AllGISTslackingaKITorPDGFRAmutationshouldbetestedforSDHdeficiencyandalternativedrivermutationsusingnext-generationsequencing(NGS).pFirstsub-bulletdeleted:TestingincludesassessmentforSDHBdeficiencybyIHCforgastrictumorsandSDHmutationtestingforSDHB-deficienttumorsbyIHC.pSecondsub-bulletmodified:Inaddition,alternativedrivermutationsusingNGSnext-generationsequencing(NGS)testing(eg,BRAF,NF1,NTRK,andFGFRfusions)shouldbeperformedforpotentialidentificationofatargetedtherapy.?Bullet8modified:GISTswithSDHmutationstypicallyariseinthestomachinyoungerindividuals,frequentlymetastasize,mayinvolvelymphnodes,andusuallygrowslowly.Theyareusuallyresistanttoimatinib.IntheabsenceofKITandPDGFRAmutations,onlyasubsetofpatientswithadvancedGISTsbenefitfromimatinib,althoughtumorsknowntobeSDHdeficientorhavingalternativedrivers(eg,NF1,BRAF)areunlikelytobenefitfromimatinib.SDH-deficienttumorsmaybenefitfromtherapywithsunitiniborregorafenib.ReferraltoageneticcounselorforgermlinetestingassessmentisrecommendedforallpatientswithSDH-deficientGISTsandthosewithGISTsthathaveNF1orSDHmutations.PatientswithSDHmutationsareatriskofparaganglioma;24-hoururinetestingisrecommendedpriortosurgery(SeeGIST-C).ConsiderationsPriortoSurgery?Bullet2modified:PatientswithSDHdeficiencyorknownSDHmutationsareatriskofparagangliomaandthereforeserum/urinecatecholamine/metanephrinetestingshouldbeconsideredbeforeanoperationpriortosurgery.GIST-D(1of2)?Thispagewasreorganizedforclarityandtoincludetreatmentoptionsforprogressionofdiseaseonavapritinib.?Titlemodified:SystemicTherapyAgentsandRegimensforResectableGISTswithSignificantMorbiditypNeoadjuvantTherapytitlemodifiedtoinclude,forResectableDiseasewithSignificantMorbiditypAdjuvantTherapytitlemodifiedtoinclude,forResectableDisease?Adjuvantimatinibforpatientswithsignificantriskofrecurrence,intermediateorhighrisk(category1"followingcompleteresectionwithnopreoperativeimatinib;category2Afollowingcompleteresectionafterpreoperativeimatinib)SeeGIST-3"?Titleofthesecondtablewasmodifiedtoinclude,"unresectable,progressive,ormetastaticdisease"?AdditionaloptionsafterprogressiononapprovedtherapiespUsefulinCertainCircumstances?Ripretinibdoseescalationto150mgBID(ifpreviouslytreatedwithripretinib150mgdaily)–ZalcbergJR,HeinrichMC,GeorgeS,etal.Clinicalbenefitofripretinibdoseescalationafterdiseaseprogressioninadvancedgastrointestinalstromaltumor:ananalysisoftheINVICTUSstudy.Oncologist2021;25:1-8.?Footnoteaisnew:Althoughmutationalanalysisisrequired(otherthanrarecircumstances,familyhistory,etc.),itisappropriatetostartneoadjuvantimatinibpendingconfirmationofthemutationalanalysis.?Footnotebmodified:Datadonotsupportroutineuseinwild-typeGISTswithoutmutationinKITorwithanimatinib-resistantmutationinPDGFRA.?Footnotecisnew:Forunresectabledisease,sunitinib,regorafenib,andpazopanibarespecialconsiderationsforSDH-deficientGIST.?Footnotehisnew:Ripretinib150mgdailyisindicatedforfourth-linetherapy.Anadditionalclinicalbenefitmaybeobtainedwiththeuseofripretinib150mgBIDuponprogressiononripretinib150mgdaily.asoundguidedreneedlebiopsyEUSCNBativesfResectablewithminimalasoundguidedreneedlebiopsyEUSCNBativesfResectablewithminimalmorbidityttherapyiscalectionkdexWORKUPATPRIMARYPRESENTATIONMANAGEMENTBASEDONTHERESULTSOFINITIALDIAGNOSTICEVALUATIONAllpatientsshouldbeevaluateddmanagedbyamultidisciplinaryteamwithpertiseandexperienceinGISTsarcoma?ForverysmallgastricGISTs<2cmapConsiderendoscopicultrasound-yEUSFNAByEUSFNABboredMassknowntobeorpiciousforGISTdonmoleculartestingimatiniborwithsignificantwithsignificanttavapritinib(forPDGFRAexon18sthatareinsensitivetosthatareinsensitivetoimatiniblincludingtheD842VdecreasesurgicaldecreasesurgicalorbidityhherapyisorbidityhherapyisbeingconsideredeUnresectableormetastaticdiseaseUnresectableormetastaticdiseaseaSepePS,etal.NatRevGastroenterolHepatol2009;6:363-371.bSeePrinciplesofBiopsyandRiskStratificationforGISTs(GIST-A).jEndoscopicultrasonographysurveillanceshouldonlybeconsideredcSeePrinciplesofImaging(GIST-E).afterathoroughdiscussionwiththepatientregardingtherisksanddSeeAmericanJointCommitteeonCancer(AJCC)Staging,8thEdition(ST-1).benefits.EvansJ,etal.GastrointestEndosc2015;82:1-8.eMutationalanalysismaypredictresponsetotherapywithtyrosinekinaseinhibitors(TKIs)kSeeGeneralPrinciplesofSurgeryforGIST(GIST-C).(SeeGIST-B).lNeoadjuvantimatinibforgenotype-sensitivediseasemayprohibitfPossiblehigh-riskEUSfeaturesincludeirregularborder,cysticspaces,ulceration,echogenicaccurateassessmentofrecurrenceriskfollowingresection(Seefoci,andheterogeneity.GIST-A).TestingtumorformutationisrecommendedpriortogSomepatientsmayrapidlybecomeunresectable;closemonitoringisessential.startingpreoperativeimatinibtoensuretumorhasagenotypehExtensivesurgeryassociatedwithsignificantmorbidity(ie,totalgastrectomytoreduceriskofthatislikelytorespondtotreatment(SeeGIST-2).Considerrecurrenceinstomach)isgenerallynotrecommendedforSDH-deficientGISTwithmultifocalneoadjuvantimatinibonlyifsurgicalmorbiditycouldbereduceddisease.bydownsizingthetumorpreoperatively.MaximalresponsemayiNeoadjuvanttherapyforgenotype-sensitivediseaseshouldbeconsideredforlocallyrequiretreatmentfor6monthsormoretoachieve.advancedGISTsincertainanatomicallocations(eg,rectum,esophagealandesophagogastricmSeeNCCNGuidelinesforSoftTissueSarcomaifthepathologyjunction,duodenum)orifamultivisceralresectionwouldberequiredtoresectallgrosstumor.resultsindicatesarcomasofGIoriginotherthanGIST.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.GIST-1Version1.2022,01/21/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN. Surgery,iffeasiblekrasibleluatePrintedbyMinTangon1/31/20229:23:49PM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved. Surgery,iffeasiblekrasibleluatedexPRIMARYNEOADJUVANTTHERAPYlFOLLOW-UPTHERAPYPRESENTATIONGISTwithsigniicantmorbiditygMutationaltestingeorAvapritinibforGISTswithPDGFRAexon18mutationsthatareinsensitivetoimatinib(includingthePDGFRAD842Vmutation)Imagingc,ntoassesspatientadherenceedoseinibiniborPDGFRAexon18toimatinibfeasiblekrotSeePostoperativeOutcomesandAdjuvantTreatment(GIST-3)cSeePrinciplesofImaging(GIST-E).eMutationalanalysismaypredictresponsetotherapywithTKIs(SeeGIST-B).gSomepatientsmayrapidlybecomeunresectable;closemonitoringisessential.kSeeGeneralPrinciplesofSurgeryforGIST(GIST-C).lNeoadjuvantimatinibforgenotype-sensitivediseasemayprohibitaccurateassessmentofrecurrenceriskfollowingresection(GIST-A).Testingtumorformutationisrecommendedpriortostartingpreoperativeimatinibtoensuretumorhasagenotypethatislikelytorespondtotreatment(SeeGIST-2).Considerneoadjuvantimatinibonlyifsurgicalmorbiditycouldbereducedbydownsizingthetumorpreoperatively.Maximalresponsemayrequiretreatmentfor6monthsormoretoachieve.nConsiderbaselinePET/CT,ifusingPET/CTduringfollow-up.PET/CTisnotasubstituteforCT.oMedicaltherapyistheusualcourseoftreatment.However,patientmayproceedtosurgeryifbleedingorsymptomatictumororpoortreatmenttolerance.pPET/CTmaygiveindicationofimatinibefficacyafter2–4weeksoftherapywhenrapidreadoutofactivityisnecessary.Diagnosticabdominal/pelvicCTorMRIwithcontrastisindicatedevery8–12weeks;routinelong-termPET/CTfollow-upisrarelyindicated.Frequencyofresponseassessmentimagingmaybedecreasedifpatientisrespondingtotreatment.qProgressionmaybedeterminedbyabdominal/pelvicCTorMRIwithcontrastwithclinicalinterpretation;increaseintumorsizeinthepresenceofdecreaseintumordensityisconsistentwithdrugefficacyorbenefit.PET/CTscanmaybeusedtoclarifyifCTorMRIareambiguous.rCollaborationbetweenmedicaloncologistandsurgeonisnecessarytodeterminetheappropriatenessandtimingofsurgery,followingmajorresponseorsustainedstabledisease.Maximalresponsemayrequiretreatmentfor6monthsormoretoachieve.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2022,01/21/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.GIST-2PrintedbyMinTangon1/31/20229:23:49PM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexPOSTOPERATIVEOUTCOMESADJUVANTTREATMENTFOLLOW-UPresectedrativeimatinibObserve(low-riskdisease)orAdjuvantimatinib(category1)preferredfororhighriskesorhighriskestSeeGISTAresectedoperativebConsidercontinuationofadjuvantimatinibofrecurrenceintermediateorhighriskeofrecurrenceintermediateorhighriskes,tCompletelyresectedafterpreoperativeavapritinib?H&Pandimagingcevery3–6mofor5y(every3moifhighrisk),thenannuallyuIfRecurrence,See(GIST-4)srldiseaseSee(GIST-4)cSeePrinciplesofImaging(GIST-E).eMutationalanalysismaypredictresponsetotherapywithTKIs(SeeGIST-B).sTheoptimaldurationofadjuvantimatinibisunknown.Availabledatasupporttheuseofadjuvantimatinibforatleast3years.ThePERSISTstudyhasshownthefeasibilityof5-yearadjuvantimatinibwithnoevidenceofrecurrenceinpatientswithimatinib-sensitiveGIST(RautCP,etal.JAMAOncol2018;4:e184060).tSomestratificationschemeshaveincludedtumorrupture,whichhasbeenassociatedwithamuchhigherriskofrecurrence.NishidaT,etal.AnnSurgOncol2018;25:1961-1969andRutkowskiP,etal.AnnSurgOncol2007;14:2018-2027.uLessfrequentsurveillancemaybeacceptableforverysmalltumors(<2cm),unlesstheyareassociatedwithhighmitoticrate.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2022,01/21/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.GIST-3PrintedbyMinTangon1/31/20229:23:49PM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexFIRST-LINEFIRST-LINETHERAPYPRESENTATIONUnresectable,recurrent,ormetastaticGIST TKI TKIeluateluateetoassessFOLLOW-UPTHERAPYResponseorstablediseaseContinueTKI,obtainsurgicalconsultation,ResectionkContinueTKIifresectionnotfeasiblemoostoperativeOutcomesandAdjuvantmoProgressionqSee(GIST-5)cSeePrinciplesofImaging(GIST-E).eMutationalanalysismaypredictresponsetotherapywithTKIs(SeeGIST-B).kSeeGeneralPrinciplesofSurgeryforGIST(GIST-C).nConsiderbaselinePET/CT,ifusingPET/CTduringfollow-up.PET/CTisnotasubstituteforCT.pPET/CTmaygiveindicationofimatinibefficacyafter2–4weeksoftherapywhenrapidreadoutofactivityisnecessary.D