Current management of gastrointestinal stromal tumors: Surgery, current biomarkers, mutations, and therapy

Surgery (United States)

Volumn 158, Issue 5, 2015, Pages 1149-1164

  Valsangkar, Nakul ^a,c   Sehdev, Amikar ^a,c   Misra, Subhasis ^b,c   Zimmers, Teresa A ^a,c   O'Neil, Bert H ^b,c   Koniaris, Leonidas G ^a,c  

^a INDIANA UNIVERSITY   (United States)

^b TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER   (United States)

^c Indianapolis VAMC   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

BIOLOGICAL MARKER; DABRAFENIB; DASATINIB; EVEROLIMUS; GANETESPIB; IMATINIB; LUMINESPIB; NILOTINIB; ONALESPIB; PERIFOSINE; REGORAFENIB; RETASPIMYCIN; SUNITINIB; TRAMETINIB; ANTINEOPLASTIC AGENT; PROTEIN KINASE INHIBITOR;

BRAF GENE; CANCER ADJUVANT THERAPY; CANCER CLASSIFICATION; CANCER DIAGNOSIS; CANCER INCIDENCE; CANCER RECURRENCE; CANCER SURGERY; CANCER THERAPY; CLINICAL FEATURE; COMPUTER ASSISTED TOMOGRAPHY; DIAGNOSTIC ERROR; DIAGNOSTIC IMAGING; GASTRECTOMY; GASTROINTESTINAL STROMAL TUMOR; GENE; HUMAN; INSULIN LIKE GROWTH FACTOR 1 RECEPTOR GENE; LAPAROSCOPIC AND ENDOSCOPIC COOPERATIVE SURGERY; LAPAROSCOPIC SURGERY; LIVER RESECTION; MAP KINASE GENE; MEK GENE; METASTASIS; METASTASIS RESECTION; MUTATIONAL ANALYSIS; ONCOGENE RAS; OUTCOME ASSESSMENT; PATHOGENESIS; PDGFRA GENE; PERSONALIZED MEDICINE; PHENOTYPE; POSITRON EMISSION TOMOGRAPHY; PRIORITY JOURNAL; RANDOMIZED CONTROLLED TRIAL (TOPIC); REVIEW; SURGICAL TECHNIQUE; TREATMENT RESPONSE; TUMOR LOCALIZATION; WEDGE RESECTION; GASTROINTESTINAL NEOPLASMS; GASTROINTESTINAL STROMAL TUMORS; GENETICS; MULTIMODALITY CANCER THERAPY; MUTATION;

ANTINEOPLASTIC AGENTS; BIOMARKERS; COMBINED MODALITY THERAPY; GASTROINTESTINAL NEOPLASMS; GASTROINTESTINAL STROMAL TUMORS; HUMANS; MUTATION; PROTEIN KINASE INHIBITORS;

EID: 84944174516     PISSN: 00396060     EISSN: 15327361     Source Type: Journal    
DOI: 10.1016/j.surg.2015.06.027     Document Type: Review

References (84)

1. J.C. Gutierrez, E.A. Perez, D. Franceschi, F.L. Moffat, A.S. Livingstone, and L.G. Koniaris Outcomes for soft-tissue sarcoma in 8249 cases from a large state cancer registry J Surg Res 141 2007 105 114
2. I. Pidhorecky, R.T. Cheney, W.G. Kraybill, and J.F. Gibbs Gastrointestinal stromal tumors: current diagnosis, biologic behavior, and management Ann Surg Oncol 7 2000 705 712
3. J.C. Gutierrez, L.O.P. De Oliveira, E.A. Perez, C. Rocha-Lima, A.S. Livingstone, and L.G. Koniaris Optimizing diagnosis, staging, and management of gastrointestinal stromal tumors J Am Coll Surg 205 2007 479 491 (quiz 524)
4. J.L. Rubin, M. Sanon, D.C. Taylor, J. Coombs, V. Bollu, and L. Sirulnik Epidemiology, survival, and costs of localized gastrointestinal stromal tumors Int J Gen Med 4 2011 121 130
5. H. Joensuu, P. Hohenberger, and C.L. Corless Gastrointestinal stromal tumour Lancet 382 2013 973 983
6. M. Miettinen, and J. Lasota Gastrointestinal stromal tumors Gastroenterol Clin North Am 42 2013 399 415
7. H. Joensuu, A. Vehtari, J. Riihimäki, T. Nishida, S.E. Steigen, P. Brabec, and et al. Risk of recurrence of gastrointestinal stromal tumour after surgery: an analysis of pooled population-based cohorts Lancet Oncol 13 2012 265 274
8. D.M. King The radiology of gastrointestinal stromal tumours (GIST) Cancer Imaging 5 2005 150 156
9. G.D. Demetri, M. von Mehren, C.R. Antonescu, R.P. DeMatteo, K.N. Ganjoo, R.G. Maki, and et al. NCCN Task Force report: update on the management of patients with gastrointestinal stromal tumors J Natl Compr Canc Netw 8 Suppl 2 2010 S1 S41 quiz S42-4
10. F.E. Pedroso, C.P. Raut, H. Xiao, C.J. Yeo, and L.G. Koniaris Has the survival rate for surgically resected gastric gastrointestinal stromal tumors improved in the tyrosine kinase inhibitor era? Ann Surg Oncol 19 2012 1748 1758
11. E.A. Perez, J.C. Gutierrez, X. Jin, D.J. Lee, C. Rocha-Lima, A.S. Livingstone, and et al. Surgical outcomes of gastrointestinal sarcoma including gastrointestinal stromal tumors: a population-based examination J Gastrointest Surg 11 2007 114 125
12. E.A. Perez, A.S. Livingstone, D. Franceschi, C. Rocha-Lima, D.J. Lee, N. Hodgson, and et al. Current incidence and outcomes of gastrointestinal mesenchymal tumors including gastrointestinal stromal tumors J Am Coll Surg 202 2006 623 629
13. M.C. Cheung, Y. Zhuge, R. Yang, and L.G. Koniaris Disappearance of racial disparities in gastrointestinal stromal tumor outcomes J Am Coll Surg 209 2009 7 16
14. Y. Zhuge, M.C. Cheung, R. Yang, and L.G. Koniaris Diagnosing gastrointestinal stromal tumors before the year 2000 Cancer Epidemiol Biomarkers Prev 18 2009 1013 1014 author reply 1014-5
15. Surveillance, Epidemiology, and End Results (SEER) Program. Research Data (1973-2011), National Cancer Institute, DCCPS, Surveillance Research Program, Surveillance Systems Branch, released August 2014. Available from: http://seer.cancer.gov/seerstat/software/. Last accessed: July 26, 2015.
16. M. Miettinen, L.H. Sobin, and J. Lasota Gastrointestinal stromal tumors of the stomach: a clinicopathologic, immunohistochemical, and molecular genetic study of 1765 cases with long-term follow-up Am J Surg Pathol 29 2005 52 68
17. L. Zhang, T.C. Smyrk, W.F. Young, C.A. Stratakis, and J.A. Carney Gastric stromal tumors in Carney triad are different clinically, pathologically, and behaviorally from sporadic gastric gastrointestinal stromal tumors: findings in 104 cases Am J Surg Pathol 34 2010 53 64
18. T.P. Plesec Gastrointestinal mesenchymal neoplasms other than gastrointestinal stromal tumors: focusing on their molecular aspects Patholog Res Int 2011 2011 952569
19. M.T. Mazur, and H.B. Clark Gastric stromal tumors. Reappraisal of histogenesis Am J Surg Pathol 7 1983 507 519
20. S. Hirota, K. Isozaki, Y. Moriyama, K. Hashimoto, T. Nishida, S. Ishiguro, and et al. Gain-of-function mutations of c-kit in human gastrointestinal stromal tumors Science 279 1998 577 580
21. L.G. Kindblom, H.E. Remotti, F. Aldenborg, and J.M. Meis-Kindblom Gastrointestinal pacemaker cell tumor (GIPACT): gastrointestinal stromal tumors show phenotypic characteristics of the interstitial cells of Cajal Am J Pathol 152 1998 1259 1269
22. E.S. Casper Gastrointestinal stromal tumors Curr Treat Options Oncol 1 2000 267 273
23. M.C. Heinrich, C.L. Corless, A. Duensing, L. McGreevey, C.-J. Chen, N. Joseph, and et al. PDGFRA activating mutations in gastrointestinal stromal tumors Science 299 2003 708 710
24. J.S. Gold, M. Gönen, A. Gutiérrez, J.M. Broto, X. García-del-Muro, T.C. Smyrk, and et al. Development and validation of a prognostic nomogram for recurrence-free survival after complete surgical resection of localised primary gastrointestinal stromal tumour: a retrospective analysis Lancet Oncol 10 2009 1045 1052
25. G.D. Demetri Gastrointestinal stromal tumor V.T. DeVita, T.S. Lawrence, S.A. Rosenberg, Practice of oncology 9th ed. 2011 Wolters Kluwer/Lippincott Williams & Wilkins Philadelphia
26. S. Muenst, S. Thies, P. Went, L. Tornillo, M.P. Bihl, and S. Dirnhofer Frequency, phenotype, and genotype of minute gastrointestinal stromal tumors in the stomach: an autopsy study Hum Pathol 42 2011 1849 1854
27. K. Kawanowa, Y. Sakuma, S. Sakurai, T. Hishima, Y. Iwasaki, K. Saito, and et al. High incidence of microscopic gastrointestinal stromal tumors in the stomach Hum Pathol 37 2006 1527 1535
28. T.S. Emory, L.H. Sobin, L. Lukes, D.H. Lee, and T.J. O'Leary Prognosis of gastrointestinal smooth-muscle (stromal) tumors: dependence on anatomic site Am J Surg Pathol 23 1999 82 87
29. R.P. DeMatteo, J.J. Lewis, D. Leung, S.S. Mudan, J.M. Woodruff, and M.F. Brennan Two hundred gastrointestinal stromal tumors: recurrence patterns and prognostic factors for survival Ann Surg 231 2000 51 58
30. B. Liegl-Atzwanger, J.A. Fletcher, and C.D. Fletcher Gastrointestinal stromal tumors Virchows Arch 456 2010 111 127
31. M.D. McCarter, C.R. Antonescu, K.V. Ballman, R.G. Maki, P.W. Pisters, G.D. Demetri, and et al. Microscopically positive margins for primary gastrointestinal stromal tumors: analysis of risk factors and tumor recurrence J Am Coll Surg 215 2012 53 59
32. D.O. Faigel, and S. Abulhawa Gastrointestinal stromal tumors: the role of the gastroenterologist in diagnosis and risk stratification J Clin Gastroenterol 46 2012 629 636
33. P. Tombesi, S. Postorivo, M. Catellani, D. Tassinari, V. Abbasciano, and S. Sartori Percutaneous ultrasonography-guided core needle biopsy of gastrointestinal lesions: what's its actual role in clinical practice? A retrospective study for safety and effectiveness Ultraschall Med 32 Suppl 1 2011 S62 S67
34. G.S. Falchook, J.C. Trent, M.C. Heinrich, C. Beadling, J. Patterson, and C.C. Bastida BRAF Mutant Gastrointestinal Stromal Tumor: First report of regression with BRAF inhibitor dabrafenib (GSK2118436) and whole exomic sequencing for analysis of acquired resistance Oncotarget 4 2013 310 315
35. O. Dudeck, M. Zeile, P. Reichardt, and D. Pink Comparison of RECIST and Choi criteria for computed tomographic response evaluation in patients with advanced gastrointestinal stromal tumor treated with sunitinib Ann Oncol 22 2011 1828 1833
36. H. Choi, C. Charnsangavej, S.C. Faria, H.A. Macapinlac, M.A. Burgess, S.R. Patel, and et al. Correlation of computed tomography and positron emission tomography in patients with metastatic gastrointestinal stromal tumor treated at a single institution with imatinib mesylate: proposal of new computed tomography response criteria J Clin Oncol 25 2007 1753 1759
37. R.S. Benjamin, H. Choi, H.A. Macapinlac, M.A. Burgess, S.R. Patel, L.L. Chen, and et al. We should desist using RECIST, at least in GIST J Clin Oncol 25 2007 1760 1764
38. A.D. Van den Abbeele The lessons of GIST-PET and PET/CT: a new paradigm for imaging Oncologist 13 Suppl 2 2008 8 13
39. C.-H. Lee, C. Liang, and I. Espinosa The utility of discovered on gastrointestinal stromal tumor 1 (DOG1) antibody in surgical pathology-the GIST of it Adv Anat Pathol 17 2010 222 232
40. P. Bucher, J.-F. Egger, P. Gervaz, F. Ris, D. Weintraub, P. Villiger, and et al. An audit of surgical management of gastrointestinal stromal tumours (GIST) Eur J Surg Oncol 32 2006 310 314
41. A. Das, R. Wilson, A.V. Biankin, and N.D. Merrett Surgical therapy for gastrointestinal stromal tumours of the upper gastrointestinal tract J Gastrointest Surg 13 2009 1220 1225
42. I. Hassan, Y.N. You, R. Shyyan, E.J. Dozois, T.C. Smyrk, S.H. Okuno, and et al. Surgically managed gastrointestinal stromal tumors: a comparative and prognostic analysis Ann Surg Oncol 15 2008 52 59
43. J.S. Gold, S.M. van der Zwan, M. Gönen, R.G. Maki, S. Singer, M.F. Brennan, and et al. Outcome of metastatic GIST in the era before tyrosine kinase inhibitors Ann Surg Oncol 14 2007 134 142
44. R.S. Benjamin, C.D. Blanke, J.-Y. Blay, S. Bonvalot, and B. Eisenberg Management of gastrointestinal stromal tumors in the imatinib era: selected case studies Oncologist 11 2006 9 20
45. S.-M. Choi, M.-C. Kim, G.-J. Jung, H.-H. Kim, H.-C. Kwon, S.-R. Choi, and et al. Laparoscopic wedge resection for gastric GIST: long-term follow-up results Eur J Surg Oncol 33 2007 444 447
46. M. Honda, N. Hiki, S. Nunobe, M. Ohashi, T. Kiyokawa, T. Sano, and et al. Long-term and surgical outcomes of laparoscopic surgery for gastric gastrointestinal stromal tumors Surg Endosc 28 2014 1 6
47. E.L. Bédard, J. Mamazza, C.M. Schlachta, and E.C. Poulin Laparoscopic resection of gastrointestinal stromal tumors: not all tumors are created equal Surg Endosc 20 2006 500 503
48. Smithsonian. A Triumph in the War Against Cancer. http://www.smithsonianmag.com/science-nature/a-triumph-in-the-war-against-cancer-1784705/?c=y%3Fno-ist. Last Accessed July 26, 2015.
49. V.P. Balachandran, and R.P. DeMatteo Gastrointestinal stromal tumors Adv Surg 48 2014 165 183
50. C.D. Blanke, C. Rankin, G.D. Demetri, C.W. Ryan, M. von Mehren, R.S. Benjamin, and et al. Phase III randomized, intergroup trial assessing imatinib mesylate at two dose levels in patients with unresectable or metastatic gastrointestinal stromal tumors expressing the kit receptor tyrosine kinase: S0033 J Clin Oncol 26 2008 626 632
51. J. Verweij, P.G. Casali, J. Zalcberg, A. LeCesne, P. Reichardt, J.-Y. Blay, and et al. Progression-free survival in gastrointestinal stromal tumours with high-dose imatinib: randomised trial Lancet 364 2004 1127 1134
52. A.T. Van Oosterom, I. Judson, J. Verweij, S. Stroobants, E. Donato di Paola, S. Dimitrijevic, and et al. Safety and efficacy of imatinib (STI571) in metastatic gastrointestinal stromal tumours: a phase I study Lancet 358 2001 1421 1423
53. C.D. Blanke, G.D. Demetri, M. von Mehren, M.C. Heinrich, B. Eisenberg, J.A. Fletcher, and et al. Long-term results from a randomized phase II trial of standard- versus higher-dose imatinib mesylate for patients with unresectable or metastatic gastrointestinal stromal tumors expressing KIT J Clin Oncol 26 2008 620 625
54. R.W. Van Leeuwen, T. van Gelder, R.H. Mathijssen, and F.G. Jansman Drug-drug interactions with tyrosine-kinase inhibitors: a clinical perspective Lancet Oncol 15 2014 e315 e326
55. I. Judson Imatinib in advanced gastrointestinal stromal tumour: when is 800 mg the correct dose? Curr Opin Oncol 20 2008 433 437
56. M.C. Heinrich, K. Owzar, C.L. Corless, D. Hollis, E.C. Borden, C.D. Fletcher, and et al. Correlation of kinase genotype and clinical outcome in the North American Intergroup Phase III Trial of imatinib mesylate for treatment of advanced gastrointestinal stromal tumor: CALGB 150105 Study by Cancer and Leukemia Group B and Southwest Oncology Gr J Clin Oncol 26 2008 5360 5367
57. GSTM-AG (MetaGIST) Comparison of two doses of imatinib for the treatment of unresectable or metastatic gastrointestinal stromal tumors: a meta-analysis of 1,640 patients J Clin Oncol 28 2010 1247 1253
58. A. Le Cesne, I. Ray-Coquard, B.N. Bui, A. Adenis, M. Rios, F. Bertucci, and et al. Discontinuation of imatinib in patients with advanced gastrointestinal stromal tumours after 3 years of treatment: an open-label multicentre randomised phase 3 trial Lancet Oncol 11 2010 942 949
59. M. Miettinen, and J. Lasota Gastrointestinal stromal tumors: pathology and prognosis at different sites Semin Diagn Pathol 23 2006 70 83
60. R.P. DeMatteo, K.V. Ballman, C.R. Antonescu, C. Corless, V. Kolesnikova, M. von Mehren, and et al. Long-term results of adjuvant imatinib mesylate in localized, high-risk, primary gastrointestinal stromal tumor: ACOSOG Z9000 (Alliance) intergroup phase 2 trial Ann Surg 258 2013 422 429
61. C.R. Antonescu, G. Sommer, L. Sarran, S.J. Tschernyavsky, E. Riedel, J.M. Woodruff, and et al. Association of KIT exon 9 mutations with nongastric primary site and aggressive behavior: KIT mutation analysis and clinical correlates of 120 gastrointestinal stromal tumors Clin Cancer Res 9 2003 3329 3337
62. C.L. Corless, A. Schroeder, D. Griffith, A. Town, L. McGreevey, P. Harrell, and et al. PDGFRA mutations in gastrointestinal stromal tumors: Frequency, spectrum and in vitro sensitivity to imatinib J Clin Oncol 23 2005 5357 5364
63. C.L. Corless, K.V. Ballman, C.R. Antonescu, V. Kolesnikova, R.G. Maki, P.W. Pisters, and et al. Pathologic and molecular features correlate with long-term outcome after adjuvant therapy of resected primary GI stromal tumor: the ACOSOG Z9001 trial J Clin Oncol 32 2014 1563 1570
64. H. Joensuu, M. Eriksson, K. Sundby Hall, J.T. Hartmann, D. Pink, J. Schütte, and et al. One vs three years of adjuvant imatinib for operable gastrointestinal stromal tumor: a randomized trial JAMA 307 2012 1265 1272
65. P.G. Casali, A.L. Cesne, A.P. Velasco, D. Kotasek, P. Rutkowski, P. Hohenberger, and et al. Imatinib failure-free survival (IFS) in patients with localized gastrointestinal stromal tumors (GIST) treated with adjuvant imatinib (IM): The EORTC/AGITG/FSG/GEIS/ISG randomized controlled phase III trial J Clin Oncol 31 Suppl 2013 Abstr 10500
66. B. Liegl, I. Kepten, and C. Le Heterogeneity of kinase inhibitor resistance mechanisms in GIST J Pathol 216 2008 64 74
67. J. Hislop, G. Mowatt, P. Sharma, C. Fraser, A. Elders, D. Jenkinson, and et al. Systematic review of escalated imatinib doses compared with sunitinib or best supportive care, for the treatment of people with unresectable/metastatic gastrointestinal stromal tumours whose disease has progressed on the standard imatinib dose J Gastrointest Cancer 43 2012 168 176
68. G.D. Demetri, A.T. van Oosterom, C.R. Garrett, M.E. Blackstein, M.H. Shah, J. Verweij, and et al. Efficacy and safety of sunitinib in patients with advanced gastrointestinal stromal tumour after failure of imatinib: a randomised controlled trial Lancet 368 2006 1329 1338
69. M.C. Heinrich, R.G. Maki, C.L. Corless, C.R. Antonescu, A. Harlow, D. Griffith, and et al. Primary and secondary kinase genotypes correlate with the biological and clinical activity of sunitinib in imatinib-resistant gastrointestinal stromal tumor J Clin Oncol 26 2008 5352 5359
70. E. Fumagalli, P. Coco, C. Morosi, R. Bertulli, and P.G. Casali Sunitinib rechallenge in two advanced GIST patients after third-line anti-tyrosine kinase therapy J Clin Oncol 28 Suppl 2010 abstr e20519
71. G.D. Demetri, P. Reichardt, Y.-K. Kang, J.-Y. Blay, P. Rutkowski, H. Gelderblom, and et al. Efficacy and safety of regorafenib for advanced gastrointestinal stromal tumours after failure of imatinib and sunitinib (GRID): an international, multicentre, randomised, placebo-controlled, phase 3 trial Lancet 381 2013 295 302
72. S. Yao FDA approves Stivarga for advanced gastrointestinal stromal tumors [Internet] 2013 FDA Available from: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm340958.htm Last accessed July 26, 2015
73. R.H. Andtbacka, C.S. Ng, C.L. Scaife, J.N. Cormier, K.K. Hunt, P.W. Pisters, and et al. Surgical resection of gastrointestinal stromal tumors after treatment with imatinib Ann Surg Oncol 14 2007 14 24
74. J.C. McAuliffe, K.K. Hunt, A.J. Lazar, H. Choi, W. Qiao, P. Thall, and et al. A randomized, phase II study of preoperative plus postoperative imatinib in GIST: evidence of rapid radiographic response and temporal induction of tumor cell apoptosis Ann Surg Oncol 16 2009 910 919
75. B. Dewaele, B. Wasag, J. Cools, R. Sciot, H. Prenen, P. Vandenberghe, and et al. Activity of dasatinib, a dual SRC/ABL kinase inhibitor, and IPI-504, a heat shock protein 90 inhibitor, against gastrointestinal stromal tumor-associated PDGFRAD842V mutation Clin Cancer Res 14 2008 5749 5758
76. C.L. Corless Gastrointestinal stromal tumors: what do we know now? Mod Pathol 27 Suppl 1 2014 S1 S16
77. S. Bauer, P. Rutkowski, P. Hohenberger, R. Miceli, E. Fumagalli, J.A. Siedlecki, and et al. Long-term follow-up of patients with GIST undergoing metastasectomy in the era of imatinib - analysis of prognostic factors (EORTC-STBSG collaborative study) Eur J Surg Oncol 40 2014 412 419
78. S.J. Park, M.-H. Ryu, B.-Y. Ryoo, Y.S. Park, B.S. Sohn, H.J. Kim, and et al. The role of surgical resection following imatinib treatment in patients with recurrent or metastatic gastrointestinal stromal tumors: results of propensity score analyses Ann Surg Oncol 21 2014 4211 4217
79. S.J. Park, M.H. Ryu, B.Y. Ryoo, Y.S. Park, B.S. Sohn, H.J. Kim, and et al. The role of surgical resection following imatinib treatment in patients with metastatic or recurrent GIST J Clin Oncol 4 Suppl 2013 Abstr No. 62
80. C.P. Raut, M. Posner, J. Desai, J.A. Morgan, S. George, D. Zahrieh, and et al. Surgical management of advanced gastrointestinal stromal tumors after treatment with targeted systemic therapy using kinase inhibitors J Clin Oncol 24 2006 2325 2331
81. Z.M. Bamboat, and R.P. Dematteo Metastasectomy for gastrointestinal stromal tumors J Surg Oncol 109 2014 23 27
82. R.W. Randle, K.R. Swett, P. Shen, J.H. Stewart, E.A. Levine, and K.I. Votanopoulos Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy in peritoneal sarcomatosis Am Surg 79 2013 620 624
83. R.S. Turley, P.D. Peng, S.K. Reddy, A.S. Barbas, D.A. Geller, J.W. Marsh, and et al. Hepatic resection for metastatic gastrointestinal stromal tumors in the tyrosine kinase inhibitor era Cancer 118 2012 3571 3578
84. L. Xia, M.-M. Zhang, L. Ji, X. Li, and X.-T. Wu Resection combined with imatinib therapy for liver metastases of gastrointestinal stromal tumors Surg Today 40 2010 936 942