at MedStar Georgetown University Hospital,

I also serve as the surgeon in chief for the Lombardi Comprehensive Cancer Center.

I have the high privilege of caring for patients with GI cancer,

soft tissue sarcoma, gastrointestinal stromal tumors

and malignant melanoma.

To be diagnosed with cancer is a devastating diagnosis, and it impacts

the way you think and it impacts your lifestyle

and all the future decisions that you have.

As a surgical oncologist, I see the glass half full.

There's a treatment option for nearly every individual.

So we're here to help our patients the best that we can

and offer those patients hope at their very vulnerable times of their life.

Surgical oncology is special to have evolved over the last 2-3 decades.

Surgeons spend 2-3 years at the major Comprehensive Cancer Center

learning tools and techniques, and I'm a member of a team

and feel intensely committed to this team approach

to individuals with these cancers.

It's challenging, it keeps you thinking all the time

at how can we help our patients and offer them the best outcomes that we can.

The diagnosis itself can be at times challenging and require

our specialized pathologist.

Some of the diseases, you have 50 types of sarcoma different from each other.

So again, you'd like to be at a center where your pathologists, surgeons,

medical oncologists, radiologists are working together,

familiar with these diseases and be able to streamline

the treatment decision for complex diseases.

So this is an environment where we're stimulated and challenged constantly

to help our patients, and I thrive in these kinds of environments

where it's research driven based on the latest treatment options

to offer our patients here at MedStar Georgetown University Hospital.

What we offer at MedStar Georgetown University Hospital

is an array of highly specialized physicians in various aspect of

the continuum of cancer care.

We have specialized surgeons with fellowship training in surgical oncology,

you have specialized medical oncologists, you have radiation therapists

who are very familiar with that various types of disease sites,

and we have a very robust partnership with the Lombardi Comprehensive Cancer Center,

one of the few cancer canters in the nation that has

a Comprehensive Cancer Center designation,

and it's the only one in the D.C metro area. So we feel that we offer our patients

cutting-edge, the latest in access to cancer clinical trials

that very few centers in the country are able to offer

these kinds of treatment options to our patients with cancer.

GIST or Gastrointestinal Stromal Tumors are a rare group of tumors

that occur in the gastrointestinal tract,

so if I may describe to you what is a gastrointestinal tract or a GI tract

it's the organs in the abdominal cavity that are starting from the esophagus,

the swallowing tube or pipe if you will

going through the stomach, then the intestines, the colon

and then the rectum ending in the anus itself.

So GIST are a group of tumors that have a tendency to occur

in the intestine itself, hence the name GI stromal tumors.

They're not very common as I mentioned, there are about 5,000-6,000 cases.

They tend to occur more commonly in the stomach because the stomach itself

has a larger surface area in the abdominal cavity.

The cause of GIST is basically due to an activation of a protein

or a molecule in a protein called KIT, spelled KIT or c-KIT

and these molecules or protein molecules

are found inside the cells of the muscles of the intestines themselves.

And the cells are called "interstitial cells of Cajal"

or "the pacemaker of the intestines" that lead to trigger

the movement of the intestines. So what happens in patients with GIST,

the cells develop in an uncontrolled manner and then lead to the development

of GIST tumors.

The spectrum of the diagnosis of GIST varies, so in many patients

they do not have a particular symptom so the diagnosis of GIST is found

incidentally during a CT scan done for a lung nodule or for another reason.

At times a gastroenterologist who's performing an endoscopy

for an unrelated symptom and then an abnormality on the stomach is found

or a surgeon is operating on a patient for another reason

and then a gastrointestinal stromal tumor is found.

At other times, if the tumor is large, patients do present with feeling full

in the intestines, they have a change in their appetite,

a palpable mass is felt in the abdomen as well.

Rarely patients may present with blockage of their intestines or bleeding.

So GIST can occur anywhere in the intestinal tract

but it's more commonly, in about 60% of patients it occurs in the stomach itself

and I want to emphasize, patients sometimes use the word "stomach"

as a reflection of the entire intestinal cavity

but "stomach" is an organ on its own that may develop tumors and cancer

including gastrointestinal stromal tumors.

So the treatment of GIST is based on the stage of the patients.

At times a patient presents with very very small GIST tumors

and the treatment at that time is based on the size,

the location and whether surgery can help those patients or not.

At other times they present with a resectable or removable mass itself in the intestines

and there we offer surgery with or without targeted therapy

or what we call imatinib therapy.

At other times, a patient will present with an advanced GIS tumor

that involves many organs and believe that the treatment should involve

at the beginning a pill that's called imatinib therapy to shrink it

in the hope that we can offer surgery.

At other times a patient unfortunately will present with a Metastatic GIST

that has spread to other organs like the liver or the lining

of the intestine itself. So essentially, the treatment is based on

the presentation or the stage itself of the disease.

So here at MedStar Georgetown University Hospital,

at Lombardi Comprehensive Cancer Center, we have a team approach

to patients with gastrointestinal tumors.

Surgeons are very experienced and well versed with those rare tumors,

medical oncologists are very experienced in terms of offering patients

the latest in gastrointestinal stromal tumors.

We have high-quality radiographic imaging as well

and we offer patients access to clinical trials

for various types of gastrointestinal stromal tumor.

The approach is a team based approach that's research driven

and based on offering patients the highest service

and quality to our patients with GIST.

In some individuals with GIST where the tumors are small

and has favorable features and that's a decision made

on how the features of the GIST itself appear after an assessment,

patients will only require surgery alone. That is surgery

with the entire tumor removed and no tumor left behind.

In patients who have larger tumors who are unusual

or unfavorable features, we include surgery with what we call "targeted therapy"

that is a pill or imatinib treatment that targets the mutation

in the molecule or the protein c-KIT itself,

it blocks the growth and minimizes the recurrence of GIST after surgery

and perhaps, improve the survival.

So in certain groups of patients we offer imatinib or targeted therapy

in addition to surgery as well.

So the prognosis depends again on the location of the GIST,

the size of the GIST,

a phenomenon called the Mitotic Index, the number of unusual cells

under the microscope, and...

whether there's...

the location of the GIST itself. So I'll give you an example.

Patients who have smaller GIS tumors have a better prognosis than larger ones.

Patients who have less abnormal cells of GIST

tend to have a better prognosis

and those who have a GIST that arises in the stomach itself

have a better prognosis than other organs of the stomach.

And on a molecular level, at times patients have different mutations of their GIST

and that determines their prognosis as well.

And the prognosis is the frequency of GIST coming back again

and the overall survival.

It's not. GIST is a form of a stomach tumor.

So the most common stomach cancer is...

is an adenocarcinoma of the stomach and that's the most common one.

Other less common ones are gastrointestinal stromal tumor

that may occur in the stomach or other organs in the abdominal cavity

but not the most common one. It definitely in most cases has

a more favorable prognosis than a patient with a gastric cancer

or gastric adenocarcinoma.

For most patients with GIST we offer them radiographic imaging

that is a CT scan with or without a PET scan

to insure that the GIST tumor is recognized as it occurs early

so we do that and follow-up a period of time.

The concern that we have after removing a GIST is recurrence,

the GIST coming back again, and that's the reason why in patients

who have a risk of recurrence of their GIST we'd offer them imatinib therapy

and watch them closely.

So the recurrence of a GIS tumor depends on the size of the GIST itself

and the Mitotic Index. So patients who have smaller GIST and less...

and a lower mitotic rate, i.e. less unusual cells,

they have a very low risk of recurrence of their GIST.

I'll give you an example. If you have a patient with a GIST

that is smaller than 2cm in size that's located in the stomach itself

with very few unusual cells, the risk of progression and recurrence

is extremely low, less than 5%

whereas if we have an individual who has a 15cm risk of... excuse me,

a 15cm size of GIST that's located in the intestines

with a high number of unusual cells

their risk of recurrence goes up above 20%-30%

if not higher within the first 3 years. So again, we use a risk stratified manner

to predict the risk of a recurrence that's based on the location of the GIST,

the size of the GIST, the mitotic rate

and whether they have some mutation as well at that level.

So the mitotic rate is the number of unusual cells

in a certain block under the microscope,

so that's a microscopic evaluation that our pathologist will provide us

at the time of diagnosis.

So very few patients have a family history of GIST.

I mean, there are described syndromes that patients have with GIST

but they're less than 10% or less than 5%.

The vast majority of patients with GIST are what we call sporadic GIST

with no strong family history or genetic component

that runs in the families themselves.