GIST Specialist for Encino, CA
Being told a tumor is too large, or that removing it means removing most of your stomach, is not always the final word. Targeted therapy can shrink a gastrointestinal stromal tumor into a far smaller operation. Joshua Ellenhorn, MD, FACS decides when that applies.
- Second opinions on tumors described as inoperable or borderline
- Clinical Professor of Surgery, Cedars-Sinai Medical Center
- Neoadjuvant imatinib sequencing, timed to the point of maximum response
- Remote imaging review before you cross the hill
Sometimes the Best First Move Is Not Surgery
Surgery cures GIST. That does not mean surgery should always come first. For a bulky tumor, or one pressing against the pancreas, the spleen, or the gastroesophageal junction, operating immediately can mean removing far more than the disease requires.
Imatinib changes that. In tumors with a responsive mutation, three to nine months of treatment can shrink the mass substantially, pulling it away from the structures it was abutting. An operation that would have taken most of the stomach becomes a wedge. A resection that looked to involve neighbouring organs becomes a clean, contained one.
The judgment is in the timing. Operate too early and the benefit is wasted. Continue past the plateau, usually visible on serial imaging, and you are delaying the curative step for no gain. That window is narrow and it is easy to miss without experience of watching tumors respond.
Which is also why mutation testing comes first. A PDGFRA D842V or wild type tumor is unlikely to shrink, and months spent discovering that are months lost. Knowing which category you are in before starting is the entire point.
What a Gastrointestinal Stromal Tumor Is
GIST develops from the interstitial cells of Cajal, pacemaker cells inside the wall of the digestive tract that coordinate the contractions moving food along. It is a sarcoma, and it does not behave like the carcinomas that account for most gastrointestinal cancer.
Because these tumors grow outward from the wall rather than into the passage, they can become genuinely large before causing symptoms. Patients are often surprised at the size of something they had no inkling of. That outward growth is also why they seldom involve lymph nodes, and why removal with a clear margin, rather than a wide anatomical clearance, is what constitutes a cure.
Nearly all carry a driver mutation in KIT, a minority in PDGFRA. That mutation is both the reason the tumor grows unchecked and the reason a tablet can shrink it. Which specific mutation you have determines whether that tablet will work at all.
Before Anything, Establish the Full Picture
For a large tumor, staging is not a formality. Contrast CT of the abdomen and pelvis defines the tumor and its relationships, and looks for liver deposits, which are the commonest site of spread. PET/CT is particularly useful here because it also gives an early read on whether a tumor is responding once treatment starts, often well before it visibly shrinks.
Biopsy with mutation testing is generally necessary when medication is being considered, and endoscopic ultrasound guided sampling is the controlled way to obtain it. The caution is real: rupturing the capsule of a large tumor can seed the abdominal cavity, so who takes the sample and how matters.
Bring or send whatever your Encino physician has already ordered. For bulky tumors the actual imaging study is far more useful than the written report, because the surgical question is about millimetres of contact with adjacent structures.
How a Large Tumor Is Actually Handled
Three phases, and the skill lies in judging when to move between them.
Stage and Genotype
Full imaging plus a biopsy with mutation testing. This establishes whether the tumor will respond to imatinib and whether disease has already reached the liver. Everything downstream depends on these two answers.
Shrink It
Imatinib for three to nine months in responsive tumors, with serial imaging to track the response. The aim is the point of maximum shrinkage, which is when the operation is smallest and safest.
Remove It
Resection at the optimal moment, frequently far more limited than what was originally proposed. Adjuvant therapy usually continues afterwards, since a large tumor carries higher recurrence risk regardless of how well it responded.
The Operations, Recorded
Real GIST resections narrated by the surgeon who performed them. Worth watching if you are trying to understand what a limited resection actually involves compared with what may have been proposed to you.
Laparoscopic Resection of a Gastric GIST
A gastric GIST removed through small incisions with the capsule intact.
Gastric GIST Resection: A Simplified Approach
A streamlined approach that shortens operating time and recovery.
Robotic Resection of a Duodenal GIST
Duodenal GIST in confined anatomy, removed robotically with the pancreas and bile duct preserved.
Get It Read Again
Unresectable and not yet resectable are very different conclusions, and the second one often changes after a few months of the right drug. Before accepting the first, have the imaging and mutation status reviewed by someone who sequences these routinely.
Credentials and Licensure
Two American Board of Surgery certifications, a Cedars-Sinai teaching appointment, and membership of the societies that set standards for this disease.
- American Board of Surgery, certified in General Surgery
- American Board of Surgery, certified in Colorectal Surgery
- California State Medical License
- Florida State Medical License
Joshua Ellenhorn, MD, FACS
Dr. Ellenhorn is a surgical oncologist and Clinical Professor of Surgery at Cedars-Sinai Medical Center, and a collaborative member of the Samuel Oschin Comprehensive Cancer Institute. He is widely regarded as one of the foremost GIST surgeons in the country.
His practice is deliberately narrow, concentrating on complex abdominal cancers and gastrointestinal stromal tumors. Bulky and borderline resectable tumors are a substantial part of that work, which is where the sequencing of drug therapy and surgery has the greatest effect on the eventual operation.
He is certified by the American Board of Surgery in General Surgery and Colorectal Surgery, a Fellow of the American College of Surgeons, and a member of the Society of Surgical Oncology and the American Society of Clinical Oncology. He practises with the Surgery Group of Los Angeles.
What Patients Say About Dr. Ellenhorn
Reviews left by patients treated by Dr. Ellenhorn at the Surgery Group of Los Angeles.
★★★★★The staff at the Surgery Group of Los Angeles are wonderful. They are kind, very attentive, the office is clean and I did not have to wait long at all. I cannot say enough great things about Dr. Ellenhorn. He is an excellent surgeon who is highly skilled and very knowledgeable. I cannot thank him enough for all he has done for my family and I.
Erika Frank
★★★★★Very kind stuff, great service. Dr Joshua Ellenhorn is a very calm doctor who takes time with his patient.
Anita Lukacevic
From Bulky Tumor to Smaller Operation
Send the Study, Not Just the Report
Call (310) 356-3792 or book online, then forward the actual CT or PET imaging along with pathology and mutation results. For large tumors the images carry information the report does not.
Agree the Sequence
You should leave knowing whether surgery comes now or after medication, what response would be needed to change the operation, and when the imaging checkpoints fall.
Operate at the Right Moment
Resection timed to maximum response, with your Encino oncologist managing the drug throughout and receiving the operative findings afterwards.
Thirty Minutes From Ventura Boulevard
Ventura Boulevard east to Coldwater Canyon, over the hill to Beverly Drive and east to 3rd Street, is the standard route from Encino. The 101 east to Laurel Canyon and south is the alternative. Either canyon adds time during the morning and evening peaks, so allow closer to thirty five minutes then.
The office is in the medical plaza attached to Cedars-Sinai Medical Center, which for a patient managing staging scans, oncology visits, and eventually surgery means one destination rather than several. Given the drive from the west Valley, that consolidation is worth more here than it is closer in.
If crossing the hill repeatedly is impractical, imaging and pathology can be reviewed remotely and much of the planning done before you travel at all.
8635 W 3rd St, Suite 880W
Los Angeles, CA 90048
Monday to Saturday, 11:00am to 8:00pm
Closed Sunday
Frequently Asked Questions
My tumor is large. Does that mean it is inoperable?
What does neoadjuvant imatinib actually do?
How long would I be on medication before surgery?
What if the tumor does not respond to the drug?
Is a large GIST more likely to have spread?
How far is your office from Encino?
Can my imaging be reviewed before I drive over the hill?
Will my Encino oncologist stay involved?
Too Large Today Does Not Mean Too Large in Six Months.
If you have been told a gastrointestinal stromal tumor is inoperable or requires a major resection, the mutation status and a course of targeted therapy may change that entirely. Have it reviewed first.
