GIST Specialist for Playa del Rey, CA
Sometimes a gastrointestinal stromal tumor is not the main problem. It turns up in a specimen removed for another cancer, or alongside one, and then the question is which disease sets the agenda. Joshua Ellenhorn, MD, FACS answers that plainly.
- Assessment of GIST discovered alongside another malignancy
- Clinical Professor of Surgery, Cedars-Sinai Medical Center
- Clear sequencing when two cancers compete for priority
- Willing to say the GIST is not the urgent problem
The Question Is Which Disease Sets the Agenda
Not every GIST diagnosis arrives as the main event. A stomach removed for gastric cancer is examined thoroughly, and a small gastrointestinal stromal tumor is found in the wall that nobody knew was there. A colon resection specimen turns up something unexpected. A staging scan for one cancer shows a mass that turns out to be a second, unrelated tumor.
The instinct in that situation is to treat everything with equal urgency, and it is the wrong instinct. Two cancers rarely carry equal weight. A small, low mitotic count gastric GIST discovered incidentally has a progression risk close to zero and, if it sat within the tissue already removed, has been definitively treated by an operation performed for something else entirely. An aggressive adenocarcinoma in the same patient is a different order of threat.
The specific harm to avoid is allowing the lesser disease to interfere with treatment of the greater one. Delaying chemotherapy to schedule a GIST resection that was not needed, or adding imatinib with its drug interactions and side effects for a tumor that did not warrant it, makes the overall situation worse rather than better. Getting this right requires someone to state a priority rather than to treat both diseases as equally pressing.
It also requires someone to own the sequencing. With two cancers there are usually two teams, and the failure mode is each politely deferring to the other while nothing is decided.
How Two Coexisting Cancers Are Sequenced
These are the common scenarios and the usual reasoning. The principle throughout is that the more threatening disease leads.
| Scenario | Usual priority | What happens to the GIST |
|---|---|---|
| Small GIST found inside a specimen removed for another cancer | The other cancer entirely | Already fully removed. Risk graded from the pathology, and usually nothing further is needed |
| Small low risk GIST alongside an aggressive separate cancer | The aggressive cancer | Surveillance rather than surgery, revisited once the dominant disease is controlled |
| Both tumors in the same operative field | A combined operation is often reasonable | Removed at the same sitting, provided it adds little additional risk |
| Both tumors significant, different sites | Judged case by case, usually the faster growing disease first | Sequenced rather than simultaneous, unless combining is genuinely safe |
| High risk GIST alongside a low risk second cancer | The GIST may well lead | Treated on its own merits, with adjuvant therapy if the grading warrants it |
| Multiple tumor types with a syndromic pattern | Depends on the syndrome | Assessed alongside genetic review, particularly where neurofibromatosis type 1 is involved |
Whichever leads, the GIST still needs proper risk grading from size, site and mitotic index. Being the secondary problem is not a reason for it to go ungraded.
Two Different Diseases That Happen to Share a Patient
GIST arises from the interstitial cells of Cajal, pacemaker cells embedded within the wall of the digestive tract, driven by a mutation in KIT or PDGFRA. It is a sarcoma. Gastric and colorectal cancers arise from the glandular lining on the inner surface, through entirely different genetic pathways. They are carcinomas.
Different cell of origin, different mechanism, different behaviour, different treatment. Neither causes the other, and their coexistence is generally either coincidence or the product of examining a specimen carefully that was removed for another reason. Patients frequently worry that finding two cancers means something systemic is wrong, and in most cases it does not.
The exceptions are worth checking. Certain inherited syndromes predispose to more than one tumour type, and neurofibromatosis type 1 is specifically associated with GIST, typically multiple small bowel tumors that are wild type and respond poorly to imatinib. A review of personal and family history is a reasonable thing to include when two primaries appear, particularly in a younger patient.
The GIST Operation Itself
Recordings of real GIST resections narrated by the surgeon who performed them. Relevant if the GIST does turn out to be the tumor requiring definitive surgery.
Laparoscopic Resection of a Gastric GIST
A gastric GIST removed through small incisions with the capsule kept intact.
Gastric GIST Resection: A Simplified Approach
A refined approach that shortens operating time and recovery, which matters more when other treatment is waiting.
Robotic Resection of a Duodenal GIST
Duodenal GIST removed robotically with the pancreas and bile duct preserved.
Which Cancer Is Driving the Plan?
With two diagnoses, someone should be able to say which one leads and why. If both teams are waiting for the other to decide, that is the problem to solve before any treatment decision gets made.
Certifications and Appointments
Two American Board of Surgery certifications, a Cedars-Sinai teaching appointment, and membership of the societies that set the 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.
A surgeon with a narrow specialty has an obvious temptation when a patient has two cancers, which is to treat the one he knows best as the important one. Resisting that is the whole value of the consultation here. A great many of these conversations end with the conclusion that the GIST needs grading, documenting, and then leaving alone while a more dangerous disease is dealt with by someone else. Being clear about that is more useful to the patient than being enthusiastic about the tumor that happens to be your subject.
He is certified by the American Board of Surgery in General Surgery and in 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
Reviews left by patients treated by Dr. Ellenhorn at the Surgery Group of Los Angeles.
★★★★★Very kind stuff, great service. Dr Joshua Ellenhorn is a very calm doctor who takes time with his patient.
Anita Lukacevic
★★★★★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
From Playa del Rey
Manchester or Jefferson east to La Cienega and north, then east along 3rd Street. The 90 east to the 405 north and the 10 is quicker outside peak hours. Twenty five to thirty minutes depending on the time of day.
The office is in the medical plaza attached to Cedars-Sinai Medical Center. For a patient with two cancers being managed by two teams, having the surgical opinion inside the same comprehensive cancer institute as medical oncology matters, because the sequencing decision described on this page is much easier to make when both parties are in the same building.
Patients travelling from outside the region, including Arizona and Nevada, can have imaging and pathology reviewed remotely.
8635 W 3rd St, Suite 880W
Los Angeles, CA 90048
Monday to Saturday, 11:00am to 8:00pm
Closed Sunday
Frequently Asked Questions
A GIST was found during my surgery for another cancer. Is that unusual?
Which cancer gets treated first?
Could the GIST have caused the other cancer, or vice versa?
Should I have both operations at once?
Will imatinib interfere with my other cancer treatment?
Does having two cancers mean something is wrong with my genes?
Who coordinates all of this?
How far is your office from Playa del Rey?
Two Diagnoses Need One Priority.
A small incidentally discovered GIST is usually not the tumor that should be setting your treatment schedule. Getting the sequencing right matters more than treating everything at once.
