Comment on: Relationship between R1 resection, tumour rupture and recurrence in resected gastrointestinal stromal tumour

Editor We read with interest the article by Holmebakk et al.1 concerning the relationship between R1 resection, tumour rupture and recurrences in resected gastrointestinal stromal tumours (GISTs). The authors pointed out that tumour rupture was independently associated with recurrences, whereas an R1 resection, which is associated strongly with tumour rupture, does not independently impact upon the prognosis. The authors defined microscopically involved resection margins (R1) as a minor defect of tumour integrity and reserved the term ‘tumour rupture’ for a major defect in tumour integrity2. However, a recent systematic review and meta-analysis3 concluded that a microscopically positive margin could impact significantly upon disease-free survival in R1 resected GISTs. While we wait for further studies to clarify the impact of tumour rupture and R1 resection on the outcome of GISTs, we believe that it is important that two major considerations should be taken into account. First, minimally invasive treatment for upper GISTs, which utilizes recently introduced modified endoscopic techniques (endoscopic enucleation, full-thickness resection or laparoscopic endoscopic cooperative surgery), is not an appropriate procedure for GIST because of the potential risk of tumour rupture according to the Oslo definition. Moreover, enucleation of GIST implies that the plane of dissection is conducted along the entire surface of the tumour on its pseudocapsule without a distance margin, so that at best, a microscopic residual tumour resection (R1) is performed4. Second, the role of laparoscopic resection for large gastrointestinal stromal tumours remains under debate due to the possibility of intraoperative tumour rupture5.