Ronald P DeMatteo

Memorial Sloan-Kettering Cancer Center, New York City, New York, United States

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Publications (361)1904.22 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Objectives This study was conducted to evaluate the prognostic value of, respectively, the 6th and 7th editions of the American Joint Committee on Cancer (AJCC) staging system for patients with resected perihilar cholangiocarcinoma (PHC).Methods Patients who underwent resection of PHC between 1991 and 2012 were identified from prospective databases at two centres. Overall survival was estimated using the Kaplan–Meier method and compared across stage groups with the log-rank test. The concordance index and Brier score were used to compare the prognostic accuracy of the staging systems.ResultsData for a total of 306 patients were analysed. Staging according to the 7th edition upstaged 63% of patients in comparison with staging by the 6th edition. The log-rank P-value for both staging systems was highly statistically significant (P < 0.001). Staging according to the 6th edition categorized 93% of patients as having stage I or II disease, whereas staging according to the 7th edition distributed patients more equally across stages. Prognostic accuracy was similar between the staging systems: the concordance index was 0.59 and the Brier score 0.17 for both the 6th and 7th editions. The same prognostic accuracy was achieved using an alternative tumour–node–metastasis (TNM) stage grouping simplified to four rather than six stage groups.Conclusions The 6th and 7th editions of the AJCC staging system for PHC have similar prognostic accuracy. Other prognostic factors can potentially improve individual patient prognostication.
    HPB 10/2014; · 1.94 Impact Factor
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    ABSTRACT: Background Microwave ablation has emerged as a promising treatment for liver malignancies, but there are scant long-term follow-up data. This study evaluated long-term outcomes, with a comparison of 915-MHz and 2·4-GHz ablation systems.Methods This was a retrospective review of patients with malignant liver tumours undergoing operative microwave ablation with or without liver resection between 2008 and 2013. Regional or systemic (neo)adjuvant therapy was given selectively. Local recurrence was analysed using competing-risk methods with clustering, and overall survival was determined from Kaplan–Meier curves.ResultsA total of 176 patients with 416 tumours were analysed. Colorectal liver metastases (CRLM) comprised 81·0 per cent of tumours, hepatocellular carcinoma 8·4 per cent, primary biliary cancer 1·7 per cent and non-CRLM 8·9 per cent. Median follow-up was 20·5 months. Local recurrence developed after treatment of 33 tumours (7·9 per cent) in 31 patients (17·6 per cent). Recurrence rates increased with tumour size, and were 1·0, 9·3 and 33 per cent for lesions smaller than 1 cm, 1–3 cm and larger than 3 cm respectively. On univariable analysis, the local recurrence rate was higher after ablation of larger tumours (hazard ratio (HR) 2·05 per cm; P < 0·001), in those with a perivascular (HR 3·71; P = 0·001) or subcapsular (HR 2·71; P = 0·008) location, or biliary or non-CRLM histology (HR 2·47; P = 0·036), and with use of the 2·4-GHz ablation system (HR 3·79; P = 0·001). Tumour size (P < 0·001) and perivascular position (P = 0·045) remained significant independent predictors on multivariable analysis. Regional chemotherapy was associated with decreased local recurrence (HR 0·49; P = 0·049). Overall survival at 4 years was 58·3 per cent for CRLM and 79·4 per cent for other pathology (P = 0·360).Conclusion Microwave ablation of liver malignancies, either combined or not combined with liver resection, and selective regional and systemic therapy resulted in good long-term survival. Local recurrence rates were low after treatment of tumours smaller than 3 cm in diameter, and those remote from vessels.
    British Journal of Surgery 10/2014; · 4.84 Impact Factor
  • Vinod P. Balachandran, Ronald P. DeMatteo
    Advances in Surgery. 09/2014;
  • Vinod P Balachandran, Ronald P DeMatteo
    Annals of Surgical Oncology 08/2014; · 4.12 Impact Factor
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    ABSTRACT: Background The reliable prediction of hepatocellular carcinoma (HCC) recurrence patterns potentially allows for the prioritization of patients for liver resection (LR) or transplantation.Objectives The aim of this study was to analyse clinicopathological factors and preoperative Milan criteria (MC) status in predicting patterns of HCC recurrence.Methods During 1992–2012, 320 patients undergoing LR for HCC were categorized preoperatively as being within or beyond the MC, as were recurrences.ResultsAfter a median follow-up of 47 months, 183 patients developed recurrence, giving a 5-year cumulative incidence of recurrence of 62.5%. Patients with preoperative disease within the MC had better survival outcomes than those with preoperative disease beyond the MC (median survival: 102 months versus 45 months; P < 0.001). Overall, 31% of patients had preoperative disease within the MC and 69% had preoperative disease beyond the MC. Estimated rates of recurrence-free survival at 5 years were 61.8% for all patients and 53.8% for patients with initial beyond-MC status. Independent factors for recurrence beyond-MC status included preoperative disease beyond the MC, the presence of microsatellite or multiple tumours and lymphovascular invasion (all: P < 0.001). A clinical risk score was used to predict survival and the likelihood of recurrence beyond the MC; patients with scores of 0, 1, 2 and 3 had 5- year incidence of recurring beyond-MC of 9.0%, 29.5%, 48.8% and 75.4%, respectively (P < 0.0001).Conclusions Regardless of initial MC status, at 5 years the majority of patients remained disease-free or experienced recurrence within the MC after LR, and thus were potentially eligible for salvage transplantation (ST). Incorporating clinicopathological parameters into the MC allows for better risk stratification, which improves the selection of patients for ST and identifies patients in need of closer surveillance.
    HPB 08/2014; · 1.94 Impact Factor
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    ABSTRACT: Readmission rates have been targeted for cost/reimbursement control. Our goal was to identify causes for readmission and delineate the pattern of early and late readmission.
    Annals of Surgical Oncology 07/2014; · 4.12 Impact Factor
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    ABSTRACT: Background Current pre-operative staging methods for gallbladder cancer (GBC) are suboptimal in detecting metastatic disease. Positron emission tomography (PET) may have a role but data are lacking.Methods Patients with GBC and PET assessed by a hepatobiliary surgeon in clinic between January 2001 and June 2013 were retrospectively reviewed. Computed tomography (CT)/magnetic resonace imaging (MRI) were correlated with PET scans and analysed for evidence of metastatic or locally unresectable disease. Medical records were reviewed to determine if PET scanning was helpful by preventing non-therapeutic surgery or enabling resection in patients initially deemed unresectable.ResultsThere were 100 patients including 63 incidental GBC. Thirty-eight patients did not proceed to surgery, 35 were resected and 27 patients were explored but had unresectable disease. PET was positive for metastatic disease in 39 patients (sensitivity 56%, specificity 94%). Five patients definitively benefitted from PET: in 3 patients PET found disease not seen on CT, and 2 patients with suspicious CT findings had negative PET and successful resections. In a further 12 patients PET confirmed equivocal CT findings. Three patients had additional invasive procedures performed owing to PET avidity in other sites. Utility of PET was higher in patients with suspicious nodal disease on CT [odds ratio (OR) 7.1 versus no nodal disease, P = 0.0004], and in patients without a prior cholecystectomy (OR 3.1 versus post-cholecystectomy, P = 0.04).Conclusion Addition of PET to conventional cross-sectional imaging has a modest impact on management pre-operatively particularly in patients without a prior cholecystectomy and to confirm suspicious nodal disease on CT.
    HPB 07/2014; · 1.94 Impact Factor
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    ABSTRACT: The role for neoadjuvant systemic therapy in resectable pancreas adenocarcinoma remains undefined.
    Annals of surgery. 07/2014; 260(1):142-148.
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    ABSTRACT: BACKGROUND The validity of the KRAS mutation as a predictor of recurrence-free survival (RFS) or overall survival (OS) is unclear. The current study investigated whether the presence of the KRAS mutation decreased RFS or OS in patients with colorectal cancer who underwent liver resection.METHODS Patients with resected colorectal liver metastases who received adjuvant hepatic arterial infusion plus systemic therapy and for whom KRAS data was available were evaluated. Correlation between KRAS and clinical factors was done using the Fisher exact test. Kaplan-Meier methods were used to estimate the median RFS and OS.RESULTSA total of 169 patients were evaluated, 118 of whom had KRAS wild-type (WT) and 51 had KRAS mutated (MUT) tumors. The 3-year RFS rate was 46% for patients with KRAS WT (95% confidence interval [95% CI], 35%-56%) and 30% (95% CI, 16%-44%) for patients with KRAS MUT (P =.005). The 3-year OS rate was 95% (95% CI, 87%-98%) and 81% (95% CI, 62%-95%), respectively, for patients with KRAS WT and KRAS MUT (P =.07). On multivariate analysis, KRAS remained a significant predictor of RFS (hazard ratio, 1.9). The 3-year cumulative recurrence rate by site of metastases was as follows: 2% versus 13.4% for bone (P≤.01), 2% versus 14.5% for brain (P =.05), 33.2% versus 58% for lung (P≤.01), and 30% versus 47% for liver (P =.10) in patients with KRAS WT versus KRAS MUT.CONCLUSIONS In the current study, among patients with resected colorectal liver metastases who were treated with adjuvant hepatic arterial infusion plus systemic therapy, patients with KRAS MUT were found to have a significantly worse 3-year RFS (30%) compared with KRAS WT (46%) p=.005. The cumulative incidence of bone, brain, and lung metastases was significantly higher for patients with KRAS MUT compared with those with KRAS WT. Cancer 2014. © 2014 American Cancer Society.
    Cancer 07/2014; · 5.20 Impact Factor
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    ABSTRACT: Objective Fibrolamellar carcinoma (FLC) is a rare disease, with limited radiographic reported information. We assessed the imaging patterns of primary and metastatic FLC. Methods CT and MR examinations of patients with FLC were retrospectively reviewed. Imaging features were assessed for primary and recurrent liver tumors, including dimension, enhancement characteristics, presence or absence of central scars. Locations of nodal and extranodal metastases were also recorded. Results Of 37 patients (18 male, 19 female; average age 23.5 years) with FLC, 24 had imaging of their primary tumor; 13 had metastases at presentation and 7 developed metastases on follow-up. The remaining 13 patients had follow-up imaging of metastatic disease. Primary FLC had a mean diameter >11 cm, with central scars in 10 (46%) patients. Most tumors enhanced heterogeneously (96%) and showed arterial enhancement (81%). On MRI, 62% of FLC were hypointense on T1 weighted imaging, and 54% were hyperintense on T2 weighted imaging. Thirteen patients (54%) had nodal metastases at presentation, mostly in the upper abdomen (92%), and commonly in the chest (38%). Extrahepatic metastases were most frequently pulmonary or peritoneal. Predominantly small and homogeneous intrahepatic recurrences were detected on follow up in 15 patients. Conclusion FLC often presents as a large hepatic tumor with nodal and distant metastases. Thoracic adenopathy and lung metastases were frequently found in our series, suggesting the need for preoperative and follow-up chest imaging. Advances in Knowledge Thoracic nodal and lung metastases are common in FLC; therefore dedicated chest imaging should be part of FLC patient evaluation.
    The British journal of radiology. 06/2014;
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    ABSTRACT: Microwave (MWA) and radiofrequency ablation (RFA) are the most commonly used techniques for ablating colorectal-liver metastases (CRLM). The technical and oncologic differences between these modalities are unclear.
    Annals of Surgical Oncology 06/2014; · 4.12 Impact Factor
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    ABSTRACT: Tumor-infiltrating lymphocytes (TIL) in colorectal cancer liver metastases (CLM) have been associated with more favorable patient outcomes, but whether MHC class I (MHC-I) expression on cancer cells affects prognosis is uncertain. Immunohistochemistry was performed on a tissue microarray of 158 patients with CLM, who underwent partial hepatectomy with curative intent. Using the antibody HC-10, which detects HLA-B and HLA-C antigens and a minority of HLA-A antigens, MHC-I expression was correlated with β-2 microglobulin (β2m; r = 0.7; P < 0.001), but not with T-cell density (r < 0.32). The median follow-up for survivors was 9.7 years. High levels of MHC-I expression in tumors concomitant with high T-cell infiltration (CD3, CD4, or CD8) best identified patients with favorable outcomes, compared with patients with one or none of these immune features. The median overall survival (OS) of patients with MHC-I(hi)CD3(hi) tumors (n = 31) was 116 months compared with 40 months for the others (P = 0.001), and the median time to recurrence (TTR) was not reached compared with 17 months (P = 0.008). By multivariate analysis, MHC(hi)CD3(hi) was associated with OS and TTR independent of the standard clinicopathologic variables. An immune score that combines MHC-I expression and TIL density may be a valuable prognostic tool in the treatment of patients with CLM. Cancer Immunol Res; 2(6); 530-7. ©2014 AACR.
    Cancer immunology research. 06/2014; 2(6):530-7.
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    ABSTRACT: Postoperative pancreatic fistula is a major contributor to complications and death associated with pancreatic resection. Pasireotide, a somatostatin analogue that has a longer half-life than octreotide and a broader binding profile, decreases pancreatic exocrine secretions and may prevent postoperative pancreatic fistula.
    New England Journal of Medicine 05/2014; 370(21):2014-22. · 54.42 Impact Factor
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    ABSTRACT: Malignant peripheral nerve sheath tumor (MPNST) is a highly aggressive tumor type that is resistant to chemotherapy and there are no effective therapies. MPNSTs have been shown to have gene amplification for receptor tyrosine kinases (RTKs), PDGFR and c-Kit. We tested the c-Kit inhibitor, imatinib, and PLX3397, a selective c-Fms and c-Kit inhibitor, to evaluate their efficacy against MPNST cells in vitro and in vivo. We tested the efficacy of imatinib or PLX3397 either alone or in combination with TORC1 inhibitor rapamycin in a cell proliferation assay in vitro and by immunoblotting to determine target inhibition. Immunoblotting and immunohistochemical analysis was further carried out using xenograft samples in vivo. Our in vitro studies show that imatinib and PLX3397 similarly inhibit cell growth and this can be enhanced with rapamycin with comparable target specificity. However, in vivo studies clearly demonstrate that compared to imatinib, PLX3397 results in sustained blockade of c-Kit, c-Fms and PDGFRβ, resulting in significant suppression of tumor growth. Moreover, staining for Iba-1, a marker for macrophages, indicates that PLX3397 results in significant depletion of macrophages in the growing tumors. The combination of PLX3397 and rapamycin results in even greater macrophage depletion with continued growth suppression, even when the drug treatment is discontinued. Taken together, our data strongly suggests that PLX3397 is superior to imatinib in the treatment of MPNST, and the combination of PLX3397 with a TORC1 inhibitor could provide a new therapeutic approach for the treatment of this disease.
    Clinical Cancer Research 04/2014; · 7.84 Impact Factor
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    ABSTRACT: BACKGROUND Little is known about the factors that predict for gastrointestinal stromal tumor (GIST) recurrence in patients treated with adjuvant imatinib.METHODS Risk factors for GIST recurrence were identified, and 2 risk stratification scores were developed using the database of the Scandinavian Sarcoma Group (SSG) XVIII trial, where 358 patients with high-risk GIST with no overt metastases were randomly assigned to adjuvant imatinib 400 mg/day either for 12 or 36 months after surgery. The findings were validated in the imatinib arm of the American College of Surgeons Oncology Group Z9001 trial, where 359 patients with GIST were randomized to receive imatinib and 354 were to receive placebo for 12 months.RESULTSFive factors (high tumor mitotic count, nongastric location, large size, rupture, and adjuvant imatinib for 12 months) were independently associated with unfavorable recurrence-free survival (RFS) in a multivariable analysis in the SSGXVIII cohort. A risk score based on these 5 factors had a concordance index with GIST recurrence of 78.9%. When a simpler score consisting of the 2 strongest predictive factors (mitotic count and tumor site) was devised, the groups with the lowest, intermediate high, and the highest risk had 5-year RFS of 76.7%, 47.5%, and 8.4%, respectively. Both scores were strongly associated with RFS in the validation cohort (P < .001 for each comparison).CONCLUSIONS The scores generated were effective in stratifying the risk of GIST recurrence in patient populations treated with adjuvant imatinib. Patients with nongastric GIST with a high mitotic count are at a particularly high risk for recurrence. Cancer 2014 © 2014 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society.
    Cancer 04/2014; · 5.20 Impact Factor
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    ABSTRACT: For patients with unresectable intrahepatic cholangiocarcinoma (ICC), treatment options are limited and survival is poor. This study summarizes the long-term outcome of two previously reported clinical trials using hepatic arterial infusion (HAI) with floxuridine and dexamethasone (with or without bevacizumab) in advanced ICC. Prospectively collected clinicopathologic and survival data were retrospectively reviewed. Response was based on Response Evaluation Criteria in Solid Tumors (RECIST). Pre-HAI dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) images were reviewed, and tumor perfusion data correlated with outcome. Forty-four patients were analyzed (floxuridine, 26; floxuridine/bevacizumab, 18). At a median follow-up of 29.3 months, 41 patients had died of disease. Partial response by RECIST was observed in 48 %, and 50 % had stable disease. Three patients underwent resection after response, and 82 % received additional HAI after removal from the trials. Median survival was similar in both trials (floxuridine 29.3 months vs. floxuridine/bevacizumab 28.5 months; p = 0.96). Ten (23 %) patients survived ≥3 years, including 5 (11 %) who survived ≥5 years. Tumor perfusion measured on pre-treatment DCE-MRI [area under the gadolinium concentration curve at 90 and 180 s (AUC90 and AUC180, respectively)] was significantly higher in ≥3-year survivors and was the only factor that distinguished this group from <3-year survivors (mean AUC90 22.6 vs. 15.9 mM s, p = 0.025, and mean AUC180 48.9 vs. 32.3 mM s, p = 0.003, respectively). Median hepatic progression-free survival was longer in ≥3-year survivors (12.9 vs. 9.3 months, respectively; p = 0.008). HAI chemotherapy can result in prolonged survival in unresectable ICC. Pre-HAI DCE-MRI may predict treatment outcome.
    Annals of Surgical Oncology 03/2014; · 4.12 Impact Factor
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    ABSTRACT: Evaluate conversion rate of patients with unresectable colorectal-liver metastasis to complete resection with hepatic-arterial infusion plus systemic chemotherapy including bevacizumab (Bev). Forty-nine patients with unresectable colorectal liver metastases (CRLM) were included in a single-institution phase II trial. Conversion to resection was the primary outcome. Secondary outcomes included overall survival (OS), progression-free survival, and response rates. Multivariate and landmark analyses were performed to evaluate survival differences between resected and nonresected patients. Median number of tumors was 14 and 65% were previously treated patients. A high biliary toxicity rate was found in the first 24 patients whose treatment included Bev. The remaining 25 patients were treated without Bev. Overall response rates were 76% (4 complete responses). Twenty-three patients (47%) achieved conversion to resection at a median of 6 months from treatment initiation. Median OS and progression-free survival for all patients were 38 (95% confidence interval: 28 to not reached) and 13 months (95% confidence interval: 7-16). Bev administration did not impact outcome. Conversion was the only factor associated with prolonged OS and progression-free survival in multivariate analysis. On landmark analysis, patients who had undergone resection had longer OS than those who did not undergo resection (3-year OS: 80% vs 26%). Currently, 10 of 49 (20%) patients have no evidence of disease (NED) at a median follow-up of 39 months (32-65 months). In patients with extensive unresectable CRLM, the majority of whom were previously treated, 47% were able to undergo complete resection after combined HAI and systemic therapy. Conversion to resection is associated with prolonged survival.
    Annals of surgery 03/2014; · 7.90 Impact Factor
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    ABSTRACT: The ACOSOG (American College of Surgeons Oncology Group) Z9001 (Alliance) study, a randomized, placebo-controlled trial, demonstrated that 1 year of adjuvant imatinib prolonged recurrence-free survival (RFS) after resection of primary GI stromal tumor (GIST). We sought to determine the pathologic and molecular factors associated with patient outcome. There were 328 patients assigned to the placebo arm and 317 to the imatinib arm. Median patient follow-up was 74 months. There were 645 tumor specimens available for mitotic rate or mutation analysis. RFS remained superior in the imatinib arm (hazard ratio, 0.6; 95% CI, 0.43 to 0.75; Cox model-adjusted P < .001). On multivariable analysis of patients in the placebo arm, large tumor size, small bowel location, and high mitotic rate were associated with lower RFS, whereas tumor genotype was not significantly associated with RFS. Multivariable analysis of patients in the imatinib arm yielded similar findings. When comparing the two arms, imatinib therapy was associated with higher RFS in patients with a KIT exon 11 deletion of any type, but not a KIT exon 11 insertion or point mutation, KIT exon 9 mutation, PDGFRA mutation, or wild-type tumor, although some of these patient groups were small. Adjuvant imatinib did not seem to alter overall survival. Our findings show that tumor size, location, and mitotic rate, but not tumor genotype, are associated with the natural history of GIST. Patients with KIT exon 11 deletions assigned to 1 year of adjuvant imatinib had a longer RFS.
    Journal of Clinical Oncology 03/2014; · 18.04 Impact Factor
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    ABSTRACT: Gastrointestinal stromal tumor (GIST) is the most common human sarcoma and a model of targeted molecular therapy. GIST depends on oncogenic KIT signaling and responds to the tyrosine kinase inhibitor imatinib. However, imatinib is rarely curative. We hypothesized that PLX3397, which inhibits KIT and CSF1R, would be more efficacious than imatinib in GIST by also depleting tumor-associated macrophages, which are generally thought to support tumor growth. We treated KitV558del/+ mice that develop GIST or mice with subcutaneous human GIST xenografts with imatinib or PLX3397 and analyzed tumor weight, cellular composition, histology, molecular signaling, and fibrosis. In vitro assays on human GIST cell lines were also performed. PLX3397 was more effective than imatinib in reducing tumor weight and cellularity in both KitV558del/+ murine GIST and human GIST xenografts. The superiority of PLX3397 did not depend on depletion of tumor-associated macrophages, since adding CSF1R inhibition did not improve the effects of imatinib. Instead, PLX3397 was a more potent KIT inhibitor than imatinib in vitro. PLX3397 therapy also induced substantial intratumoral fibrosis, which impaired the subsequent delivery of small molecules. PLX3397 therapy has greater efficacy than imatinib in pre-clinical GIST models and warrants study in GIST patients. The resultant intratumoral fibrosis may represent one of the barriers to achieving complete tumor eradication.
    Clinical Cancer Research 02/2014; · 7.84 Impact Factor
  • Danielle M Bello, Ronald P Dematteo, Charlotte E Ariyan
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    ABSTRACT: The high response rates to the tyrosine kinase inhibitor imatinib in KIT-mutated gastrointestinal stromal tumors (GIST) has led to a paradigm shift in cancer treatment. In a parallel fashion, the field of melanoma is shifting with the utilization of targeted therapy to treat BRAF-mutated melanoma. We reviewed published literature in PubMed on GIST and melanoma, with a focus on both past and current clinical trials. The data presented centers on imatinib, vemurafenib, and most recently dabrafenib, targeting KIT and BRAF mutations and their outcomes in GIST and melanoma. The BRAF(V600E) melanoma mutation, like the KIT exon 11 mutation in GIST, has the highest response to therapy. High response rates with inhibition of KIT in GIST have not been recapitulated in KIT-mutated melanoma. Median time to resistance to targeted agents occurs in ~7 months with BRAF inhibitors and 2 years for imatinib in GIST. In GIST, the development of secondary mutations leads to resistance; however, there have been no similar gatekeeper mutations found in melanoma. Although surgery remains an important component of the treatment of early GIST and melanoma, surgeons will need to continue to define the thresholds and timing for operation in the setting of metastatic disease with improved targeted therapies. Combination treatment strategies may result in more successful clinical outcomes in the management of melanoma in the future.
    Annals of Surgical Oncology 02/2014; · 4.12 Impact Factor

Publication Stats

13k Citations
1,904.22 Total Impact Points


  • 1999–2014
    • Memorial Sloan-Kettering Cancer Center
      • • Department of Surgery
      • • Department of Pathology
      • • Hepatopancreatobiliary Service
      New York City, New York, United States
  • 2010–2013
    • Emory University
      • Department of Surgery
      Atlanta, Georgia, United States
    • Weill Cornell Medical College
      New York City, New York, United States
    • University of Ottawa
      • Department of Surgery
      Ottawa, Ontario, Canada
    • National and Kapodistrian University of Athens
      • Division of Surgery V
      Athens, Attiki, Greece
    • University of Manitoba
      • Department of Surgery
      Winnipeg, Manitoba, Canada
  • 2012
    • University of Colorado
      • Department of Surgery
      Denver, CO, United States
    • Helsinki University Central Hospital
      • Department of Oncology
      Helsinki, Province of Southern Finland, Finland
  • 2011
    • San Antonio Military Medical Center
      Texas City, Texas, United States
    • University of Illinois at Chicago
      • Department of Surgery (Chicago)
      Chicago, IL, United States
    • Naval Hospital Camp Pendleton
      Camp Pendleton North, California, United States
    • Boston University
      • Department of Surgery
      Boston, MA, United States
    • Memorial Hospital, TN
      Chattanooga, Tennessee, United States
    • Universität Heidelberg
      • Department of General, Visceral and Transplantation Surgery
      Heidelberg, Baden-Wuerttemberg, Germany
  • 2010–2011
    • University of Texas Southwestern Medical Center
      • Division of Surgical Oncology
      Dallas, TX, United States
  • 2009
    • Robert Wood Johnson University Hospital
      New Brunswick, New Jersey, United States
    • Houston Methodist Hospital
      Houston, Texas, United States
  • 2008
    • University of Wisconsin–Madison
      • Department of Surgery
      Madison, Wisconsin, United States
    • Indiana University Bloomington
      • Department of Surgery
      Bloomington, IN, United States
  • 2007
    • The University of Edinburgh
      Edinburgh, Scotland, United Kingdom
  • 2006
    • San Giovanni Hospital Complex
      Roma, Latium, Italy
    • Massachusetts General Hospital
      • Division of Surgical Oncology
      Boston, MA, United States
    • Indiana University-Purdue University Indianapolis
      • Department of Surgery
      Indianapolis, IN, United States
  • 2005
    • Yale University
      • Department of Surgery
      New Haven, CT, United States
  • 2004
    • Yale-New Haven Hospital
      New Haven, Connecticut, United States
    • Brigham and Women's Hospital
      • Department of Medicine
      Boston, MA, United States
  • 2003
    • University of Louisville
      Louisville, Kentucky, United States
  • 2001
    • New York Presbyterian Hospital
      New York City, New York, United States