Adjuvant therapy for resectable gastrointestinal stromal tumors: evidence, controversies, and practical guidance

INTRODUCTION: Surgical resection remains the cornerstone for localized gastrointestinal stromal tumors (GIST), but recurrence risk varies widely. Targeted therapy with imatinib has transformed outcomes in advanced disease and is now used in the adjuvant setting for selected patients. AREAS COVERED: A targeted literature search of PubMed, Embase, major conference abstracts and guidelines documents was conducted up to 1 August 2026. Key evidence on adjuvant imatinib in GIST was reviewed, including randomized trials, prospective cohorts, guidelines, and relevant retrospective studies, with particular focus on treatment benefit, duration, molecular subtypes, and emerging data on extended therapy. Trial data were cross-checked against primary publications and differences in endpoint definitions were harmonized for cross-trial comparison. EXPERT OPINION: Adjuvant imatinib should be individualized using validated clinicopathologic risk models plus molecular testing. Key unresolved issues include optimal duration for the highest-risk subsets, the role and dose of adjuvant therapy for KIT exon 9 tumors, and adjuvant strategies for imatinib-resistant genotypes.