The role of drugs that intervene with the tirosine kinase activity on the c-kit receptors in the treatment of gastrointestinal stromal tumors (GISTs) has been considered very important, mainly in large tumors. We report a case of a male patient, 56 years-old, obese, presenting with feeling of rectal pressure and incomplete evacuation. Work-up revealed a large inferior rectal GIST located in the posterior wall, suspected on MRI and confirmed by immunohistochemical study of a parasacral biopsy guided by tomography. The supposed initial approach was an abdominoperineal resection, since tumor was compressing anal canal and sphincter complex. In order to save the sphincters, we have decided to refer patient to neoadjuvant treatment with imatinib mesylate (Glyvec®). After four months of treatment, a down staging of tumor was observed during rectal exam (about 50%), which was smaller on pelvic RNM. Patient was undergone to total mesorectal excision with manual coloanal anastomosis and protective ileostomy. He presented necrosis of mobilized left colon and underwent to resection, and terminal iliac colostomy. Subsequently, patient refused to undergo through a new coloanal anastomosis and remain with iliac colostomy after ileostomy takedown. In the treatment of unresectable or large rectal GISTs, the use of imantinib should be strongly considered, since that radical surgery is the main approach to reduce the possibility of local recurrence.
