OPINION Everything on this page was said in a consultation or call, not written in a signed document; it is the doctor's view, not an established fact. How to read the tags
Bottom line
Start a second-line TKI now — two months have already been lost. She names sunitinib or ripretinib as the two she would use ("they think that sunitinib, again, sunitinib or ripretinib"); sunitinib is the one she would start with because it is available and recommended, but ripretinib is equally acceptable to her clinically — the obstacle is price and access, not her opinion of the drug. Regorafenib is also a good option, but harder to tolerate. Reassess at 3 months with a repeat PET-CT and switch quickly if it fails or is not tolerated. Local liver treatment: consult interventional radiology first (referral to Dr Benedet), systemic therapy continues either way.
Systemic therapy
- Imatinib has failed — "it's progressing, so we don't continue it". Resistance is inevitable: "it always becomes resistant; we have six, at least six more TKIs".
- Sunitinib first — "available, the recommended option".
- Ripretinib: also endorsed. Her UpToDate AI check returned "sunitinib, again, sunitinib or ripretinib"; she is a co-author of a ripretinib real-world cohort paper and offered to prescribe it. She did not rank one above the other on efficacy — sunitinib is simply the available one. Her only comparative remark on ripretinib was on cost: "I think it’s more expensive than the other one."
- To the objection that FoundationOne flags exon 18 A829P against sunitinib: "Right, theoretically — but there is no perfect option covering 11+13+18; start and see."
- Regorafenib — "also a good option… but we as oncologists would think regorafenib is harder on the patient".
- TKI side effects broadly similar (blood pressure, rash, blood/urine changes); monitor blood pressure. Which drug matters less than starting one.
- TKI combinations to cover exons 13 + 18: "probably more toxic" — no.
- Immunotherapy, bezuclastinib, heat-shock-protein inhibitors: "I can't recommend — no evidence. I would just start another TKI." New precision TKIs: research only.
- Imatinib 400 → 800 mg: she raised it; accepted without pushback once told consultants had ruled it out for exon 11 (escalation applies to exon 9).
- Repeat tissue biopsy: not needed — "Foundation is better, it shows tumour heterogeneity".
Local treatment of the liver lesions
- Referral: Dr Benedet, Israeli interventional radiologist ("very good"). Consult first, then decide.
- Tools she considers applicable: RFA, TACE (chemoembolisation), SIRT (radioactive beads), external radiotherapy — "we do use radio in GIST, something we didn't discuss before".
- Surgery: agreed it is not a good option.
- Systemic therapy continues regardless of any local treatment.
- "Creative" combinations (TACE one lesion + thermal ablation of another, piece-by-piece destruction of dormant masses): "not something we usually do — ask the interventional radiologist".
- Doing the procedure more cheaply in Turkey after an Israeli consultation: "I have no idea."
Ripretinib — access and real price
- She is willing to prescribe it and rates it alongside sunitinib, not below it. She is a co-author of a ripretinib real-world cohort paper: Frumin Edri HT, Shalata W, Berezhnov I, et al. "From Rapid Progression to Long-Lasting Complete Response: A Wide Range of Ripretinib Activity for Metastatic GIST — A Real-World Cohort." Medical Sciences (MDPI) 2026;14(5):549, doi:10.3390/medsci14050549.
- She can issue an Israeli prescription — "I can give a prescription and you can buy it in Israel" — valid only in Israel; she cannot dispense or ship the drug.
- Price — corrected after the call. Her in-call estimate of "20,000 shekel, which is like 5,000 dollars" per month was wrong. The clinic's coordinator corrected it by e-mail: one pack of Qinlock (ripretinib) 50 mg, 90 tablets, costs ₪110,985.51 ≈ US$36,583, and at the prescribed 150 mg/day (3 × 50 mg) one pack lasts about a month. Their note: "our specialists are very strong medically but do not follow drug prices". Discounts on such drugs are typically only 2–5 %.
- Route if pursued: prescription (short remote consult with Anastasia to take her on as a patient) → self-pay purchase at an Israeli pharmacy → carried or couriered to Ukraine (import rules for a 1–3 month personal supply to be checked) → monthly refills need prescription renewals; PET-CT every 3 months.
Trials and access
- No trials known in Israel; Manor does not run trials.
- 1–2 Israeli companies search trials and contact sponsors — contacts via the coordinator.
- Trial economics: the drug is covered, "they can ask payment for everything around"; acceptance uncertain given the brain-haemorrhage history.
- Coordinator's caveat (by e-mail): in practice Israeli trials prioritise Israeli patients; over years of trying, enrolling foreign patients "practically does not work".
Open question to settle before committing. Sunitinib or ripretinib first — she considers both appropriate and did not separate them on efficacy. What decides it in practice: the exon 13 V654A + exon 18 A829P resistance pattern, and the real ripretinib price of about US$36,583 per month against roughly US$1,000 per month for regorafenib in Ukraine.