Feasibility and oncological outcomes of limited duodenal resection in patients with primary nonmetastatic duodenal GIST

INTRODUCTION

Duodenal gastrointestinal stromal tumors (GISTs) are rare but still represent approximately 30 % of primary duodenal tumors. This study aimed to audit the feasibility and oncological outcomes of limited duodenal resection in patients with primary nonmetastatic duodenal GIST.

METHODS

Twelve patients who underwent surgery at our institution since 2002 were prospectively followed up. The duodenal GISTs were located in the first (n = 3), second (n = 1), third (n = 3), and fourth of duodenum (n = 1). Involving both D1/D2 (n = 2), D2/D3 (n = 1), and D3/D4 (n = 1). The primary endpoint for this analysis was disease-free survival.

RESULTS

The commonest presentation was melena and anemia (83 %). All the patients underwent limited resection; six wedge resections with primary closures and six segmental resections with end-to-end anastomosis. The median tumor size was 8 cm (range, 5-16 cm). According to Fletcher scale, two GISTs were low risk, while 10 patients were intermediate and high risk. The latter received adjuvant therapy. All the patients had a complete resection with no postoperative mortality. One patient had three liver metastases 4 months after limited resection and had partial hepatectomy. After median follow-up of 45 (15-78) months, all patients are alive and disease free.

CONCLUSION(S)

When technically feasible, limited resection should be considered a reliable and curative option for duodenal GIST achieving satisfactory disease-free survival. The technical feasibility is guided by the tumor size, possible adjacent organ involvement, and its exact anatomical location.

Presentation and Management of Gastrointestinal Stromal Tumors of the Duodenum

Duodenal gastrointestinal stromal tumors (GIST) have been described primarily in isolated case reports. In order to learn more about duodenal GIST, a retrospective review of patients with GIST managed at a single institution between 2000 and 2005 was conducted. Thirty-eight GIST of the stomach and small bowel were analyzed. Eight (21%) were duodenal GIST. The median size of duodenal GIST (6.0 cm) and small bowel GIST (6.3 cm) was larger than the median size of gastric GIST (3.0 cm). The most common presentation of duodenal GIST was bleeding (50%) which was similar to other small bowel GIST (49%) but different from gastric GIST which were most commonly an incidental finding (62%). Two patients (25%) with duodenal GIST had a history of neurofibromatosis. The duodenal GIST were located in the 2nd (n = 5, 63%) and 3rd portion of duodenum (n = 3, 37%). Seven of 8 patients underwent complete resection of duodenal GIST. Pancreaticoduodenectomy was the most common operation performed (n = 5); 2 patients were treated with partial duodenal resection. No patients undergoing pancreaticoduodenectomy (n = 5) were found to have lymph node metastases. No patients received neo-adjuvant or adjuvant therapy with Imatinib. Following resection, 2 patients have recurred (12 and 48 mo.), 4 patients are without disease (1, 6, 6, and 24 mo.), 1 patient died postoperatively. Duodenal GIST are relatively rare tumors that present most commonly with gastrointestinal bleeding. Duodenal GIST are associated with neurofibromatosis. Many duodenal GIST require pancreaticoduodenectomy for complete removal.