Clinicopathological features, surgical strategy and prognosis of duodenal gastrointestinal stromal tumors: a series of 300 patients

Duodenal gastrointestinal stromal tumor presenting with life-threatening upper GI bleeding in a young patient: A case report and literature review

Key Clinical Message

Duodenal GISTs are rare and challenging tumors. Acute life-threatening upper GI bleeding is a possible presentation of duodenal GISTs. Surgery is the standard treatment for localized duodenal GISTs. Imatinib is an effective adjuvant therapy for duodenal GISTs.

Abstract

GIST is the most common mesenchymal neoplasm of the gastrointestinal tract, accounting for 1%-2% of gastrointestinal tumors. They originate from the interstitial cells of Cajal and are rare in patients younger than 30 years. The stomach is the most common site, followed by the small intestine and colon. GISTs are caused by a gain-of-function mutation in the proto-oncogene receptor tyrosine kinase, with activating mutations in KIT being the most common. Most GISTs are asymptomatic. Even if gastrointestinal bleeding is the most common complication life-threatening hemorrhage is extremely uncommon. We present a case of a 31-year-old male patient presented with massive active hematemesis and melena with hemorrhagic shock. The patient presented with massive hematemesis and melena of 1 h duration. Endoscopy showed pulsating active bleeding from the third part of the duodenum which was difficult to manage via endoscopy. Histopathologic evaluation showed spindle cell type GIST. Intraoperatively, there was a nodular mass with active bleeding on the third part of the duodenum. Duodenectomy with end-to-end anastomosis was done. Discharged with no postoperative complication and was put on imatinib. There are considerable challenges that arise in the diagnosis and treatment of duodenal gastrointestinal stromal tumors (GISTs) when they present with life-threatening upper gastrointestinal hemorrhage. In order to achieve the best possible outcomes for patients, it is crucial to have a comprehensive understanding of the clinical presentation, diagnostic methods, and treatment approaches.

Duodenal Ampulla Neuroendocrine Tumor with GISTs of the Proximal Jejunum: A Case Report

Neuroendocrine tumors (NEN) are a type of heterogenous, slow-growing tumors, that only in about half of the cases can be found in the gastrointestinal tract. Half of these is in the small intestine. The ampullary NENs are rare, accounting for less than 1% of gastroenteropancreatic NENs. Gastrointestinal stromal tumors (GIST) are a more common type of tumors of the gastrointestinal tract that consist of pacemaker cells. The occurrence of both tumors simultaneously is rare, but in patients with neurofibromatosis type 1, the co-existence of NEN and GIST is more often. Here we report a case of simultaneous occurrence of a well-differentiated NEN and a GIST in a patient without neurofibromatosis. Also, we provide a short review of the current knowledge and treatment strategies regarding these tumors.

Comparison of prognosis between neoadjuvant imatinib and upfront surgery for GIST: A systematic review and meta-analysis

Background: Significant survival benefit of adjuvant imatinib therapy has been observed in gastrointestinal stromal tumor (GIST). However, the impact of neoadjuvant imatinib on prognosis of GIST remains unclear. This meta-analysis aimed to compare the prognostic impact between upfront surgery and neoadjuvant imatinib plus surgery on GIST.

Methods: A comprehensive literature search was performed to identify eligible studies up to 30 Sep 2021, through PubMed, Embase, Web of Science, and Cochrane Library. Studies compared the impact of upfront surgery and neoadjuvant imatinib plus surgery on disease-free (DFS) or overall survival (OS) in patients with GIST were selected.

Results: Seven eligible studies with 17,171 patients were included. The reduction rates of tumor size in rectal and mixed site GIST were 33% and 29.8%, respectively. Neoadjuvant imatinib was not significantly associated with DFS compared with no-neoadjuvant therapy in rectal GIST (HR: 0.71, 95% CI: 0.35–1.41). The OS of rectal GIST was significantly improved by neoadjuvant imatinib compared with no-neoadjuvant therapy (HR: 0.36, 95% CI: 0.17–0.75).

Conclusion: Neoadjuvant imatinib therapy contributed to tumor shrinkage and R0 resection of rectal GIST. Neoadjuvant imatinib plus surgery significantly improved overall survival of rectal GIST in comparison with upfront surgery.

Safety and efficacy of surgical and endoscopic resection in the treatment of duodenal subepithelial lesions

BACKGROUND

Duodenal subepithelial lesions (D-SELs) are rare and their resection is challenging. Unfortunately, data on surgical and endoscopic resection of D-SELs are scarce. This study aimed to assess the safety and efficacy of surgical resection and endoscopic resection (ER) for D-SELs.

METHODS

We retrospectively analyzed clinical data of patients with non-ampullary D-SELs who underwent ER or surgery and compared the outcomes between ER and surgery with no/low-risk SELs over 15 mm from March 2010 to August 2020. Clinicopathologic findings, procedure-related parameters, and follow-up data were analyzed.

RESULTS

A total of 107 patients (108 lesions) were enrolled; 52 patients (53 lesions) received ER and 55 patients (55 lesions) received surgery. In ER group, en bloc resection rate and R0 resection rate were 94 and 89%, respectively. Major adverse events rate was 6%. One (2%) patient experienced local recurrence. In surgery group, R0 resection was achieved in all cases. Major adverse events rate was 20%. Recurrence rate and distant metastases rate were 4 and 8%, respectively. One (2%) patient died from septicemia during follow-up. Thirty-three patients in each group were enrolled in the comparison. There were no significant differences in age, sex, lesion size and location (P > 0.05). More histologically GISTs and muscularis propria-originated lesions were treated by surgery (P < 0.05). ER was significantly associated with a shorter operation time, shorter hospital stay, lower cost, less estimated blood loss, and lower major adverse events rate compared to the surgery group (P < 0.05). However, R0 resection rate, mortality, recurrence rate, and metastases rate were not significant different (P > 0.05).

CONCLUSIONS

ER is an effective and safe treatment modality for selected patients with non-ampullary D-SELs by expert endoscopists. Surgery is a radical method for D-SELs that should be reserved for D-SELs not amenable to ER.

Gastrointestinal stromal tumor in the fourth portion of the duodenum does not express the CD117: A case report

Introduction

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the digestive tract.

Presentation of case

54-year-old woman with a history of phyllodes tumor of the left breast he patient was admitted to our hospital for management of retroperitoneal soft tissue tumor, attached to the fourth portion of the duodenum, opposite the head of the pancreas. The patient underwent a large excision of the tumor, the duodenojejunal flexure, and the third and fourth portions of the duodenum along with the head of the pancreas. The histopathological examination confirmed the presence of a spindlecell mesenchymal proliferation. These cells do not express CD117, but they express DOG1. A PDGFRA mutation was identified later. The final diagnosis was duodenal GIST.

Discussion

few cases of GIST in the fourth portion of the duodenum had been reported in the literature. PDGFRA mutation is identified as GISTs tumorigenesis to 15% of cases, and the diagnosis of GISTs is not based solely on the expression of the protein Kit.

Conclusion

the molecular biology examinations are very helpful in the direction of the correct diagnosis in case of negative staining for CD117.

Comparison of Prognosis Between Microscopically Positive and Negative Surgical Margins for Primary Gastrointestinal Stromal Tumors: A Systematic Review and Meta-Analysis

Background

This meta-analysis aimed to determine the prognostic impact of microscopically positive margins (R1) on primary gastrointestinal stromal tumors.

Methods

A literature search was performed using PubMed, Embase, Web of Science, and Cochrane Library for studies up to 23 November 2020. The pooled disease-free survival (DFS) and overall survival (OS) between R1 and negative margins (R0) were estimated using a random-effects model.

Results

Twenty studies with 6,465 patients were included. Compared with R0 resection, R1 was associated with poor DFS in patients who did not receive adjuvant Imatinib (HR: 1.62, 95% CI: 1.26-2.09; P = 0.48, I² = 0%; reference: R0). This negative impact of R1 disappeared with the use of adjuvant Imatinib (HR: 1.23, 95% CI: 0.95-1.60; P = 0.38, I2 = 6%; reference: R0). R1 was related to poor DFS in gastric GISTs (HR: 2.15, 95% CI: 1.15-5.02, I² = 0%; reference: R0), which was attenuated in the subgroup of adjuvant Imatinib (HR: 2.24, 95% CI: 0.32-15.60; P = 0.84, I² = 0%; reference: R0). Rectal GIST with R1 margin who even received adjuvant Imatinib still had poor DFS (HR: 3.79, 95% CI: 1.27-11.31; P = 0.54, I² = 0%; reference: R0). Patients who underwent R1 resection had similar OS compared with those underwent R0 resection regardless of the use of adjuvant Imatinib.

Conclusion

R1 was associated with poor DFS for primary GISTs, which was attenuated by adjuvant therapy with Imatinib. Similar result was observed in the gastric GISTs subgroup. Rectal GIST patients with R1 resection had poor DFS even when they received adjuvant Imatinib. The R1 margin did not influence the OS of GISTs.

Current surgical management of duodenal gastrointestinal stromal tumors

Duodenal gastrointestinal stromal tumors (D-GISTs) are uncommon mesenchymal tumors and are managed differently to common duodenal epithelial tumors. They may pose surgical challenges due to their unique but complex pancreaticoduodenal location of the gastrointestinal tract near the ampulla of Vater, pancreas, mesenteric blood vessels, biliary and pancreatic ducts. The surgical management of D-GISTs can be performed safely with good oncological outcomes provided an adequate resection margin can be achieved. The current surgical options of resectable primary D-GISTs varies with increasing complexity depending on the location, size and involvement of surrounding structures such as wedge resection with primary closure, segmental resection with small bowel anastomosis or radical pancreaticoduodenectomy. Laparoscopic approaches have been shown to be feasible and safe with good oncological outcomes in experienced hands. The minimally invasive techniques including robotic-assisted approach will likely increase in the future. D-GISTs have a prognosis comparable to gastric and other small bowel GISTs. However, the heterogeneity of different studies and the limited use of systemic tyrosine kinase inhibitor in the neoadjuvant and adjuvant settings may influence the overall survival of resected D-GISTs. The use of limited resection when condition allows is recommended due to lower surgical morbidity, less postoperative complications and better oncologic outcomes.

A Rare Case of Three Distinct Gastrointestinal Neoplasms Occurring Simultaneously in an Elderly Patient

Duodenal adenocarcinoma (DA), gastrointestinal stromal tumor (GIST), and pancreatic neuroendocrine tumor (PNET) are a set of rare gastrointestinal (GI) cancers characterized by nonspecific symptoms such as anemia, weight loss, and abdominal pain. We report an interesting case of DA, GIST, and PNET in a 79-year-old African American male who presented to the emergency department with syncope. The patient was tachycardic and found to have severe anemia. Further computed tomography (CT) of the abdomen and pelvis with contrast revealed a mass within the duodenal bulb along with a pancreatic cystic lesion. The patient underwent gastroduodenectomy and distal pancreatectomy with incidental findings of GIST in the posterior gastric wall. The patient after surgical removal of all tumors no longer experienced abdominal pain and had hematocrit and hemoglobin (H&H) level of 9.1/31.7 postoperation day (POD) 14. The case unfolds a rare presentation of three neoplasms that were moderate to well-differentiated with no metastases. It highlights the importance of assessment of rare GI neoplasms concurrently with colorectal cancer when geriatric patients present with nonspecific GI symptoms.

Robotic resection of duodenal gastrointestinal stromal tumour: Preliminary experience from a single centre

BACKGROUND

Experience in minimally invasive surgery in the treatment of duodenal gastrointestinal stromal tumors (DGISTs) is accumulating, but there is no consensus on the choice of surgical method.

AIM

To summarize the technique and feasibility of robotic resection of DGISTs.

METHODS

The perioperative and demographic outcomes of a consecutive series of patients who underwent robotic resection and open resection of DGISTs between May 1, 2010 and May 1, 2020 were retrospectively analyzed. The patients were divided into the open surgery group and the robotic surgery group. Pancreatoduodenectomy (PD) or limited resection was performed based on the location of the tumour and the distance between the tumour and duodenal papilla. Age, sex, tumour location, tumour size, operation time (OT), estimated blood loss (EBL), postoperative hospital stay (PHS), tumour mitosis, postoperative risk classification, postoperative recurrence and recurrence-free survival were compared between the two groups.

RESULTS

Of the 28 patients included, 19 were male and 9 were female aged 51.3 ± 13.1 years. Limited resection was performed in 17 patients, and PD was performed in 11 patients. Eleven patients underwent open surgery, and 17 patients underwent robotic surgery. Two patients in the robotic surgery group underwent conversion to open surgery. All the tumours were R0 resected, and there was no significant difference in age, sex, tumour size, operation mode, PHS, tumour mitosis, incidence of postoperative complications, risk classification, postoperative targeted drug therapy or postoperative recurrence between the two groups (P > 0.05). OT and EBL in the robotic group were significantly different to those in the open surgery group (P < 0.05). All the patients survived during the follow-up period, and 4 patients had recurrence and metastasis. No significant difference in recurrence-free survival was noted between the open surgery group and the robotic surgery group (P > 0.05).

CONCLUSION

Robotic resection is safe and feasible for patients with DGISTs, and its therapeutic effect is equivalent to open surgery.

Limited Resection Versus Pancreaticoduodenectomy for Duodenal Gastrointestinal Stromal Tumors? Enucleation Interferes in the Debate: A European Multicenter Retrospective Cohort Study

BACKGROUND

The optimal surgical procedure for duodenal gastrointestinal stromal tumors (D-GISTs) remains poorly defined. Pancreaticoduodenectomy (PD) allows for a wide resection but is associated with a high morbidity rate.

OBJECTIVES

The aim of this study was to compare the short- and long-term outcomes of PD versus limited resection (LR) for D-GISTs and to evaluate the role of tumor enucleation (EN).

METHODS

In this retrospective European multicenter cohort study, 100 patients who underwent resection for D-GIST between 2001 and 2013 were compared between PD (n = 19) and LR (n = 81). LR included segmental duodenectomy (n = 47), wedge resection (n = 21), or EN (n = 13). The primary objective was to evaluate disease-free survival (DFS) between the groups, while the secondary objectives were to analyze the overall morbidity and mortality, radicality of resection, and 5-year overall survival (OS) and recurrence rates between groups. Furthermore, the short- and long-term outcomes of EN were evaluated.

RESULTS

Baseline characteristics were comparable between the PD and LR groups, except for a more frequent D2 tumor location in the PD group (68.3% vs. 29.6%; p = 0.016). Postoperative morbidity was higher after PD (68.4% vs. 23.5%; p < 0.001). OS (p = 0.70) and DFS (p = 0.64) were comparable after adjustment for D2 location and adjuvant therapy rate. EN was performed more in American Society of Anesthesiologists (ASA) stage III/IV patients with tumors < 5 cm and was associated with a 5-year OS rate of 84.6%, without any disease recurrences.

CONCLUSIONS

For D-GISTs, LR should be the procedure of choice due to lower morbidity and similar oncological outcomes compared with PD. In selected patients, EN appears to be associated with equivalent short- and long-term outcomes. Based on these results, a surgical treatment algorithm is proposed.

Duodenal gastrointestinal stromal tumors: A retrospective study based on a 13 years experience of a single center in China

AIM

Duodenal gastrointestinal stromal tumors (GISTs) constitute a small rare subset. This study aims to analyze the prognostic differences between duodenal and jejunoileal GISTs and evaluate the clinical treatment and prognostic characteristics of patients with duodenal GISTs.

METHODS

Data of patients with primary duodenal or jejunoileal GISTs were collected. Patients were matched through propensity score matching (PSM). Perioperative and long-term outcomes of patients with duodenal GISTs were compared based on surgical approach.

RESULTS

Altogether, 101 duodenal and 219 jejunoileal GISTs were identified. In patients with duodenal GISTs, 79 (78%) underwent local resection (LR) and 22 (22%) underwent pancreaticoduodenectomy (PD). Patients undergoing PD had a longer postoperation stay (18.5 vs 13 days, P = 0.001) and more complications (Clavien-Dindo I-II complications for PD vs LR, 31.8 vs 15.2%; Clavien-Dindo III-V complications for PD vs LR, 22.7 vs. 2.5%; P < 0.001). There was no difference in recurrence-free survival (RFS) (P = 0.8) or overall survival (OS) (P = 0.9) when comparing patients who underwent LR versus PD. Multivariable analysis showed that tumor size >5 cm was the only independent predictor of shorter RFS (P = 0.004) and OS (P = 0.012). After matching, there was no significant difference in RFS and OS between patients with duodenal versus jejunoileal GISTs (both P > 0.05).

CONCLUSION

The prognosis of duodenal and jejunoileal GISTs are similar. Recurrence and OS of duodenal GISTs primarily depend on tumor size. For duodenal GISTs, LR is associated with comparable long-term survival when compared to PD, but with superior short-term outcomes.

Small bowel gastrointestinal stromal tumor presenting with gastrointestinal bleeding in patient with type 1 Neurofibromatosis: Management and laparoscopic treatment. Case report and review of the literature

INTRODUCTION AND IMPORTANCE

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm of the gastrointestinal tract. It may be asymptomatic; nevertheless, gastrointestinal bleeding is the most frequent symptom, due to mucosal erosion. Its poor lymph node metastatic spread makes GIST often suitable of minimally invasive surgical approach. The importance of this study is to increase the awareness among physicians about this condition in particular scenarios as in our case and to stress the role of laparoscopic surgery.

CASE PRESENTATION

A 74-year-old female patient presented to the emergency department with hematemesis, followed by haematochezia and melena. The patient had a medical history of type 1 Neurofibromatosis (NF1). She underwent, after CT scan, esophagogastroduodenoscopy, and endoscopic haemostasis. Finally, we performed a laparoscopic resection of a mass of the first jejunal loop. The postoperative period was predominantly uneventful. Pathological examination confirmed a low-risk GIST.

CLINICAL DISCUSSION

Proximal jejunal GIST may cause an upper and lower gastrointestinal bleeding. A multidisciplinary team approach is mandatory for the correct management of this disease and its complications (bleeding). GISTs are indicated as the most commonly gastrointestinal NF1 associated tumours. In case of localised and resectable GIST surgical treatment is the mainstay and laparoscopic surgery is a valid alternative.

CONCLUSION

In case of abdominal bleeding mass in a NF1 patient, it is important to keep in mind the well-known association between NF1 and GIST to facilitate the diagnosis and to quickly perform the appropriate treatment. Laparoscopic approach is safe and effective if the oncological radicality is respected.

Duodenal giant stromal tumor combined with ectopic varicose hemorrhage: A case report

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are mesenchymal tissue tumors originating from Cajal cells, presenting diverse clinical manifestations due to the different sizes, locations, and growth patterns of the lesions. Duodenum is an uncommon site of GISTs, more with gastrointestinal obstruction and bleeding as the first symptoms. Ectopic duodenal varix, as a rare varix occurring outside the gastroesophageal region, is the main type of heterotopic varices and an unusual cause of gas-trointestinal hemorrhage. The etiology is mainly seen in liver cirrhosis, portal hypertension, vasculitis, portal vein embolism and obstruction caused by various factors. Reports of duodenal stromal tumor combined with ectopic variceal hemorrhage are rarely seen; however, when it occurs, the situation can sometimes be urgent and life-threatening, especially when traditional endoscopy and imaging fail to detect the lesion timely.

CASE SUMMARY

We report a 52-year-old female patient who had no obvious inducement to develop black stool. Gastroscopy in a local hospital revealed that the duodenal horizontal ectopic varices were ruptured and bleeding. After metal clamping hemostasis, she still had gastrointestinal bleeding and was transferred to our hospital. Gastroscopy showed that active bleeding was still seen in the horizontal part of duodenum, and suspicious submucosal eminence was seen in the bleeding part. Abdominal computed tomography showed a huge stromal tumor of duodenum, specimens were pathologically confirmed after surgery. After a 3-mo follow-up, no gastrointestinal hemorrhage and complications occurred.

CONCLUSION

Ectopic variceal hemorrhage is rare but sometimes fatal. It may be combined with stromal tumor, which can be diagnosed by multiple methods. Endoscopic and surgical treatment are effective.

Pancreatic Neuroendocrine Neoplasms and Gastrointestinal Stromal Tumors: A Single-Institution Experience of a Rare Association and Review of the Literature

OBJECTIVE

Pancreatic neuroendocrine neoplasms (pNENs) and gastrointestinal stromal tumors (GISTs) represent rare neoplasms. Nonsyndromic cases of pNENs associated with a synchronous GIST were evaluated, and a review of the literature was performed.

METHODS

We evaluated clinicopathologic features, postoperative outcome, and follow-up of patients operated on for nonsyndromic synchronous pNENs and GISTs in our unit (2003-2017).

RESULTS

Five (3.2%) of 156 patients with a pNEN had an associated GIST (3 male/2 female; average age, 67 years). They were diagnosed with a pNEN preoperatively and underwent pancreatic surgery. In 4 patients, GISTs were detected intraoperatively. Histology showed 3 G1 and 2 G2 pNENs. All GISTs were low risk (median size, 0.9 cm). Two patients were alive without disease 108 and 132 months after surgery. In the literature, 7 cases were described. They had low-risk GISTs, with a gastric location in 6 cases (median size, 2.85 cm).

CONCLUSIONS

Sporadic pNENs coexisting with a GIST have been demonstrated in 12 cases. This association is considered fortuitous, and its true incidence may be underestimated. Surgery should be performed on the GIST during the pancreatic surgery. The prognosis strictly depends on the pancreatic NENs.

Optimal Laparoscopic Management and Oncological Outcomes of Gastrointestinal Stromal Tumors in Duodenum: Pancreaticoduodenectomy or Pancreas-Sparing Duodenectomy?

Background

Gastrointestinal stromal tumors (GIST) of the duodenum are rarely reported and optimal minimally invasive management has not been well proposed. Pancreaticoduodenectomy and different types of pancreas-sparing duodenectomy can be chosen; however, which to choose and its corresponding clinical outcomes and oncological concerns remain controversial.

Patients and Methods

Patients diagnosed with GIST of duodenum underwent laparoscopic pancreaticoduodenectomy (L-PD) or pancreas-sparing duodenectomy (L-PSD) in Zhejiang Provincial People's Hospital were enrolled. All prospectively maintained data were analyzed retrospectively. Patients were grouped into the L-PD group or the L-PSD group, and the clinical outcomes and oncological outcomes were analyzed.

Results

Between June 2013 and March 2019, a total of 22 patients (11 males/11 females) underwent surgical management, including 13 L-PDs and 9 L-PSDs. The average age was 58.2±9.5 year-old (median 60.5 year-old). The most common presentations were GI bleeding (54.5%) and abdominal discomfort (27.2%), and the dominant lesion located in the second portion of duodenum (59.1%). Compared with L-PD group, L-PSD group showed much shorter operation time (364.2±58.7min vs. 230.0±12.3min, P<0.001), less blood loss (176.9±85.7mL vs. 61.1±18.2min, P<0.001), faster recovery to off-bed (2.6±1.3d vs. 1.1±0.3d, P=0.003), anus flatus (4.5±1.0d vs. 2.4±0.5d, P<0.001) and liquid intake (4.9±1.3d vs. 2.3±0.5d, P<0.001). Lymph node retrieval was much less in L-PSD, but no lymph node metastasis was observed in any patients. L-PSD had much Lower morbidity of both minor (Grade I/II) and major (III/IV/V) complications than that of L-PD (11.1% vs. 61.6%, P=0.02), resulting in shorter hospital stays (10.9±3.8d vs. 20.6±11.1d, P=0.021) and less total cost (76,972.4±11,614.8yuan vs 125,628.7±46,356.8yuan, P=0.006). The median follow-up was 42 months (range from 12 to 82months) without loss. Only 1 L-PD patient suffered hepatic metastasis 36months after surgery, and given sunitinib to stabilize the disease, none of the rest observed recurrence or metastasis.

Conclusion

For GIST located opposite the major papilla, L-PSD showed comparable safety and oncological benefits when compared to L-PD, with shorter operation time, less blood loss and much faster recovery time, resulting in much less total cost. L-PSD should be applied in selected patients with experienced hands.

Clinical outcomes of tumor bleeding in duodenal gastrointestinal stromal tumors: a 20-year single-center experience

BACKGROUND

Duodenal gastrointestinal stromal tumors (GISTs) are rare, and reports on duodenal GIST bleeding are few. We analyzed the risk factors and clinical outcomes of hemorrhagic duodenal GISTs and compared them with those of gastric GISTs.

METHODS

Primary duodenal GISTs surgically diagnosed between January 1998 and December 2017 were retrospectively reviewed. Furthermore, patients with duodenal GIST were compared with those with primary gastric GIST histopathologically diagnosed between January 1998 and May 2015 using previously published data.

RESULTS

Of the 170 total patients with duodenal GISTs, 48 (28.2%) exhibited tumor bleeding. Endoscopic intervention, embolization, and non-interventional conservative treatment were performed for initial hemostasis in 17, 1, and 30 patients, respectively. The 5-year survival rate was 81.9% in the bleeding group and 89.4% in the non-bleeding group (P = 0.495). Multivariate analysis showed that p53 positivity was a significant risk factor for duodenal GIST bleeding (hazard ratio [HR] 2.781, P = 0.012), and age ≥ 60 years (HR 3.163, P = 0.027), a large maximum diameter (comparing four groups: < 2, 2-5, 5-10, and ≥ 10 cm), and mitotic count ≥ 5/high-power field (HPF) (HR 3.265, P = 0.032) were risk factors for overall survival. The incidence of bleeding was significantly higher in duodenal GISTs than in gastric GISTs (28.2% vs. 6.6%, P < 0.001), and the re-bleeding rate after endoscopic hemostasis was also higher in duodenal GISTs than in gastric GISTs (41.2% vs. 13.3%, P = 0.118).

CONCLUSION

In patients with duodenal GIST with old age, large tumor diameter, and mitotic count ≥ 5/HPF, a treatment plan should be established in consideration of the poor prognosis, although tumor bleeding does not adversely affect the prognosis. Duodenal GISTs have a higher incidence of tumor bleeding and re-bleeding rate after endoscopic hemostasis than gastric GISTs.

A rare case report of locally recurrent hemorrhagic duodenal gastrointestinal stromal tumor: therapeutic challenges and review of prognostic indicators for recurrence

Gastrointestinal stromal tumor is a rare neoplasm affecting gastrointestinal tract. Duodenal gastrointestinal stromal tumor originating from the fourth segment is considered an extremely rare disease. Surgical challenges arise when managing locally recurrent hemorrhagic duodenal gastrointestinal stromal tumor. A 58-year-old male presented with melena for the last 10 days. Thirty months previously, he had segmental resection of the fourth duodenal portion due to hemorrhagic gastrointestinal stromal tumor. No adjuvant imatinib therapy was administered (low risk for recurrence). The latest investigations showed actively bleeding tumor in the distal third portion of the duodenum, indicating a locally recurrent gastrointestinal stromal tumor. Uneventful emergent limited resection was performed. To the best of our knowledge, this is the first case report describing locally recurrent gastrointestinal stromal tumor in the distal duodenal portion. We will explain the therapeutic challenges and risk stratification and discuss gastrointestinal bleeding as a prognostic indicator for gastrointestinal stromal tumor recurrence.

Chondroid gastrointestinal stromal tumor in the stomach with early adenocarcinoma

OBJECTIVE

To explore the pathologic features of gastric chondroid gastrointestinal stromal tumors.

METHODS

The clinicopathologic data of one case of gastric chondroid gastrointestinal stromal tumor were collected and the features were analyzed by literature review.

RESULTS

The male patient was 64 years old and had suffered from upper abdominal fullness discomfort without obvious cause for 5 years. Gastroscopic examination showed a rough area located in the lesser curvature of the gastric antrum, measuring 6 cm × 4 cm. CT scan showed the stomach wall was unevenly thick at the gastric antrum and stomach outlet. Multiple enlarged lymph nodes were seen nearby. The biopsy pathology showed adenocarcinoma of gastric antrum. The patient underwent laparoscopic gastrectomy and gastric chondroid gastrointestinal stromal tumor was found with adenocarcinoma of the stomach. Asp842Val mutation was found in the PDGFRα 18 exon.

CONCLUSION

Gastric chondroid gastrointestinal stromal tumors are rare and low risk. Tumor cells express CD117 and Asp842Val mutation in the PDGFRα 18 exon revealed by genetic sequencing suggesting this kind of tumor might be resistant to imatinib.

Clinicopathologic features and prognostic grouping of gastrointestinal stromal tumors (GISTs) in Pakistani patients: an institutional perspective

Objectives

Gastrointestinal stromal tumors (GISTs) are rare tumors of gastrointestinal tract, prognosis of which largely depends upon histopathologic characteristics of resection specimens, which were not widely studied in our population. Therefore we aimed to evaluate the histopathologic characteristics of GISTs in our population and their prognostic grouping according to college of American pathologist’s guidelines.

Results

Mean age of patients was 53.4 years (18–71 years). 92% of cases were of primary GISTs and stomach was the most common site (57.7%). 75% of cases were of spindle cell morphology and 53.8% belonged to high risk prognostic group. Comparison of stomach and intestinal GISTs showed that intestinal GISTs were found to be of high grade (70%) and of high risk prognostic group (75 and 80%) compared to stomach GISTs (43% were of high risk prognostic group), however this finding was not statistically significant. GISTs are infrequent gastrointestinal tumors but early diagnosis and identification of adverse histological features are key to successful treatment. We found a large majority of GISTs to be located in stomach, however intestinal GISTs were found more likely to be associated with adverse prognostic parameters. However more large scale studies are warranted to establish this finding.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3562-8) contains supplementary material, which is available to authorized users.