Duodenal gastrointestinal stromal tumor: clinicopathological characteristics, surgical outcomes, long term survival and predictors for adverse outcomes. Am J Surg. 2013;206:360-367. [PMID: 23673012 DOI: 10.1016/j.amjsurg.2012.11.010]

Groove pancreatitis: From enigma to future directions-A comprehensive review

Groove pancreatitis (GP) is a rare and clinically distinct form of chronic pancreatitis affecting the pancreaticoduodenal groove comprising the head of the pancreas, duodenum, and the common bile duct. It is more prevalent in individuals in their 4-5th decade of life and disproportionately affects men compared with women. Excessive alcohol consumption, tobacco smoking, pancreatic ductal stones, pancreatic divisum, annular pancreas, ectopic pancreas, duodenal wall thickening, and peptic ulcers are significant risk factors implicated in the development of GP. The usual presenting symptoms include severe abdominal pain, nausea, vomiting, diarrhea, weight loss, and jaundice. Establishing a diagnosis of GP is often challenging due to significant clinical and radiological overlap with numerous benign and malignant conditions affecting the same anatomical location. This can lead to a delay in initiation of treatment leading to increasing morbidity, mortality, and complication rates. Promising research in artificial intelligence (AI) has garnered immense interest in recent years. Due to its widespread application in diagnostic imaging with a high degree of sensitivity and specificity, AI has the potential of becoming a vital tool in differentiating GP from pancreatic malignancies, thereby preventing a missed or delayed diagnosis. In this article, we provide a comprehensive review of GP, covering the etiology, pathogenesis, clinical presentation, radiological and endoscopic evaluation, management strategies, and future directions. This article also aims to increase awareness about this lesser known and often-misdiagnosed clinical entity amongst clinicians to ultimately improve patient outcomes.

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.

Exposed endoscopic full-thickness resection for duodenal submucosal tumors: Current status and future perspectives

Exposed endoscopic full-thickness resection (EFTR), with or without laparoscopic assistance, is an emergent natural orifice transluminal endoscopic surgery technique with promising safety and efficacy for the management of gastrointestinal submucosal tumors (SMTs) arising from the muscularis propria (MP), especially of the gastric wall. To date, evidence concerning duodenal exposed EFTR is lacking, mainly due to both the technical difficulty involved because of the special duodenal anatomy and concerns about safety and effectiveness of transmural wall defect closure. However, given the non-negligible morbidity and mortality associated with duodenal surgery, the recent availability of dedicated endoscopic tools for tissue-approximation capable to realize full-thickness defect closure could help in promoting the adoption of this endosurgical technique among referral centers. The aim of our study was to review the current evidence concerning exposed EFTR with or without laparoscopic assistance for the treatment of MP-arising duodenal SMTs.

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.

Endoscopic resection in combination with ligation for the treatment of duodenal subepithelial lesions: a single-center experience

Duodenal subepithelial lesions (SELs) are increasingly detected during an endoscopic examination. However, no feasible and safe methods are available for removing duodenal SELs. In the present study, we aimed to assess the feasibility and safety of endoscopic resection in combination with ligation (ER-L) in removing the duodenal SELs. A total of 101 patients with duodenal SELs received ER-L from February 2010 to February 2020. The primary outcomes were complete resection, en bloc resection, and R0 resection. The secondary outcomes included procedure duration, bleeding, perforation, and residual lesions. A total of 101 patients with 101 duodenal SELs (ranged from 8.4 mm to 20.2 mm in size) were included in this study. Most of the SELs (95.1%) originated from the submucosal layer and were successfully removed using ER-L. The rates of complete resection, en bloc resection, and R0 resection were 100%, 96.0%, and 88.1%, respectively. The median procedure duration was 8 min. There was no severe complication, except for four patients who developed post-procedure bleeding (4.0%) and recovered after conservative treatment. Furthermore, no residual lesions were detected during the follow-up period (median of 36 months). Indeed, logistic regression analysis showed that the size of duodenal SELs was an independent factor for R0 resection during the ER-L procedure. Conclusively, ER-L was feasible and safe to remove the duodenal SELs that originated from the submucosal layer and were less than 20 mm. However, the feasibility and safety of the ER-L should be further confirmed when removing the duodenal SELs that originated from the muscularis propria (MP) layer and were larger than 20 mm in diameter.

Investigation of the factors influencing surgical treatment of duodenal gastrointestinal stromal tumors

BACKGROUND

Duodenal gastrointestinal stromal tumor (DGIST) is a rare tumor with a specific anatomic site and biological characteristics. As the incidence of lymph node metastasis is very low, the main treatment method is surgery. Two main surgical techniques (local resection and Whipple) are performed in patients with DGISTs. The critical question is which surgical technique to choose.

AIM

To identify factors influencing the choice of surgery for DGISTs.

METHODS

The clinicopathological data of patients with DGISTs who underwent surgery between January 1999 and January 2021 were analyzed. We used the Student’s t-test or Mann-Whitney U-test and the χ² test or Fisher’s exact test to determine the differences between the two groups of patients. Furthermore, we used logistic analysis to identify the relevant factors and independent factors related to the type of surgery. The Kaplan-Meier method was used to analyze the patient’s survival information and Cox regression analysis was performed to determine prognostic risk factors.

RESULTS

Overall, 86 patients were analyzed, including 43 men (50%) and 43 women (50%). We divided the patients into two groups based on surgical technique (local resection or Whipple surgery). There were no differences in the age, mitotic figures, and complications between the two groups; however, the tumor size, tumor location, risk grade, postoperative hospital stay, and abdominal drainage time were significantly different. Based on univariate logistic analysis, the Whipple procedure was chosen if the tumor size was ≥ 5.0 cm, the tumor was located in the descending part of the duodenum, or the risk grade was medium or high. In our research, the five-year overall survival rate of patients was more than 90%. We also describe two DGIST patients with liver metastases at first diagnosis and analyzed their management in order to provide advice on complicated cases.

CONCLUSION

The Whipple procedure was performed if the primary tumor was in the descending part of the duodenum, tumor size was ≥ 5.0 cm, or the tumor risk grade was medium or high.

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.

Laparoscopic Limited Resection for Duodenal Gastrointestinal Stromal Tumors

BACKGROUND

Laparoscopic surgery may be a suitable treatment for gastrointestinal stromal tumors (GISTs) in terms of oncological feasibility and being minimally invasive. Case series of laparoscopic resection for duodenal GISTs have not been reported in detail, so in this report, the detail of laparoscopic surgeries for duodenal GISTs is summarized.

METHODS

This is a single-center retrospective case series of six consecutive patients with duodenal GISTs who underwent laparoscopic limited resection of the duodenum between 2003 and 2019.

RESULTS

Tumors were located within the first portion in three patients, the second portion in two patients, and the third portion in one patient. Median tumor size was 25 mm. Four patients underwent a laparoscopic and endoscopic full-thickness resection with primary closure, one patient underwent a laparoscopic wedge resection, and one patient underwent a laparoscopic segmental duodenectomy with Roux-en-Y gastrojejunostomy. Median blood loss was minimal (10 ml) with median operative time of 2 h, and there were no conversions to open surgery. There were no intraoperative or postoperative complications. All patients underwent curative resection with negative surgical margins, and none had recurrence of their duodenal GISTs. All patients were alive at the end of the follow-up period of 54 months.

CONCLUSION

Laparoscopic limited resection is a feasible, safe, and ideal treatment procedure for duodenal GISTs in terms of short- and long-term surgical outcomes.

Current and Potential Applications of Artificial Intelligence in Gastrointestinal Stromal Tumor Imaging

The most common mesenchymal tumors are gastrointestinal stromal tumors (GISTs), which have malignant potential and can occur anywhere along the gastrointestinal system. Imaging methods are important and indispensable of GISTs in diagnosis, risk staging, therapy, and follow-up. The recommended imaging method for staging and follow-up is computed tomography (CT) according to current guidelines. Artificial intelligence (AI) applies and elaborates theses, procedures, modes, and utilization systems for simulating, enlarging, and stretching the intellectual capacity of humans. Recently, researchers have done a few studies to explore AI applications in GIST imaging. This article reviews the present AI studies in GISTs imaging, including preoperative diagnosis, risk stratification and prediction of prognosis, gene mutation, and targeted therapy response.

Assessment of tumor heterogeneity: Differentiation of periampullary neoplasms based on CT whole-lesion histogram analysis

PURPOSE

To investigate the utility of whole-lesion histogram analysis from multidetector computed tomography (MDCT) for discrimination of duodenal adenocarcinoma (DAC), pancreatic ductal adenocarcinoma (PDAC) and gastrointestinal stromal tumor (GIST) around the periampullary area.

MATERIALS AND METHODS

171 patients suspicious of periampullary tumors were examined by MDCT (arterial and venous phases) and treated with surgery. A total of 74 patients were finally included in this retrospective study (26 DACs, 20 PDACs, and 28 GISTs). The interobserver agreement was evaluated by intra-class correlation coefficient (ICC) test between two radiologists. Volumetric histogram analysis based on CT Kinetics software was performed on enhanced MDCT images that recorded different histogram parameters of arterial and venous phases, including mean, median, 10th, 25th, 75th, and 90th percentiles, as well as skewness, kurtosis and entropy. The extracted histogram parameters were compared between DAC, PDAC and GIST respectively by Mann-Whitney U tests with Bonferroni corrections. Receiver operating characteristic (ROC) curve analysis was used to determine the diagnostic ability of each significant parameter and the area under the curve (AUC) was calculated.

RESULTS

The whole-lesion CT histogram analysis demonstrated significant differences between DAC, PDAC, and GIST with different histogram features on both arterial and venous phase scans (all P < 0.05). In the ROC analysis, the 90th percentile of venous phase demonstrated the highest AUC of 0.854 (P < 0.001) for discriminating DAC from PDAC. Excellent discriminators of periampullary tumors were noted among the histogram features, namely the 90th percentile of arterial phase, which demonstrated AUCs of 0.809 and 0.936 (P < 0.001) respectively for distinguishing DAC and PDAC from GIST.

CONCLUSION

The whole-lesion CT histogram analysis could be useful for differential diagnosis of DAC, PDAC and GIST arising from the periampullary area. Further assessment is warranted to investigate the clinical role of histogram analysis based on MDCT.

Surgery for duodenal gastrointestinal stromal tumor: A systematic review and meta-analysis of pancreaticoduodenectomy versus local resection

The purpose of this study is to assess the clinical outcomes and prognostic factors for survival of patients with duodenal gastrointestinal stromal tumors (GIST) who underwent pancreaticoduodenectomy (PD) or local resection (LR). PubMed database was searched for relevant studies. A meta-analysis was performed with Review Manager 5.3 software. Twenty-seven observational studies involving 1103 patients were included in the review. The overall morbidity and 30-day mortality was 27% and 0.5% respectively. The median (range) 5-year overall survival (OS) and disease-free survival (DFS) rates were 87% (60-100%) and 71% (44-100%) respectively. In meta-analyses, factors associated with shorter DFS included male sex, mitotic index >5/50 high-power fields, high risk, tumor size >5 cm, and the PD procedure. Factors associated with shorter OS included mitotic index >5/50 high-power fields and tumor size >5 cm. Patients in PD group had a higher incidence of mitotic index >5/50 HPF, a higher incidence of high-risk classification, a higher incidence of tumors in the second portion of the duodenum, a larger tumor size, a longer duration of operation, more intraoperative blood loss, a greater blood transfusion requirement, a higher morbidity rate, a longer hospital stay, and an increased recurrence rate than those in LR group. In conclusion, the current literature review demonstrates that the postoperative prognosis of duodenal GIST is promising and mainly affected by tumor factors. The choice of the surgical approach should depend on the anatomical location and tumor size.

Laparoscopic Partial Sleeve Duodenectomy for the Infra-Ampullary Gastrointestinal Stromal Tumors of the Duodenum

BACKGROUND

Although organ-preserving operations are regarded as effective strategies for duodenal gastrointestinal stromal tumors (GISTs), laparoscopic partial sleeve duodenectomy (lap PSD) has not been fully evaluated. The aims of this study were to evaluate the effectiveness and technical feasibility of lap PSD.

STUDY DESIGN

Between January 2011 and March 2016, we reviewed 13 patients who underwent laparoscopic approach among 22 patients who underwent PSD. PSD for the infra-ampullary lesions was defined as infra-ampullary duodenal resection including the first portion of the jejunum. After resection, all patients underwent reconstruction via side-to-side duodenojejunostomy.

RESULTS

The total mean operation time was 273 min (range 160-346 min), and estimated mean blood loss was 80 ml (range scanty-200 ml). One patient was converted to open laparotomy because of mesocolonic tumor involvement. The median postoperative hospital stay was 10.5 days (range 4-36 days). There were no postoperative mortalities. Postoperative complications included 2 instances of delayed gastric emptying (DGE), 1 duodenojejunostomy stricture, and 2 intestinal obstructions. No patient was treated with adjuvant therapy. One patient experienced hepatic metastasis 28 months after surgery during a mean follow-up period of 48.6 months.

CONCLUSION

Lap PSD might be an oncologically effective strategy for duodenal GIST, and the laparoscopic approach is a technically feasible and appealing surgical modality in terms of safety and perioperative results. However, DGE and anastomosis strictures are concerns for postoperative complications, which need to be further investigated.

Surgical treatment of gastrointestinal stromal tumors of the duodenum: a literature review

Background

Gastrointestinal stromal tumors (GIST) are the most frequent mesenchymal tumours in the digestive tract. The duodenal GIST (dGIST) is the rarest subtype, representing only 4-5% of all GIST, but up to 21% of the resected ones. The diagnostic and therapeutic management of dGIST may be difficult due to the rarity of this tumor, its anatomical location, and the clinical behavior that often mimic a variety of conditions; moreover, there is lack of consent for their treatment. This study has evaluated the scientific literature to provide consensus on the diagnosis of dGIST and to outline possible options for surgical treatment.

Methods

An extensive research has been carried out on the electronic databases MEDLINE, Scopus, EMBASE and Cochrane to identify all clinical trials that report an event or case series of dGIST.

Results

Eighty-six studies that met the inclusion criteria were identified with five hundred forty-nine patients with dGIST: twenty-seven patients were treated with pancreatoduodenectomy and ninety-six with only local resection (segmental/wedge resections); in four hundred twenty-six patients it is not possible identify the type of treatment performed (pancreatoduodenectomy or segmental/wedge resections).

Conclusions

dGISTs are a very rare subset of GISTs. They may be asymptomatic or may involve symptoms of upper GI bleeding and abdominal pain at presentation. Because of the misleading clinical presentation the differential diagnosis may be difficult. Tumours smaller than 2 cm have a low biological aggressiveness and can be followed annually by endoscopic ultrasound. The biggest ones should undergo radical surgical resection (R0). In dGIST there is no uniformly adopted surgical strategy because of the low incidence, lack of experience, and the complex anatomy of the duodenum. Therefore, individually tailored surgical approach is recommended. R0 resection with 1-2 cm clear margin is required. Lymph node dissection is not recommended due to the low incidence of lymphatic metastases. Tumor rupture should be avoided.

Metastatic Cutaneous Duodenal Gastrointestinal Stromal Tumor: A Possible Clue to Multiple Metastases

We report a case of a 69-year-old man with metastatic cutaneous duodenal gastrointestinal stromal tumor, which led to find multiple metastases on orbital muscle and scalp. The patient presented with a rapidly growing chest nodule with mild tenderness. He underwent surgical resection for duodenal gastrointestinal stromal tumor and had been treated with imatinib for three years. Histopathological examination of the chest nodule was consistent with gastrointestinal stromal tumor. A brain magnetic resonance imaging of follow work-up revealed multiple metastases at the left superior rectus muscle and occipital scalp. Under the diagnosis with imatinib-resistant duodenal gastrointestinal stromal tumors, a second-line therapy with sunitinib was tried. After six weeks, his skin lesion was completely improved and other metastatic cancers showed a response of stable disease. This is the first reported case of a cutaneous metastasis from duodenal GIST. This report emphasizes the importance of a full-skin examination in patients with a medical history of gastrointestinal stromal tumor which leads to find multiple metastases.

Prognostic Analysis of Duodenal Gastrointestinal Stromal Tumors

AIM

This study aims to analyze factors possibly related to the prognosis of duodenal gastrointestinal stromal tumors (DGISTs).

METHODS

We collected and retrospectively analyzed clinical and pathological data of 62 patients with primary DGISTs. All the patients were hospitalized and received complete surgical resection at Shanghai Ruijin Hospital from September 2003 to April 2015. We followed up the patients to determine survival outcomes. We also analyzed the effect of clinical and pathological factors on disease-free survival (DFS) and overall survival (OS) of the patients.

RESULTS

Kaplan-Meier univariate survival analysis demonstrated that tumor size, mitotic index, Ki-67 index, and pathological risk were correlated with the DFS and OS of the patients (DFS P = 0.039, 0.001, <0.001, and 0.005, resp.; OS P = 0.027, 0.007, <0.001, and 0.012, resp.). Cox multivariate regression analysis revealed that Ki-67 index was an independent prognostic factor affecting DFS and OS (P = 0.007 and 0.028, resp.). Moreover, Kaplan-Meier survival analysis showed that imatinib treatment for patients with recurrence was correlated with prolonged OS (P = 0.002).

CONCLUSION

Prognosis for DGIST treated by R0 resection is favorable. High level of Ki-67 can be an independent risk factor of DGIST prognosis. Adjuvant imatinib therapy for patients with tumor recurrence could probably lead to prolonged survival.

Endoscopic full-thickness resection of gastric and duodenal subepithelial lesions using a new, flat-based over-the-scope clip

Background

Surgical resection of upper gastrointestinal (GI) subepithelial tumors (SETs) is associated with significant morbidity and mortality. A new over-the-scope (OTS) clip can be used for endoscopic full-thickness resection (eFTR). We aimed to prospectively evaluate feasibility and safety of upper GI eFTR with a new, flat-based OTS clip.

Methods

Consecutive patients with a gastric or duodenal SET < 20 mm were prospectively included. After identification of the lesion, the clip was placed and lesions were resected. Patients were followed for 1 month to assess severe adverse events (SAEs); 3–6 months after eFTR, endoscopy was performed.

Results

eFTR was performed on 13 lesions in 12 patients: 7 gastric and 6 duodenal SETs. Technical success was achieved in 11 cases (85%). In all 11 cases, R0-resection was achieved. In all 6 duodenal cases and in one gastric case, FTR was achieved (64%). One SAE (pain) was observed after eFTR of a gastric SET. After eFTR of duodenal SETs, several SAEs were observed: perforation (n = 1), microperforation (n = 3), and hemorrhage (n = 1). During follow-up endoscopy, the clip was no longer in situ in most patients (7 of 10; 70%).

Conclusions

eFTR with this new flat-based OTS clip is feasible and effective. Although gastric eFTR was safe, eFTR in the duodenum was complicated by (micro)perforation in several patients. Therefore, the design of the clip or the technique of resection needs further refinement to improve safety of resection of SET in thin-walled areas such as the duodenum before being applied in clinical practice.

Dutch trial register: NTR5023.

Electronic supplementary material

The online version of this article (10.1007/s00464-017-5989-8) contains supplementary material, which is available to authorized users.

Endoscopic ultrasound-guided fine-needle aspiration for diagnosing a rare extraluminal duodenal gastrointestinal tumor

Duodenal gastrointestinal stromal tumors (GISTs) are extremely rare disease entities, and the extraluminal type is difficult to diagnose. These tumors have been misdiagnosed as pancreatic tumors; hence, pancreaticoduodenectomy has been performed, although partial duodenectomy can be performed if accurately diagnosed. Developing a diagnostic methodology including endoscopic ultrasonography (EUS) and fine-needle aspiration (FNA) has allowed us to diagnose the tumor directly through the duodenum. Here, we present a case of a 50-year-old woman with a 27-mm diameter tumor in the pancreatic uncus on computed tomography scan. EUS showed a well-defined hypoechoic mass in the pancreatic uncus that connected to the duodenal proper muscular layer and was followed by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Histological examination showed spindle-shaped tumor cells positively stained for c-kit. Based on these findings, the tumor was finally diagnosed as a duodenal GIST of the extraluminal type, and the patient underwent successful mass resection with partial resection of the duodenum. This case suggests that EUS and EUS-FNA are effective for diagnosing the extraluminal type of duodenal GISTs, which is difficult to differentiate from pancreatic head tumor, and for performing the correct surgical procedure.

Clinicopathological and Prognostic Features of Surgical Management in Duodenal Gastrointestinal Stromal Tumors

BACKGROUND AND OBJECTIVES

The rarity of duodenal gastrointestinal stromal tumors (DGIST) led to only limited data being available on their management and prognosis. We retrospectively analyzed the clinicopathological features, surgical treatments, adjuvant therapy, and prognosis of DGIST.

METHODS

Sixty-one patients were identified at diagnosis of primary DGIST from February 2005 to December 2015. One hundred twenty six patients with small intestinal gastrointestinal stromal tutors (GIST) were selected as control groups. Survival analyses were calculated using the Kaplan-Meier method.

RESULTS

Three- and five-year recurrence/metastasis-free survival rates of patients with DGIST were similar to those of patients with small intestinal GIST (p > 0.05 for all). Out of 61 cases with DGIST, 45 patients were treated with Limited Resection (LR). Sixteen patients were treated with Pancreaticoduodenectomy (PD). The 3- and 5-year recurrence/metastasis-free survival rates of the PD group and LR group were of no significant difference (p > 0.05 for all). Univariate analysis indicated that factors including surgical approaches, mitotic count, size, and risk grades were significantly associated with recurrence/metastasis-free survival (log-rank test, p < 0.05). Multivariate analysis demonstrated that the mitotic count was independently correlated with a worse recurrence/metastasis-free survival.

CONCLUSIONS

Patients with radical resected DGIST had a favourable prognosis, which is similar to that of small intestinal GIST. Both LR and PD were optimal choices for treating DGIST.

Paraduodenal pancreatitis: benign and malignant mimics at MRI

Paraduodenal pancreatitis, also known as groove pancreatitis, is a rare form of chronic pancreatitis that masquerades as pancreatic adenocarcinoma affecting the pancreaticoduodenal groove, a potential space between the head of the pancreas, duodenum, and common bile duct. Two forms of groove pancreatitis have been described. The segmental form involves the pancreatic head with development of scar tissue within the groove, whereas the pure form affects the groove only, sparing the pancreatic head. Imaging findings of groove pancreatitis often overlap with primary duodenal, ampullary, or pancreatic neoplasms, which often results in a diagnostic challenge. In addition, paraduodenal pancreatitis can be mistaken for cystic pancreatic lesions, especially when there is involvement of the duodenal wall. Preoperative recognition of this entity is very important in order to avoid unnecessary procedures, although surgery, such as pancreaticoduodenectomy, may still be required to relieve obstructive symptoms. In this article, the pathophysiology and magnetic resonance imaging characteristics of paraduodenal pancreatitis and important benign and malignant mimics are discussed.

Urgency surgical treatment for duodenal GISTs: analysis of aged patients and review of the literature

INTRODUCTION

Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal neoplasms (85%) of the gastrointestinal (GI) tract; duodenal GISTs constitute 3-5% of all GISTs and represent 10-30% of all malignant tumours of the duodenum. Rarely, patients present severe bowel obstruction, perforation or severe bleeding. The radical resection with complete removal of the tumour remains the main therapeutic approach. We performed a local resection in patients with suspected GIST admitted for emergency treatment for GI bleeding.

CASES

We present three cases of patients admitted for GI bleeding. The cause could be a GIST bleeding. In all cases, local resection was performed without a pancreaticoduodenectomy. Histological examination on surgical preparations showed that in two cases it was a GIST and in one case, it was a leiomyoma.

DISCUSSION

Surgery remains the treatment of choice in the case of a GIST primitive without evidence of metastases, even for patients who are hospitalized for a bleeding emergency. Wide resections are not needed; it is important to remove completely the disease. In the case of duodenal GIST, it is important to get negative margins near the head of the pancreas, and this could take a PD. According to our experience and to the literature review, we believe that if the duodenal papilla or the periampullary region is not interested, you must perform a local resection. This is also because non-malignant tumours may present as GISTs and in these cases it is not recommended to run a PD.

CONCLUSION

The treatment of choice for duodenal GISTs is complete surgical resection with negative resection margins. When the papilla or the periampullary region is involved we choose to perform pancreaticoduodenectomy; otherwise it is better to perform a local resection. In fact, local resection has lower morbidity and mortality, with a comparable outcome.

Diagnosis and treatment of massive duodenal gastrointestinal stromal tumors: Our experience with 12 cases

AIM: To investigate the diagnosis and treatment of massive duodenal gastrointestinal stromal tumors.

METHODS: We retrospectively analyzed the diagnosis, treatment and follow-up data for 12 patients with massive duodenal gastrointestinal stromal tumors treated at our hospital since January 2000.

RESULTS: Among the 12 patients, 6 without any adjuvant therapy died of tumor recurrence and metastasis, whose survival time was 23 to 36 mo. One patient died of liver and abdominal metastases and intestinal obstruction at 13 mo, who developed intraoperative tumor rupture and refused reoperation and other therapies. The rest five patients are still alive, all of whom had received Gleevec treatment for 1-3 years; liver metastasis occurred in 3 cases and was controlled with Gleevec, and 1 case survived for 61 mo, who is still on Gleevec targeted therapy.

CONCLUSION: Massive tumor and nuclear division phase > 5/50 at high magnification are main risk factors for postoperative recurrence and metastasis in duodenal gastrointestinal stromal tumors. Complete resection, even combined with resection of other organs, is the only means to cure massive duodenal gastrointestinal stromal tumors, because it can achieve R₀ resection and avoid intraoperative tumor rupture. Gleevec targeted therapy of patients with risk factors for recurrence is an effective method of prevention and treatment of recurrence and metastasis.

Local resection for duodenal gastrointestinal stromal tumors

BACKGROUND

Duodenal gastrointestinal tumors (GIST) present infrequently, and surgical resection with negative margins remains the mainstay of therapy; however, given the lack of lymphatic and submucosal spread and anatomic location near the bile duct and pancreas, the optimal approach for resection is unknown. Options include local resection (LR), segmental resection, and pancreaticoduodenectomy (PD).

METHODS

All cases of gastrointestinal stromal tumors originating from the duodenum from 2000 to 2015 were identified from administrative databases. Clinical and pathologic information was abstracted from the medical record and compared between patients who received LR vs PD. The chi-square with Fisher's exact test was used to detect differences between groups.

RESULTS

Fifteen patients met the inclusion criteria, of which 7 had an LR and 8 had a PD. The second portion of the duodenum was the most common origin of GIST in the PD group, whereas the third portion was most common in the LR group. Patients who underwent LR tended to be younger, but there was no difference in tumor size, mitotic rate, margin positivity, readmission rate, or recurrence. PD was associated with more complications, higher blood loss, and longer length of stay.

CONCLUSIONS

Local resection is a reasonable option for resection of duodenal GIST and should be routinely considered if technically feasible.

Endoscopic versus surgical resection of GI stromal tumors in the upper GI tract

BACKGROUND AND AIMS

Endoscopic resection has been performed for treatment of GI stromal tumors (GISTs) in the upper GI tract. However, the therapeutic roles of the endoscopic procedure remain debatable. We aimed in this retrospective study to evaluate the feasibility and long-term follow-up results of endoscopic resection of GISTs in the upper GI tract, compared with surgery.

METHODS

Between March 2005 and August 2014, 130 cases of GIST in the upper GI tract were resected. We compared baseline characteristics and clinical outcomes including R0 resection rate and recurrence rate between the endoscopy group (n = 90) and surgery group (n = 40).

RESULTS

The most common location of GIST was the stomach body in the endoscopy group, whereas it was the duodenum in the surgery group (P = .001). Tumor size was significantly smaller (2.3 vs 5.1 cm; P < .001), and procedure time (51.8 ± 36.2 vs 124.6 ± 74.7 minutes; P < .001) and hospital stay (3.3 ± 2.4 vs 8.3 ± 5.4 days; P < .001) were significantly shorter in the endoscopy group than in the surgery group. The R0 resection rate was 25.6% in the endoscopy group, whereas it was 85.0% in the surgery group (P = .001), and 50.0% of resected tumors belonged to a very low-risk group in the endoscopy group, whereas 35.0% and 30.0% belonged to low-risk and high-risk in the surgery group (P = .001). However, during 45.5 months of follow-up, the recurrence rate was not significantly different between the 2 groups (2.2% vs 5.0%; P = .586).

CONCLUSIONS

Endoscopic resection might be an alternative therapeutic modality for GISTs in the upper GI tract in selective cases.

Limited resections for duodenal gastrointestinal stromal tumors and their oncologic outcomes

PURPOSE

Limited resection is considered a treatment option for duodenal gastrointestinal stromal tumors (GISTs) whenever technically feasible, but the optimal technique for this is still not well defined. We present the various types of limited resections for duodenal GISTs and analyze their postoperative outcomes.

METHODS

The subjects of this retrospective clinicopathologic analysis were 21 patients who underwent limited resections for duodenal GIST between May, 2001 and June, 2014. The median follow-up period was 52 months (range 5-125 months).

RESULTS

The patients comprised 12 men and 9 women, with a median age of 59 years (range 45-75 years), all of whom were treated by various forms of limited resection with clear margins. There were ten wedge resections with primary closure (eight open/two laparoscopic), two wedge resections with Roux-en Y duodenojejunostomy, three segmental duodenectomies with end-to-end duodenoduodenostomy, and six segmental duodenectomies with end-to-end duodenojejunostomy. Hepatic metastasis was found 27 months after surgery in one patient, who was given imatinib mesylate for 17 months to slow disease progression. The other 20 patients were alive and recurrence free at the time of writing.

CONCLUSION

Excellent recurrence-free survival was achieved after limited resections, supporting the consideration of various methods of limited resection as the treatment of choice for duodenal GISTs.

Duodenal gastrointestinal stromal tumor: From clinicopathological features to surgical outcomes

Duodenal gastrointestinal tumors represent an extremely rare subset of stromal tumors arising from interstitial cells of Cajal. In the last 30 years the comprehension of the pathophysiology and natural history of this previously misunderstood clinical entity, in association with developments in endoscopy, imaging technology, and immunohistochemistry has resulted in novel diagnostic and treatment approaches. This is a comprehensive review of the current data of the literature on the various aspects of the diagnosis and treatment of these tumors. The duodenum is the less commonly involved site for these tumors in the digestive tract. Endoscopy and computed tomography can usually establish the diagnosis, confirmed by immunohistochemical staining and occasionally molecular genetic analysis. Endoscopic ultrasound with fine needle aspiration has been recently found to be the gold diagnostic standard with high sensitivity and specificity rates, diagnosing GIST in up to 80% of patients. Due to the complex anatomy of the pancreatico-duodenal region optimal therapeutic strategy of duodenal GISTs are challenging. Nevertheless surgical resection with microscopically clear resection margins seems to be the only potentially curative treatment for non-metastatic primary GISTs of the duodenum. Imatinib mesylate plays a key role in the management of GISTs both as neoadjuvant therapy and in patients with recurrent and metastatic disease. Meanwhile, the advances in the comprehension of the pathophysiology and natural history of this previously misunderstood clinical entity as well as the treatment of these tumors may render feasible, in the near future, the advent of newer and more effective treatment options.

Differential diagnosis of pancreatic cancer from other solid tumours arising from the periampullary area on MDCT

PURPOSE

To investigate CT features and differential diagnosis of pancreatic adenocarcinoma compared to other solid tumours arising in the periampullary area.

MATERIALS AND METHODS

One hundred and ninety-five patients with pathologically proven, solid periampullary tumours, including pancreatic adenocarcinoma (n = 98), neuroendocrine tumours (n = 52), gastrointestinal stromal tumours (n = 31), and solid pseudopapillary neoplasms (n = 14), underwent preoperative CT. Two radiologists reviewed CT features and rated the possibility of pancreatic adenocarcinoma.

RESULTS

Statistically common findings for pancreatic adenocarcinoma included: patient age >50 years; ill-defined margin; completely solid mass; homogeneous enhancement; hypoenhancement on arterial and venous phases; atrophy; and duct dilatation. Statistically common findings for GIST included: heterogeneous enhancement; hyperenhancement on arterial and venous phases; rim enhancement; and prominent feeding arteries. The hyperenhancement on arterial and venous phases is statistically common in NET, and heterogeneous enhancement, hypoenhancement on the arterial and venous phases are statistically common in SPN. Diagnostic performance of CT for differentiating pancreatic adenocarcinomas from other solid periampullary tumours was 0.962 and 0.977 with excellent interobserver agreement (κ = 0.824).

CONCLUSION

CT is useful not only for differentiating pancreatic adenocarcinoma form other solid tumours but also for differentiating between other solid tumours, including NET, SPN, and GIST, arising in the periampullary area.

KEY POINTS

• Periampullary tumours arise within 2 cm of major duodenal papilla. • Many mass-forming periampullary tumours can be completely removed by minimal surgery. • Accurate differentiation of pancreatic adenocarcinoma from other solid tumours is important. • CT is useful for differentiating pancreatic adenocarcinoma from other solid tumours. • CT is useful for characterization of periampullary tumours other than adenocarcinomas.