Skip to main content

Advertisement

SpringerLink
Log in

Surgical Strategy and Outcomes in Duodenal Gastrointestinal Stromal Tumor

  • Bone and Soft Tissue Sarcomas
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

The surgical management of duodenal gastrointestinal stromal tumors (DGIST) is poorly characterized. Limited resection may be technically feasible and oncologically safe, but anatomic considerations may compromise the resection margins due to the proximity of critical structures, thereby necessitating more extensive resections such as pancreaticoduodenectomy.

Methods

Patients undergoing surgery for DGIST at two institutions from 1994 to 2014 were identified. Clinicopathologic and survival data were analyzed to compare outcomes in patients treated with limited or radical resection.

Results

Sixty patients underwent surgery for DGIST. Pancreaticoduodenectomy was performed in 38 % while the rest underwent limited resections. The most common type of limited resection was wedge resection and primary closure (49 %) followed by segmental resection with an end-to-end or side-to-side duodenojejunostomy (27 %). The pancreaticoduodenectomy group tended to have larger tumors with the majority located in D2/3 (87 %) and at the mesenteric border (91 %). The pancreaticoduodenectomy group also had significantly greater intraoperative blood loss, longer operative time, longer hospital stay, and higher 90-day morbidity and readmission rates. The 5-year relapse-free survival, recurrence-free survival, and overall survival for the pancreaticoduodenectomy versus limited resection were 81 versus 56 % (p = 0.05), 64 versus 53 % (p = 0.5), and 76 versus 72 % (p = 0.6), respectively. A surgical algorithm based on the location and size of the tumor is proposed.

Conclusions

Limited resection of DGIST is safe, but may be associated with lower 5-year relapse-free survival. Pancreaticoduodenectomy is recommended for selected patients with DGIST when an R0 resection cannot be performed without removing the ampulla or part of the pancreas.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Joensuu H, DeMatteo RP. The management of gastrointestinal stromal tumors: a model for targeted and multidisciplinary therapy of malignancy. Annu Rev Med. 2012;63:247–58.

    Article  CAS  PubMed  Google Scholar 

  2. Corless CL, Fletcher JA, Heinrich MC. Biology of gastrointestinal stromal tumors. J Clin Oncol. 2004;22:3813–25.

    Article  CAS  PubMed  Google Scholar 

  3. Heinrich MC, Rubin BP, Longley BJ, et al. Biology and genetic aspects of gastrointestinal stromal tumors: KIT activation and cytogenetic alterations. Hum Pathol. 2002;33:484–95.

    Article  CAS  PubMed  Google Scholar 

  4. DeMatteo RP, Lewis JJ, Leung D, et al. Two hundred gastrointestinal stromal tumors: recurrence patterns and prognostic factors for survival. Ann Surg. 2000;231:51–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Schottenfeld D, Beebe-Dimmer JL, Vigneau FD. The epidemiology and pathogenesis of neoplasia in the small intestine. Ann Epidemiol. 2009;19:58–69.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Zhou B, Zhang M, Wu J, et al. Pancreaticoduodenectomy versus local resection in the treatment of gastrointestinal stromal tumors of the duodenum. World J Surg Oncol. 2013;11:196.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Bourgouin S, Hornez E, Guiramand J, et al. Duodenal gastrointestinal stromal tumors (GISTs): arguments for conservative surgery. J Gastrointest Surg. 2013;17:482–7.

    Article  PubMed  Google Scholar 

  8. Tien YW, Lee CY, Huang CC, et al. Surgery for gastrointestinal stromal tumors of the duodenum. Ann Surg Oncol. 2010;17:109–14.

    Article  PubMed  Google Scholar 

  9. Goh BK, Chow PK, Kesavan S, et al. Outcome after surgical treatment of suspected gastrointestinal stromal tumors involving the duodenum: is limited resection appropriate? J Surg Oncol. 2008;97:388–91.

    Article  PubMed  Google Scholar 

  10. Goh BK, Chow PK, Ong HS, et al. Gastrointestinal stromal tumor involving the second and third portion of the duodenum: treatment by partial duodenectomy and Roux-en-Y duodenojejunostomy. J Surg Oncol. 2005;91:273–5.

    Article  PubMed  Google Scholar 

  11. Chok AY, Koh YX, Ow MY, et al. A systematic review and meta-analysis comparing pancreaticoduodenectomy versus limited resection for duodenal gastrointestinal stromal tumors. Ann Surg Oncol. 2014;21:3429–38.

    Article  PubMed  Google Scholar 

  12. El-Gendi A, El-Gendi S, El-Gendi M. Feasibility and oncological outcomes of limited duodenal resection in patients with primary nonmetastatic duodenal GIST. J Gastrointest Surg. 2012;16:2197–202.

    Article  PubMed  Google Scholar 

  13. Choi H, Charnsangavej C, Faria SC, et al. Correlation of computed tomography and positron emission tomography in patients with metastatic gastrointestinal stromal tumor treated at a single institution with imatinib mesylate: proposal of new computed tomography response criteria. J Clin Oncol. 2007;25:1753–9.

    Article  PubMed  Google Scholar 

  14. Eisenhauer EA, Therasse P, Bogaerts J, et al. New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer. 2009;45:228–47.

    Article  CAS  PubMed  Google Scholar 

  15. Dematteo RP, Ballman KV, Antonescu CR, et al. Adjuvant imatinib mesylate after resection of localised, primary gastrointestinal stromal tumour: a randomised, double-blind, placebo-controlled trial. Lancet. 2009;373(9669):1097–104.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Fischer M, Matsuo K, Gonen M, et al. Relationship between intraoperative fluid administration and perioperative outcome after pancreaticoduodenectomy: results of a prospective randomized trial of acute normovolemic hemodilution compared with standard intraoperative management. Ann Surg. 2010;252:952–8.

    Article  PubMed  Google Scholar 

  17. Fletcher CD, Berman JJ, Corless C, et al. Diagnosis of gastrointestinal stromal tumors: a consensus approach. Hum Pathol. 2002;33:459–65.

    Article  PubMed  Google Scholar 

  18. Miettinen M, Lasota J. Gastrointestinal stromal tumors: review on morphology, molecular pathology, prognosis, and differential diagnosis. Arch Pathol Lab Med. 2006;130:1466–78.

    CAS  PubMed  Google Scholar 

  19. Uchida H, Sasaki A, Iwaki K, et al. An extramural gastrointestinal stromal tumor of the duodenum mimicking a pancreatic head tumor. J Hepatobiliary Pancreat Surg. 2005;12:324–7.

    Article  PubMed  Google Scholar 

  20. Johnston FM, Kneuertz PJ, Cameron JL, et al. Presentation and management of gastrointestinal stromal tumors of the duodenum: a multi-institutional analysis. Ann Surg Oncol. 2012;19:3351–60.

    Article  PubMed  Google Scholar 

  21. Colombo C, Ronellenfitsch U, Yuxin Z, et al. Clinical, pathological and surgical characteristics of duodenal gastrointestinal stromal tumor and their influence on survival: a multi-center study. Ann Surg Oncol. 2012;19:3361–7.

    Article  CAS  PubMed  Google Scholar 

  22. Miettinen M, Kopczynski J, Makhlouf HR, et al. Gastrointestinal stromal tumors, intramural leiomyomas, and leiomyosarcomas in the duodenum: a clinicopathologic, immunohistochemical, and molecular genetic study of 167 cases. Am J Surg Pathol. 2003;27:625–41.

    Article  PubMed  Google Scholar 

  23. Zhang Q, Shou CH, Yu JR, et al. Prognostic characteristics of duodenal gastrointestinal stromal tumours. Br J Surg. 2015;102:959–64.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Duffaud F, Meeus P, Bachet JB, et al. Conservative surgery vs duodeneopancreatectomy in primary duodenal gastrointestinal stromal tumors (GIST): a retrospective review of 114 patients from the French sarcoma group (FSG). Eur J Surg Oncol. 2014;40:1369–75.

    Article  CAS  PubMed  Google Scholar 

  25. Koh YX, Chok AY, Zheng HL, et al. A systematic review and meta-analysis comparing laparoscopic versus open gastric resections for gastrointestinal stromal tumors of the stomach. Ann Surg Oncol. 2013;20:3549–60.

    Article  PubMed  Google Scholar 

  26. Karakousis GC, Singer S, Zheng J, et al. Laparoscopic versus open gastric resections for primary gastrointestinal stromal tumors (GISTs): a size-matched comparison. Ann Surg Oncol. 2011;18:1599–605.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Cavallaro G, Polistena A, D’Ermo G, et al. Duodenal gastrointestinal stromal tumors: review on clinical and surgical aspects. Int J Surg. 2012;10:463–5.

    Article  CAS  PubMed  Google Scholar 

  28. Yamashita S, Sakamoto Y, Saiura A, et al. Pancreas-sparing duodenectomy for gastrointestinal stromal tumor. Am J Surg. 2014;207:578–83.

    Article  PubMed  Google Scholar 

  29. Winfield RD, Hochwald SN, Vogel SB, et al. Presentation and management of gastrointestinal stromal tumors of the duodenum. Am Surg. 2006;72:719–22.

    PubMed  Google Scholar 

  30. McCarter MD, Antonescu CR, Ballman KV, et al. Microscopically positive margins for primary gastrointestinal stromal tumors: analysis of risk factors and tumor recurrence. J Am Coll Surg. 2012;215:53–9.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Wang D, Zhang Q, Blanke CD, et al. Phase II trial of neoadjuvant/adjuvant imatinib mesylate for advanced primary and metastatic/recurrent operable gastrointestinal stromal tumors: long-term follow-up results of Radiation Therapy Oncology Group 0132. Ann Surg Oncol. 2012;19:1074–80.

    Article  CAS  PubMed  Google Scholar 

  32. Rutkowski P, Gronchi A, Hohenberger P, et al. Neoadjuvant imatinib in locally advanced gastrointestinal stromal tumors (GIST): the EORTC STBSG experience. Ann Surg Oncol. 2013;20:2937–43.

    Article  PubMed  Google Scholar 

  33. Hohenberger P, Eisenberg B. Role of surgery combined with kinase inhibition in the management of gastrointestinal stromal tumor (GIST). Ann Surg Oncol. 2010;17:2585–600.

    Article  PubMed  Google Scholar 

  34. Eisenberg BL, Trent JC. Adjuvant and neoadjuvant imatinib therapy: current role in the management of gastrointestinal stromal tumors. Int J Cancer. 2011;129:2533–42.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgment

Supported by National Cancer Institute Grants CA102613 (RPD) and Cancer Center Support Grant P30 CA008748.

Disclosure

The authors declare no conflict of interest.

Author information

Authors and Affiliations

  1. Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA

    Ser Yee Lee MD, MSc, MMed, FRCS(Ed), Eran Sadot MD, Rahul Rajeev MBBS, Vinod P. Balachandran MD, T. Peter Kingham MD, Peter J. Allen MD, Michael I. D’Angelica MD, William R. Jarnagin MD, Daniel Coit MD & Ronald P. DeMatteo MD

  2. Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore

    Ser Yee Lee MD, MSc, MMed, FRCS(Ed), Brian K. P. Goh MBBS, MSc, MMed, FRCS(Ed) & Alexander Y. F. Chung MBBS, FRCS

  3. Duke–National University of Singapore (NUS) Medical School, Singapore, Singapore

    Ser Yee Lee MD, MSc, MMed, FRCS(Ed), Brian K. P. Goh MBBS, MSc, MMed, FRCS(Ed), Wai Keong Wong MBBS, FRCS, Hock Soo Ong MBBS, FRCS & Alexander Y. F. Chung MBBS, FRCS

  4. Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA

    Mithat Gönen PhD

  5. Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital, Singapore, Singapore

    Wai Keong Wong MBBS, FRCS & Hock Soo Ong MBBS, FRCS

Authors
  1. Ser Yee Lee MD, MSc, MMed, FRCS(Ed)
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Brian K. P. Goh MBBS, MSc, MMed, FRCS(Ed)
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Eran Sadot MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Rahul Rajeev MBBS
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Vinod P. Balachandran MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Mithat Gönen PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. T. Peter Kingham MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Peter J. Allen MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Michael I. D’Angelica MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. William R. Jarnagin MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Daniel Coit MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Wai Keong Wong MBBS, FRCS
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Hock Soo Ong MBBS, FRCS
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Alexander Y. F. Chung MBBS, FRCS
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. Ronald P. DeMatteo MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ronald P. DeMatteo MD.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lee, S.Y., Goh, B.K.P., Sadot, E. et al. Surgical Strategy and Outcomes in Duodenal Gastrointestinal Stromal Tumor. Ann Surg Oncol 24, 202–210 (2017). https://doi.org/10.1245/s10434-016-5565-9

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-016-5565-9

Keywords

Search

Navigation