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(a) Endoscopic image of duodenal GIST. (b) CE-EUS image of duodenal GIST. (c) EUS-EG image of duodenal GIST. (d-f) Operational processes of the EUS-FNA for duodenal GIST. CE-EUS, contrast-enhanced endoscopic ultrasound; EUS-EG, endoscopic ultrasound-guided elastography; EUS-FNA, endoscopic ultrasound-guided fine-needle aspiration; GIST, gastrointestinal stromal tumor.
Source publication
Objectives:
The diagnostic value of different noninvasive diagnostic modalities and the endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) reliability of duodenal gastrointestinal stromal tumors (GISTs) are ambiguous in the present studies.
Methods:
Patients with a histopathological diagnosis of the primary duodenal GISTs between the...
Contexts in source publication
Context 1
... duodenal GISTs presented as hypoechoic masses arose from the muscularis propria in EUS (Figure 1c,d). Using contrastenhanced EUS (CE-EUS) and EUS elastography could further improve the diagnostic accuracy (Figure 2a-c). The EUS diagnostic sensitivity was 82.0%, and the positive predictive value was 90.9%. ...
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Backgrounds/aims:
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M...
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Background:
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Case summary:
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Citations
... [1,2,3]. These tumors can range in size from less than 1 cm to more than 40 cm, with an average size of 5 cm at the time of clinical diagnosis [4,5,6]. ...
... 1. Benign GISTs (70%): These are usually not life-threatening and are typically smaller than 2 to 5 cm. 2. Malignant GISTs (30%): These cancerous tumors can invade nearby tissues within the abdomen and spread to other parts of the body, such as the liver and lungs, through lymphatic or blood transmission [4,6]. ...
... The goal of surgery is complete resection with an intact pseudo-capsule and negative microscopic margins. The type of surgery depends on the size and location of the tumor in the GI tract: [4,6,12]. ...
Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors that typically occur in the gastrointestinal tract. About 70% of GISTs are benign, while approximately 30% are malignant. GISTs represent less than 0.1% to 3% of all gastrointestinal tumors. These tumors are thought to originate from intestinal cells of Cajal (ICCs) or stem cell-like precursors. ICCs, often referred to as the "pacemaker" cells of the GI autonomic nervous system, regulate GI motility and are found around the myenteric plexus and the muscularis propria throughout the GI tract. GISTs are composed of different types of cells: approximately 70% are spindle cells, 20% are epithelioid cells, and 10% are mixed cells. Around 85% of GISTs contain mutations in one of two receptor tyrosine kinases (RTKs), KIT or PDGFRA, which play a central role in the pathogenesis of these tumors. Additionally, about 95% of GISTs test positive for the CD117 antigen. Clinically, GISTs are most commonly found in the stomach (60%), followed by the small intestine (30%), duodenum (5%), rectum (3%), colon (1%), and oesophagus (0.5%). Occurrences in the omentum and mesentery are rare. GISTs affect men and women equally and most commonly occur between the ages of 50 to 70 years. The annual incidence rate is between 6.5 and 14.5 per million people worldwide. In our study, we report three cases of GISTs located in the duodenum, jejunum, and transverse colon. Diagnosis in these cases was confirmed via CT scan and all cases tested positive for the CD117 antigen.
... The CT and magnetic resonance imaging (MRI) features of GIST, including large, circular, or lobulated soft tissue masses prone to cyst formation or necrosis in the center, and nonuniform delayed enhancement, have been reported in previous studies (15)(16)(17). Compared with traditional imaging techniques, PET/CT offers distinct advantages as it can simultaneously provide anatomical and metabolic information of lesions. ...
Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors affecting the gastrointestinal tract. Typically, GISTs are solitary; however, in rare cases, they may be multiple and appear in one or more organs. Multiple GISTs can appear in familial GISTs, children, or certain tumor syndromes such as neurofibromatosis type 1, Carney syndrome, and Carney-Stratakis syndrome. However, the diagnosis of primary multiple sporadic GISTs is often more difficult than that of these diseases. Herein, we report a case of multiple primary sporadic GISTs in a 64-year-old man, affecting the abdominal cavity and retroperitoneum, as identified through dual-time point positron emission tomography (PET) with ¹⁸F-labeled fluoro-2-deoxyglucose (¹⁸F-FDG) and computed tomography (¹⁸F-FDG PET/CT). Notably, the dual-time-point PET/CT revealed the migration of masses near the lower abdomen into the abdominal cavity. Furthermore, a significant increase in radioactive uptake of the mass 3 h after ¹⁸F-FDG injection compared with that 1 h after injection may be an important cue for its diagnosis.
... También evidencia que la toma de biopsia con aguja fina mediante EUS proporciona mayor valor para el diagnóstico de GIST que la biopsia por endoscopia convencional (73 % vs 33,3 %, P = 0.006). (9) Según interpreta Tian Lim, (10) estos resultados con las pruebas diagnósticas quedan explicados por la calidad de los equipos de diagnóstico y la experiencia creciente de los operadores durante años. ...
Gastrointestinal stromal tumors are rare tumors and correspond to 1% of all gastrointestinal neoplasms; duodenal location only represents between 3-5%. This case report was made for disclosing the surgical strategy followed in a patient with invasive gastrointestinal stromal tumors (>10 cm) of atypical location in the duodenum fourth portion. Hospitalization was due to abdominal tumor and anemia. The clinical exercise consisted of identifying a left abdominal mass with lumbar contact. The diagnostic tests performed were: blood chemistry tests, abdominal ultrasound, computerized axial tomography, and digestive endoscopy with biopsy that confirmed the diagnosis. The surgical procedure was resection of the duodenum fourth portion and the first jejunal loops, with restoration of intestinal function through duodenum (second portion) lateral jejunostomy. The surgery was interrupted due to the patient's hemodynamic instability, and four days later he was taken back to the operating room due to peritonitis, with pus coming out of the abdominal drains, which was resolved by washing the cavity. Morbidity was accompanied by a pancreatic fistula. In the third surgical time, resection of the residual tumor, left nephrectomy, and control of the pancreatic fistula were performed. After one year the patient is free of tumor disease. The management strategy in patients with atypically located gastrointestinal stromal tumors represents a challenge for the surgeon as a member of the multidisciplinary group and depends on the extent of the tumor, the patient's condition, and the surgical team timely management.
... PD is a more radical procedure and is associated with substantial morbidity (32.5-61.6%) [5][6][7][8][9][10] and mortality (1-7.7%) [5,6,10]. ...
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.
... Большинство ГИСО спорадические, однако в 5% наблюдений их выявляют у пациентов с нейрофиброматозом I типа (НФ-1) и триадой Карнея [15]. Кли ническая картина неспецифична: симптомы желудочно-кишеч ного кровотечения (44,4%), следующие за абдоминальной болью и метеориз-мом (27,5%) [16]. В ДПК ГИСО чаще локализуются в сегментах D2 (52,1%) и D1 (19%) [16]. ...
... Кли ническая картина неспецифична: симптомы желудочно-кишеч ного кровотечения (44,4%), следующие за абдоминальной болью и метеориз-мом (27,5%) [16]. В ДПК ГИСО чаще локализуются в сегментах D2 (52,1%) и D1 (19%) [16]. ...
... В одном из исследований чувствительность КТ и МРТ составила 66,7 и 61,9%, что авторы объясняют неправильной трактовкой результатов [16]. Возможной причиной может быть редкое применение ДВИ в протоколах исследований. ...
Aim : To present the computed tomography and magnetic resonance imaging assessments of benign and malignant duodenal tumors, pancreatic head adenocarcinoma invading the duodenum, and duodenal dystrophy.
Methods : We searched for scientific papers and clinical guidelines in the information and analytical databases PubMed and Google Scholar from the 2013–2021 period using the following search terms: duodenal neoplasms, adenocarcinoma, duodenum, duodenal neuroendocrine tumors, duodenal adenoma, gastrointestinal stromal tumor, cholangiocarcinoma, radiology, magnetic resonance imaging, computed tomography, pancreatic head cancer. Then, we examined the reference lists of all the identified studies to collate the papers that would meet the eligibility criteria.
Results : We analyzed 1494 articles, 22 of which were included in our review. From the papers published within 1992–2021, 35 articles from the reference lists were additionally included. Based on the search results, several domains of articles were clustered; the articles from those domains were reviewed and evaluated that involved the abovementioned diagnostic features.
Conclusion : The early diagnosis and selection of appropriate management methods remain extremely relevant for the treatment of duodenal tumors, and hence, require careful attention from diagnosticians and clinicians.
... Traditional Whipple surgery results in severe surgical injury; therefore, local resection is performed to preserve more healthy tissue [3,4]. In recent years, there have been some reports on DGISTs; however, there is a lack of large-scale reports as the incidence of DGISTs is low [5,6]. In the present study, we excluded patients with liver metastasis. ...
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 χ 2 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.
... All GISTs have malignant potential, which appears to be higher in those arising in the small intestine comparing to the gastric ones [8,9]. Histologically, the best known prognostic factors are tumour size and the mitotic index. ...
... Tumors which are ≤2 cm in diameter with ≤5 mitoses per 50 high power fields are usually benign with good prognosis. GIST which are >5 cm or >5mitoses per 50 high power fields are likely to be malignant; and poor prognostic factors include tumour necrosis, extensive hemorrhage unrelated to surgery, hypercellularity, marked cellular atypia and epithelioid pattern with mucosal invasion [8,9]. About 30-50% of the GIST are malignant with 5 year survival of 50%; malignant tumors usually metastasize to liver and peritoneum [9]. ...
Introduction and importance
Duodenal Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors of the digestive tract. The tumors are derived from interstitial cells of Cajal and usually they present as gastrointestinal bleeding or non-specific abdominal pain, but they can also be asymptomatic even when they have reached considerable size.
Case presentation
We report a case of a 40-year-old male presented to our emergency department after sustaining a stab wound on the abdomen. Abdominal imaging tests weren't done; instead an emergency laparotomy was undertaken upfront in an attempt to catch up with a “golden hour”. Intra-operatively, an incidental solid mass measuring 4 × 5 cm was noted on the third/fourth portion of the interior duodenal flexure. Histopathologically, the lesion demonstrated spindled shaped cells which were immunopositive for positive CD117. The patient fared well postoperatively and during subsequent follow up visits.
Clinical discussion
High-risk GISTs have malignant potential. In some cases, GIST is diagnosed as incidentally finding, mostly during surgical procedure, upper endoscopy or radiological studies related to GI tract. Surgical resection is recommended curative option and its extension depends on different factors. Tyrosine kinase inhibitors are of the utmost importance in high-risk and metastatic disease.
Conclusion
Even considerably large duodenal GISTs can be asymptomatic, thus incidentally found during an abdomino-pelvic imaging tests. Histopathological evaluation of the operative specimen plays a key role in assessing the need of adjuvant therapy, with a significant impact on the patients' survival.
Surgical management of duodenal gastrointestinal stromal tumors (GIST) remains challenging due to the anatomical complexity of the region. While pancreaticoduodenectomy is considered standard, it is associated with significant morbidity, mortality, and life-long metabolic consequences. Herein, we present a case where segmental resection was performed for a distal second portion of duodenum GIST using a Fogarty catheter to identify and protect the ampulla during transection. This technique allowed safe, function-preserving surgery.
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.
Lim KT. Current surgical management of duodenal gastrointestinal stromal tumors. World J Gastrointest Surg 2021; 13(10): 1166-1179 [DOI: 10.4240/wjgs.v13.i10.1166]
