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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 16  |  Issue : 1  |  Page : 33-35

Aggressive surgical resection following neoadjuvant imatinib therapy for advanced duodenal tumor with hepatic metastasis


Department of Surgical Gastroenterology, Indraprastha Apollo Hospital, New Delhi, India

Date of Web Publication11-Mar-2019

Correspondence Address:
Varun Madaan
Department of Surgical Gastroenterology, Indraprastha Apollo Hospital, Opd No. 1241, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_90_18

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  Abstract 


Duodenal gastrointestinal stromal tumors (GISTs) are rare tumors which constitute <5% of all cases of GIST. The treatment of locally advanced/inoperable and metastatic GIST is primarily tyrosine kinase inhibitor therapy (TKI), i.e., imatinib mesylate. In some patients, initial TKI therapy may result in significant downstaging of the primary tumor and metastatic disease. The role of aggressive surgical resection in such patients remains controversial. We present a case of advanced duodenal GIST treated successfully by Whipple's procedure with liver wedge resection following neoadjuvant TKI therapy. This case shows that aggressive surgical resection for metastatic duodenal GIST following neoadjuvant imatinib seems to be a feasible treatment option.

Keywords: Duodenal gastrointestinal stromal tumor, imatinib, locally advanced gastrointestinal stromal tumor


How to cite this article:
Madaan V, Gupta R, Adithya G K, Jindal SP, Govil D. Aggressive surgical resection following neoadjuvant imatinib therapy for advanced duodenal tumor with hepatic metastasis. Apollo Med 2019;16:33-5

How to cite this URL:
Madaan V, Gupta R, Adithya G K, Jindal SP, Govil D. Aggressive surgical resection following neoadjuvant imatinib therapy for advanced duodenal tumor with hepatic metastasis. Apollo Med [serial online] 2019 [cited 2019 May 24];16:33-5. Available from: http://www.apollomedicine.org/text.asp?2019/16/1/33/253878




  Introduction Top


Duodenal gastrointestinal stromal tumors (GISTs) are uncommon tumors which constitute <5% of all cases of GIST. The treatment of locally advanced/inoperable and metastatic GIST is primarily tyrosine kinase inhibitor therapy (TKI), i.e., imatinib mesylate. In some patients, initial TKI therapy may result in significant downstaging of the primary tumor and metastatic disease. The role of aggressive surgical resection in such patients remains controversial. We present a case of advanced duodenal GIST treated successfully by Whipple's procedure with liver wedge resection following neoadjuvant TKI therapy.


  Case Report Top


A 54-year-old male patient presented with a history of melena, weakness, and vomiting for 1-month duration. On endoscopic evaluation, he was found to have duodenal mass, and biopsy of lesion could not be taken due to bleeding from the mass. Contrast-enhanced computed tomography (CECT) abdomen showed large multilobulated peripherally rim-enhancing, centrally necrotic lesion arising from posterosuperior margin of D2 and D3, abutting the major vessels with infiltration of head and uncinated process of pancreas; there was loss of fat plane with jejunum and hepatic flexure of the colon and the right ureter was surrounded by the tumor. There was a focal lesion in segment IVa of the liver (1.3 cm × 1.2 cm). Endoscopic ultrasound (EUS) showed a mass arising from D1 and body of stomach having both solid and cystic components, infiltrating head of pancreas andPortal vein (PV) with subcarinal lymph nodes. EUS-guided FNAC was taken which showed spindle cell tumor. Angioembolization of feeding vessel of duodenal mass was done, with which melena settled. Imatinib 400 mg twice daily was started and the patient was followed up. After 1 month of imatinib treatment, the patient presented to us with complaints of recurrent fever. Repeat CECT abdomen showed large thickened-wall, heterogeneously enhancing mass lesion (10.3 cm × 9.2 cm × 6 cm) arising from the medial wall of 2nd/3rd part of duodenum, with internal necrosis and ulceration showing few internal air pockets extending up to the uncinate process of the pancreas, abutting the right Gerota's fascia anteriorly, and the adjacent small bowel loops appear adherent to the mass [Figure 1]. In view of persistent fever and necrosis in the tumor, resection in the form of Whipple's procedure and wedge resection of liver lesion was done [Figure 2]. Postoperative period was uneventful except the delayed gastric emptying which settled with conservative treatment. Final pathology report was duodenum GIST (spindle cell type, intermediate risk category). Maximum tumor size was 8 cm, infiltrating into the duodenal submucosa and invading head of pancreas. The pancreatic free surface as well as pancreatic resection margin and the proximal gastric and distal intestinal margins were free from tumor. Lymphovascular/perineural invasion was not seen. No lymph node metastasis was present (0/8). Resected wedge of the liver showed metastatic deposit of tumor with clear margins. At present, the patient is on imatinib (400 mg daily) and is asymptomatic at 18 months of follow-up.
Figure 1: Contrast-enhanced computed tomography abdomen showing edematous duodenal wall (d) and mass lesion (m)

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Figure 2: Intraoperative picture showing mass lesion arising from the duodenum

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  Discussion Top


GISTs are more often located in the stomach (56%) followed by small bowel (32%), colorectum (6%), and esophagus (<1%), with duodenum being the least common site. Duodenum GISTs are rarely observed and often manifest as nonspecific abdominal pain, gastrointestinal hemorrhaging, and intestinal obstruction may infrequently have been observed.[1] The median survival for patients with unresectable and/or metastatic disease is 12 months (ranging from 2 to 20 months). In a large randomized multicenter trial conducted by Demetri et al., imatinib induced a sustained objective response in over half of patients with advanced unresectable or metastatic GIST.[2] The estimated 1-year survival was 88%. A number of other trials similarly have shown good response rate and survival in patients with advanced GIST. Imatinib is a very promising treatment modality for the GIST, but complete surgical extirpation remains the only curative treatment of malignant GIST. When possible, segmental resection should be the procedure of choice; nonetheless, due to peculiar anatomic location, pancreaticoduodenectomy is often necessary.[3] Neoadjuvant treatment with TKI has been proposed to downstage GISTs and possibly increases the chance of preserving normal biliary and pancreatic anatomy which would otherwise require more aggressive surgery.[4] The first line of treatment for patients with metastatic or recurrent GISTs is TKI (imatinib mesylate) in the form of neoadjuvant or adjuvant therapy.[5] The appropriate time for surgical intervention is still unknown. It is proposed to consider surgery if a complete cytoreductive resection is feasible after 6–9 months with a TKI. In view of locally advanced and metastatic GIST, we planned for neoadjuvant treatment. After 1 month of therapy, due to persistent fever and necrosis in tumor, we considered for early aggressive surgery followed by imatinib treatment. Complete resection of the tumor was possible along with wedge of liver harboring metastatic deposit.


  Conclusion Top


  • Aggressive surgical resection for metastatic duodenal GIST following neoadjuvant imatinib seems to be a feasible treatment option
  • Depending on individual circumstances, we should choose the most desirable treatment modality, and the combination of surgical extirpation and imatinib therapy should help improve the prognosis of GIST patients in some cases.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Johnston FM, Kneuertz PJ, Cameron JL, Sanford D, Fisher S, Turley R, et al. Presentation and management of gastrointestinal stromal tumors of the duodenum: A multi-institutional analysis. Ann Surg Oncol 2012;19:3351-60.  Back to cited text no. 1
    
2.
Demetri GD, von Mehren M, Blanke CD, Van den Abbeele AD, Eisenberg B, Roberts PJ, et al. Efficacy and safety of imatinib mesylate in advanced gastrointestinal stromal tumors. N Engl J Med 2002;347:472-80.  Back to cited text no. 2
    
3.
Tien YW, Lee CY, Huang CC, Hu RH, Lee PH. Surgery for gastrointestinal stromal tumors of the duodenum. Ann Surg Oncol 2010;17:109-14.  Back to cited text no. 3
    
4.
Chok AY, Koh YX, Ow MY, Allen JC Jr., Goh BK. A systematic review and meta-analysis comparing pancreaticoduodenectomy versus limited resection for duodenal gastrointestinal stromal tumors. Ann Surg Oncol 2014;21:3429-38.  Back to cited text no. 4
    
5.
Bamboat ZM, DeMatteo RP. Metastasectomy for gastrointestinal stromal tumors. J Surg Oncol 2014;109:23-7.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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