A rare case of large gastrointestinal stromal tumor

of duodenum
 CASE PRESENTATION

55 year female came with complaints of pain in abdomen and generalized

weakness.

On examination patient had pallor and lump in right hypochondriac region.

Ultrasonography was suggestive of 6x4 cm lymph nodal mass.

CASE PRESENTATION
CECT Abdomen: A tumor of
size 6 x 6 cm inseparable
from duodenum and pancreas
Duodenum

Pancreatic head

Tumor
 MANAGEMENT
Pt was posted for exploratory laparotomy.
Intraoperative photograph showing tumor of size 5.5 x 4.5 cms, arising from
anterior surface of second and third part of duodenum:
Second part of duodenum

Pancreatic head

Tumor
 MANAGEMENT

Wedge resection of tumor with 1 cm duodenal margin was done.

Duodenal defect due to tumor resection was closed with side to side
duodenojejunostomy.

Feeding jejunostomy was done.

 MANAGEMENT

Postoperative day 3: Patient started with jejunostomy feeding.

Postoperative day 6: Oral diet started

Postoperative day 8: abdominal drain removed

Postoperative day 11:Sutures removed. Patient discharged.

Postoperative day 21: Feeding jejunostomy removed

MANAGEMENT

Histopathology:
Spindle shaped tumor
cells with elongated
nuclei and eosinophilic
cytoplasm suggestive
of GIST.
< 5 mitotic figures/hpf
 MANAGEMENT
Iummunohistochemistry:

CD117 POSITIVE DOG1 POSITIVE Ki 67 Negative

 MANAGEMENT

Chemotherapy was started with Imatinib.

There was no recurrence after 6 months of follow up .

 DISCUSSION

Gastrointestinal stromal tumors are low-grade malignant mesenchymal tumors of

the gastrointestinal tract. [1]

They are believed to originate from the neoplastic transformation of the

interstitial cells of Cajal (the gastrointestinal pacemaker cells)

Most common site: Stomach, jejunum, ileum, duodenum, rectum. [2]

Resistant to conventional chemotherapy.

Requires surgical excision along with Imatinib. [3]

 DISCUSSION

Duodenal GIST is a rare entity. They have atypical presentation. [4]

So preoperative diagnosis is problematic.

It difficult to differentiate from pancreatic head tumors. [5]

Surgical treatment of GISTs involves complete removal of tumor with clear

surgical margins and avoidance of tumor rupture.

Surgery for duodenal pathology is challenging because of its retroperitoneal

position and shared blood supply with the pancreas. [6]
 DISCUSSION
Surgical options: pancreaticoduodenectomy
Segmental Resection of duodenum
Previous few case reports demonstrated wedge resection of GIST followed by
closure of defect by primary closure with equal oncological outcomes. [7]
Duodenal defect after excision of tumor was large in our case, so defect was
closed with duodenojenunostomy.
Postoperative period was uneventful in our patient
 REFERENCES
1. Rammohan, Ashwin et al. “A gist of gastrointestinal stromal tumors: A review.” World journal of gastrointestinal
oncology vol. 5,6 (2013): 102-12.
2. Kjetil Søreide et al, Global epidemiology of gastrointestinal stromal tumours (GIST): A systematic review of
population-based cohort studies, Cancer Epidemiology, Volume 40, 2016, Pages 39-46.
3. Bamboat ZM, Dematteo RP. Updates on the management of gastrointestinal stromal tumors. Surg Oncol Clin N Am.
2012;21(2):301–316. doi:10.1016/j.soc.2011.12.004
4. Shen C, Chen H, Yin Y, et al. Duodenal gastrointestinal stromal tumors: clinicopathological characteristics, surgery,
and long-term outcome. BMC Surg. 2015;15:98. Published 2015 Aug 15. doi:10.1186/s12893-015-0084-3
5. Beham A, Schaefer IM, Cameron S, et al. Duodenal GIST: a single center experience. Int J Colorectal Dis.
2013;28(4):581–590. doi:10.1007/s00384-012-1432-8
6. G. Cavallaro, A. Polistena, G. D'Ermo, G. Pedullà, G. De Toma, Duodenal gastrointestinal stromal tumors: Review on
clinical and surgical aspects, International Journal of Surgery, Volume 10, Issue 9, 2012, Pages 463-465.
7. Alexander Shaw, John Jeffery, Laura Dias, and Sarfraz Nazir, “Duodenal Wedge Resection for Large Gastrointestinal
Stromal Tumour Presenting with Life-Threatening Haemorrhage,” Case Reports in Gastrointestinal Medicine, vol.
2013, Article ID 562642, 5 pages, 2013.