Duodenal GIST: Lokasyona göre cerrahi tedavi. Literatür derlemesi ile tek merkez deneyimleri

Amaç: Gastrointestinal stromal tümörler (GIST) en yaygın sindirim yolu mezenkimal neoplazileridir, ancak GIST'lerin sadece% 1-5'i duodenumda görülür. Klinik belirtiler, yönetim, cerrahi tedavi ve bunların sonuçları tam olarak tanımlanmamıştır. Bu çalışmanın amacı, kurumumuzdaki cerrahi deneyimi ortaya koymak, duodenumdaki tümörün konumuna göre cerrahi prosedürleri analiz etmek ve anatomik olarak karmaşık olan bu bölgedeki GIST'lerin cerrahi yönetimini gözden geçirmektir.Yöntemler: Son 5 yılda (Ocak 2014 - Aralık 2019) merkezimizde küratif amaçla cerrahi olarak tedavi edilen duodenal GIST'li hastalar bu retrospektif kohort çalışmaya dahil edildi. Demografik veriler, klinik tablo, GIST yeri, tanısal değerlendirme, onkolojik tedavi, cerrahi prosedür, mortalite ve morbidite, patolojik ve morfolojik GIST özellikleri, patolojik risk kategorisi, takip ve sağkalım not edildi.Bulgular: Merkezimizde son 5 yılda duodenal GIST tanısı alan 5 hasta ameliyat edildi. İyileştirme amaçlı ve negatif rezeksiyon sınırları ile dört ameliyat yapıldı. Sadece biri laparoskopik yaklaşımla yapıldı. Tüm vakalarda sınırlı rezeksiyon R0 yapıldı. Hiçbir hasta ameliyattan önce neoadjuvan tedavi almadı. Tüm hastaların ortalama yaşı 63 yıldı (52-70 yıl) ve hepsi kadındı. Klinik belirtiler karın ağrısı ve üst gastrointestinal kanamadan oluşuyordu. Vakalardan biri tesadüfen teşhis edildi. Postoperatif mortalite olmadı. Ortalama hastanede kalış süresi 8 gündü (4-26 gün). Ortanca takip süresi 33 aydı (6 ay - 8 yıl). Takip sırasında 2 hasta GIST dışı nedenlerle kaybedildi ve bir hasta ilk ameliyattan 29 ay sonra rezektabl periton metastazı nedeniyle ameliyat edildi.Sonuç: Tümör biyolojisi, duodenal GIST'nin onkolojik sonuçları için cerrahi işlemden daha önemlidir. Duodenumda görülen, cerrahi rezeksiyon endikasyonu olan GIST, karmaşık duodenum anatomisi nedeniyle cerrah için zordur.

Anahtar Kelimeler:

Gastrointestinal stromal tümör, Duodenum, Cerrahi işlemler

Duodenal GIST: Surgical treatment based on the location. A single center experience with review of the literature

Aim: Gastrointestinal stromal tumors (GIST) are the most common digestive tract mesenchymal neoplasms, but only 1 to 5% of GISTs occur in the duodenum. Consequently, clinical manifestations, management and surgical treatment and their results remain poorly defined. The aim of this study is to expose the surgical experience in our institution, analyze surgical procedures according to the location of the tumor in the duodenum, and review the surgical management of GISTs in this anatomically complex region.Methods: Patients with duodenal GISTs who were surgically treated with curative intention in our center during the last 5 years (January 2014 - December 2019) were included in this retrospective cohort study. Demographic data, clinical presentation, GIST location, diagnostic evaluation, oncologic treatment, surgical procedure, mortality and morbidity, pathological and morphological GIST characteristics, pathological risk category, follow up and survival were noted.Results: Five patients diagnosed with duodenal GIST were operated in our center during the last 5 years. Four surgeries were performed with intent to cure and negative margins of resection. Only one was performed by laparoscopic approach. Limited resection R0 was done in all cases. None of the patients received neoadjuvant treatment before surgery. All patients were women with a mean age of 63 years (52-70 years). Clinical manifestations consisted of abdominal pain and upper gastrointestinal bleeding. One of the cases was incidentally diagnosed. There was no postoperative mortality. Mean length of stay was of 8 days (4-26 days). The median follow-up time was 33 months (6 months - 8 years). During the follow up, 2 patients passed away due non-GIST related causes, and one patient was operated for resectable peritoneum metastasis 29 months after the initial surgery. Conclusion: Tumor biology is more important than the surgical procedure for oncologic results of duodenal GIST. GIST located in duodenum with surgical indication is a challenge for the surgeon due to the complex duodenum anatomy.

Keywords:

Gastrointestinal stromal tumor, Duodenum, Surgery procedures,

PDF

___

1. Demetri GD, von Mehren M, Antonescu CR, DeMatteo RP, Ganjoo KN, Maki RG, et al. NCCN Task Force Report: Update on the management of patients with gastrointestinal stromal tumors. J Natl Compr Canc Netw. 2010;8(2):S-1-S-41. doi: 10.6004/jnccn.2010.0116
2. Chok AY, Koh YX, Ow MYL, Allen JC, Goh BKP. A systematic review and meta-analysis comparing pancreaticoduodenectomy versus limited resection for duodenal gastrointestinal stromal tumours. Ann Surg Oncol. 2014;21(11):3429-38. doi: 10.1245/s10434-014-3788-1
3. Miettinen M, Kopczynski J, Makhlouf HR, Sarlomo-Rikala M, Gyorffy H, Burke A, et al. Gastrointestinal stromal tumours, intramural leiomyomas, and leiomyosarcomas in the duodenum: A clinicopathologic, immunohistochemical, and molecular genetic study of 167 cases. Am J Surg Pathol. 2003;27(5):625-41. doi: 10.1097/00000478-200305000-00006
4. Chung JC, Chu CW, Cho GS, Shin EJ, Lim CW, Kim HC, et al. Management and outcome of gastrointestinal stromal tumours of the duodenum. J Gastrointest Surg. 2010;14(5):880-3. doi: 10.1007/s11605-010-1170-6
5. Marano L, Boccardi V, Marrelli D, Roviello F. Duodenal gastrointestinal stromal tumour: From clinicopathological features to surgical outcomes. Eur J Surg Oncol. 2015;41(7):814-22. doi: 10.1016/j.ejso.2015.04.004
6. Brierley J, Gospodarowicz MK, Wittekind C. TNM classification of malignant tumours. Eighth edition. Chichester, West Sussex, UK ; Hoboken, NJ: John Wiley & Sons, Inc; 2017.
7. Casali PG, Abecassis N, Bauer S, Biagini R, Bielack S, Bonvalot S, et al. Gastrointestinal stromal tumours: ESMO–EURACAN Clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2018;29:68-78. doi: 10.1093/annonc/mdy095
8. Dindo D, Demartines N, Clavien P-A. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205-13. doi: 10.1097/01.sla.0000133083.54934.ae
9. Beltrán MA. Current management of duodenal gastrointestinal stromal tumours. Clin Oncol. 2016;1:10.
10. Liu Z, Zheng G, Liu J, Liu S, Xu G, Wang Q, et al. Clinicopathological features, surgical strategy and prognosis of duodenal gastrointestinal stromal tumours: a series of 300 patients. BMC Cancer. 2018;18(1):563. doi: 10.1186/s12885-018-4485-4
11. Popivanov G, Tabakov M, Mantese G, Cirocchi R, Piccinini I, D’Andrea V, et al. Surgical treatment of gastrointestinal stromal tumours of the duodenum: a literature review. Transl Gastroenterol Hepatol. 2018;3:71-71. doi:.10.21037/tgh.2018.09.04
12. Joensuu H. Risk stratification of patients diagnosed with gastrointestinal stromal tumour. Human Pathology. 2008;39(10):1411-9. doi.org/10.1016/j.humpath.2008.06.025
13. Lee SJ, Song KB, Lee Y-J, Kim SC, Hwang DW, Lee JH, et al. Clinicopathologic characteristics and optimal surgical treatment of duodenal gastrointestinal stromal tumour. J Gastrointest Surg. 2019;23(2):270-9. doi: 10.1007/s11605-018-3928-1
14. Soft tisue sarcoma. NCCN clinic practice guidelines [Internet] Versión 6.2019. http:// www.nccn.org
15. Fernández JÁ, Sánchez-Cánovas ME, Parrilla P. Controversias en el tratamiento quirúrgico de los tumores del estroma gastrointestinal (GIST) primarios. Cir Esp. 2010;88(2):69-80. doi: 10.1016/j.ciresp.2010.01.007
16. Tien Y-W, Lee C-Y, Huang C-C, Hu R-H, Lee P-H. Surgery for gastrointestinal stromal tumours of the duodenum. Ann Surg Oncol. 2010;17(1):109-14. doi: 10.1245/s10434-009-0761-5
17. Zhou Y, Wang X, Si X, Wang S, Cai Z. Surgery for duodenal gastrointestinal stromal tumour: A systematic review and meta-analysis of pancreaticoduodenectomy versus local resection. Asian J Surg. 2020;43(1):1-8. doi.org/10.1016/j.asjsur.2019.02.006
18. Mennigen R, Wolters HH, Schulte B, Pelster FW. Segmental resection of the duodenum for gastrointestinal stromal tumour (GIST). World J Surg Oncol. 2008;6:105 doi: 10.1186/1477-7819-6-105
19. Hashimoto D, Inoue R, Beppu T. Limited resection of the duodenum for nonampullary duodenal tumours, with review of the literature. Am Surg. 2016;82(11):8.
20. Kamath AS, Sarr MG, Nagorney DM, Que FG, Farnell MB, Kendrick ML, et al. Gastrointestinal stromal tumour of the duodenum: single institution experience. HPB. 2012;14(11):772-6. doi: 10.1111/j.1477-2574.2012.00535.x