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01-03-2021 | Endoscopy

Clinical outcomes of tumor bleeding in duodenal gastrointestinal stromal tumors: a 20-year single-center experience

Authors: Gyu Young Pih, Ji Yong Ahn, Ji Young Choi, Hee Kyong Na, Jeong Hoon Lee, Kee Wook Jung, Do Hoon Kim, Kee Don Choi, Ho June Song, Gin Hyug Lee, Hwoon-Yong Jung

Published in: Surgical Endoscopy | Issue 3/2021

Abstract

Background

Duodenal gastrointestinal stromal tumors (GISTs) are rare, and reports on duodenal GIST bleeding are few. We analyzed the risk factors and clinical outcomes of hemorrhagic duodenal GISTs and compared them with those of gastric GISTs.

Methods

Primary duodenal GISTs surgically diagnosed between January 1998 and December 2017 were retrospectively reviewed. Furthermore, patients with duodenal GIST were compared with those with primary gastric GIST histopathologically diagnosed between January 1998 and May 2015 using previously published data.

Results

Of the 170 total patients with duodenal GISTs, 48 (28.2%) exhibited tumor bleeding. Endoscopic intervention, embolization, and non-interventional conservative treatment were performed for initial hemostasis in 17, 1, and 30 patients, respectively. The 5-year survival rate was 81.9% in the bleeding group and 89.4% in the non-bleeding group (P = 0.495). Multivariate analysis showed that p53 positivity was a significant risk factor for duodenal GIST bleeding (hazard ratio [HR] 2.781, P = 0.012), and age ≥ 60 years (HR 3.163, P = 0.027), a large maximum diameter (comparing four groups: < 2, 2–5, 5–10, and ≥ 10 cm), and mitotic count ≥ 5/high-power field (HPF) (HR 3.265, P = 0.032) were risk factors for overall survival. The incidence of bleeding was significantly higher in duodenal GISTs than in gastric GISTs (28.2% vs. 6.6%, P < 0.001), and the re-bleeding rate after endoscopic hemostasis was also higher in duodenal GISTs than in gastric GISTs (41.2% vs. 13.3%, P = 0.118).

Conclusion

In patients with duodenal GIST with old age, large tumor diameter, and mitotic count ≥ 5/HPF, a treatment plan should be established in consideration of the poor prognosis, although tumor bleeding does not adversely affect the prognosis. Duodenal GISTs have a higher incidence of tumor bleeding and re-bleeding rate after endoscopic hemostasis than gastric GISTs.

Nilsson B, Bumming P, Meis-Kindblom JM, Oden A, Dortok A, Gustavsson B, Sablinska K, Kindblom LG (2005) Gastrointestinal stromal tumors: the incidence, prevalence, clinical course, and prognostication in the preimatinib mesylate era—a population-based study in western Sweden. Cancer 103(4):821–829. https://doi.org/10.1002/cncr.20862CrossRefPubMed

Tran T, Davila JA, El-Serag HB (2005) The epidemiology of malignant gastrointestinal stromal tumors: an analysis of 1,458 cases from 1992 to 2000. Am J Gastroenterol 100(1):162–168. https://doi.org/10.1111/j.1572-0241.2005.40709.xCrossRefPubMed

Schottenfeld D, Beebe-Dimmer JL, Vigneau FD (2009) The epidemiology and pathogenesis of neoplasia in the small intestine. Ann Epidemiol 19(1):58–69. https://doi.org/10.1016/j.annepidem.2008.10.004CrossRefPubMedPubMedCentral

Buchs NC, Bucher P, Gervaz P, Ostermann S, Pugin F, Morel P (2010) Segmental duodenectomy for gastrointestinal stromal tumor of the duodenum. World J Gastroenterol 16(22):2788–2792. https://doi.org/10.3748/wjg.v16.i22.2788CrossRefPubMedPubMedCentral

Miettinen M, Lasota J (2001) Gastrointestinal stromal tumors–definition, clinical, histological, immunohistochemical, and molecular genetic features and differential diagnosis. Virchows Arch 438(1):1–12. https://doi.org/10.1007/s004280000338CrossRefPubMed

Fletcher CD, Berman JJ, Corless C, Gorstein F, Lasota J, Longley BJ, Miettinen M, O'Leary TJ, Remotti H, Rubin BP, Shmookler B, Sobin LH, Weiss SW (2002) Diagnosis of gastrointestinal stromal tumors: a consensus approach. Hum Pathol 33(5):459–465. https://doi.org/10.1053/hupa.2002.123545CrossRefPubMed

Joensuu H, Fletcher C, Dimitrijevic S, Silberman S, Roberts P, Demetri G (2002) Management of malignant gastrointestinal stromal tumours. Lancet Oncol 3(11):655–664. https://doi.org/10.1016/S1470-2045(02)00899-9CrossRefPubMed

Miettinen M, Sobin LH, Lasota J (2005) Gastrointestinal stromal tumors of the stomach: a clinicopathologic, immunohistochemical, and molecular genetic study of 1765 cases with long-term follow-up. Am J Surg Pathol 29(1):52–68. https://doi.org/10.1097/01.pas.0000146010.92933.deCrossRefPubMed

Caterino S, Lorenzon L, Petrucciani N, Iannicelli E, Pilozzi E, Romiti A, Cavallini M, Ziparo V (2011) Gastrointestinal stromal tumors: correlation between symptoms at presentation, tumor location and prognostic factors in 47 consecutive patients. World J Surg Oncol 9:13. https://doi.org/10.1186/1477-7819-9-13CrossRefPubMedPubMedCentral

10.

Park KS, Huh KC, Hwang I, Kwon JH, Kwon JG, Kim GH, Shin JE, Kim ES, Cho KB (2013) Multi-center study regarding the risk factors for bleeding in gastrointestinal stromal tumor. Hepatogastroenterology 60(122):235–239. https://doi.org/10.5754/hge12622CrossRefPubMed

11.

Liu Q, Li Y, Dong M, Kong F, Dong Q (2017) Gastrointestinal bleeding is an independent risk factor for poor prognosis in GIST patients. Biomed Res Int 2017:7152406. https://doi.org/10.1155/2017/7152406CrossRefPubMedPubMedCentral

12.

Pih GY, Jeon SJ, Ahn JY, Na HK, Lee JH, Jung KW, Kim DH, Choi KD, Song HJ, Lee GH, Jung HY, Kim SO (2019) Clinical outcomes of upper gastrointestinal bleeding in patients with gastric gastrointestinal stromal tumor. Surg Endosc. https://doi.org/10.1007/s00464-019-06816-9CrossRefPubMed

13.

Miettinen M, Lasota J (2006) Gastrointestinal stromal tumors: pathology and prognosis at different sites. Semin Diagn Pathol 23(2):70–83. https://doi.org/10.1053/j.semdp.2006.09.001CrossRefPubMed

14.

Wasag B, Debiec-Rychter M, Pauwels P, Stul M, Vranckx H, Oosterom AV, Hagemeijer A, Sciot R (2004) Differential expression of KIT/PDGFRA mutant isoforms in epithelioid and mixed variants of gastrointestinal stromal tumors depends predominantly on the tumor site. Mod Pathol 17(8):889–894. https://doi.org/10.1038/modpathol.3800136CrossRefPubMed

15.

Watson RR, Binmoeller KF, Hamerski CM, Shergill AK, Shaw RE, Jaffee IM, Stewart L, Shah JN (2011) Yield and performance characteristics of endoscopic ultrasound-guided fine needle aspiration for diagnosing upper GI tract stromal tumors. Dig Dis Sci 56(6):1757–1762. https://doi.org/10.1007/s10620-011-1646-6CrossRefPubMed

16.

Rutkowski P, Nowecki ZI, Michej W, Debiec-Rychter M, Wozniak A, Limon J, Siedlecki J, Grzesiakowska U, Kakol M, Osuch C, Polkowski M, Gluszek S, Zurawski Z, Ruka W (2007) Risk criteria and prognostic factors for predicting recurrences after resection of primary gastrointestinal stromal tumor. Ann Surg Oncol 14(7):2018–2027. https://doi.org/10.1245/s10434-007-9377-9CrossRefPubMed

17.

Wozniak A, Rutkowski P, Piskorz A, Ciwoniuk M, Osuch C, Bylina E, Sygut J, Chosia M, Rys J, Urbanczyk K, Kruszewski W, Sowa P, Siedlecki J, Debiec-Rychter M, Limon J, GIST Polish Clinical Registry (2012) Prognostic value of KIT/PDGFRA mutations in gastrointestinal stromal tumours (GIST): Polish Clinical GIST Registry experience. Ann Oncol 23(2):353–360. https://doi.org/10.1093/annonc/mdr127CrossRefPubMed

18.

Mercadante S, Fusco F, Valle A, Fulfaro F, Casuccio A, Silvestro S, Donelli E (2004) Factors involved in gastrointestinal bleeding in advanced cancer patients followed at home. Support Care Cancer 12(2):95–98. https://doi.org/10.1007/s00520-003-0519-8CrossRefPubMed

19.

Kim YI, Choi IJ, Cho SJ, Lee JY, Kim CG, Kim MJ, Ryu KW, Kim YW, Park YI (2013) Outcome of endoscopic therapy for cancer bleeding in patients with unresectable gastric cancer. J Gastroenterol Hepatol 28(9):1489–1495. https://doi.org/10.1111/jgh.12262CrossRefPubMed

20.

Sheibani S, Kim JJ, Chen B, Park S, Saberi B, Keyashian K, Buxbaum J, Laine L (2013) Natural history of acute upper GI bleeding due to tumours: short-term success and long-term recurrence with or without endoscopic therapy. Aliment Pharmacol Ther 38(2):144–150. https://doi.org/10.1111/apt.12347CrossRefPubMed

21.

Seya T, Tanaka N, Yokoi K, Shinji S, Oaki Y, Tajiri T (2008) Life-threatening bleeding from gastrointestinal stromal tumor of the stomach. J Nippon Med Sch 75(5):306–311. https://doi.org/10.1272/jnms.75.306CrossRefPubMed

22.

Aboutaleb E, Kothari M, Damrah O, Canelo R (2009) c-KIT positive gastrointestinal stromal tumor presenting with acute bleeding in a patient with neurofibromatosis type 1: a case report. Int Semin Surg Oncol 6:17. https://doi.org/10.1186/1477-7800-6-17CrossRefPubMedPubMedCentral

23.

Bianchi M, De Pascalis B, Koch M (2010) Jejunal GIST: an unusual cause of gastrointestinal bleeding. Dig Liver Dis 42(10):744. https://doi.org/10.1016/j.dld.2009.06.008CrossRefPubMed

24.

Anjiki H, Kamisawa T, Sanaka M, Ishii T, Kuyama Y (2010) Endoscopic hemostasis techniques for upper gastrointestinal hemorrhage: a review. World J Gastrointest Endosc 2(2):54–60. https://doi.org/10.4253/wjge.v2.i2.54CrossRefPubMedPubMedCentral

25.

Hall PA, McCluggage WG (2006) Assessing p53 in clinical contexts: unlearned lessons and new perspectives. J Pathol 208(1):1–6. https://doi.org/10.1002/path.1913CrossRefPubMed

26.

Wong NA, Young R, Malcomson RD, Nayar AG, Jamieson LA, Save VE, Carey FA, Brewster DH, Han C, Al-Nafussi A (2003) Prognostic indicators for gastrointestinal stromal tumours: a clinicopathological and immunohistochemical study of 108 resected cases of the stomach. Histopathology 43(2):118–126. https://doi.org/10.1046/j.1365-2559.2003.01665.xCrossRefPubMed

27.

Hillemanns M, Pasold S, Bottcher K, Hofler H (1998) Prognostic factors of gastrointestinal stromal tumors of the stomach. Verh Dtsch Ges Pathol 82:261–266PubMed

28.

Cunningham RE, Abbondanzo SL, Chu WS, Emory TS, Sobin LH, O'Leary TJ (2001) Apoptosis, bcl-2 expression, and p53 expression in gastrointestinal stromal/smooth muscle tumors. Appl Immunohistochem Mol Morphol 9(1):19–23. https://doi.org/10.1097/00129039-200103000-00005CrossRefPubMed

29.

Chang MS, Choe G, Kim WH, Kim YI (1998) Small intestinal stromal tumors: a clinicopathologic study of 31 tumors. Pathol Int 48(5):341–347. https://doi.org/10.1111/j.1440-1827.1998.tb03916.xCrossRefPubMed

30.

Giuliano K, Nagarajan N, Canner J, Najafian A, Wolfgang C, Schneider E, Meyer C, Lennon AM, Johnston FM, Ahuja N (2017) Gastric and small intestine gastrointestinal stromal tumors: do outcomes differ? J Surg Oncol 115(3):351–357. https://doi.org/10.1002/jso.24514CrossRefPubMed

31.

Liu Z, Zheng G, Liu J, Liu S, Xu G, Wang Q, Guo M, Lian X, Zhang H, Feng F (2018) Clinicopathological features, surgical strategy and prognosis of duodenal gastrointestinal stromal tumors: a series of 300 patients. BMC Cancer 18(1):563. https://doi.org/10.1186/s12885-018-4485-4CrossRefPubMedPubMedCentral

32.

Iorio N, Sawaya RA, Friedenberg FK (2014) Review article: the biology, diagnosis and management of gastrointestinal stromal tumours. Aliment Pharmacol Ther 39(12):1376–1386. https://doi.org/10.1111/apt.12761CrossRefPubMed

33.

Miettinen M, Wang ZF, Lasota J (2009) DOG1 antibody in the differential diagnosis of gastrointestinal stromal tumors: a study of 1840 cases. Am J Surg Pathol 33(9):1401–1408. https://doi.org/10.1097/PAS.0b013e3181a90e1aCrossRefPubMed

34.

Valsangkar N, Sehdev A, Misra S, Zimmers TA, O'Neil BH, Koniaris LG (2015) Current management of gastrointestinal stromal tumors: surgery, current biomarkers, mutations, and therapy. Surgery 158(5):1149–1164. https://doi.org/10.1016/j.surg.2015.06.027CrossRefPubMed

Title: Clinical outcomes of tumor bleeding in duodenal gastrointestinal stromal tumors: a 20-year single-center experience
Authors: Gyu Young Pih
Ji Yong Ahn
Ji Young Choi
Hee Kyong Na
Jeong Hoon Lee
Kee Wook Jung
Do Hoon Kim
Kee Don Choi
Ho June Song
Gin Hyug Lee
Hwoon-Yong Jung
Publication date: 01-03-2021
Publisher: Springer US
Keywords: Endoscopy
Gastrointestinal Stromal Tumor
Published in: Surgical Endoscopy / Issue 3/2021
Print ISSN: 0930-2794
Electronic ISSN: 1432-2218
DOI: https://doi.org/10.1007/s00464-020-07486-8

At a glance: The STEP trials

Springer Medicine

Clinical outcomes of tumor bleeding in duodenal gastrointestinal stromal tumors: a 20-year single-center experience

Abstract

Background

Methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

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