A rare case report of locally recurrent hemorrhagic duodenal gastrointestinal stromal tumor: therapeutic challenges and review of prognostic indicators for recurrence

Abstract

Gastrointestinal stromal tumor is a rare neoplasm affecting gastrointestinal tract. Duodenal gastrointestinal stromal tumor originating from the fourth segment is considered an extremely rare disease. Surgical challenges arise when managing locally recurrent hemorrhagic duodenal gastrointestinal stromal tumor. A 58-year-old male presented with melena for the last 10 days. Thirty months previously, he had segmental resection of the fourth duodenal portion due to hemorrhagic gastrointestinal stromal tumor. No adjuvant imatinib therapy was administered (low risk for recurrence). The latest investigations showed actively bleeding tumor in the distal third portion of the duodenum, indicating a locally recurrent gastrointestinal stromal tumor. Uneventful emergent limited resection was performed. To the best of our knowledge, this is the first case report describing locally recurrent gastrointestinal stromal tumor in the distal duodenal portion. We will explain the therapeutic challenges and risk stratification and discuss gastrointestinal bleeding as a prognostic indicator for gastrointestinal stromal tumor recurrence.

Figure 1

(A, B) Upper GI endoscopy shows centrally ulcerated recurrent tumor in the third portion of the duodenum with active bleeding.

Figure 2

Enhanced CT scan (A) axial section and (B) coronal section: shows well enhanced mass 5 × 4.5 cm (arrow) at previous duodenojejunal anastomosis without intraperitoneal or liver metastasis.

Figure 3

Recurrent tumor on the previous (end-side) duodenojejunal anastomosis (white arrow) and pancreas (black arrow).

Figure 4

Limited resection of the distal third part of the duodenum (white arrow) with proximal jejunum including the mass (black arrow).

Figure 5

(A) The cut end of the distal third portion of the duodenum (arrow). (B) The closed end of the distal third portion of the duodenum (arrow). (C) Side-to-side anastomosis between the second duodenal portion and jejunum (white arrow), the site of previous feeding jejunostomy tube (black arrow).

Figure 6

(A) Hematoxylin and eosin (H&E) stain: proliferation of spindle cells of varying cellularity, hyperchromasia and nuclear pleomorphism (GIST spindle cell type). (B) H&E stain: vascular invasion with tumor emboli (arrow). (c): Immunohistochemical staining for CD117 is positive (arrows).