Comment on

Conservative surgery vs. duodeneopancreatectomy in primary duodenal gastrointestinal stromal tumors (GIST): a retrospective review of 114 patients from the French sarcoma group (FSG). [Eur J Surg Oncol. 2014

Balducci, Genoveffa

Caterino, Salvatore

Cavallini, Marco

Fanna, M

Frezza, Barbara

Lorenzon, Laura

Comment on
Conservative surgery vs. duodeneopancreatectomy in primary duodenal gastrointestinal stromal tumors (GIST): a retrospective review of 114 patients from the French sarcoma group (FSG). [Eur J Surg Oncol. 2014

LORENZON, LAURA

CAVALLINI, Marco

BALDUCCI, Genoveffa

CATERINO, Salvatore

Archivio della ricerca- Università di Roma La Sapienza

Available online at www.sciencedirect.comScienceDirectEJSO 41 (2015) 805e807 www.ejso.comCorrespondenceSurgical strategies for duodenal GISTs:Benefits and limitations of minimalresectionsTable 1Clinical and pathological features of duodenal GISTs treated with minimalsurgical resection.Sex e n (%)M 5 (62.5%)F 3 (37.5%)M/F 1.66Age - yearsMean; SD 57.3; 14.3Range 28e76Location e n (%)D1 2 (25.0%)D2 1 (12.5%)D3 2 (25.0%)D4 3 (37.5%)Symptoms e n (%)Gastrointestinal bleeding/anemia 4 (50.0%)Abdominal pain 1 (12.5%)Diarrhea 1 (12.5%)Incidental diagnosis 2 (25.0%)Resection e n (%)Duodenal resection þ end to end anastomosis 2 (25.0%)Wedge resection 6 (75.0%)Tumor’s diameter e cmMean; SD 3.7; 2.0Range 1.5e8Mitosis e n/50HPFMean; SD 9.75; 17,3Range 0e52Risk Classification e n (%)Very low risk 1 (12.5%)Low risk 4 (50.0%)High risk 3 (37.5%)Dear Editor,We read with great interest the manuscript by Duffaudand co-authors focused on the conservative managementof duodenal GISTs1 and we would like to further discussthis approach.Duodenal GISTs are rare neoplasms, but the surgicalstrategy might be challenging in relation to the proximityto the surrounding structures as the biliary tree or thepancreas.According to this, a pancreaticoduodenotomy might berequired. It seems important to highlight, however, that asstated by the NCCN guidelines the goal of surgical treat-ment is a complete resection of the tumor with negativemicroscopic margins, avoiding whenever possible tumor’srupture.2 Moreover a lymphadenectomy is usually notrequired, because nodal metastases are very rare in sporadicGISTs,2 although are common in a setting of Carney Triador in pediatric GISTs.3From 1999 to-date 92 patients underwent surgical resec-tion for GIST at our Department and among these, 8 pa-tients underwent a surgical treatment for duodenal GIST(8.69% of our case series, previously described4e6),Table 1.We reported a mild prevalence of males and a mean ageat presentation of 57.3 years, in keeping with Duffaund’sfindings,1 even though we reported a prevalence of D4 lo-calizations and a smaller mean tumor’s diameter.Pre-operative work-out was consistent with a clinicaldiagnosis of stromal tumors in all cases (Fig. 1).Notably none of the patients underwent a pancreatico-duodenotomy, but all tumors were considerate suitable fora minimal resection with preservation of the pancreas andthe biliary structures.All the resections, anastomosis and sutures were care-fully reviewed intra-operatively and were consideredDOI of original article: http://dx.doi.org/10.1016/j.ejso.2014.04.011http://dx.doi.org/10.1016/j.ejso.2015.03.2320748-7983/ 2015 Elsevier Ltd. All rights reserved.tension-free, thus a reconstruction using a jejunal Rouxand Y anastomosis was not required.6All the resections were proved to be R0 at the pathologicalexamination, with freemargins. All tumorswere c-kit positiveand fivewere concurrentlyCD34 positive (whereasCD34wasnot tested in the remaining 3 patients). DOG1 was investi-gated in three patients resulting positive in all the cases.Even though the 50.0% of the patients were classified in thelow-risk group, the 37.5%was considered as high-risk GISTs.Post-operative course was un-eventful in six patients(75%): one patient had a post-operative chylous fistulaFollow-up e monthsMean; SD 62.0; 44.9Range 4e128Figure 1. Duodenal GIST of the first portion. a. Endoscopy; b. contrast-enhanced abdominal CT scan; c. Wedge duodenal resection with primarysuture.806 Correspondence / EJSO 41 (2015) 805e807(Claviens’s C27) - and another patient had a post-operativebleeding (Clavien’s C3).Mean follow-up was of 62.0 months. One high-risk pa-tient underwent adjuvant treatment (Imatinib) and experi-enced a recurrence after 62 months; the patient died dueto disease-progression 90 months after the surgicaltreatment.As Duffaund and co-authors suggested, relapses mightbe related to risk criteria and cellular type, rather than thesurgical approach, in line with the results reported by John-ston and our experience.1,8However, Hoeppner, consistently also with our findings,documented that a high-risk duodenal GIST might not bein-frequent since 3/9 (33%) of the tumors he reportedwere at high risk.9Even if the long-term results of local resections are com-parable to the ones obtained by pancreaticoduodenectomies,tumor’s location, diameter and duodenal vascularisationmight represent limitations to a conservative treatment,thus a multidisciplinary approach is highly recommend inorder to evaluate the optimal strategy and a possible neo-adjuvant treatment.In conclusion, we agree with the authors in favouring thepreservation of pancreas whenever possible, but on the ba-sis of our experience and of the review of the literature, wealso identified some key-features that surgeons should care-fully evaluate in the management of duodenal GISTs, in or-der to assess the feasibility of a local resection:1. Patients should be carefully staged in order to assess apossible involvement of the surrounding structures e.g.biliary tree and pancreas.2. Kamath and Johnston reported a mean diameter of2.5 cm and 3.5 cm for duodenal GISTs treated withlocal resection and a mean diameter 5.0 cm and 7 cmfor GISTs requiring a pancreaticoduodenotomy,8,10therefore it would be recommended to discuss in amultidisciplinary team the management of large tumors>5 cm and/or involving the papilla. Indeed, a localresection could be a possible option whenever the tu-mor could be managed with a R0 procedure.3. Local resections could be performed with a wedge or aduodenal resection. The defect of the wall might beclosed with a primary suture, with an end-to-end anas-tomosis or with a jejunal-duodenal anastomosis, in rela-tion to the position or the tension derived by thesutures. A duodenal trans-resection could be a possiblechoice if the marginal vascularisation is conservable.6On this basis, a pancreaticoduodenotomy should beconsidered for large GISTs tumors involving the papilla,the biliary tree or the pancreas, since it has been associatedwith a longer hospital stay, a higher morbidity rate and withsimilar outcome comparing with local resections.8Conflict of interest disclosureNone of the authors has any potential financial conflictof interest related to this manuscript.References1. Duffaud F, Meeus P, Bachet JB, et al. Conservative surgery vs. duode-neopancreatectomy in primary duodenal gastrointestinal stromal tu-mors (GIST): a retrospective review of 114 patients from the Frenchsarcoma group (FSG). Eur J Surg Oncol 2014;40(10):1369–75.2. Demetri GD, Benjamin RS, Blanke CD, et al. NCCN Task Forcereport: management of patients with gastrointestinal stromal tumor(GIST)-update of the NCCN clinical practice guidelines. J Natl ComprCanc Netw 2007;5(Suppl 2):S1–S29.. quiz S30.3. Otto C, Agaimy A, Braun A, et al. Multifocal gastric gastrointestinalstromal tumors (GISTs) with lymph node metastases in children andyoung adults: a comparative clinical and histomorphological studyof three cases including a new case of Carney triad. Diagn Pathol2011; 10;6:52.807Correspondence / EJSO 41 (2015) 805e8074. Caterino S, Lorenzon L, Petrucciani N, et al. Gastrointestinal stromaltumors: correlation between symptoms at presentation, tumor locationand prognostic factors in 47 consecutive patients. World J Surg Oncol2011;9:13.5. Salvi PF, Lorenzon L, Caterino S, et al. Gastrointestinal stromal tu-mors associated with neurofibromatosis 1. A single centre experienceand systematic review of the literature including 252 cases. Int J SurgOncol 2013. http://dx.doi.org/10.1155/2013/398570.6. Cavaniglia D, Petrucciani N, Lorenzon L, et al. Partial duodenectomywith end-to-end anastomosis for duodenal gastrointestinal stromal tu-mor. Am Surg 2012;78:E273–5.7. Dindo D, Demartines N, Clavien PA. Classification of surgical compli-cations: a new proposal with evaluation in a cohort of 6336 patientsand results of a survey. Ann Surg 2004;240(2):205–13.8. Johnston FM, Kneuertz PJ, Cameron JL, et al. Presentation and man-agement of gastrointestinal stromal tumors of the duodenum: a multi-institutional analysis. Ann Surg Oncol 2012;19:3351–60.9. Hoeppner J, Kulemann B, Marjanovic G, et al. Limited resection forduodenal gastrointestinal stromal tumors: surgical management andclinical outcome. World J Gastrointest Surg 2013;5:16–21.10. Kamath AS, Sarr MG, Nagorney DM, et al. Gastrointestinal stromaltumour of the duodenum: single institution experience. HPB Oxf2012;14:772–6.L. Lorenzon*M. CavalliniG. BalducciB. FrezzaM. FannaS. CaterinoSurgical and Medical Department of TranslationalMedicine, Sant’Andrea Hospital, Faculty of Medicine andPsychology, University of Rome “La Sapienza”, Italy*Corresponding author. Surgical and Medical Departmentof Translational Medicine, Sant’Andrea Hospital, Facultyof Medicine and Psychology University of Rome “LaSapienza”, St. Andrea Hospital, Via di Grottarossa1035-39, 00189 Rome, Italy. Tel.: þ39 0633775989; fax:þ39 0633775322.E-mail address: laura.lorenzon@uniroma1.it (L. Lorenzon)Accepted 28 March 2015

Surgical strategies for duodenal GISTs: benefits and limitations of minimal resections

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Surgical strategies for duodenal GISTs: benefits and limitations of minimal resections

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