Gastrointestinal stromal tumors(GIST) have become a well established entity and its taxonomy is no more ambiguous. Better understanding of the cell of origin and immunohistochmical markers have made this possible. Their treatment has been revolutionized with the advent of targeted molecular therapy, namely Imatinib mesylate. Herein we report a rare and interesting case of a thirty year old South Indian Lady with an extremely large Duodenal GIST with massive Liver secondaries. The phenomenon of metastatic GIST responding to Imatinib mesylate is not new. What is interesting in this case is the enormous tumor load at the time of presentation as exemplified by the cross sectional images. This kind of tumor response and patient survival deserves documentatio

C Sturgeon

ES Casper

GD Demetri

K Anand

M Subramanian

N Venu

PJ Roberts

RP DeMatteo

S Sankar

T Arunkumar

Winfield

English

PubMed

Crossref

BioMed CentralCases Journal
ssOpen AcceCase Report
Large duodenal GIST with massive liver secondaries melting under 
Imatinib: a case report
S Sankar*1, M Subramanian2, T Arunkumar3, N Venu4 and K Anand4
Address: 1Department of Surgical gastroenterology, D-2 Private clinic, Sri Ramachandra Medical College & Research Center, Chennai, 600116, 
Tamilnadu, India, 2Department of Surgical gastroenterology, D-2 Private clinic, Sri Ramachandra Medical College & Research Center, Chennai, 
600116, Tamilnadu, India, 3Department of Surgical gastroenterology, D-2 Private clinic, Sri Ramachandra Medical College & Research Center, 
Chennai, 600116, Tamilnadu, India and 4Department of Surgical gastroenterology, D-2 Private clinic, Sri Ramachandra Medical College & 
Research Center, Chennai, 600116, Tamilnadu, India
Email: S Sankar* - drsshankar@gmail.com; M Subramanian - gastrosurg@yahoo.co.in; T Arunkumar - arunsurgery70@yahoo.com; 
N Venu - venu369@yahoo.com; K Anand - dranand@hotmail.com
* Corresponding author    
Abstract
Gastrointestinal stromal tumors(GIST) have become a well established entity and its taxonomy is
no more ambiguous. Better understanding of the cell of origin and immunohistochmical markers
have made this possible. Their treatment has been revolutionized with the advent of targeted
molecular therapy, namely Imatinib mesylate. Herein we report a rare and interesting case of a
thirty year old South Indian Lady with an extremely large Duodenal GIST with massive Liver
secondaries. The phenomenon of metastatic GIST responding to Imatinib mesylate is not new.
What is interesting in this case is the enormous tumor load at the time of presentation as
exemplified by the cross sectional images. This kind of tumor response and patient survival
deserves documentation
Case presentation
Thirty year old South Indian Lady, a home maker pre-
sented to us in May 2005 with severe anemia and weight
loss of three months duration. Her weight was 50 kg and
height was 160 cm. She was neither an alcoholic nor a
smoker. She had few episodes of malena during this
period. She also had abdominal fullness, but no vomiting
or pain. Clinical examination revealed a very pale patient
with gross hepatomegaly with nodularity suggestive of
secondaries Liver. Except for a grossly low hemoglobin,
her other hemogram and biochemistry were within nor-
mal levels. Esophagogastroduodenoscopy picked up a
fleshy protruding tumor in the second part of the duode-
num(fig 1). CT abdomen showed a highly vascular and
bulky tumor arising from the second part of the duode-
num with massive secondary deposits in both the lobes of
Liver(fig 2&3). Biopsies were done from the duodenal
tumor and Liver metastasis. Histopathological report
proved it to be Gastrointestinal stromal tumor(GIST) pos-
itive for CD 117.
Anemia was corrected with blood transfusion. Since she
had a metastatic GIST, she was started on Imatinib
mesylate 400 mg once daily. The follow up CT showed a
very dramatic response with almost complete clearance of
metastatic deposit in the liver(fig 4). The duodenal tumor
regressed in size(Fig 5). Since the Liver metastasis
responded dramatically, we offered surgery for the pri-
mary duodenal tumor, which patient refused. At the point
of writing this article, that is three years and six months
Published: 30 September 2008
Cases Journal 2008, 1:197 doi:10.1186/1757-1626-1-197
Received: 2 July 2008
Accepted: 30 September 2008
This article is available from: http://www.casesjournal.com/content/1/1/197
© 2008 Sankar et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 3
(page number not for citation purposes)
Cases Journal 2008, 1:197 http://www.casesjournal.com/content/1/1/197after diagnosis, patient is fine and asymptomatic and con-
tinues to take Imatinib mesylate.
Discussion
Gastrointestinal stromal tumor is not an uncommon
entity in clinical practice with majority of them arising
from stomach. Small intestine accounts for 20%–30% of
the GIST. Majority of the small intestinal GIST arises from
the jejunum and Ileum. Duodenum being the least com-
mon site. Duodenal GIST usually present with vague
Endophytic fleshy tumor of duodenumFigure 1
Endophytic fleshy tumor of duodenum.
Large duodenal tumor with brisk contrast enhancementFigure 2
Large duodenal tumor with brisk contrast enhance-
ment.
Massive bilobar liver metastasisFigure 3
Massive bilobar liver metastasis.
Dramatic response after Imatinib mesylateFigure 4
Dramatic response after Imatinib mesylate.Page 2 of 3
(page number not for citation purposes)
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abdominal pain(50%–70%) or they bleed into the
lumen(20%–50%)[1,2]. Small bowel GIST have a high
propensity to exhibit malignant behavior[3]. Second part
of the duodenum seems to be the common site of duode-
nal GIST and most of them will require pancreatoduo-
denectomy for complete resection[4]. Completely
resected GIST has a five year survival of 30%–80%[5].
Incompletely resected tumors have a high recurrence
rate(upto 90%). Historically Unresectable/metastatic
GIST has a median survival of 12 months[6]. Imatinib
mesylate, a specific tyrosikine kinase inhibitor has pro-
duced a paradigm shift in the treatment of GIST, due to
the targeted molecular therapy. Imatinib produce sus-
tained clinical response in more than 50% of the patients
with advanced GIST and one year survival in these
patients was 88%[7].
Conclusion
Metastatic GIST responding to Imatinib is not an unusual
phenomenon. But considering the sheer size and magni-
tude of the primary and secondary deposit, the response
to imatinib has been immaculate. With the kind of tumor
load this patient had, survival for more than three years is
worth documenting. This case of GIST is rare and unusual
for the following reasons
1. Duodenum being an uncommon site of GIST
2. Age of the patient 30 years. Usual age of GIST is beyond
40 years
3. Phenomenal cell kill achieved with imatinib
4. Despite the various poor prognostic factors patient con-
tinues to survive without any symptoms
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
SS prepared the manuscript, KA edited the photos and all
others read and approved the manuscript.
Consent
Written and informed consent has been obtained from
the patient for publication of the article and photos and
the copy of the same is available for review by the editors.
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Partial response of duodenal tumorFigure 5
Partial response of duodenal tumor.Page 3 of 3
(page number not for citation purposes)


Large duodenal GIST with massive liver secondaries melting under Imatinib: a case report

Springer - Publisher Connector

Clinical management of gastrointestinal stromal tumors: Before and after STI-571. Human Pathol

Clinical presentation of gastrointestinal stromal tumors and treatment of operable disease.

Efficacy and safety of imatinib mesylate in advanced gastrointestinal stromal tumors.

Espat NJ: Gastrointestinal stromal tumors: a spectrum of disease. Surg Oncol

Gastrointestinal stromal tumors. Curr Treat Options Oncol

MF: Two hundred gastrointestinal stromal tumors: recurrence patterns and prognostic factors for survival. Ann Surg

http://citeseerx.ist.psu.edu/viewdoc/summary?doi=10.1.1.278.3466

Large duodenal GIST with massive liver secondaries melting under Imatinib: a case report

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