Gastrointestinal stromal tumors of the duodenum: Surgical management and survival results

Table 1 Summary of patient preoperative information

No.	Age (yr)	Sex	Chief complaint	Comorbidity	Past history	Hb	US	CT	MRI	GI	ES	EUS	DSA	Biopsy	Preoperative diagnosis
1	28	F	Melena	Cholecystolithiasis		46	0	1	N	1	1	N	N	1/ES	Duodenal GIST(Biopsy)
2	48	F	Incidentally found		Sub gastrectomy	79	0	1	N	1	N	N	N	N	Duodenal tumor
3	60	M	Melena			104	1	1	N	1	0	N	N	0/CT	Duodenal GIST (CT)
4	70	M	Pain			128	0	1	1	1	1	1	N	1/EUS	Duodenal GIST(Biopsy)
5	71	M	Incidentally found			130	0	0	N	N	0	N	N	N	Abdominal tumor
6	76	F	Melena	Cholecystolithiasis	Appendectomy, stripping of right great saphenous vein	65	0	1	N	N	1	1	N	0/EUS	Duodenal GIST (EUS)
7	42	F	Melena			50	0	1	N	N	N	N	N	N	Duodenal tumor
8	74	M	Melena			81	1	1	N	N	1	N	N	0/ES	Duodenal tumor
9	53	F	Melena			75	1	1	N	N	1	N	N	1/ES	Duodenal GIST(Biopsy)
10	47	F	Melena		Schistosomiasis	99	0	1	N	1	0	N	N	N	Duodenal tumor
11	55	F	Melena			61	1	1	N	1	0	N	N	N	Duodenal tumor
12	51	M	Melena			66	1	1	N	1	1	N	N	1/ES	Duodenal GIST (Biopsy)
13	50	M	Hematemesis	Polyp of gallbladder (1.9 cm)	Essential hypertension	52	0	0	N	N	1	N	N	0/ES	Duodenal tumor
14	69	F	Pain			87	0	0	N	N	N	N	N	N	Retroperitoneal tumor
15	65	M	Melena			65	1	1	N	N	1	1	N	0/EUS	Duodenal GIST (EUS)
16	63	M	Acute abdomen			148	1	N	N	N	N	N	N	N	Acute abdomen
17	44	F	Hematemesis			56	0	1	N	1	1	N	N	0/ES	Duodenal tumor
18	57	F	Discomfort		Cholecystectomy, left nephrectomy	126	1	1	N	N	N	N	N	N	Duodenal GIST (CT)
19	20	F	Melena			61	0	1	N	N	1	N	N	0/ES	Duodenal tumor
20	52	M	Pain			118	0	0	N	N	N	N	N	N	Abdominal tumor
21	53	F	Pain			118	0	0	N	1	N	N	N	N	Abdominal tumor
22	71	F	Early satiety			131	0	1	1	1	0	1	N	0/EUS	Retroperitoneal tumor
23	53	M	Early satiety		Resection of gluteal hemangioma	156	0	1	1	N	1	1	N	0/EUS	Duodenal GIST (EUS)
24	50	F	Melena	Cholecystolithiasis	Right radical mastectomy, hysteromyomectomy	91	0	1	N	N	1	N	N	0/ES	Duodenal tumor
25	46	F	Pain			93	0	0	N	N	N	N	N	N	Abdominal tumor
26	55	M	Melena		Appendectomy	69	0	0	N	N	1	N	N	0/ES	Tumor of pancreas head
27	51	M	Incidentally Found			155	0	1	1	0	0	N	N	N	Duodenal tumor
28	46	F	Melena		Radical cystectomy	87	0	1	N	N	N	N	1	N	Duodenal GIST (CT)

0: Negative; 1: Positive; N: Not evaluated; Hb: The initial hemoglobin (g/L) before liquid resuscitation; M: Male; F: Female; CT: Computed tomography; US: Ultrasonography; GIST: Gastrointestinal stromal tumor; MRI: Magnetic resonance imaging; GI: Gastrointestinal; ES: Gastroduodenoscopy; EUS: Endoscopic ultrasonography; DSA: Digital subtraction angiography.

Table 2 Summary of surgery and perioperative information

No.	Surgery	Site	Size (L)	Size (W)	Size (H)	Combined operation	Transfusion1	ICU stay	Major complications	Reoperation (post-operative time)	POS
1	SR (G-J)	D2	4	3.5	3	Cholecystectomy	Y	0		Hepatectomy for liver metastasis (103 mo)	22
2	WR	D2	4	3	3		Y	2			12
3	PD	D2	10	9	7.5		Y	0			17
4	PD	D2	11	9	7.5		Y	1	Leakage of choledochoenterostomy	Abdominal irrigation and drainage (8 d)	14
5	SR (D-D)	D3	9	6	6	Partial colectomy	N	1	vessel injury in the mesocolon transversum		11
6	SR (D-J)	D2	4	4	4	Cholecystectomy	Y	5	Anastomotic leakage		36
7	PD	D2	6	5.5	5		Y	0			6
8	WR	D1	3.5	2.5	2.5		Y	1			8
9	SR (D-D)	D1	2.5	1.5	1.5		Y	0			5
10	PD	D2	4	3	2.5		Y	0			11
11	SR (G-J)	D4	8	5.5	3		Y	0			10
12	PD	D2	12	10	8.5		Y	0			10
13	WR	D2	3.5	3.2	3	Cholecystectomy	Y	0			15
14	PD	D3	13	11	11	Major enterectomy	Y	5	Injury of superior mesenteric vessels	Total enterectomy (1 d)	5
15	SR (D-J)	D3	5	4	3.5		Y	0	DGE	Gastrojejunostomy (21 d)	32
16	PD	D2	6.5	5	4		N	4			24
17	PD	D2	9.5	8.5	8		Y	1		Gastroscopic injection of sclerosing agents (21 mo)	28
18	SR (D-J)	D3	5.5	5	4		N	0	DGE		46
19	SR (D-D)	D2	2	2	2		Y	0	DGE		47
20	SR (D-J)	D4	20	18	8.5		Y	2	DGE		26
21	WR	D2	15	12	6.5		Y	0			10
22	SR (G-J)	D2	5.5	5	2.5		Y	2			42
23	WR	D1	1.6	1.3	1.2		N	0			8
24	SR (G-J)	D1	4.5	3	2	Cholecystectomy	N	0	DGE		17
25	SR (D-D)	D2	7.6	5	4.6		Y	0			8
26	PD	D2	6	4	4		Y	0		Adhesiolysis for ileus (43 mo)	9
27	SR (D-J)	D3	5.5	4.5	3.5		N	1	DGE		35
28	PD	D2	6	5	4		Y	0			22

¹Perioperative transfusion, including the transfusion before surgery; Size (L/W/H): tumor size (length, width and height in centimeters) measured after fixation by 10% neutral buffered formalin; DGE: Delayed gastric empty; POS: Post-operative stay till discharge; ICU: Intensive care unit; PD: Pancreaticoduodenectomy; WR: Wedge resection; SR: Segmental resection.

Table 3 Summary of pathological data and risk classifications

No.	CD117	CD34	SMA	S100	Vimentin	Actin	Desmin	Mitotic rate/50HPF	Fletcher's risk	Miettinen's risk	UICC TNM	Gold’s point	RFS	DRS	Status of death	Glivec
1	1	0	1	0	N	0	0	0-1	L	L	UICC I	64	103	164	0	0
2	1	1	1	0	1	0	N	0-1	L	L	UICC I	64	RF	146	0	0
3	1	0	1	0	1	0	N	5-8	H	H	UICC IIIB	173	54	61	1	0
4	1	1	1	1	1	0	N	> 10	H	H	UICC IIIB	175	26	35	1	0
5	1	1	1	0	1	N	N	1-2	I	H	UICC II	89	RF	23	1 (lung cancer)	0
6	1	1	0	1	1	1	0	2-3	L	L	UICC I	64	RF	25	1 (pneumonia)	0
7	1	0	1	1	1	N	0	6-8	H	H	UICC IIIB	155	64	73	1	0
8	0	1	0	0	1	1	N	0-1	L	L	UICC I	61	RF	61	1 (stroke)	0
9	1	1	1	1	N	0	N	3-4	L	L	UICC I	55	RF	116	0	0
10	1	0	1	1	N	0	N	0-1	L	L	UICC I	64	101	111	1	0
11	1	1	0	1	N	0	N	5-6	H	H	UICC IIIB	164	29	55	1	0
12	1	1	0	1	1	N	N	> 10	H	H	UICC IIIB	178	15	23	1	0
13	1	1	1	0	1	0	N	0-1	L	L	UICC I	61	RF	102	0	0
14	1	1	1	0	1	1	N	> 10	H	H	UICC IIIB	180	NN	NN	1	0
15	1	1	1	0	N	0	N	1-4	L	L	UICC I	70	62	68	1	0
16	1	1	0	1	1	0	N	5-8	H	H	UICC IIIB	156	37	49	1	0
17	1	1	0	1	N	0	N	> 10	H	H	UICC IIIB	172	21	33	1	0
18	1	1	0	0	N	0	N	2-3	I	H	UICC II	71	53	57	1	0
19	1	0	1	0	N	N	0	0-1	VL	L	UICC I	51	RF	86	0	0
20	1	1	0	0	N	N	0	> 10	H	H	UICC IIIB	190	22	33	1	0
21	1	0	1	0	N	0	N	5-8	H	H	UICC IIIB	184	29	40	1	0
22	1	1	0	0	N	0	0	1-2	I	H	UICC II	71	47	59	1	0
23	1	0	1	1	N	N	0	0-1	VL	L	UICC I	50	RF	75	0	0
24	1	0	1	0	N	N	0	3-5	L	L	UICC I	67	69	73	0	0
25	1	0	1	0	N	0	N	0-1	I	H	UICC II	81	51	71	0	1 (20 mo/PR)
26	1	0	0	1	1	N	N	5-7	H	H	UICC IIIB	155	59	70	0	0
27	1	1	0	0	N	N	0	0-1	I	H	UICC II	71	RF	63	0	1 (24 mo)
28	1	1	1	1	1	N	N	0-1	I	H	UICC II	73	RF	61	0	0

0: Negative; 1: Positive; N: Not evaluated; HPF: High-power fields; VL: Very low; L: Low; I: Intermediate; H: High; RF: Relapse free; NN: Not necessary; PR: Partial remission; UICC: Union for International Cancer Control; TNM: Tumor, nodes, metastasis; RFS: Relapse-free survival; DRS: Disease-related survival; SMA: Smooth muscle actin.

Table 4 Results of survival analysis

	n	Median RFS (mo)	95%CI of HR	Median DRS (mo)	95%CI of HR	Median Gold’s point (range)	Predicted 2-year RFS probability	Actual 2-year RFS rate	Predicted 5-year RFS probability	Actual 5-year RFS rate
Total	25	60.5	-	73	-	73 (50-190)	83%	83.30%	70%	50%
Fletcher’s risk
Very low/low	9	103ce	1.564-158.6	Undefined	0.6931-149.1	64 (50-70)df	86%	100%	75%	100%
Intermediate	5	53	0.7675-7.845	Undefined	0.9385-10.78	71 (71-81)bf	84%	100%	70%	40%
High	11	29bd	4.812-68.51	40bd	3.449-44.94	173 (155-190)bd	< 10%	70%	< 10%	< 10%
Miettinen's risk
Low	9	103f	2.882-26.67	Undefined	2.224-21.94	64 (50-70)f	86%	100%	75%	100%
High	16	47b	-	56	-	160 (71-190)b	< 10%	80%	< 10%	20%

^aP < 0.05,

^bP < 0.01 vs Very low/Low;

^cP < 0.05,

^dP < 0.01 vs Intermediate;

^eP < 0.05,

^fP < 0.01 vs High; DRS: Disease-related survival; RFS: Relapse-free survival.

Table 5 Results of Cox multivariate analysis

Variable	RFS P value	DRS P value
Mitotic rate/50HPF	0.0000	0.0000
Gold’s point	0.0000	0.0000
Fletcher’s risk	0.0000	0.0000
Miettinen’s risk	0.0001	0.0009
Size > 5 cm	0.0001	0.0009
Preoperative diagnoses as duodenal tumors or DGISTs	0.0048	> 0.05
Age > 60 yr	0.0428	0.0059
LR or PD	> 0.05	0.0346
ICU stay	> 0.05	0.0054

HPF: High-power fields; DRS: Disease-related survival; RFS: Relapse-free survival; ICU: Intensive care unit; LR: Limited resection; PD: Pancreaticoduodenectomy.