GIST: Not a Simple Management Problem

Abstract

Purpose: A 55-year-old woman with a significant past medical history of hypertension, diabetes mellitus, coronary artery disease with coronary stent on plavix and aspirin, and an infrarenal aortic aneurysm was referred to Gastroenterology clinic for evaluation of microcytic anemia with hemoglobin of 9 gm% and an MCV of 75. She had non-specific symptoms including dyspepsia and abdominal discomfort. On physical examination, she had epigastric tenderness and hemoccult positive, brown stools. Patient underwent upper GI endoscopy which showed a 2.5 cm friable mass in the 3rd portion of the duodenum. Mucosal biopsies showed a well differentiated GIST tumor shown by histopathology and immunohistochemistry to be composed of spindle-shaped cells with round nuclei expressing CD 117. CT examination showed a mass in the 3rd portion of duodenum. On retrospective observation, this mass had been present for at least 6 years with gradual growth from sub-centimeter to a current size of 2.5 cm. Its presence had not been commented on during 3 previous imaging studies. Due to the location of the GIST in the thin walled duodenum, our consultants declined to peform endoscopic resection. The patient was presented at a surgical conference and the patient was deemed a poor surgical candidate. Based on these results, we decided to proceed with medical management using Imatinib. Discussion: With the advent of newer endoscopic techniques, the limits of what is possible endoscopically have been stretched. Endoscopic resection in the third portion of the duodenum remains off limits in this case. In this patient, vasculopathy and multiple comorbidities deemed her not fit for surgical segmental resection of the duodenum. Endoscopic therapy could not be attempted as surgical resection would not be possible in the event of a treatment complication.