Is Laparoscopic Resection the AppropriateManagement of a Jejunal GastrointestinalStromal Tumor (GIST)? Report of a Case

Michail Pitiakoudis, MD,* Petros Zezos, MD,w Nikos Courcoutsakis, MD,zNikolaos Papanas, MD,y Alexandra Giatromanolaki, MD,J Efthimios Sivridis, MD,J

Georgios Kouklakis, MD,w and Constantinos Simopoulos, MD*

Abstract: A 51-year-old female patient presented with irondeciency anemia. Upper and lower gastrointestinal endoscopywere unremarkable. Computed tomography enteroclysis showed anovoid 34-cm jejunal tumor with intraluminal protrusion andexophytic growth pattern, without lymphadenopathy or metastaticdisease. Laparoscopic resection of the tumor was successfullycarried out. Histologically, a mesenchymal tumor composed ofspindle cells with an interlacing bundle pattern and high-mitoticactivity greater than10 mitoses/50 high-power elds were observed.The immunohistochemistry showed that the tumor was KIT(CD117)-, vimentin-, smooth muscle actin-, and S-100-positive,whereas it was CD34-negative. These ndings were consistent withthe features of a gastrointestinal stromal tumor. The patient had anuneventful postoperative course, and after 10 months of follow-up,she is well without any evidence of tumor recurrence.

Key Words: computed tomography enteroclysis, gastrointestinal

bleeding, gastrointestinal stromal tumor(GIST), small bowel GIST,

laparoscopic resection

(Surg Laparosc Endosc Percutan Tech 2010;20:e160e163)

Gastrointestinal stromal tumors (GISTs) are the mostcommon mesenchymal tumors of the gastrointestinal(GI) tract, accounting for less than 1% of all GI tumors.Their incidence is estimated between 10 and 20 cases per 106

people per year. They originate from the interstitial cells ofCajal or its precursors and are dened as spindle cell,epitheloid, and occasionally pleomorphic mesenchymaltumors of the GI tract. GISTs are characterized by theexpression of the tyrosine kinase receptor KIT (CD 117,stem cell factor receptor) or CD 34 (hematopoietic humanprogenitor cell antigen) on immunohistochemistry. Thesetumors have uncertain clinical behavior ranging frombenign to highly malignant, and are commonly located inthe stomach (40% to 70%) and the small bowel (20% to40%), although they can also be found anywhere in the GItract.1,2

The clinical presentation of GISTs is nonspecic anddepends on the localization and the size of the tumor. SmallGISTs are often asymptomatic and are incidentallydetected during endoscopy, surgery, or imaging studies(CT or MRI) for other conditions. Symptomatic GISTspresent most commonly with GI bleeding (obscure or overt)or with symptoms related to mass eects.1,2 Completesurgical resection is currently the treatment of choice for thelocalized primary disease, whereas imatinib mesylate, anoral tyrosine kinase inhibitor, is indicated for metastatic,recurrent, or unresectable GISTs.13 There is no clear re-commendation in current consensus guidelines for theappropriate use of minimally invasive surgery in treatingGISTs, but accumulating evidence suggest that laparo-scopic GIST resection is a feasible, safe, and eectivetreatment in expert hands.3,4

We report the case of a 51-year-old woman whopresented with iron deciency anemia because of obscureGI bleeding of a jejunal GIST that was treated successfullywith laparoscopic resection.

CASE REPORTA 51-year-old female patient was admitted to our Depart-

ment with fatigue, vague abdominal pain, and sporadic melenicstool for the last 4 weeks. On admission, she was hemodynamicallystable with a blood pressure of 135/75mm Hg and a pulse rate of80/min. Her past medical history included acute pancreatitis6 years ago because of cholelithiasis and a subsequent laparoscopiccholecystectomy. The patient did not take any medication and shewas not a smoker or an alcohol consumer. Mild epigastrictenderness was found on clinical examination and the digital rectalexanimation was negative for hematochezia or melena. Laboratorydata showed microcytic anemia with hematocrit 28.4%, hemoglo-bin 9.2 g/dL, MCV 80, and ferritin 8 ng/mL. Upper gastrointest-inal endoscopy and colonoscopy were normal, not showing thecause of obscure GI bleeding.

Subsequently, computed tomography (CT) of the abdomenand CT enteroclysis (CTE) with neutral enteral contrast agent andintravenous infusion of iodinated contrast medium were carriedout, revealing an ovoid, smooth, well circumscribed, and inten-sively enhancing 34-cm tumor in the jejunum with intraluminalprotrusion and exophytic growth pattern (Fig. 1). No lymphadeno-pathy or metastatic disease was noticed.

Under general endotracheal anesthesia with the patient in thesupine position, a 12-mm trocar was inserted in a standardsubumbilical position using the open technique owing to earlierlaparoscopic cholecystectomy and a pneumoperitoneum wascreated by carbon dioxide insuation. One accessory 10-mmtrocar in the right upper and another one 5mm in the left lowerabdominal quadrant laterally to the rectus muscle border wereplaced under direct vision. General laparoscopic inspection of theCopyright r 2010 by Lippincott Williams & Wilkins

Received for publication January 15, 2010; accepted May 9, 2010.From the *2nd Department of Surgery; wGastrointestinal Endoscopy

Unit; zDepartment of Radiology; y2nd Department of InternalMedicine; and JDepartment of Pathology, Democritus Universityof Thrace, University General Hospital of Alexanroupolis,Dragana Alexandroupolis, Greece.

Reprints: Petros Zezos, MD, 40 Venizelou Street, 68100 DraganaAlexandroupolis, Greece (e-mail: zezosp@hol.gr).

CASE REPORT

e160 | www.surgical-laparoscopy.com Surg Laparosc Endosc Percutan Tech Volume 20, Number 5, October 2010

peritoneal cavity was normal except for the earlier cholecystectomyclips. During careful laparoscopic manipulation of the small bowelloops from the ileocecal valve to the ligament of Treitz, a fullymobile small bowel tumor was identied about 2.5 metersproximally to the valve (Fig. 2A). Careful dissection of themesentery and its vessels with the LigaSure vessel sealing systemwas carried out and a segmental jejunal resection was accomplishedusing the endoscopic stapling device (ENDO GIA) (Fig. 2B).Finally, the specimen was removed into an ENDO CATCH bag(Fig. 2C) through the submbilical port that was extended to 3 cmand an extracorporeal end to end bowel anastomosis was comple-ted (Fig. 2D). The operative time was about 80min, with minimalblood loss.

On macroscopic examination, the size of the tumor was334 cm with exophytic growth (Figs. 3A, B). Microscopically,a mesenchymal tumor with low grade of dierentiation arisingfrom the inner circular muscle layer of the small bowel was

observed. The tumor was composed of spindle cells arranged in astoriform pattern and exhibited a high-mitotic activity with greaterthan 10 mitoses/50 high-power elds (HPF). Immunohistochemicalanalysis revealed that the lesion was positive for KIT (CD117),vimentin, smooth muscle actin, and S-100, whereas it was negativefor CD34, myosin, and desmin (Fig. 4). Molecular analysis ofmutations was not carried out.

The postoperative course was uneventful and the patient wasdischarged from the hospital 4 days after surgery and a regularfollow-up including physical examination, blood tests, and radi-ologic surveillance with chest x-ray and abdominal CT scan every 3months was instituted. After 10 months of follow-up, she is wellwithout evidence of tumor recurrence.

DISCUSSIONGISTs have an uncertain clinical behavior and all have

a malignant potential, which is dicult to predict.Although currently there is no staging system for GISTs,the location and the size of the tumor together with themitotic count are considered as the most useful predictorsof their malignant potential.57 Small intestinal GISTs aremore aggressive than gastric (malignancy 40% versus 20%),7

whereas tumors

with 22 months for those who had incomplete resection orwhose tumor was unresectable. However, local recurrence,most commonly in the peritoneal surface and the liver, aftercomplete surgical resection was reported to a rate ofapproximately 50% and the disease-specic survival ratewas 54% at 5 years. They also found that the tumor sizedetermines survival and not the negative microscopicmargins. Recently, Wu et al12 reported that the recurrencerate after resection of 85 small bowel GISTs was 51.8%after a median follow-up of 33.2 months.

Therefore, the complete resection of tumor with grossnegative margins, typically wedge resection of the stomachor segmental resection of the intestine, is adequate for localtherapy. Extensive surgery is rarely required and lympha-denectomy is not necessary because lymph nodes are rarelyinvolved. Importantly, gentle operative management of theGISTs is mandatory as they are soft, fragile, and prone torupture, which increases the risk of peritoneal seeding.13

As the status of the microscopic margin of resectiondoes not aect survival and routine lymphadenectomy isnot necessary, laparoscopic surgery may be considered asan ideal treatment choice for the majority of the resectableGISTs. Moreover, laparoscopic surgery oers the advan-tages of minimally invasive surgery on morbidity andrecovery. The European Society of Medical Oncology 2004consensus stated that the laparoscopic surgery should beavoided for GISTs except for the cases of small (

In our case, the patient presented with symptoms ofiron deciency anemia, endoscopy was negative, and thesmall bowel GIST was discovered with CT and CTEabdominal scan. Nguyen et al17 reported that 27% (4/15) ofthe small bowel cases were indentied with CT scan, 50%were identied with endoscopy (push enteroscopy orcapsule endoscopy), and 7% were found incidentally duringsurgery. GISTs appearance on imaging examinationcorresponds to a mass that can be smooth, irregular, orlobulated exhibiting intense enhancement, central areas ofnecrosis, ulcerations, or calcications on CT.18 CTE may beconsidered an ideal imaging modality for the evaluation ofGISTs that combines the advantages of conventionalenteroclysis with those of cross-sectional imaging (CT).19

Although conventional enteroclysis is highly accurate indiagnosing a small bowel tumor manifested with irondeciency anemia or melena, CTE is important for tumorcharacterization by attenuation values and contrast en-hancement pattern, assessment of extraluminal tumorextent, and the disclosure of associated abnormalities suchas regional lymphadenopathy and distant metastases.

In our patient, the 34-cm GIST tumor was easilyidentied during laparoscopy in the jejunum; and laparo-scopic segmental bowel resection with extracorporealanastomosis was carried out successfully. According tothe risk stratication of primary GIST, the tumor in ourpatient was classied as high risk for progressive disease(small intestine GIST, 34 cm with over 5 mitoses per 50HPFs).6 The patient was placed at a regular follow-up withpostoperative surveillance for recurrence with abdominaland pelvic CT scan every 3 months without adjuvanttreatment with imatinib mesylate.6 Imatinib mesylate isindicated for metastatic, recurrent, or unresectable GISTs,but its use as an adjuvant therapy after the completeresection of primary GIST is under evaluation in clinicaltrials in USA and Europe.1,2,6 Recently, Tsukuda et al20

studied the outcome of primary GISTs after completesurgical resection in their institute and concluded thatadjuvant treatments are strongly required for high-riskpatients as they showed poor prognosis, whereas a long-term follow-up is also necessary for patients with low riskand intermediate-risk tumors. Although no data supportthe adjuvant use of imatinib in primary completely resectedGIST outside of a clinical trial, some physicians administeradjuvant imatinib for high-risk patients.6

CONCLUSIONSAs the experience of minimally invasive surgery is

increasing in the last decade, the indications for laparo-scopic surgery are expanding. Scarce data have recentlyshown the feasibility and safety of the laparoscopicresection of gastric and small bowel GISTs. Radicalsurgical resection is the treatment of choice for the primarynonmetastatic GISTs of the small bowel, but laparoscopyand laparoscopic surgery could be an excellent choice fortreating these tumors. Minimally invasive surgery providesthe advantage of complete macroscopic resection withminimal touch and lowers the risk of rupture. We havedescribed an additional case of small bowel GIST resectedlaparoscopically, and we believe that the future consensusstatements should recommend minimally invasive surgeryas a feasible and safe treatment option for GISTs in experthands.

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Surg Laparosc Endosc Percutan Tech Volume 20, Number 5, October 2010 Laparoscopic Resection of a Jejunal GIST

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