Don't give up too soon! Management of metastatic duodenal GISTs with tumor-bowel fistula: A case report and literature review

Abstract

The prognosis of advanced/metastatic GISTs has improved significantly through treatment with a combination of neoadjuvant and/or adjuvant imatinib, a tyrosine kinase inhibitor, and surgical resection. However, GISTs often show variable response to neoadjuvant therapy and there are currently no well-established guidelines for some of the management decisions faced by both medical and surgical oncologists. We present two cases of patients with advanced duodenal gastrointestinal stromal tumors who developed tumor-bowel fistulas while on neoadjuvant tyrosine kinase inhibitor therapy. Both patients experienced tumor progression while on neoadjuvant therapy as well as treatment-related complications, including the formation of a fistula connecting the tumor and bowel lumen. This phenomenon has seldom been mentioned in the existing literature, and has rarely been discussed as a life-threatening complication of tyrosine kinase therapy. We use these cases to elucidate an under-recognized treatment-related complication and to discuss the highly complex medical and surgical decision-making process when treating advanced GISTs. We aim to convey the rationale supporting a more aggressive surgical approach, when appropriate, as well as to emphasize the importance of strong medical and surgical collaboration for these cases.

Keywords

• Gastrointestinal stromal tumor
• GIST
• Tyrosine kinase inhibitors
• Imatinib
• Tumor-bowel fistula