Current surgical management of duodenal gastrointestinal stromal tumors

Table 1 Summary of cohort studies on duodenal gastrointestinal stromal tumors

Ref.	Duodenal location D1-D4 (%)	Median size (cm) in all patients	Surgical approach	Operative complications or morbidity & mortality	Pathological risk classification using NIH or AFIP criteria	Survival in all patients
Liu et al[12] (n = 300)	D1 (15.8); D2 (51.5); D3 (24.4); D4 (8.3)	4 (0.1-28.0)	LR n = 199 (66.3%); PD n = 78 (26.0%); Not available n = 13 (4.3%); No surgery n = 10 (3.3%)	Not available	Very low n = 23 (12.8%); Low n = 87 (48.6%); Intermediate n = 2 (1.1%); High n = 67 (37.4%)	1-, 3-, 5-, 10-yr DFS: 94.4%, 75.2%, 64.4%, 46.5%; 1-, 3-, 5-, 10-yr DSS: 99.5%, 93.4%, 80.9%, 54.5%
Liang et al[23] (n = 28)	D1 (14.3); D2 (60.7); D3 (17.9); D4 (7.1)	5.8 (1.6-20.0) (95%CI: 5.3-8.6)	WR n = 5 (17.9%); SR n = 13 (46.3%); PD n = 10 (35.7%)	Morbidity 35.7%; Mortality 3.6%	Low n = 11 (39.3%); High n = 17 (60.7%)	2- and 5-yr RFS: 83.3% and 50.0%; Median OS: 64.5 mo
Colombo et al[32] (n = 84)	D1 (11); D2 (39); D3 (30); D4 (20)	5 (1-19)	LR n = 56 (66.6%); PD n = 28 (33.3%)	LR 9%; PD 36%	Low n = 35 (45%); Intermediate n = 4 (5%); High n = 39 (50%)	3, 5 yr OS: 98%, 89%; 3-, 5-yr DFS: 67%, 64%
Daffaud et al[33] (n = 117)	D1 (7); D2 (33); D3 (24); D4 (13)	5.0 (0.4-31.0)	Operated n = 109; LR n = 82 (74%); PD n = 23 (21%)	LR 18%; PD 26%	Very low n = 43 (39.0%); Low n = 52 (54.7%); High n = 19 (16.0%)	2-, 5-yr EFS: 82.0%, 54.5%; 3-, 5-yr OS: 94.9%, 86.5%
Shen et al[34] (n = 74)	D1 (22.97); D2 (47.30); D3 (16.22); D4 (13.51)	5.08 ± 2.90	WR n = 18 (24.3%); SR n = 39 (52.7%); PD n = 17 (23.0%)	WR 5.6%; SR 2.6%; PD 23.5%	Low n = 32 (43.24%); Intermediate n = 8 (10.81%); High n = 34 (45.96%)	1-, 3-, 5-yr RFS: 93.9%, 73.7%, 69.0%; 1-, 3-, 5-yr OS: 100%, 92.5%, 86.0%
Lee et al[35] (n = 60)	D1 (12); D2 (63); D3 (22); D4 (3)	5.2 (3.5-8.8)	LR n = 37 (62%); PD n = 23 (38%)	LR 24%; PD 70%	Very low/Low n = 24 (40%); Intermediate n = 12 (20%); High n = 24 (40%)	5-yr RpFS, RFS, OS: LR 56%, 53%, 72%, PD 81%, 64%, 76%
Zhang et al[36] (n = 52)	D1 (9.6); D2 (65.4); D3/4 (25.0)	5.0 (0.5-13.5)	LR n = 45 (26.9%); PD n = 37 (71.2%)	LR 10.8%; PD 21.4%	Low n = 16 (45.7%); Intermediate n = 7 (20.0%); High n = 12 (34.3%)	1-, 3-, 5-yr RFS: 93.5%, 77.8%, 72.9%; 1-, 3-, 5-yr OS: 100%, 94.6%, 89.1%
Lee et al[37] (n = 118)	D 1 (8.5); D2 (51.7); D3 (31.4); D4 (8.5)	3.9 (3.0-5.4)	LR n = 73 (61.8%); PD n = 45 (38.1%)	LR 20.4%; PD 37.8%	Very low n = 13 (11.0%); Low n = 63 (53.4%); Intermediate n = 19 (16.1%); High n = 23 (43.2%)	5-, 10-yr OS: 94.9%, 89.9%
Tien et al[38] (n = 25)	D1 (12); D2 (52); D3 (25); D4 (16)	6.7 ± 5.2	LR n = 16 (64%); PD n = 9 (26%)	LR 12.5%; PD 44.0%	Very low n = 3 (12%); Low n = 8 (32%); Intermediate n = 5 (20%); High n = 8 (32%)	7 disease recurrence with median follow up 18-mo (9-92)
Kamath et al[39] (n = 41)	D1 (7.3); D2 (63.4); D3 (19.5); D4 (9.7)	3.3-6.2 (0.5-17.0)	LR n = 19 (43.0%); SR n = 11 (26.8%); PD n = 11 (26.8%)	Morbidity 29.2%; Mortality 0%	Low n = 27 (65.8%); Intermediate n = 5 (12.1%); High n = 9 (21.9%)	3-, 5-yr OS: 85%, 74%; 3-, 5-yr DFS: both 80%
Johnston et al[40] (n = 96)	D1 (8.4); D2 (49.0); D3/4 (42.7)	4.0 (0.1-32.0)	LR n = 58 (60%); PD n = 38 (40%)	LR 29.3%; PD 57.9%	Very low n = 8 (8.3%); Low n = 46 (47.9%); Intermediate n = 25 (26.0%); High n = 16 (16.7%); Unknown n = 1 (1.0%)	1-, 2-, 5-yr RFS: 94.2%, 82.3%, 67.3%; 1-, 2-, 5-yr OS: 98.3%, 87.4%, 82.0%
Zhou et al[54] (n = 48)	D1 (22.9); D1/2 (16.7); D2 (35.4); D2/3 (8.3); D3 (12.5); D4 (4.2)	4.7 (2.0-15.0)	LR n = 34 (70.8%); PD n = 14 (29.2%)	LR 11.8%; PD 35.7%; Mortality in LR 5.9% (n = 2)	Low n = 28 (58.3%); Intermediate n = 11 (22.9%); High n = 9 (18.8%)	1-, 3-yr DFS: 100%, 88%
Yang et al[56] (n = 22)	D1 (13.6); D2 (63.6); D3/4 (22.7)	3.75 (1.40-14.00)	LR n = 10 (45.0%); SR n = 3 (13.6%); PD n = 6 (27.0%); PPPD n = 3 (13.6%)	LR 15.4%; PD 88.9%	Very low n = 3 (13.6%); Low n = 7 (31.8%); Intermediate n = 7 (31.8%); High n = 5 (22.7%)	1-, 2-, 5-yr RFS: 95%, 89.5%, 86.7%
Shi et al[64] (n = 61)	D1 (14.8); D2 (54.1); D3 (21.3); D4 (9.8)	4.0 (1.0-16.0)	LR n = 45 (73.8%); PD n = 16 (26.2%)	LR 33.3%; PD 56.3%	Very low n = 8 (13.1%); Low n = 29 (47.5%); Intermediate n = 14 (23.0%); High n = 10 (16.4%)	3-, 5-yr RFS: 93.3%, 81.3%
Chen et al[66] (n = 64)	D1 (21.9); D2 (46.9); D3 (17.2); D4 (14.1)	4.25 (1.00-15.00)	LR n = 41 (64%); PD n = 23 (36%)	LR 31.7%; PD 69.6%	Very low n = 4 (6.3%); Low n = 27 (42.2%); Intermediate n = 8 (12.5%); High n = 25 (39.1%)	3-, 5-yr RFS: 62.9%, 44.3%; 3-, 5-yr OS: 85.7%, 59.5%
Sugase et al[69] (n = 25)	D1 (12); D2 (56); D3/4 (32)	3.8 (1.5-16.0)	LR n = 16 (64%); PD n = 9 (36%)	LR 31%; PD 33%	Very low n = 4 (16%); Low n = 12 (48%); Intermediate n = 0 (0%); High n = 9 (36%)	2-yr RFS, 2-yr OS, 5-yr OS: LR 85%, 100%, 89%; PD 34%, 80%, 45%

AFIP: Armed Forces Institute of Pathology; CI: Confidence interval; DFS: Disease-free survival; DSS: Disease-specific survival; EFS: Event-free survival; LR: Limited resection; NIH: National Institutes of Health; OS: Overall survival; PD: Pancreaticoduodenectomy; PPPD: Pylorus preserving pancreaticoduodenectomy; RFS: Recurrence-free survival; RpFS: Relapsed-free survival; SR: Segmental resection; WR: Wedge resection.

Table 2 Summary of systematic review and meta-analysis and propensity score matching studies comparing limited resection vs pancreaticoduodenectomy for duodenal gastrointestinal stromal tumors

Ref.	Outcome parameters	LR group	PD group
Systematic review and meta-analysis
Chok et al[61] (n = 162)	Surgical morbidity; Oncologic outcomes	Better (20.7%); Better DFS (HR 2.07, 95%CI: 1.07–4.01), lower rate of distant metastasis (8.9% vs 25.8%, OR 0.28, 95%CI: 0.13–0.59)	Worse (48.3%) (RR 2.34, 95%CI: 1.61–3.42). Worse: Related to large tumor (≥ 5 cm) (76.0% vs 36.6%, OR 5.49, 95%CI: 1.8–16.76), high mitotic count ≥ 5/50 HPF (33.7% vs 18.5%, OR 2.23, 95%CI: 1.22–4.08), high-risk classification (60.3% vs 32.0%, OR 3.23, 95%CI: 1.65–6.34) and which were located at D2 (80.5% vs 28.6%, OR 10.33, 95%CI: 5.22–20.47)
Shen et al[62] (n = 623)	Complications; Long term prognosis	Less; Better	More (OR 2.90; 95%CI: 1.90-4.42; P < 0.001); Worse (HR 1.93; 95%CI: 1.39-2.69; P < 0.001); Related to invasion of the D2, higher degree tumor mitosis (> 5/50 HPF) and high-risk classification (P < 0.001)
Zhou et al[63] (n = 1103)	Surgical outcomes	Better	Worse: Related to higher incidence of mitotic index > 5/50 HPF, high-risk classification, D2 tumor, tumor size, operative duration, intraoperative blood loss, blood transfusion requirement, morbidity, length of hospital stay and recurrence rate (P < 0.001)
Propensity score matching study
Wei et al[67] (n = 325)	Impact of surgical modalities on long term survival outcomes	Similar	Similar: OS (HR 1.160; 95%CI: 0.662-2.033); DSS (HR 1.208; 95%CI: 0.686-2.128)
Uppal et al[68] (n = 1084 of which 874 had resection)	Lymph node and stage; Survival; Adjuvant systemic therapy rate	Fewer and negative for disease; Better. 21.5%	Higher T3/4 stage, extra nodal involvement and performed more at academic center. Poorer, higher mortality, uninsured status. 31.3%

CI: Confidence interval; DFS: Disease-free survival; DSS: Disease-specific survival; HPF: High power field; HR: Hazard ratio; LR: Limited resection; OR: Odds ratio; OS: Overall survival; PD: Pancreaticoduodenectomy; RR: Relative risk.