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

• Published in: Current problems in cancer. Case reports 2022-06, Vol.6, p.100165, Article 100165
• Main Authors: Hartlein, Taylor E., Ramsey, Walter A., Collier, Amber L., Livingstone, Alan S.
• Format: Article
• Language: English
• Subjects: Gastrointestinal stromal tumor; GIST; Imatinib; Tumor-bowel fistula; Tyrosine kinase inhibitors
• ISSN: 2666-6219; 2666-6219
• DOI: 10.1016/j.cpccr.2022.100165

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.