case_images: PMC6260393_01
case_images: (a) Upper gastrointestinal endoscopy showed a duodenal submucosal protruding lesion which caused bleeding. (b) Gastrointestinal bleeding was controlled with endoscopic clips and the bleeding point was distal to the duodenal papilla (third portion).
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case_images: PMC6260393_01_gr1.jpg
case_images: fig0005
case_images: Upper digestive endoscopy was performed, revealing a submucosal protruding duodenal lesion with central ulceration and bleeding (Fig. 1a). The bleeding was easily controlled with endoscopic clips although the bleeding site was distal to the duodenal papilla (third portion) (Fig. 1b).
case_images: (a) Coronal contrast-enhanced computed tomography (CT) scan showed a heterogeneously enhanced 50 mm tumor in the pancreatic uncus. Arrow indicates clips used for endoscopic hematemesis. (b) Axial contrast enhanced CT scan showed a well-defined exophytic mass (arrow) accompanied by a rich network of feeding vessels passing through the mass. (c) The tumor was fed by the inferior pancreaticoduodenal artery. (d) Abdominal ultrasonography showed a 45 x 30 mm tumor in the head of the pancreas with a smooth surface and simple low-echogenicity, without pancreatic ductal dilatation (arrow).
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case_images: PMC6260393_01_gr2.jpg
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case_images: An abdominal dynamic contrast-enhanced CT scan showed a 50 mm tumor in the pancreatic uncus, which was well defined and enhanced from the arterial to the venous phase (Fig. 2a, b). The tumor was supplied by the inferior pancreaticoduodenal artery (Fig. 2c) without evidence of distant metastases. Abdominal ultrasonography showed a 45 x 30 mm tumor in the head of the pancreas with a smooth surface and low-echogenicity, without pancreatic ductal dilatation (Fig. 2d).
case_images: (a) At laparotomy, the tumor was found between the third portion of the duodenum and the pancreatic uncus (arrow). (b) Arrow indicates the scar after endoscopic hemostasis using clips. (c) The resected specimen showed a 45 x 28 x 50 mm submucosal tumor in the duodenum, compressed and extended to the uncus of the pancreas with central necrosis (arrow). (d) Histopathological findings showed the tumor was composed of spindle-shaped cells. (Hematoxylin-Eosin stain, 100x). (e) Immunostaining revealed that the cells were positive for c-kit. (f) The cells stained positive for CD34 (100x). Immunohistochemical study established the diagnosis of a duodenal gastrointestinal stromal tumor.
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case_images: PMC6260393_01_gr3.jpg
case_images: fig0015
case_images: The patient underwent a laparotomy and the tumor was found between the third portion of duodenum and the pancreatic uncus (Fig. 3a). The resected specimen showed a 45 x 28 x 50 mm submucosal tumor, compressed and invading the uncus of the pancreas with clear resection margins (Fig. 3b, c). The tumor was comprised of spindle-shaped cells (Fig. 3d) on histologic evaluation without lymph node involvement. Immunohistochemical studies revealed that the tumor cells were positive for c-kit (Fig. 3e) and CD34 (Fig. 3f).