Primary Small Bowel Adenocarcinoma Research Articles

Case Report: Primary small bowel adenocarcinoma with peritoneal metastasis responded well to a CapeOX + bevacizumab regimen

BackgroundSmall bowel adenocarcinoma (SBA) is a rare condition often presenting with various non-specific gastrointestinal symptoms, making its diagnosis challenging. Delayed diagnosis is common, as patients may not receive the correct diagnosis until complications arise, necessitating further investigations. Furthermore, the management of SBA patients poses difficulties due to the scarcity of high-quality evidence.Case presentationIn this report, we present the case of an elderly man with SBA in the ileum who arrived at our emergency room with acute abdominal pain. The diagnosis was not made until the SBA caused a perforation, leading to acute abdominal pain. An emergent exploratory laparotomy revealed a 3 cm × 3 cm perforated tumor in the ileum, along with widespread metastatic nodules on the omentum, ascending colon, descending colon, and rectum. Postoperative pathological evaluation confirmed the diagnosis of SBA with peritoneal metastasis (pT4N2M1, stage IV). Following surgery, the patient received palliative systemic chemotherapy, which included the CapeOX regimen and the anti-VEGF monoclonal antibody bevacizumab. Remarkably, the patient responded well to this therapy, displaying good tolerance, and we observed no signs of disease progression. As of now, the patient is in good health and continuing with regular follow-up.ConclusionThe early diagnosis of small bowel adenocarcinoma remains a challenge. Delayed diagnosis can lead to a poor prognosis, underscoring the importance of considering SBA as a potential diagnosis for patients with unexplained abdominal pain and gastrointestinal symptoms. This case also highlights the efficacy of palliative chemotherapy with the CapeOX regimen combined with bevacizumab in controlling SBA.

Metastasis Pattern and Survival Analysis in Primary Small Bowel Adenocarcinoma: A SEER-Based Study.

Background: Small bowel adenocarcinoma (SBA) is a rare gastrointestinal tumor with high malignancy. The aim of this study was to comprehensively evaluate the distant metastasis pattern and establish nomograms predicting survival for SBA.Methods: From 2010 to 2015, patients diagnosed with SBA were identified based on the Surveillance, Epidemiology, and End Results (SEER) database. Kaplan–Meier survival analysis was applied to compare survival differences between metastasis patterns. Then, univariate and multivariate cox analyses were applied to screened out independent prognostic factors of cancer-specific survival (CSS) and overall survival (OS), and identify the risk factors for metastasis of SBA. To assess the discrimination and calibration of nomograms, the concordance index (C-index), calibration curves, receiver-operating characteristic curve (ROC), and decision curve analysis (DCA) were calculated.Results: Kaplan–Meier curves revealed that metastasis patterns were significantly correlated with CSS (p < 0.001) and OS (p < 0.001). Then, the metastasis pattern was showed to be an independent prognostic factor of OS and CSS in patients with SBA, as well as age, grade, T stage, N stage, surgery, retrieval of regional lymph nodes, and chemotherapy. Combining these factors, we constructed prognostic nomograms, which suggested that the metastasis pattern made the greatest contribution to the survival of patients with SBA. Nomograms for OS and CSS had a C-index of 0.787 and 0.793, respectively. Calibration curves showed an excellent agreement between probability and actual observation in the training and validation cohort. Decision curve analysis also exhibited its clinical value with an improved net benefit. In addition, the models we constructed had better prognostic accuracy and clinical utility than traditional TNM staging based on C-index and ROC. Further, Cox regression analysis showed that old age, poor differentiation, N2, and not receiving chemotherapy were the risk factors for prognosis in patients with metastatic SBA.Conclusion: As an independent prognostic factor, the metastasis pattern exhibited the greatest predictive effect on OS and CSS for patients with SBA. Adjuvant chemotherapy had a positive effect on the survival of patients with SBA. Nomograms for predicting 3-and 5-year OS and CSS of patients with SBA were constructed, which could identify patients with higher risk and might be superior in predicting the survival of patients with SBA than TNM staging.

Coexistence of gastrointestinal stromal tumor of the stomach and small bowel adenocarcinoma: A case report

The coexistence of gastrointestinal tumors (GIST’s) with other several primary malignant neoplasms has been demonstrated. However, there is no study that reported simultaneous occurrence of primary small bowel adenocarcinoma (SBA) and a GIST located in the stomach. Here, we report the first case of SBA and a synchronous gastric GIST. Surgical resection and clinicopathological characterization were performed for the masses identified through endoscopic and radiologic studies. Computed tomography scan showed a 13 mm mass located at the gastric antrum and another mass lesion partially occluding the jejunum. A biopsy specimen was obtained from the mass at the proximal jejunum by enteroscopy. The tumor was reported as adenocarcinoma. The patient was operated by the general surgery team. The features of the submucosal lesion resected from the antrum were consistent with a diagnosis of a GIST which contained spindle cells and showed positive staining with CD-117 and CD-34. Mitosis was not observed and Ki67 index was below 10%. This is the first case of coexistence of GIST of the stomach and SBA to be reported in English-language literature. The prominent characteristics of our case include its antral localization, male sex, absence of mitosis and incidental diagnosis.

Clinical features, treatment, and prognosis of different histological types of primary small bowel adenocarcinoma: A propensity score matching analysis based on the SEER database

PurposeThis aim of this study was to provide a comprehensive understanding of the clinical characteristics, treatment, and prognosis of patients with small bowel adenocarcinoma (SBA), mucinous small bowel adenocarcinoma (MSBA), and signet ring cell carcinoma of the small bowel (SRCSB). MethodsInformation on patients with SBA, MSBA, and SRCSB (2004–2015) was obtained from the Surveillance, Epidemiology and End Results (SEER) database. Cox proportional hazards models and Kaplan–Meier curves were used for the survival analyses. Propensity-score matching (PSM) was implemented to determine the differences among these tumors. ResultsIn all, 3697 patients with SBA (n = 3196), MSBA (n = 325) and SRCSB (n = 176) were ultimately eligible for this study. Poor differentiation, local invasion, and lymph node metastasis were more likely to be observed in SRCSB than in SBA and MSBA. Surgery was the most common treatment modality in all groups. The prognosis of SBA was similar to that of MSBA, but better than that of SRCSB in both unmatched and matched cohorts. M stage, surgery, and chemotherapy were identified as independent predictors of survival in all patients. Surgery and chemotherapy could significantly improve outcomes in all groups before and after PSM. Radiotherapy was associated with a survival benefit in patients with SBA, but this trend was not maintained after PSM. Survival advantages of SBA and MSBA were remarkable in the stratified analysis of surgery after PSM. ConclusionPatients with SRCSB had the worst prognosis among all histological types examined. However, surgery and chemotherapy could improve patients survival, regardless of histological type.

Gastrointestinal tract metastasis of lung cancer: The PD-L1 expression and correlated clinicopathological variables.

The gastrointestinal tract is a rare site for metastatic lung cancer. Programmed cell death-ligand 1 (PD-L1) expression in lung cancer is a biomarker for the response to anti-PD-1/PD-L1 therapy. We investigated clinicopathological features and PD-L1 expression in 25 gastrointestinal metastatic tumors from the lung and primary adenocarcinoma of the small bowel. The small bowel was the most common site (16/25; 64%) of gastrointestinal tract lung cancer metastasis. A total of 19 (76%) of the gastrointestinal metastasis showed PD-L1 expression in ≥5% of tumor cells, with 14 (56%) showing high expression levels (≥50%). In contrast, 21 (84%) expressed PD-L1 in ≥5% immune cells, including 4 (16%) showing a high expression levels (≥50%). The PD-L1 expression on tumor cells and immune cells in primary lung cancer and corresponding gastrointestinal metastasis was concordant in 13 (68%) and 11 (58%) of the 19 paired cases, respectively. Small-bowel metastasis of lung cancer was characterized by a higher incidence of perforation (31% vs. 0%), ulcerated mass (83% vs. 60%), and neoplastic PD-L1 expression (75% vs. 0%) compared to primary small-bowel adenocarcinoma. Gastrointestinal metastasis from lung cancer might be a potential target for immune checkpoint inhibitor therapy, given its high expression of PD-L1.

Radical resection for duodenal carcinoma with isolated bilateral ovarian metastasis: a case report

Natural history of duodenal adenocarcinoma is not well known. Although extremely rare, the incidence of primary small bowel adenocarcinoma has been increasing. Primary duodenal cancer is a very rare, which has accounted for only 0.3% of all gastrointestinal cancers. Isolated ovarian metastasis from duodenal carcinoma is extremely rare entity. We report a case of duodenal carcinoma with isolated bilateral ovarian metastasis in a 39-year-old female patient managed surgically with Whipple’s procedure with bilateral oophorectomy. She presented with complaints of dyspepsia and intermittent vomiting since 1½ years. History of anorexia and weight loss present. Upper gastrointestinal endoscopy was suggestive of circumferential ulcerated friable lesion at duodenum (D1-2) region and histopathology suggestive of moderately differentiated adenocarcinoma. Subsequent imaging studies revealed 6×5 cm duodenal mass in D1 and D2 without IHBRD with right ovarian mass. She underwent staging laparoscopy with open classic Whipple’s procedure with bilateral oophorectomy was done. Intraoperatively 6×6 cm mass involving first and second part of duodenum involving head of pancreas was found with 3×3 cm right ovarian mass. Post-operative period was uneventful and she discharged on POD6. Final biopsy was suggestive of moderately differentiated adenocarcinoma of duodenum with bilateral ovarian metastasis and she received adjuvant chemotherapy. Now at 1 year, on regular follow up she is completely asymptomatic and imaging showed no recurrent disease. Isolated ovarian metastasis may not be a contraindication for radical surgery in selected group of patients with duodenal carcinoma.

Primary small bowel adenocarcinoma : a case report

Abstract A 69-year-old woman visited our outpatient clinic due to abdominal pain and anorexia. She received initial diagnostic workup, and was admitted to the hospital as an inpatient because of ileus. CT showed tumor with a diameter of 3cm in upper left abdomen, liver metastasis, peritoneal fluid localized in the pelvic cavity, and peritoneal node. Upper and lower gastrointestinal endoscopy showed no abnormalities, and percutaneous liver biopsy confirmed adenocarcinoma. PET showed a focal abnormal uptake in proximal jejunum, but no abnormalities in pancreas and biliary tract. We diagnosed the patient with small bowel cancer. It was considered unresectable, and FOLFOX chemotherapy was initiated. However, during FOLFOX chemotherapy after 1st course, CT showed that exacerbation of primary lesion and liver mass, and significant increase in ascites. She subsequently died of pneumonia day 32 after the start of chemotherapy. Autopsy findings revealed primary small bowel adenocarcinoma with proximal jejunum. Histological response was Grade1a. The incidence of small bowel adenocarcinoma (SBA) is very low, accounting for 0.1%-0.3% of all gastrointestinal malignant neoplasms. Many cases have been reported to be within 50 cm of Treitz ligament or Bauhin valve. For diagnosis of SBA, some reports suggest small bowel series, gastrointestinal endoscope, CT, and PET are useful. However, in many advanced cases it is difficult to apply curative therapy at the time of discovery. There is no standard treatment especially for unresectable small bowel cancer, and the prognosis is poor. In this case SBA was confirmed by metastatic lesion biopsy and exclusion diagnosis. Because the disease was already advanced at the time of diagnosis and furthermore time was necessary for diagnostic workup, it caused deterioration of the general condition. As a result, adequate chemotherapy could not be performed. There is a need for further case studies to establish diagnosis and treatment of SBA.

18F]fluorodeoxyglucose-positron emission tomography and glucose-transporter type 1 expression in untreated primary small bowel adenocarcinoma.

Literature reporting [18F]fluorodexoyglucose positron emission tomography (FDG-PET) of small bowel adenocarcinoma, a rare tumor, is sparse. To assess FDG uptake in small bowel adenocarcinoma, we retrospectively analyzed a large, single-center database and determined the expression of glucose-transporter type 1 (GLUT-1). Screening of PET datasets in the database (N.=28,961 scans) for untreated histologically-confirmed primary small bowel adenocarcinoma revealed evaluable PET datasets for eight patients. Maximum and peak standardized uptake values (SUV<inf>max</inf> and SUV<inf>peak</inf>, respectively) were calculated via volume-of-interest (VOI) analysis. Additionally, GLUT-1 expression on tumor specimens was prospectively immunohistochemically assessed. All primary tumors showed high FDG uptake: mean SUVmax was 9.5±2.6 (range: 5.0-13.0) and SUVpeak, 8.1±2.3 (range: 3.9-10.7). Corresponding biopsy specimens (N.=7) demonstrated high GLUT-1 expression. Primary small bowel adenocarcinomas have a high GLUT-1 expression. Tumor lesions consistently demonstrated high FDG uptake pre-treatment, suggesting FDG-PET utility in staging and follow-up of these tumors.

Clinical characteristics of primary small bowel adenocarcinoma

Clinical characteristics of primary small bowel adenocarcinoma

A rare case of primary small bowel adenocarcinoma with intussusception

Other than in childhood, intussusception is unusual and nearly always caused by a structural and well demonstrable lesion. In contrast with the colon tract, the incidence of primary malignancies in the small bowel is very low. We report the case of a 51-year-old man presenting with jejunal intussusception due to a primary adenocarcinoma. To our knowledge, only a few similar cases have been reported in the literature to date. The patient was referred to our division for bowel obstruction. A CT scan showed a jejunal intussusception and surgical exploration was hence considered. At laparotomy, jejunal intussusception located just after the ligament of Treitz due to a polypoid lesion was confirmed and resection of the first jejunal loop was carried out. Histological examination of the specimen resulted in a diagnosis of a primary adenocarcinoma of the small bowel. In adult intestinal intussusception, resection without reduction is considered the optimal management if an underlying primary malignancy cannot be excluded.

Clinical use of molecular targeted agents for primary small bowel adenocarcinoma: A multicenter retrospective cohort study by the Osaka Gut Forum.

Primary small bowel adenocarcinoma (SBA) is a rare cancer for which effective treatment strategies have not yet been established. The results of previous retrospective studies suggest that chemotherapy contributes to a longer survival time in patients with SBA. However, there are few case reports about the efficacy of molecular targeted agent-containing chemotherapy for SBA. In the present study, the treatment and follow-up data of patients with SBA who received chemotherapy with or without molecular targeted agents were retrospectively analyzed. Each patient was treated in one of ten hospitals participating in the Osaka Gut Forum between April 2006 and March 2014. The following factors were evaluated: Age, sex, Eastern Cooperative Oncology Group performance status (PS), tumor location, tumor differentiation, chemotherapy regimen, resection of primary tumor, tumor biomarker expression, distant metastasis, best response under chemotherapy, time to disease progression, subsequent treatments, survival status and treatment toxicity. A total of 27 patients (17 males and 10 females; mean age, 63.4 years old; range, 36-83 years old) received chemotherapy due to non-curative tumor resection, unresectable tumor or post-operative recurrence. The median overall survival time was 14.8 months (range, 2-58 months). A univariate analysis revealed a PS of 0 (P=0.0228) and treatment with platinum-based chemotherapy (P=0.0048) were significant factors for an improved prognosis. An age-adjusted multivariate analysis also revealed that a platinum-based regimen was a significant positive prognostic factor (P=0.0373). Molecular targeted agents were administered to 8 patients, for whom it was their first- or second-line therapy. Among the 17 patients who received oxaliplatin-based chemotherapy as a first-line chemotherapy, a PS of 0 (P=0.0255) and treatment with bevacizumab (P=0.0121) were significant positive prognostic factors. Toxicities higher than Grade 3 occurred in 8/27 patients with SBA; however, serious side effects due to the molecular targeted agents were not experienced. The results of the present study indicate that chemotherapy containing molecular targeted agents is a well-tolerated and effective treatment option for SBA.

Therapy with Bevacizumab Is Associated with Reduced Expression of KLF2 in Peripheral Blood Mononuclear Cells: A Potential Prothrombotic Mechanism

Background: Bevacizumab, the first approved anti-angiogenic agent for metastatic colon cancer, is associated with an increased risk of arterial thromboembolism (ATE) and potentially venous thromboembolism (VTE). The molecular mechanisms underlying this association are incompletely understood. The transcription factor Kruppel-like factor 2 (KLF2) is a master regulator of cellular inflammatory responses, and decreased expression of KLF2 is associated with a prothrombotic phenotype. KLF2 is particularly important in regulating inflammatory and prothrombotic genes in endothelial cells and monocytes.Objective: To determine whether bevacizumab therapy was associated with alterations in the expression of KLF2 or other genes potentially associated with thrombosis in peripheral blood mononuclear cells.Methods: We conducted a prospective observational cohort study of consecutive patients initiating bevacizumab therapy for metastatic colorectal, lung, or brain cancer. Patients with prior history of VTE or on anticoagulation were excluded. Blood was collected at baseline (prior to initiation of treatment) and every 4 weeks (± 1 week) for up to 16 weeks while on Bevacizumab therapy. Total RNA was isolated and levels of KLF2 mRNA as well as mRNA encoding 18 other genes potentially associated with thrombosis were measured using a customized qPCR microarray (Qiagen RT2 Profiler). Changes in gene expression levels were standardized through inclusion of housekeeping genes, RT, and PCR controls on each array. Associations with clinical events were assessed by stepwise linear regression.Results: The study population comprised 25 patients who received from one to four courses of bevacizumab. Primary sites of cancer included colorectal adenocarcinoma (N=18), non-small cell lung cancer (N=2), primary brain tumor (N=4) and small bowel adenocarcinoma (N=1). The average patient age was 58 years. Average length of study participation was 71.8 days. PCR analyses demonstrated a significant decrease in KLF2 mRNA after the first cycle of bevacizumab, and levels of KLF2 remained suppressed in patients who remained on study through at least three cycles of therapy ( p = 0.0015, 0.0139, 0.011, respectively). No significant change in the expression of other prothrombotic genes was demonstrated. Levels of KLF2 correlated inversely with levels of D-dimer (p = 0.008).Conclusions: Therapy with Bevacizumab was associated with significant and durable decreases in the expression of KLF2 in peripheral blood mononuclear cells. These findings suggest a potentially new mechanism which may contribute to the prothrombotic phenotype of these patients through loss of thromboprotective gene expression in monocytes. Enhancement of KLF2 expression may provide a potential strategy to explore for circumventing thrombosis in patients treated with bevacizumab.Acknowledgment: This work was supported by funds from the Scott Hamilton Cares Initiative, the Stephen Hardis Chair in Oncology Research, and the V Foundation. DisclosuresNo relevant conflicts of interest to declare.

Crohn enteritis–associated small bowel adenocarcinomas exhibit gastric differentiation

Primary small bowel adenocarcinoma is rare. Although generally similar to colonic adenocarcinoma, some small bowel adenocarcinomas exhibit unique morphologic features, particularly those arising in association with Crohn disease. In this study, 15 sporadic small bowel adenocarcinomas and 11 Crohn enteritis-associated small bowel adenocarcinomas were examined for histology and immunohistochemical profile including cytokeratins (CK) 7 and 20, intestinal markers CDX2 and MUC2, and gastric epithelial markers MUC5AC and MUC6. We found that Crohn enteritis-associated small bowel adenocarcinomas frequently resemble gastric tubular adenocarcinoma histologically. In addition, when compared to sporadic small bowel adenocarcinoma, the former expressed MUC5AC and MUC6 with much higher frequency (82% vs. 7% and 73% vs. 0%, respectively). Ten of 11 Crohn enteritis-associated small bowel adenocarcinomas (91%) were positive for at least one gastric-type marker (MUC5AC or MUC6). Expression of CK7 was also more frequent in Crohn enteritis-associated small bowel adenocarcinoma (73% versus 27%) while expression of CK20 was less frequent (64% vs. 100%). There was no difference between sporadic and Crohn enteritis-associated small bowel adenocarcinoma in expression of CDX2 (100% vs. 91%) and MUC2 (93% vs. 73%). These observations suggest that there is a difference in the morphologic and immunohistochemical characteristics of sporadic versus Crohn enteritis-associated small bowel adenocarcinoma, particularly in their expression of gastric-type mucin. The findings also suggest that gastric differentiation in Crohn enteritis-associated small bowel adenocarcinoma is related to gastric metaplasia, a common phenomenon in Crohn disease.

Primary Small Bowel Adenocarcinoma in the Setting of Chronic Crohnʼs Disease

Purpose: 59 Y/O Female with a history of Crohn's disease with a recent flare, complicated by small bowel obstruction treated with IV corticosteroids, infliximab and nasogastric decompression. She presents now with diffuse cramping abdominal pain, anorexia, nausea, vomiting and abdominal distention. She denied fever, chills, diarrhea, or gastrointestinal bleeding. She quit tobacco 20 years ago and denies alcohol or illicit drug use. Her family history was negligible for cancer. Exam revealed a well nourished female. Her skin had no rashes, ulcers or jaundice. Abdominal exam demonstrated a mildly distended abdomen with hyperactive bowel sounds. She had no organomegaly. No rebound or guarding tenderness was elicited. Laboratory exams were normal. CT-enterography with contrast demonstrated diffuse small bowel dilatation. There was mucosal hyper enhancement, wall thickening and mural stratification. Findings were consistent with active Crohn's disease, stricture and small bowl obstruction. She underwent laparoscopic ileocolectomy with primary anastomosis. Pathological results of resected small bowl revealed a T3 N0 adenocarcinoma of the small bowel in a background of active and chronic Crohn's disease. She was discharged and is being followed by oncology. • Small bowel adenocarcinoma in the setting of longstanding Crohn's disease is usually diagnosed on post operative pathohistological analysis. • Signet ring cells are found in 30% of specimens received from patients with Crohn's disease. • The risk of small bowel adenocarcinoma 10-25 years after the diagnosis of ileal Crohn's disease is approximately 2.2%. • Males between the ages of 30-55 are at highest risk for small bowel malignancy. • Positron emission tomography, CT- Scan and double barium enema serve a role in early preoperative detection of small bowel adenocarcioma. • Delayed diagnosis in patients with small bowel adenocarcinoma leads to poor long term prognosis. Conclusion: The diagnosis of small bowel adenocarcinoma in the setting of chronic Crohn's disease should be entertained in patients presenting with small bowl obstruction secondary to stricture formation. Studies such as positron emission tomography, computer tomography and double barium enema may serve to increase the rate of early detection and initiation of treatment.Figure: [1584]

P-0149 Small Bowel Adenocarcinoma: A Single Center Experience

ABSTRACT Introduction Small bowel adenocarcinoma is a rare cancer with limited data available to guide its diagnosis and treatment. Methods The records of 20 patients hospitalized between 1990 and 2010 at the Centre Hospitalier Universitaire de Sherbrooke for small bowel adenocarcinoma were retrospectively reviewed for clinical and follow-up data, including epidemiologic and tumor characteristics, cancer treatment history (surgery and chemotherapy) and survival. To study exclusively primary small bowel adenocarcinoma, cases with any known history of adenocarcinoma in other organs were excluded. Tumors arising from the ampullary region were also excluded. Results 20 patients were included in the study. The median age at diagnosis was 65 years, 60% were female. Tumors were located in the duodenum (35%), jejunum (40%), and ileum (30%). The majority (60%) of tumors were moderately differentiated while 15% were poorly differentiated. Most tumors were metastatic at diagnostic (Stage 4: 64.7%). The most common presenting symptom was abdominal pain (65%) while 55% had small bowel obstruction and 55% had anemia at the time of diagnosis. The median duration of symptoms prior to diagnostic was 47 days. A noteworthy proportion of patient had predisposing conditions: 15% suffer from Crohn's disease and 10% from celiac disease. Interestingly, 8 patients display adenoma at the tumor site suggesting an adenoma-carcinoma sequence (40%). The median overall survival was 33 months, with a 5-year overall survival of 40%. The median overall survival was significantly shorter for stage 4 (24 days) than for stage 1-3 (105 days) (p=0.026). Predictors of poor survival were: age (p= 0.055), tumor stage (p=0.026) and resectability (p=0.004). Eight patients received adjuvant chemotherapy and the commonly used regimen was based on 5FU. The median interval between surgery and chemotherapy was 58 days. Of note, adjuvant therapy did not influence overall survival (p=0.079). Conclusion Small bowel adenocarcinoma remains a rare digestive cancer, diagnosed at advanced stage. The only curative treatment is surgical resection and the role of adjuvant chemotherapy is still controversial.

Immune Thrombocytopenic Purpura as the Presenting Feature of Primary Small Bowel Adenocarcinoma

Introduction • Small bowel adenocarcinoma is a rare malignancy with only 6,969 cases reported annually in the US, accounting for approximately 2% of gastrointestinal tumors and less than 0.4% of all malignancies. • Immune thrombocytopenic purpura (ITP) is a common hematological disorder with an incidence of two cases per 100,000 people. While ITP has many clinical manifestations, it uncommonly is the presenting feature of a malignancy.

Mucosal Colonization by Metastatic Carcinoma in the Gastrointestinal Tract

The gastrointestinal (GI) tract is a common site for both primary and metastatic carcinomas. Distinguishing the two can occasionally be difficult, particularly when metastatic tumor reaches the mucosal surface. Features that are typically used to make this distinction include the presence of an adenomatous precursor lesion, regional lymph node involvement, and gross configuration of the tumor. However, we recently encountered 2 index cases of metastatic carcinoma in the small intestine (1 from the colorectum and 1 of endocervical origin) that were initially misinterpreted as primary small bowel carcinomas because of apparent in situ growth in the mucosal surface resembling polypoid, adenomatous precursor lesions. We, therefore, studied 100 GI resections from 1987 to 2009 that were reported to show mucosal involvement by metastatic carcinoma, and compared the histologic features with a control group of 29 primary small bowel adenocarcinomas. Gross descriptions and histologic sections were evaluated for the following: (1) tumor spread along an intact basement membrane of villi/crypts (mucosal colonization), (2) resemblance to an adenoma/precursor lesion, (3) gross configuration of the tumor, (4) lymphovascular invasion, and (5) regional lymph node involvement in the metastatic site. Metastatic sites included the small intestine (n=74), colorectum (n=16), or both (n=10). Primary tumors were GI (n=55, with 47 from colorectum), gynecologic (n=28), pulmonary (n=8), genitourinary (n=6), head and neck (n=2), and breast (n=1). Overall, 42 (42%) of the metastases that reached the mucosal surface of the bowel showed at least focal mucosal colonization, 26% resembled a precursor adenoma, 62% had regional lymph node positivity, and only 24% cases showed a classic serosal-based configuration. In 4 cases (2 of GI origin and 2 of gynecologic origin), metastatic tumors were initially interpreted as new primaries by the pathologist (n=2) or clinicians (n=2). Metastatic carcinomas originating from the GI tract were significantly more likely to show mucosal colonization (60% vs. 20%, P<0.0001) and resemblance to a precursor lesion (45% vs. 2%, P<0.0001) than other primary tumors. In a comparison between 29 primary small bowel carcinomas and 41 metastatic colorectal carcinomas in the small bowel, metastatic tumors were distinguished by a higher prevalence of multiple lesions (0% vs. 39%, P<0.0001), whereas small bowel primaries were more likely to show high tumor grade (41% vs. 17%, P=0.03). There were no significant differences in the mean age (61.4 y vs. 60.9 y), number of male participants (69% vs. 56%), growth along basement membranes (62% vs. 63%), apparent precursor lesion (55% vs. 46%), lymphovascular invasion (69% vs. 73%), or lymph node positivity (68% vs. 37.5%, P=0.065). These results confirm that metastatic carcinomas involving the mucosal surface of the intestines frequently exhibit gross and histologic features, which mimic second primaries, especially when they originate from the GI tract. In situ growth and presence of an apparent adenoma cannot be taken as prima facie evidence of a primary neoplasm.

A clinicopathological study of 10 cases of primary small bowel adenocarcinoma

A clinicopathological study of 10 cases of primary small bowel adenocarcinoma

Primary Small Bowel Tumour Presenting as Bowel Obstruction in a Patient with a Virgin Abdomen

Primary malignancies of the small bowel are rare and usually present with vague, non-specific symptoms. This leads to diagnostic difficulties for both physician and radiologists alike. We present a case of a 54-year-old lady with a virgin abdomen who initially presented to hospital with vague abdominal symptoms suggestive of gastroenteritis. She responded partially to conservative treatment but represented to hospital 3 weeks later with obstructive symptoms. Contrast CT was inconclusive with regards to diagnosis. A diagnostic laparoscopy was performed, revealing an infiltrative growth. Consequently, she underwent segmental laparoscopic-assisted small bowel resection and recovered well post-operatively. After further histological and endoscopic investigations, a final diagnosis of primary small bowel adenocarcinoma was given. As the prognosis of small bowel malignancy is stage-dependent, this case demonstrates a high index of suspicion is necessary to reach early diagnosis, especially for symptoms non-responsive to conventional treatment. Diagnostic laparoscopy should be considered early as a definitive diagnostic tool.

Small Bowel Adenocarcinoma: Understaged and Undertreated?

Primary small bowel adenocarcinoma (SBA) is a rare, chemoresistant tumor with an aggressive clinical nature. Surgery is the mainstay of therapy, but the extent of lymph node (LN) recovery necessary for optimal care of jejunoileal SBA is unknown. The SEER database was queried to identify patients whose primary jejunoileal SBA was diagnosed between 1995 and 2005. Patients were grouped by AJCC stage and number of LNs recovered from the surgical specimen. Of 1444 patients with primary SBA, 93 (6.4%), 529 (36.6%), 356 (24.7%), and 466 (32.3%) were initially diagnosed with stage I, II, III, and IV disease, respectively. Five-year overall survival (OS) rate was 59.8%, 39.5%, 27.0%, and 3.2% for patients with stage I, II, III, and IV SBA, respectively. When≥10 nodes were recovered, OS rate increased nonsignificantly in stage I (73.2% vs. 55.6%) and significantly in stage II (61.8% vs. 32.9%, P<.001) but was unchanged in stage III (27.4% vs. 27.3%, P=.13). Recovery of≥10 nodes occurred in 26.9%, 23.6%, and 42.1% of patients with stage I, II, and III SBA, respectively. Multivariate analysis identified age, AJCC stage, site of primary tumor, recovery of≥10 LNs, and number of positive nodes as significant for OS. We have found SBA staging is largely inadequate. Our results suggest recovery of≥10 LNs ensures accurate staging. Improvement in stage II SBA OS after adequate LN may reflect a high degree of understaging in this dataset rather than a therapeutic effect of LAD.