Small bowel adenocarcinoma: epidemiology, risk factors, diagnosis and treatment

Thyro-entero-gastric autoimmunity: Pathophysiology and implications for patient management

The association between autoimmune atrophic gastritis and thyroid disorders has been observed since the early 1960s and the expression "thyrogastric syndrome" was coined to indicate the presence of thyroid autoantibodies or autoimmune thyroid disease in patients with pernicious anemia, a late clinical stage of autoimmune atrophic gastritis. More recently, it was confirmed that autoimmune thyroid disorders, in particular Hashimoto's thyroiditis, may be frequently associated with other organ-specific, immune-mediated disorders, such as autoimmune atrophic gastritis or celiac disease. The association of Hashimoto's thyroiditis with autoimmune atrophic gastritis or celiac disease in adult patients is currently considered part of the polyglandular autoimmune syndromes which include several autoimmune disorders associated with an autoaggressive impairment of endocrine glands. From a clinical point of view, the thyro-entero-gastric autoimmunity may lead to potentially serious consequences like anemia, micronutrients deficiencies, and drugs malabsorption, as well as to an increased risk for malignancies. These alterations may frequently present in an underhand manner, with consequent diagnostic and treatment delays. Many aspects of the association between thyroid, gastric and intestinal autoimmune diseases still await clarification. The present review focuses on the embryological, genetic and pathophysiological aspects of thyro-entero-gastric autoimmunity. In particular, the current diagnostic criteria of autoimmune thyroid disease, autoimmune atrophic gastritis, and celiac disease are reviewed, along with the evidences for their association in poly-autoimmunity syndromes. The benefits of proactive screening of autoimmune thyroid disorders in patients with autoimmune gastritis or enteropathy and viceversa are also discussed.

Small bowel adenocarcinoma incarcerated within an inguinal hernia

Background

Small bowel adenocarcinomas are rare malignant tumors that account for less than 2% of gastrointestinal malignancies. In addition, tumor incarceration in an inguinal hernia is also rare entity. We herein report a first case of small bowel adenocarcinoma incarcerated within an inguinal hernia.

Case presentation

A 75-year-old man with asymptomatic anemia (hemoglobin, 8.6 g/dl) had a checkup at our hospital. Colonoscopy revealed bleeding through the ileocecal valve and an annular stricture by a tumor in the ileum. Endoscopic biopsy revealed a well-differentiated adenocarcinoma of the small bowel. Enhanced computed tomography showed a hypervascular solid tumor incarcerated within a right inguinal hernia. With a diagnosis of small bowel adenocarcinoma incarcerated within a right inguinal hernia, the patient underwent elective laparotomy with midline excision. The small bowel tumor, located at 30 cm from the terminal ileum, was incarcerated within a right inguinal hernia, and the small bowel was adherent to the hernia sac. A 24-cm segment of the distal ileum and regional lymph nodes were resected. The hernia sac was ligated, and the bottom of the hernia sac was resected. The hernia orifice was closed by tissue repair technique via a standard oblique incision in the right inguinal region. Postoperatively, the patient remains well with no evidence of tumor or hernia recurrence as of 1 year after operation.

Conclusions

We reported to our knowledge the first case of small bowel adenocarcinoma incarcerated within an inguinal hernia.

Surgical Management of Jejunal Tumors: Experience from Tertiary Care Centre

INTRODUCTION

Small bowel is an uncommon site for primary neoplasm in the gastrointestinal tract. Traditionally, duodenum has been combined with jejunum and ileum in analysing the presentation and management of these tumors. Given the different presentation pattern, diagnostic difficulties and anatomical considerations, jejunal tumors may differ from duodenal tumors.

METHODOLOGY

Retrospective analysis of a prospectively maintained database of patients with histology proven jejunal tumors was done. Clinico-radiological characters, histological findings, surgical procedures and the outcomes in these patients were studied.

RESULTS

Sixteen patients were included in the study. Median age at presentation was 42 years (26-76 years) and majority were males (n = 11, 68.8%). Seven (43.7%) patients presented with emergencies. Endoscopic tissue diagnosis could be obtained in 5 (31.3%) patients. Histology of tumors were adenocarcinoma, gastrointestinal stromal tumor and lymphoma in 6 (37.5%), 5 (31.3%) and 3 (18.8%) respectively. Sarcoma (myxofibroma) and metastasis (urothelial origin) were present in one patient each. Two patients with adenocarcinoma had neoadjuvant chemotherapy. Curative resection was feasible in 14 patients. Resection of tumor-bearing segment with anastomosis was performed in 9 patients. Among these, 5 had duodenojejunostomy. One patient had resection and double-barrel jejunostomy. One patient with jejunal GIST had sleeve resection. Multi-visceral resection was performed in 3 patients. There were no mortality and median postoperative hospital stay was 11 days (range 7-33 days).

CONCLUSION

Histology spectrum of jejunal tumors are distinct. Difficulty in obtaining preoperative tissue diagnosis of these lesions need to be addressed by improved endoscopic and image-directed biopsy techniques.

A case of small bowel adenocarcinoma wherein nivolumab conferred temporary benefit in disease control

Small bowel adenocarcinomas are rare. There is no definite consensus as to whether they should be treated in a manner similar to gastric or to colon cancer. We report the case of a young woman with a primary jejunal adenocarcinoma, bilateral ovary metastases, and peritoneal dissemination. First- and second-line chemotherapy for the gastric cancer failed. She was then treated with the immune checkpoint inhibitor nivolumab and had temporary improvement in her condition. To the best of our knowledge, this is the first case wherein nivolumab has been used to treat small bowel adenocarcinoma.

A Rare Case of Duodenal Adenocarcinoma Presenting as a Subepithelial Lesion in a Patient Undergoing Investigation for Iron Deficiency Anaemia

Introduction

Adenocarcinomas account for approximately 40% of small bowel cancers. They are typically mucosal lesions with distinctive features on endoscopy. We describe a rare case of duodenal adenocarcinoma presenting as a subepithelial lesion which posed a diagnostic challenge.

Case

An 85-year-old male patient presented for investigation of iron deficiency anaemia. Initial upper endoscopy found a subepithelial duodenal lesion with central depression but otherwise normal appearing mucosa. Superficial biopsies of the duodenal lesion were unremarkable. Subsequent antegrade single balloon enteroscopy revealed active bleeding from the lesion which was refractory to endoscopic treatment. A complete local excision of the lesion via laparotomy was necessary to achieve haemostasis. Histopathology from the lesion showed a moderately differentiated duodenal adenocarcinoma with invasion into the submucosa but no evidence of lymphovascular spread.

Conclusion

Duodenal adenocarcinomas are rare gastrointestinal tumours associated with a poor prognosis. This case report outlines a rare presentation of duodenal adenocarcinoma and highlights the importance of judicious assessment of lesions found on endoscopy. Advances in endoscopic diagnostic modalities could facilitate early diagnosis and improve therapeutic outcomes.

Rare presentation of small bowel adenocarcinoma with neuroendocrine differentiation in the jejunum: A case report and summary of diagnostic and management options

Cancer of the small bowel (SB) is rare. The most common SB malignancy is neuroendocrine, followed by adenocarcinoma. SB adenocarcinoma with overlapping neuroendocrine differentiation (NED) is very uncommon. The present case report discusses the case of a young African American female who presented with high-grade SB perforation and underwent urgent surgical repair. Histology of the tumor revealed jejunal adenocarcinoma with NED. To the best of our knowledge, this type of tumor has not yet been reported in the jejunum. Referring patients that present with insidious and nonspecific abdominal discomfort for imaging studies that are more sensitive to the SB could potentially identify tumors earlier, prevent the development of emergent gastrointestinal complications and offer a chance for cure. An overview of diagnostic tools for SB evaluation was provided.

Analysis of gastric and duodenal biopsy results in patients presenting with dyspepsia: a cross-sectional study in a middle eastern population

OBJECTIVE

Correa's cascade is a 'Model for Gastric Cancer Development' described by Peleyo Correa. The reversibility of Correa's cascade remains debatable. The literature contains insufficient data on the specific stage of the cascade during which Helicobacter pylori is detected, treated, and the effect on prognosis. Herein, we aim to determine the prevalence of various precancerous and cancerous gastric lesions in patients presenting with dyspepsia, the prevalence of gastritis and H. pylori infection, the prevalence of duodenal pathology in patients presenting with dyspepsia, identify the stage of H. pylori detection in relation to Correa's cascade, and investigate a possible relationship between H. pylori and celiac disease.

DESIGN

Retrospective cross-sectional study conducted on a middle eastern population at a Lebanese tertiary hospital centre. 1428 patients presenting with dyspepsia underwent gastroscopy with gastric and duodenal biopsies. Variables include age, sex, presence/absence of H. pylori infection, and histopathological analysis of gastric and duodenal biopsies.

RESULTS

Being above 40 years of age was associated with increased likelihood of exhibiting abnormal gastric biopsy result. Gastritis and metaplasia were detected more frequently than glandular atrophy (p<0.001) with gastritis being present the most (p<0.001). The presence of H. pylori and the gastric biopsy results were not associated with any of the duodenal biopsy results.

CONCLUSION

The burden of H. pylori infection in patients with dyspepsia was high. H. pylori was detected at various precancerous lesions with varying significance. The prevalence of duodenal adenocarcinoma in dyspeptic patients is unexpectedly high. No association between gastric and duodenal pathologies was found.

Stage IV jejunal adenocarcinoma: a multimodal therapeutic success story

Small bowel adenocarcinoma is rare with an incidence of 2.6 in 100 000 patients. Diagnosis is often fortuitous and usually presents late. We present the case of a 36-year-old male who attended the emergency department with worsening abdominal discomfort. A computed tomography scan showed high-grade jejunal obstruction secondary to a jejunal mass suspicious for carcinoma with disseminated peritoneal carcinomatosis and hepatic metastases. Following a conservative approach, his obstruction settled. He commenced on a total of 12 cycles of FOLFOX (folinic acid, fluorouracil and oxaliplatin) and bevacizumab. After re-presenting with intermittent intussusception, a decision for surgical resection was made. On laparoscopy, there was no evidence of hepatic metastases or peritoneal carcinomatosis. A jejunal resection was carried out with an uneventful postoperative period. The patient remains disease free. Despite presenting with an advanced stage, a multimodal approach to these rare tumors may yield surprising and optimistic outcomes.

Palliative chemotherapy for patients with synchronous metastases of small-bowel adenocarcinoma: A reflection of daily practice

Background

As small-bowel adenocarcinoma (SBA) is scarce, no standard systemic regimen in metastatic disease has been defined.

Objective

To obtain insights into the use and effects of palliative chemotherapy in patients with metastatic SBA in a population-based setting.

Methods

Data from the Netherlands Cancer Registry of patients with metastatic SBA between 2007 and 2016 were used (n = 522). For patients treated with palliative chemotherapy, differences in treatment regimens and survival were evaluated.

Results

Palliative chemotherapy was received by 38% of patients (n = 199). First-line combination chemotherapy was administered to 80% of patients, mainly CAPOX/FOLFOX. Single-agent chemotherapy mostly consisted of capecitabine. Second-line treatment, mostly irinotecan-based (58%), was prescribed to 27% of patients. Age 70 years or older was an adverse predictive factor for receiving first-line combination chemotherapy (odds ratio (OR) 0.2, 95% confidence interval (CI) 0.08-0.62) and second-line therapy (OR 0.3, 95% CI 0.10-0.72). Median overall survival with palliative chemotherapy was 9.3 months, compared with 3.0 months without. In subanalyses, patients who received only first-line treatment had a median overall survival of 5.6 and 7.0 months after single-agent and combination chemotherapy, respectively.

Conclusion

A minority of patients were treated with palliative chemotherapy. First-line treatment consisted predominantly of oxaliplatin-based combination chemotherapy, whereas second-line treatment was mainly irinotecan-based. Population-based median overall survival for selected patients treated with chemotherapy amounted to nine months.

Assessment of the external validity of the AJCC 8th staging system for small intestinal adenocarcinoma: a time to reconsider the role of tumor location?

Background

The current study evaluates the validity and performance of the 8^th edition of the American Joint Committee on Cancer (AJCC) staging system for small intestinal adenocarcinoma patients.

Methods

Surveillance, Epidemiology and End Results (SEER) database [2004-2015] was explored and AJCC 6^th, 7^th, and 8^th versions were assigned for each patient. Through Kaplan-Meier estimates, overall survival analyses were conducted. Cox regression analysis (adjusted for age, race, gender, sub-site, grade and surgical treatment) was conducted for cancer-specific survival and additionally, pairwise hazard ratio comparisons were performed.

Results

A total of 2,997 small intestinal adenocarcinoma patients were eligible and included in the analysis. Overall survival was compared according to the three AJCC staging systems. For the three versions, the P value for the trend in overall survival was significant (P<0.0001). Cancer-specific Cox regression hazard was calculated for the three staging systems. Pairwise hazard ratio comparisons between different AJCC 6^th stages were conducted and all P values for comparisons were significant (P<0.0001). Pairwise hazard ratio comparisons between different AJCC 7^th and 8^th stages were also performed, and all comparisons were significant (P<0.05) except for stage IIB vs. IIIA. C-statistic (using death from small intestinal adenocarcinoma as the dependent variable) for AJCC 6^th staging system was: 0.645 [standard error (SE): 0.011; 95% CI: 0.623-0.668]; for c-statistic for AJCC 7^th staging system was 0.658 (SE: 0.011; 95% CI: 0.637-0.680); while c-statistic for AJCC 8^th staging system was 0.660 (SE: 0.011; 95% CI: 0.638-0.682). Multivariate analysis of factors affecting cancer-specific survival suggested that older age (P=0.005), higher lymph node ratio (P<0.0001) and duodenal localization of the primary are associated with worse outcomes (P=0.008).

Conclusions

There is no evidence that AJCC 8^th system provided better prognostic characterization compared to previous AJCC staging systems for small intestinal adenocarcinoma. Subsite-specific staging paradigms should be explored in future editions of the staging system.

Prognostic Factors and Survival Time in Patients with Small Bowel Tumors: A Retrospective Observational Study

This study examines survival time in patients with small bowel tumors and determines its contributing factors. In this retrospective analytical study, the medical records of 106 patients with small bowel cancer (from 2006 to 2011) were investigated. The patients' data were extracted, including age, gender, clinical presentation, location of tumor, histological type, grade of tumor, site of metastasis, and type of treatment. The Kaplan-Meier test was used to estimate the overall survival time and the Log-rank test to compare the survival curves. The Cox regression was also used to evaluate the effect of the confounding variables on survival time. This study was conducted on 106 patients with a median age of 60 years (Min: 7, Max: 87). The tumor types included adenocarcinoma (n=78, 73.6%), MALToma (n=22, 20.8%), neuroendocrine tumors (n=4, 3.8%), and sarcoma (n=2. 1.8%). Grade 3 adenocarcinomas had a significantly lower survival time (HR: 1.48, 95% CI: 0.46-2.86; P=.001). Combined therapy (chemotherapy and surgery) vs. single-therapy (only surgery) had no significant effects on the survival of the patients with MALToma (5 vs. 3 months, 95% CI: 1.89-5.26; P=.06). There were no significant differences between the survival time in adenocarcinoma and MALToma (12 vs. 20 months, 95% CI: 6.24-24.76; P=.49). Tumor grade was the only independent prognostic factor that affected survival in adenocarcinoma. The patients diagnosed with MALToma in the study also had a poor prognosis, and the type of treatment had no significant effect on their survival.

Primary Small Bowel Adenocarcinoma Presenting with Duodenal Stricture and Hepatic and Gastroduodenal Artery Encasement: A Case Report

Primary small bowel adenocarcinoma is rare, with an estimated U.S. annual incidence of 3.9 cases per million persons, and is often associated with a poor prognosis. We report a case of a 68-year-old male diagnosed with primary duodenal adenocarcinoma with hepatic artery and gastroduodenal artery encasement. The patient initially presented with persistent nausea and vomiting unresponsive to ondansetron and metoclopramide, and initial computed tomography (CT) of abdomen and pelvis revealed significant stomach distension concerning for gastric outlet obstruction. Esophagogastroduodenoscopy (EGD) revealed significant duodenal stricture, with results of triple phase CT of pancreas significant for tissue encasing the common hepatic artery and the origin of the gastroduodenal artery. Pathology results verified the presence of a moderately differentiated adenocarcinoma involving the small bowel. Due to artery encasement by the tumor, the patient was deemed to be a poor surgical candidate, and instead received a duodenal stent for symptomatic relief with initiation of a chemotherapy regimen consisting of folinic acid, oxaliplatin, and fluorouracil (FOLFOX) as an outpatient. This case highlights the presentation and diagnostic workup of a rare cancer.

Prognostic factors and treatment outcomes in patients with non-ampullary small bowel adenocarcinoma: Long-term analysis

Small bowel adenocarcinoma (SBA) is a relatively rare malignancy in gastrointestinal tumors. In addition, the difficulty of early diagnosis, its poor prognosis compared to large bowel adenocarcinoma, and inadequate treatment experiences due to lack of prospective randomized trials make it necessary to explore the characteristics of the disease for early diagnosis and treatment.Patients diagnosed with primary malignant tumor of small intestine in West China Hospital of Sichuan University between January 2001 and 2013 were reviewed retrospectively. A total of 208 patients with SBA were selected and 160 patients with duodenal periampullary tumor were excluded. Forty-two cases of patients were finally enrolled for statistical analysis as 6 patients were lost of follow-up. The clinical characteristics, the response to treatment and their overall survival (OS) time were reviewed and analyzed.Of the 42 patients, 11 (26.2%) primary tumors were originated from duodenum, 29 (69.0%) from jejunum, and 2 (4.8%) from ileum. All patients (64.3% male; median age, 54.7 years) included in this study underwent primary resection of the tumor to confirm final diagnosis. Three-year survival rate is 21% and 5-year survival rate is 9%. Median OS were 24.2 months (95% CI: 4.0-72.0). The univariate predictors for prognosis of SBA were as follows: age (P = .021), severe intestinal symptoms at first diagnosis (P < .001), T4 of tumor stage (P = .011), tumor size (P = .004), relatively late clinical stage (P < .001), peritoneal metastasis (P < .001), and no chemotherapy (P = .011). The multivariate predictors for poor prognosis were age of more than 60 years old (P = .035), intestinal obstruction or perforation at first diagnosis (P = .026), relatively late clinical stage (P = .000), and no chemotherapy (P = .027).SBA was a relatively rare malignancy that was difficult for early diagnosis and treatment. Intestinal obstruction was the common clinical manifestation at first diagnosis, with a tendency of early peritoneal metastasis. Precaution of the disease in early phase, radical resection of the primary tumor while resectable, followed with in-time chemotherapy might improve prognosis and survival of patients with SBA.

Impact of tumor site on the prognosis of small bowel adenocarcinoma

Background:

Because of a lack of large-scale prospective studies there is no clear indication about the management of patients with small bowel adenocarcinoma (SBA). This study evaluated clinical outcome of patients diagnosed with SBA at our institution.

Methods:

Clinicopathologic features, treatments, and clinical outcome of patients diagnosed with SBA between 2006 and 2017 were retrospectively analyzed. Median time of survival was calculated and compared using the log-rank test. Multivariate Cox regression was used to test independence of significant factors in univariate analysis.

Results:

Forty patients were included in the study; the majority (82.5%) had a tumor in the duodenum (including ampulla of Vater) and an early stage disease at the diagnosis. Median overall survival (OS) in the whole study population was 26.5 months. Patients with a tumor of the lower part of the small intestine (jejunum, ileum, and appendix) showed a better OS compared with that of patients with upper SBA (40 months vs 26 months, respectively; P=0.09). Primary tumor site and stage were independent predictors of OS.

Conclusions:

Our results suggest a prognostic role for the primary tumor site. This finding deserves to be further investigated to ensure better classification as well as more effective management strategies for SBA.

Small bowel adenocarcinoma as a complication of celiac disease: clinical and diagnostic features

BACKGROUND

Small bowel adenocarcinoma (SBA) is a rare neoplasm, which can occur in a sporadic form or can be associated with a number of predisposing conditions such as hereditary syndromes and immune-mediated intestinal disorders, e.g. celiac disease (CD). However, the features of SBA in the context of CD remain only partly understood. This study was aimed to show the main clinical features, diagnostic procedures and management options of SBA cases detected in a large cohort of celiac patients diagnosed in a single tertiary care center.

METHODS

We retrospectively reviewed all the SBA cases detected in a cohort of 770 CD patients (599 females; F / M ratio: 3.5:1; median age at diagnosis 36 years, range 18-80 years), diagnosed at the Celiac Disease Referral Center of our University Hospital (Bologna, Italy) from January 1995 to December 2014.

RESULTS

Five (0.65%) out of our 770 CD patients developed SBA. All of them were female with a mean age of 53 years (range 38-72 years). SBA, diagnosed at the same time of the CD diagnosis in three cases, was localized in the jejunum in four cases and in the duodenum in one case. The clinical presentation of SBA was characterized by intestinal sub-occlusion in two cases, while the predominant manifestation of the remaining three cases was iron deficiency anaemia, abdominal pain and acute intestinal obstruction, respectively. All the patients were referred to surgery, and three cases with advanced stage neoplasia were also treated with chemotherapy. The overall survival rate at 5 years was 80%.

CONCLUSIONS

Although in a limited series, herein presented CD-related SBA cases were characterized by a younger age of onset, a higher prevalence in female gender and a better overall survival compared to sporadic, Crohn- and hereditary syndrome-related SBA.

Epidemiology of Cancers of the Small Intestine: Trends, Risk Factors, and Prevention

The latest data from the United States and Europe reveal that rare small intestine cancer is on the rise, with the number of cases having more than doubled over the past 40 years in the developed world. Mortality has grown at a slower pace, thanks to improvements in early diagnosis and treatment, as well as a shift in the etiology of neoplasms affecting the small intestine. Nevertheless, 5-year survival for small intestine adenocarcinomas has lingered at only 35%. Lifestyle in developed nations, including the rise in obesity and physical inactivity, consumption of alcohol, tobacco, and red and processed meats, and occupational exposures may be to blame for the proliferation of this rare cancer. Identification of hereditary and predisposing conditions, likely to blame for some 20% of cases, may help prevent and treat cancers of the small intestine. Studies of the neoplasm have been limited by small sample sizes due to the rarity of the disease, leaving many questions about prevention and treatment yet to be answered.

Comparison of three lymph node staging schemes for predicting the outcome in patients with small bowel adenocarcinoma: A population-based cohort and international multicentre cohort study

BACKGROUND

The prognostic roles of three common lymph node staging schemes, number of positive lymph nodes (pN), lymph node ratio (LNR) and log odds of positive lymph nodes (LODDS) in small bowel adenocarcinoma (SBA) are unclear. We assessed their prognostic ability in SBA.

METHODS

A total of 2128 patients diagnosed with SBA between 1988 and 2010 from the Surveillance, Epidemiology, and End Results (SEER) database and 186 patients from 15 hospitals in France and China were identified. We evaluated the prognostic ability of the schemes in both continuous and stratified patterns using R2, Harrell's C, and time-dependent receiver operating characteristic curve analyses.

FINDINGS

For continuous pattern, the LODDS had a better capacity of discrimination and higher accuracy of prognosis than pN and LNR. Similarly, the stratified LODDS classification had a better performance of discrimination and higher accuracy of prognosis than the pN and LNR classification. The multivariable model using the LODDS classification also showed superiorly predictive accuracy and discriminatory capacity to those of the 7th and, 8th TNM node and LNR classification. These results were fully validated in an independent international multicentre cohort.

INTERPRETATION

The LODDS scheme showed a better prognostic performance than the LNR or pN schemes in patients with SBA regardless of continuous or stratified pattern. The LODDS scheme could serve as an auxiliary to lymph node staging systems in future revisions of the American Joint Committee on Cancer (AJCC) manual. FUND: This work was funded by the Zhejiang Province Natural Science Fund of China.

Clinical characteristics of primary small bowel adenocarcinoma

BACKGROUND

Adenocarcinoma of the small bowel is rare in comparison with other gastrointestinal malignancies but its incidence is rising. The non-specific symptoms with which they present often pose a high rate of missed diagnosis and misdiagnosis. It is of great significance to explore the clinical characteristics of small bowel adenocarcinoma in order to improve its early diagnosis and prognosis.

AIM

To analyze the clinical characteristic of primary small bowel adenocarcinoma, in order to improve its early diagnosis and prognosis.

METHODS

From January 2012 to September 2017, 98 patients with pathologically diagnosed primary small bowel adenocarcinoma at the First Affiliated Hospital of Zhengzhou University were retrospectively enrolled.

RESULTS

There were 58, 29, and 11 cases of adenocarcinoma in the duodenum, jejunum, and ileum, respectively. The common clinical manifestations included abdominal pain (47 cases), jaundice (31 cases), intestinal obstruction (25 cases), and gastrointestinal bleeding (7 cases). The examination methods included digestive tract angiography, CT, endoscopy and so on. Preoperative misdiagnosis occurred in 35 (35.7%) cases. Univariate analysis showed that misdiagnosis was related to tumor location, growth pattern, and tumor size (P < 0.05). Ninety-six patients underwent surgical treatment.

CONCLUSION

The preoperative misdiagnosis rate of primary small bowel adenocarcinoma is high due to the absence of specific clinical manifestations. The main therapy is still surgery.

Duodenal tumor risk in Lynch syndrome

BACKGROUND AND AIMS

Lynch syndrome (LS) is associated with an increased risk of small bowel tumors but routine screening is not recommended in international guidelines. The aim of our study was to determinate the prevalence of duodenal tumors in a French cohort of LS patients.

METHODS

Patients carrying a germline pathogenic variant in a MMR gene, supported by our local network, in which at least one upper endoscopy had been performed, were included. We registered the occurrence of duodenal lesions in those patients.

RESULTS

154 LS patients were identified including respectively 85 MSH2 and 41 MLH1 mutated patients respectively. Seven out of 154 (4.5%) had at least one duodenal lesion. Median age at diagnosis was 58 years (range: 49-73). The twelve lesions locations were: descending duodenum (n = 7), genu inferius (n = 2), duodenal bulb (n = 1), ampulla (n = 1), fourth duodenum (n = 1). Three lesions were invasive adenocarcinomas. The incidence rate of duodenal lesions in patients with MSH2 or MLH1 pathogenic variants was respectively 7.1% (6 out of 85) and 2.4% (1 out of 41) emphasizing a trend toward increased risk of developing duodenal lesion in MSH2 mutated patients: OR: 5.17, IC95% (0.8-60.07), p = 0.1307.

CONCLUSION

Regarding this high prevalence rate, especially in MSH2 patients, regular duodenal screening during upper endoscopy should be considered in routine in LS patients.

Intestinal obstruction caused by small bowel adenocarcinoma misdiagnosed as psychogenic disorder

We describe a case of intestinal obstruction caused by a small bowel adenocarcinoma misdiagnosed as psychogenic disorder. A woman in her 40s was admitted to Nagoya City University Hospital with fatigue, anorexia, nausea and vomiting. CT, oesophagogastroduodenoscopy and colonoscopy revealed no signs of organic abnormality in her gastrointestinal tract. As the patient had previously been diagnosed with and treated for depression, her symptoms were suspected to be due to psychogenic disorder. Therefore, she was diagnosed with severe depression and was administered antidepressant agents. Despite intense psychiatric treatment, her symptoms worsened and she was later diagnosed with ileus due to adenocarcinoma in the jejunum. After drainage by insertion of a transnasal decompression tube, a partial jejunum resection was performed. After the resection, the patient's symptoms including fatigue and depression resolved without the use of antidepressant agents.

Small Bowel Carcinomas Associated with Immune-Mediated Intestinal Disorders: The Current Knowledge

Small bowel carcinomas (SBC) are uncommon neoplasms, whose predisposing conditions include hereditary syndromes and immune-mediated intestinal disorders including coeliac disease (CD) and Crohn's disease (CrD). Although both CD-associated SBC (CD-SBC) and CrD-associated SBC (CrD-SBC) arise from an inflammatory background, they differ substantially in tumour cell phenotype, frequency of microsatellite instability and nuclear β-catenin expression, as well as in prognosis. For these patients, high tumour-infiltrating lymphocyte density and glandular/medullary histotype represent independent positive prognostic factors. Dysplasia adjacent to SBC is rare and characterized by intestinal phenotype and nuclear β-catenin in CD, while it is frequent and typified by gastro-pancreatobiliary marker expression and preserved membranous β-catenin in CrD. Recent evidence suggests that Epstein-Barr virus-positive dysplasia and SBC, albeit exceptional, do exist and are associated with CrD. In this review, we summarize the novel pathological and molecular insights of clinical and therapeutic interest to guide the care of CD-SBC and CrD-SBC.

Gastrointestinal Malignancy Presenting with a Virchow's Node in a Patient with Rothmund-Thomson Syndrome

Rothmund-Thomson syndrome is a genetic disorder with characteristic findings in childhood as well as a predisposition to osteosarcoma, skin cancer, and hematological malignancy. We present the first reported case of duodenal malignancy in a patient with Rothmund-Thompson syndrome. An enlarged Virchow's node was noted and an advanced duodenal adenocarcinoma was diagnosed shortly thereafter. The features of Rothmund-Thomson syndrome are discussed, as well as current management and screening guidelines for duodenal adenocarcinoma.

Resection of small bowel adenocarcinoma metastases: Results of the ARCAD-NADEGE cohort study

INTRODUCTION

Data are lacking with regard to curative resection of metastasis from small bowel adenocarcinoma (SBA). This study evaluated outcomes and prognostic factors in patients with curatively resected metastatic SBA.

METHODS

A series of 34 patients undergoing resection of metastatic SBA from January 2009 to November 2014 at French centers were included into this cohort study. The primary endpoint was overall survival (OS). Secondary endpoints were recurrence-free survival (RFS) and prognostic factors. Univariate analyses were performed to determine prognostic risk factors.

RESULTS

The sites of SBA metastases were peritoneal (29.4%), liver (26.5%), lymph nodes (11.8%), lung (2.9%), multiple (14.7%), and other (14.7%). Thirty (88.2%) patients received adjuvant or perioperative chemotherapy, mainly was oxaliplatin-based (76.5%). The median OS was 28.6 months and RFS was 18.7 months. Fourteen (41.2%) patients survived for more than 36 months. In univariate analysis, poor differentiation (P = 0.006), invaded margins (P = 0.003), and lymphatic invasion in the primary tumor (P = 0.039) were associated with decreased OS.

CONCLUSION

Overall survival of patients after resection of metastatic SBA remains poor, but long-term survivors are observed. Resection of metastatic SBA should be consider if patients are expected to be operated on with curative intent and have moderately or well-differentiated tumors.

Management of Advanced Small Bowel Cancer

OPINION STATEMENT

Small bower cancer is a rare disease, despite its incidence is increasing in the last decade. Both benign and malignant tumors can arise from the small intestine. The main histological cancer types are adenocarcinomas, neuroendocrine tumors, sarcomas, gastrointestinal stromal tumors (GISTs), and lymphomas. Due to the rarity of these malignances, all the currently available data are based on small studies or retrospective series, although recent breakthroughs are redirecting our approach to these patients. Immunotherapy for small bowel adenocarcinomas, several multikinase inhibitors in resistant GIST patients, as well as everolimus and ¹⁷⁷Lu-DOTATATE in neuroendocrine tumors are only few of the novel therapeutic options that have changed, or may change in the future, the therapeutic landscape of these rare cancers. Larger and more powerful studies on the molecular profile of these tumors may lead to a better design of clinical trials, which eventually would provide our patients with more efficacious treatments to improve both overall survival and quality of life.

ERBB3-Activating Mutations in Small Bowel Adenocarcinomas

Purpose

Functional studies have demonstrated that some mutations of ERBB3, which encodes for human epidermal growth factor receptor (HER) 3, are oncogenic via activation of the ErbB family signaling pathway. Significant clinical activity of anti-HER2 therapies (trastuzumab plus lapatinib combination or afatinib) has been reported in patients with ERBB3-mutated cancers. This study was designed to report the rate of activating ERBB3 mutations in small bowel adenocarcinoma (SBA), a rare tumor type in which we previously reported a high rate (12%) of ERBB2-activating mutations.

Materials and Methods

DNA from 74 SBAs, previously characterized for ERBB2 mutations and mismatch repair status, was submitted for sequencing of ERBB3 exons 3, 6, 7, 8, and 23. Orthogonal validation by targeted next-generation sequencing was performed.

Results

Four of 74 SBAs (5.4%) displayed ERBB3-activating mutations, including three p.V104M mutations (c.310 G>A) in exon 3 and one p.E928G mutation (c.2783 A>G) in exon 23. No mutations were detected in exons 6, 7, and 8. ERBB3-activating mutations were associated with microsatellite instability ( P = .002) and the presence of ERBB2-activating mutations ( P = .002). Two SBAs with co-occurrence of ERBB2 and ERBB3 mutations were further analyzed by targeted next-generation sequencing. Mutant allelic frequencies suggested that both mutations were shared by the same clone rather than being harbored by mutually exclusive tumor subclones.

Conclusion

SBAs display a high rate of ERBB3-activating mutations, which have been shown to be targetable by anti-HER2 therapies. Strikingly, ERBB3 was frequently comutated with ERBB2, suggesting a strong oncogenic addiction of these SBAs to the HER2 pathway.

Expression of Gastric Markers Is Associated with Malignant Potential of Nonampullary Duodenal Adenocarcinoma

BACKGROUND

Sporadic nonampullary duodenal epithelial tumors (NADETs) are uncommon, and thus their clinicopathological features have not been fully assessed.

AIMS

In this study, we have analyzed a series of early sporadic NADETs, focusing on various immunohistological features.

METHODS

We conducted a multicenter retrospective analysis of 68 patients with endoscopically resected sporadic NADETs. Associations between immunohistological features and clinicopathological features were statistically analyzed.

RESULTS

The 68 patients consisted of 46 men (68%) and 22 women (32%) with a mean age of 60.7 ± 12.2 years (range 37-85 years). The 68 tumors were composed of 39 adenomas (57%) and 29 early-stage adenocarcinomas (43%). Duodenal adenocarcinomas were larger in size than adenomas and had papillary architecture in their pathological diagnosis with statistical significance. Duodenal adenocarcinomas also demonstrated a significantly higher expression of gastric markers (MUC5AC and MUC6) and a higher MIB-1 index. Duodenal adenomas were contrastively apt to express intestinal markers (MUC2, CDX1 and CDX2). Of the 68 cases analyzed, there were only 3 tumors positive for p53 staining, all of which were adenocarcinoma. When 7 submucosal invasive cancers and 21 intramucosal cancers were compared, submucosal invasion was positively associated with expression of MUC5AC. Also, submucosal invasion showed strong association with double-positivity of MUC5AC and MUC6.

CONCLUSIONS

Our results indicate that immunohistochemical evaluation is useful for predicting malignant potential of NADETs, especially focusing on the expression of gastrointestinal markers.

Risks for lymphoma and gastrointestinal carcinoma in patients with newly diagnosed adult-onset celiac disease: Consequences for follow-up: Celiac disease, lymphoma and GI carcinoma

Background

The association between celiac disease (CD) and the development of lymphoid and gastrointestinal (GI) malignancies have been reported. However, data are scarce yet needed to develop evidence-based follow-up programs.

Objective

The objective of this article is to assess relative (RR) and absolute risks of lymphoma and GI carcinoma for newly diagnosed patients.

Methods

A case-control design to determine RR was performed with cases (lymphoma or GI carcinoma) and controls (melanoma or basal cell carcinoma) diagnosed 1994–2014, retrieved from the Dutch nationwide population-based pathology database (PALGA). Within this population, individuals with histologically proven CD before or simultaneously diagnosed with the malignancy were identified.

Results

A total of 349/301,425 cases (0.1%) and 282/576,971 (0.05%) controls were diagnosed with CD. Risk of T-cell lymphoma, predominantly enteropathy-associated T-cell lymphoma (EATL), was strongly associated with CD diagnosis (RR = 35.8 (95% CI 27.1–47.4)). Although most often synchronously diagnosed, T-cell lymphoma RR ≥ 1 year after CD diagnosis was still elevated (RR = 12.7 (95% CI 7.6–21.3)). Other CD-associated malignancies were small bowel adenocarcinoma (RR = 11.9 (95% CI 8.2–17.2)) and esophageal squamous cell carcinoma (RR = 3.5 (95% CI 2.1–5.8)). Absolute risks were relatively low. Other types of lymphomas and GI carcinomas were not associated with CD.

Conclusion

Increased risk for specific malignancies in CD should alert physicians for EATL (both intestinal and extraintestinal) and small bowel adenocarcinoma in patients with CD diagnosed at age ≥ 50 years.

Small Bowel Adenocarcinoma

Small bowel adenocarcinoma is a clinically and anatomically distinct gastrointestinal cancer that lacks prospective data to support its optimal management. Patients with inflammatory bowel disease and inherited conditions that cause gastrointestinal polyps are at especially high risk. Due to a lack of effective surveillance programs resulting in missed or delayed diagnoses only when symptoms develop, this disease is generally discovered at an advanced stage. Surgical resection is the only treatment modality with a chance of cure. Currently accepted treatment considerations are often generalized from large bowel and pancreatic-biliary cancers, due to some anatomic and clinical parallels. Additional research, however, is desperately needed to characterize the unique molecular differences of this disease to better prognosticate patients and establish rational clinical trials that would improve their outcomes.

Computed Tomography Enterography

Computed tomography (CT) enterography is a noninvasive imaging modality with superb spatial and temporal resolution, specifically tailored to evaluate the small bowel. It has several advantages over other radiologic and optical imaging modalities, all of which serve as complementary investigations to one another. This article describes CTE technique, including dose reduction techniques, special considerations for the pediatric population, common technical and interpretive pitfalls, and reviews some of the more common small bowel entities seen with CTE.

Update on small bowel surveillance in hereditary colorectal cancer syndromes

Despite its rarity in the general population, small bowel adenocarcinoma risk is increased in individuals with hereditary colorectal cancer syndromes (HCCS). In the last decade, the advent of capsule endoscopy and device-assisted balloon enteroscopy procedures in patients with HCCS have allowed to investigate the whole small bowel, increasing the diagnostic yield of small bowel tumor. Nonetheless, there is a significant variability in the international guideline recommendations. The aim of this review is to provide an update on surveillance of small bowel in HCCS and to identify the key points for the clinical management of these patients.

Meta-analysis of postoperative adjuvant therapy for small bowel adenocarcinoma

Objective

The role of adjuvant therapy in small bowel adenocarcinoma (SBA), a rare malignancy with a poor prognosis, is controversial. The purpose of this article is to investigate the impact of adjuvant therapy on the survival of patients with SBA in a meta-analysis.

Methods

We performed a comprehensive search of PubMed, EMBASE and the Cochrane Library database between 2010 and 2017. Hazard ratios (HR) with 95% confidence intervals (95%CI) were used to assess the effect of adjuvant chemotherapy and/or radiation treatment after curative surgery in patients with SBA. Moreover, impact of age, sex, stage, differentiation, lymph node involvement, and margin status was also evaluated.

Results

We included 15 studies to evaluate the effect of adjuvant therapy on the survival of patients with SBA. The pooled HR of overall survival (OS) involving 5986 patients showed that adjuvant therapy did not have a statistically significant effect on the survival of patients with SBA (pooled HR = 0.89, 95% CI = 0.73–1.09, p = 0.25). Further, 607 patients with duodenal adenocarcinoma (DA) had similar results (pooled HR = 0.96, 95% CI = 0.75–1.23, p = 0.77). Similarly, adjuvant treatment vs. non-adjuvant treatment in terms of disease-free survival (DFS) or relapse-free survival (RFS) showed the same results (pooled HR = 0.89, 95% CI = 0.64–1.23, p = 0.48). However, we found that adjuvant therapy resulted in favorable postoperative survival in Europe according to the subgroup analysis (pooled HR = 0.63, 95% CI = 0.5–0.8, p = 0.0002). In addition, the pooled HR shows that stage, differentiation, lymph node involvement, and margin status were related to the OS of patients with SBA.

Conclusion

Patients with SBA who received adjuvant therapy after surgery did not receive a significant survival benefit. Adjuvant therapy may be more useful in advanced cancer or metastatic patients.

Primary small bowel adenomas and adenocarcinomas-recent advances

The small intestine represents 75% of the length and 90% of the absorptive surface area of the gastrointestinal tract (GIT), yet only 2% of digestive system cancers occur at this site. Adenocarcinoma accounts for half of small bowel malignancies. There have been a number of important recent advances in our understanding, classification and treatment of small bowel tumours. Over recent years, ampullary tumours have become recognised as a form of small bowel carcinoma, distinct from head of pancreas and lower biliary tract tumours. This is reflected in separate TNM systems and increasing interest in separating intestinal from pancreatobiliary subtypes. The recognition of the importance of microsatellite (MSI) status and the advent of molecular pathology has also changed our approach to these neoplasms.

Patient with Lynch syndrome with subsequent development of small bowel adenocarcinoma

Small bowel adenocarcinoma (SBA) is a rare cancer in the general population, but the incidence increases in patients with Lynch syndrome. The present case describes a 57-year-old white woman with a history of colon cancer status posthemicolectomy and diagnosis of Lynch syndrome. Twenty years after her operation, the patient presented with vague abdominal discomfort and constipation, and underwent an exploratory laparotomy which revealed a stage 3A SBA. Genetic testing of the specimen provided evidence of microsatellite instability and faulty DNA repair supporting aetiology of Lynch syndrome. This case is unique in that SBA, if present in patients with Lynch syndrome, is usually a presenting symptom and has not been widely described in literature as an occurrence so many years after. As a result, this case highlights the importance of a low threshold for a thorough evaluation in patients with Lynch syndrome who present with signs of small bowel obstruction.

The evolving management of small bowel adenocarcinoma

BACKGROUND

Small bowel adenocarcinoma (SBA) is rare despite the fact that the small bowel represents the longest part and has the largest surface of all alimentary tract sections. Its incidence is 50-fold lower than that of colorectal carcinoma. It is often diagnosed at an advanced stage due to atypical and late symptoms, its low index of suspicion, difficult endoscopic access and poor detection by radiological imaging, resulting in impaired outcome. Due to its rarity and being molecularly a unique intestinal cancer, data regarding its optimal management are relatively sparse.

MATERIAL AND METHODS

A PubMed search was performed to identify relevant manuscripts that were recently published. Emerging data regarding the pathogenesis, the diagnosis and the treatment of SBA that resulted from recent research are discussed in this comprehensive review.

RESULTS

Genomic analysis has demonstrated that SBA is a molecularly unique intestinal cancer. Double balloon enteroscopy and capsule endoscopy are novel techniques which may result in earlier diagnosis and consequently in improvement of the generally poor prognosis. For clinically localized disease, the quality of surgery has recently been defined, with removal of at least 8-10 lymph nodes correlating with improved prognosis. Moreover, adjuvant chemotherapy seems to improve outcome of stage III disease. The combination of a fluoropyrimidine and oxaliplatin appears to be the most effective systemic chemotherapy for disseminated disease. Genomic profiling can identify potentially targetable genomic alterations in a significant proportion of SBA patients. The role of administration of targeted agents or immune checkpoint inhibitors is still unknown and subject of ongoing clinical trials. In the common case of peritoneal metastases, recent studies have shown that cytoreductive surgery and intraoperative hyperthermic intraperitoneal chemotherapy may be an attractive treatment option in selected patients.

CONCLUSIONS

SBA is a rare and unique malignancy, whose diagnostic approach and treatment are evolving, resulting in improved outcome.

Small bowel tumours: update in diagnosis and management

PURPOSE OF REVIEW

The aim of this study was to summarize the role of recently developed diagnostic techniques in the diagnosis and management of patients with small bowel tumours (SBTs).

RECENT FINDINGS

Recent studies show that the overall SBT incidence is increasing. The introduction of small bowel dedicated diagnostic tools [i.e. capsule endoscopy, device-assisted enteroscopy (DAE), computed tomography (CT) and MRI-enterography] might partially explain this trend. In patients with SBT, DAE might represent an ideal tool by coupling careful mucosal inspection with sampling capability. Unfortunately, DAE is an invasive procedure and seldom allows complete small bowel evaluation in a single setting. Therefore, DAE is more often used in clinical practice as confirmatory tool, when other less invasive and readily available tests (i.e. capsule endoscopy or radiological tests) identify relevant findings. Nevertheless, in patients with SBT, capsule endoscopy is burdened by an increased risk of capsule retention and/or missing proximal small bowel lesions, whereas dedicated cross-sectional imaging techniques often identify nonspecific findings of limited clinical significance.

SUMMARY

Despite recent technical improvements, in patients with SBT, the result of a single diagnostic procedure is often insufficient to provide a definite diagnosis. A balanced combination of different tests allows reaching a final diagnosis and drive further management.

Cytoreductive Surgery Plus Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Metastases From a Small Bowel Adenocarcinoma: Multi-Institutional Experience

BACKGROUND

The multi-institutional registry in this study evaluated the outcome after cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with peritoneal metastases (PM) from small bowel adenocarcinoma (SBA).

METHODS

A multi-institutional data registry including 152 patients with PM from SBA was established. The primary end point was overall survival (OS) after CRS plus HIPEC.

RESULTS

Between 1989 and 2016, 152 patients from 21 institutions received a treatment of CRS plus HIPEC. The median follow-up period was 20 months (range 1-100 months). Of the 152 patients, 70 (46.1%) were women with a median age of 54 years. The median peritoneal cancer index (PCI) was 10 (mean 12; range 1-33). Completeness of cytoreduction (CCR) 0 or 1 was achieved for 134 patients (88.2%). After CRS and HIPEC, the median OS was 32 months (range 1-100 months), with survival rates of 83.2% at 1 year, 46.4% at 3 years, and 30.8% at 5 years. The median disease-free survival after CCR 0/1 was 14 months (range 1-100 months). The treatment-related mortality rate was 2%, and 29 patients (19.1%) experienced grades 3 or 4 operative complications. The period between detection of PM and CRS plus HIPEC was 6 months or less (P = 0.008), and multivariate analysis identified absence of lymph node metastasis (P = 0.037), well-differentiated tumor (P = 0.028), and PCI of 15 or lower (P = 0.003) as independently associated with improved OS.

CONCLUSION

The combined treatment strategy of CRS plus HIPEC achieved prolonged survival for selected patients who had PM from SBA with acceptable morbidity and mortality.

Pancreas-sparing and superior mesenteric artery first approach in duodenal adenocarcinoma of the fourth portion of duodenum: A case report

•

Adenocarcinoma of the distal duodenum is uncommon with bad prognosis.

•

Pancreas-sparing resection is preferred to avoid pancreatectomy-related morbi-mortality.

•

The artery-first approach of the SMA should be considered by surgeons to early identify contra-indications to proceed during operation.

•

The aim of surgery is R0 resection with 5-year survival between 25% and 75%.

Introduction

Peroperative assessment of resectability in pancreas-sparing duodenectomy for distal duodenal (D3-D4) adenocarcinoma is challenging for surgeons.

Presentation of case

We report a 68-year-old man with biopsy-proven adenocarcinoma of the fourth portion of duodenum which had been diagnosed with upper endoscopy and CT. A pancreas-sparing duodenectomy with loco-regional lymph node resection using the superior mesenteric artery first approach was performed.

Discussion

Adenocarcinoma of the fourth portion of duodenum is rare. It has non-specific symptoms. The diagnosis is difficult and is frequently delayed. Surgery is the only chance of cure. After peroperative assessment of resectability, with intraoperative ultrasound, complete exposition of the duodenum and entire dissection of the superior mesenteric artery (SMA) using the artery-first approach technique should be done to assess for tumor resectability, which should include the possibility of complete lymphadenectomy of the mesenteric root. If technically feasible, a pancreas-sparing resection should be preferred to avoid pancreatectomy-related morbi-mortality. The aim of the surgery is a R0 resection which has a 5-year survival rate between 25% and 75%.

Conclusion

Artery-first approach of the SMA should be considered by surgeons in adenocarcinoma of the distal duodenum to identify any contra-indications to proceed further.

Exome-wide somatic mutation characterization of small bowel adenocarcinoma

Small bowel adenocarcinoma (SBA) is an aggressive disease with limited treatment options. Despite previous studies, its molecular genetic background has remained somewhat elusive. To comprehensively characterize the mutational landscape of this tumor type, and to identify possible targets of treatment, we conducted the first large exome sequencing study on a population-based set of SBA samples from all three small bowel segments. Archival tissue from 106 primary tumors with appropriate clinical information were available for exome sequencing from a patient series consisting of a majority of confirmed SBA cases diagnosed in Finland between the years 2003–2011. Paired-end exome sequencing was performed using Illumina HiSeq 4000, and OncodriveFML was used to identify driver genes from the exome data. We also defined frequently affected cancer signalling pathways and performed the first extensive allelic imbalance (AI) analysis in SBA. Exome data analysis revealed significantly mutated genes previously linked to SBA (TP53, KRAS, APC, SMAD4, and BRAF), recently reported potential driver genes (SOX9, ATM, and ARID2), as well as novel candidate driver genes, such as ACVR2A, ACVR1B, BRCA2, and SMARCA4. We also identified clear mutation hotspot patterns in ERBB2 and BRAF. No BRAF V600E mutations were observed. Additionally, we present a comprehensive mutation signature analysis of SBA, highlighting established signatures 1A, 6, and 17, as well as U2 which is a previously unvalidated signature. Finally, comparison of the three small bowel segments revealed differences in tumor characteristics. This comprehensive work unveils the mutational landscape and most frequently affected genes and pathways in SBA, providing potential therapeutic targets, and novel and more thorough insights into the genetic background of this tumor type.

Small bowel adenocarcinoma is a rare but aggressive disease with limited treatment options. Of gastrointestinal tumors, small bowel tumors account for 3%, of which around one third are adenocarcinomas. Due to the scarcity of evidence-based treatment recommendations there is a dire need for knowledge on the biology of these tumors. Here, we performed the first large exome sequencing effort of 106 small bowel adenocarcinomas from a Finnish population-based cohort to comprehensively characterize the genetic background of this tumor type. The set included tumors from all three small bowel segments allowing us to also compare the genetic differences between these subsets. We defined significantly mutated genes and frequently affected pathways, providing potential therapeutic targets, such as BRAF, ERBB2, ERBB3, ERBB4, PIK3CA, KRAS, ATM, ACVR2A, ACVR1B, BRCA2, and SMARCA4, for this disease.

Neoadjuvant chemotherapy in locally advanced duodenal adenocarcinoma

Duodenal adenocarcinoma (ADC) represents only 0.3% of gastrointestinal neoplasms. With the frequency being higher between the ages of 40 and 60, it is predominantly located in the second part of the duodenum and around the periampullary region. Symptoms are nonspecific, so the majority of patients present with advanced disease. Neoadjuvant chemotherapy is a therapeutic option that has not been well studied. The global literature includes only isolated reports on this subject. This is why we are presenting the following case: a 60-year-old female patient with a locally advanced, inoperable duodenal ADC received neoadjuvant chemotherapy. Having presented a favourable response as observed in the post-neoadjuvant extension studies, a pancreaticoduodenectomy was performed without any perioperative complications and with satisfactory progress. The final biopsy reported a complete pathological response. After being monitored for 34 months, the patient was free from locoregional and distant metastatic disease. During the last weeks of monitoring, she developed a second primary breast tumour, which has been corroborated by immunohistochemistry.

Epidemiology of Second Primary Tumors in Women With Ovarian Cancer

OBJECTIVE

The last large study of second primary tumors (SPTs) in women with ovarian cancer was published in 1996, prior to major changes in the differential diagnosis and treatment. The present study reports on the incidence of SPTs in a contemporary cohort of patients with a diagnosis of ovarian cancer.

METHODS

Ovarian cancer patients with a diagnosis of an ovarian malignancy between 1992 and 2012 were identified and characterized from 13 registries of the Surveillance, Epidemiology, and End Results database.

RESULTS

Of 41,073 women with a diagnosis of an ovarian malignancy between 1992 and 2012, 1831 (4.5%) developed a microscopically confirmed SPT. There was no significant difference in the risk of developing an SPT at all sites between women with an ovarian cancer and the general population. There was an elevated risk of site-specific SPTs of the small intestine, vagina, thyroid gland, and acute nonlymphocytic leukemia in ovarian cancer patients compared with the general Surveillance, Epidemiology, and End Results population. Conversely, the risk of lung and non-Hodgkin lymphoma was significantly decreased in women with ovarian cancer. An elevated risk of SPTs was observed in women with mucinous, endometrioid, and germ cell tumors. White women had an overall decreased risk of developing a second primary solid tumor, whereas American Indian and Asian/Pacific Islander women had an overall increased risk of an SPT at any site.

CONCLUSIONS

The incidence of SPTs in women with ovarian cancer was not significantly different as compared with the general population. However, divergent rates of SPTs in relation to histology, latency, age, and race were observed.

Small bowel adenocarcinoma: French intergroup clinical practice guidelines for diagnosis, treatments and follow-up (SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO)

BACKGROUND

This document is a summary of the French intergroup guidelines regarding the management of small bowel adenocarcinoma published in October 2016.

METHOD

This collaborative work, co-directed by most French Medical Societies, summarizes clinical practice recommendations (guidelines) on the management of small bowel adenocarcinoma. Given the lack of specific data in the literature, all references are given by analogy with colon cancer. The classification used is the AJCC (American Joint Committee on Cancer) pTNM classification (7th edition 2009).

RESULTS

Small bowel adenocarcinoma has a poor prognosis; less than 30% of patients survive for 5 years after the (first) diagnosis (5-year survival of less than 30%). Due to the rarity of the disease and the retrospective data, most recommendations are based on expert agreement. The initial evaluation is based on chest-abdomen-pelvis CT scan, CEA assay, GI endoscopy and colonoscopy in order detect lesions associated with a predisposing disease. Surgical treatment is currently the only curative option for stage I and II. Adjuvant chemotherapy can be discussed for Stage III and Stage II with T4 (expert agreement). With regard to metastatic tumors, treatment with fluoropyrimidine combined with platinum salts should be considered (expert agreement).

CONCLUSION

Few specific data exist in the literature on this type of tumor; most of the recommendations come from expert agreements or by analogy with colon cancer. Thus, each case must be discussed within a multidisciplinary team.

Intestinal Obstruction of Uncommon Cause and Point-of-Care Ultrasonography - Where Do We Stand?

Malignant neoplasms of the small bowel, especially from the jejunum, are among the rarest types of cancer. Given its location, a delayed diagnosis is frequent and sometimes only made in an emergency context. The authors present a case of intestinal obstruction, where ultrasonography was pivotal in establishing a diagnosis. Point-of-care ultrasonography seems to be particularly sensitive in assessing emergency patients with abdominal pain, allowing effective orientation and saving human and technical resources.

Rare Coexistance of Ileal Diverticulosis, Crohn's Disease and Small Bowel Adenocarcinoma: Report of a Case

BACKGROUND/AIM

Adenocarcinoma is one of the most common malignant tumors of the small intestine complicating Crohn's disease. However, the coexistence of both conditions with diverticulosis of small bowel in young age makes this coincidence rare and clinical diagnosis very difficult.

CASE REPORT

We report a case of a woman admitted to our Department with acute abdominal pain and fever. The surgical and histological investigation, revealed a rare coexistence that has never been mentioned in the published medical literature.

CONCLUSION

Ileal diverticulosis is not frequent and often asymptomatic as well as adenocarcinoma of the small bowel. In this case, those diseases along with Crohn's disease led the patient to acute symptoms.

Cftr Modulates Wnt/β-Catenin Signaling and Stem Cell Proliferation in Murine Intestine

BACKGROUND & AIMS

Cystic fibrosis (CF) patients and CF mouse models have increased risk for gastrointestinal tumors. CF mice show augmented intestinal proliferation of unknown etiology and an altered intestinal environment. We examined the role of the cystic fibrosis transmembrane conductance regulator (Cftr) in Wnt/β-catenin signaling, stem cell proliferation, and its functional expression in the active intestinal stem cell (ISC) population. Dysregulation of intracellular pH (pH_i) in CF ISCs was investigated for facilitation of Wnt/β-catenin signaling.

METHODS

Crypt epithelia from wild-type (WT) and CF mice were compared ex vivo and in intestinal organoids (enteroids) for proliferation and Wnt/β-catenin signaling by standard assays. Cftr in ISCs was assessed by immunoblot of sorted Sox9 ^{enhanced green fluorescent protein(EGFP)} intestinal epithelia and pH_i regulation by confocal microfluorimetry of leucine-rich G-protein-coupled receptor 5 ISCs. Plasma membrane association of the Wnt transducer Dishevelled 2 (Dvl2) was assessed by fluorescence imaging of live enteroids from WT and CF mice crossed with Dvl2-EGFP/ACTB-tdTomato,-EGFP)Luo/J (Rosa^mT/mG) mice.

RESULTS

Relative to WT, CF intestinal crypts showed an ∼30% increase in epithelial and Lgr5+ ISC proliferation and increased Wnt/β-catenin signaling. Cftr was expressed in Sox9^EGFPLo ISCs and loss of Cftr induced an alkaline pH_i in ISCs. CF crypt-base columnar cells showed a generalized increase in plasma membrane Dvl2-EGFP association as compared with WT. Dvl2-EGFP membrane association was charge- and pH-dependent and increased in WT crypt-base columnar cells by Cftr inhibition.

CONCLUSIONS

CF intestine shows increased ISC proliferation and Wnt/β-catenin signaling. Loss of Cftr increases pH_i in ISCs, which stabilizes the plasma membrane association of the Wnt transducer Dvl, likely facilitating Wnt/β-catenin signaling. Absence of Cftr-dependent suppression of ISC proliferation in the CF intestine may contribute to increased risk for intestinal tumors.

Stereotactic ablative radiation therapy as a potential curative treatment in duodenal adenocarcinoma: a case report

PURPOSE

One of the rarest gastrointestinal neoplasm is small bowel cancer. Experience with its treatment modalities is limited. Stereotactic ablative radiation therapy (SABR) has improved, with image-guided radiation therapy becoming a curative option in many tumors. Especially when surgery cannot be performed due to comorbidities, SABR provides a good toxicity profile and an excellent tumor control rate owing to its specific schedule: high dose on a limited and well-defined area.

METHODS

An 83-year-old man had arterial hypertension and congestive cardiomyopathy, with recent history of upper abdominal pain, weight loss over 10 kg, and progressive severe fatigue. The patient underwent endoscopy that showed a large mass partially obstructing the second part of the duodenum; a biopsy revealed a moderately differentiated adenocarcinoma. A staging CT scan confirmed localized disease. Due to the patient's age and comorbidities, a SABR was proposed as the preferred treatment. In order to localize the tumor during radiotherapy sessions, surgical clips were placed endoscopically next to the lesion as fiducial markers. The patient received 25 Gy in 5 fractions on alternate days.

RESULTS

Resolution of duodenal obstruction and bleeding lasted for 14 months. The patient died of myocardial infarction.

CONCLUSIONS

This case suggests that SABR could have a role in the palliative treatment of small bowel cancers, with good toxicity profile, particularly in patients for whom surgical treatment is not a viable option.