Adenocarcinoma of the duodenum and the Gardner syndrome

An autopsy case of alpha-fetoprotein-producing large duodenal adenocarcinoma

We report an autopsy case of a large duodenal adenocarcinoma that produced alpha-fetoprotein (AFP). The patient was a man in his 70s with diabetes mellitus. He presented with epigastralgia and was referred to our hospital. Upper gastrointestinal endoscopy and abdominal computed tomography revealed a large tumor of 11 cm in diameter in the descending limb of the duodenum. A tumor biopsy showed poorly differentiated adenocarcinoma. Although his carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels were within the normal range, his AFP levels were significantly elevated (42,078.4 ng/mL). Due to vascular invasion, curative resection was not feasible, and chemotherapy was chosen as the treatment option. After gastrojejunostomy was performed to enable oral intake, one cycle of modified leucovorin/5-fluorouracil/oxaliplatin (mFOLFOX6) therapy was administered. However, it proved ineffective, and the patient's anorexia gradually worsened. Ultimately, he succumbed to the progression of cancer cachexia. Autopsy findings revealed a 14-cm-long duodenal carcinoma primarily located in the duodenal bulb, with direct invasion into the stomach, pancreas, and liver. A pathological examination confirmed a diagnosis of poorly differentiated adenocarcinoma with AFP production. Duodenal cancer is rare, and AFP-producing duodenal cancer is even rarer, with only 21 reported cases, including our own. We present this autopsy case of AFP-producing duodenal adenocarcinoma and review the cases reported in the relevant literature.

Duodenal adenocarcinoma: Advances in diagnosis and surgical management

Duodenal adenocarcinoma is a rare but aggressive malignancy. Given its rarity, previous studies have traditionally combined duodenal adenocarcinoma (DA) with either other periampullary cancers or small bowel adenocarcinomas, limiting the available data to guide treatment decisions. Nevertheless, management primarily involves complete surgical resection when technically feasible. Surgery may require pancreaticoduodenectomy or segmental duodenal resection; either are acceptable options as long as negative margins are achievable and an adequate lymphadenectomy can be performed. Adjuvant chemotherapy and radiation are important components of multi-modality treatment for patients at high risk of recurrence. Further research would benefit from multi-institutional trials that do not combine DA with other periampullary or small bowel malignancies. The purpose of this article is to perform a comprehensive review of DA with special focus on the surgical management and principles.

Sporadic nonampullary duodenal adenoma/carcinoma is associated with not only colon adenoma/carcinoma but also gastric cancer: association of location of duodenal lesions with comorbid diseases

BACKGROUND

It is well known that in patients with sporadic nonampullary duodenal adenoma/carcinoma (SNADA) with no polyposis syndrome, including familial adenomataous polyposis, the rates of colorectal adenoma/carcinoma are high. However, the prevalence rates of other tumor types, for example, gastric cancer, in SNADA patients remain unknown. In this study, we aimed to analyze the prevalence rate of comorbid diseases in SNADA patients.

METHODS

We retrospectively analyzed 78 patients with SNADA treated by endoscopic resection between May 2005 and September 2014 at our institution.

RESULTS

Overall, 51 of the 78 (65.4%) SNADA patients had comorbid colorectal adenoma/carcinoma. Further, 10 of the 78 (12.8%) SNADA patients had comorbid gastric cancer, and all of them were positive for Helicobacter pylori infection. SNADA lesions were located significantly more frequently at the oral side of the major papilla in patients with H. pylori infection than in those without H. pylori infection (27 of 36 [75.0%] vs. 19 of 42 [45.2%], p = 0.008, chi-square test). In contrast, SNADA lesions were located significantly more frequently at the anal side of the major papilla in patients with colorectal adenoma/carcinoma than in those without colorectal adenoma/carcinoma (27 of 51 [52.9%] vs. 5 of 27 [18.5%], p = 0.003, chi-square test).

CONCLUSION

SNADA patients showed comorbidity with not only colorectal adenoma/carcinoma but also gastric cancer. H. pylori infection is known to cause gastric cancer and may influence tumorigenesis of SNADA lesions at the oral side of the major papilla.

Adenocarcinoma of the third and fourth portion of the duodenum: a case report and review of the literature

A 65-year-old woman presented with abdominal pain, weight loss, fatigue, and microcytic anemia. Esophagogastroduodenoscopy, until the second part of duodenum, was normal. Ultrasound and computed tomography demonstrated a solid mass in the distal duodenum. A repeat endoscopy confirmed an ulcerative, intraluminar mass in the third and fourth part of the duodenum. Segmental resection of the third and fourth portion of the duodenum was performed. Histology revealed an adenocarcinoma. On the 4^th postoperative day, the patient developed severe acute pancreatitis leading to multiple organ failure and died on the 30^th postoperative day.

Surveillance and management of upper gastrointestinal disease in Familial Adenomatous Polyposis

Almost all patients affected by Familial Adenomatous polyposis (FAP) will develop foregut as well as hindgut polyps, and following prophylactic colectomy duodenal cancer constitutes one of the leading causes of death in screened populations. Without prophylactic colectomy, FAP patients predictably develop colorectal cancer, but the lifetime risk of upper gastrointestinal cancer is lower, estimated at approximately 5%. Management of the upper gastrointestinal cancer risk is one of the greatest challenges facing clinicians involved in the care of Polyposis families, and with improved survival following prophylactic colectomy, the burden of foregut disease (particularly duodenal adenomatosis) will increase. Until recently, the value of upper gastrointestinal surveillance in FAP populations has been contentious, but with improved understanding of the natural history coupled with developments in surgery, interventional endoscopy and medical therapy, treatment algorithms for duodenal adenomatosis in FAP are becoming clearer.

Familial adenomatous polyposis

Familial adenomatous polyposis (FAP) is an autosomal dominant condition resulting in the development of more than 100 adenomatous polyps in the large bowel. In addition, a number of extracolonic manifestations of the condition may occur. Recently, increasing knowledge relating to the extracolonic abnormalities, and localization and sequencing of the gene for FAP, have had important implications for screening and long-term follow-up of those affected. In this review the natural history of the disease and the extracolonic manifestations associated with it are considered. Surgical management and advances in understanding at a molecular level are discussed, as well as the problems relating to screening for FAP and the implications of the new knowledge.

Malignant tumours of the small bowel

Early diagnosis of small intestinal cancers provides the best probability of cure. The astute clinician will include these tumours in the differential diagnosis when vague or non-specific abdominal complaints occur and a more common cause is not discovered. Failure to evaluate the small bowel, which is a blind spot to routine endoscopic and radiological diagnostic tests, constitutes a common error when confronted with occult gastrointestinal blood loss and normal upper and lower gastrointestinal examination. Surgical resection remains the cornerstone of therapy for these malignancies. Advances in effective chemotherapy for large bowel carcinoma may have an impact on the management of small intestinal adenocarcinomas. Substantial palliation can be offered to the patient with metastatic carcinoid tumour, but the long-term outlook for these patients remains poor. Early stage lymphomas of the intestine are readily treated by combined modality therapy while advanced stage disease remains resistant to curative management. The patient prognosis for a small bowel sarcoma is largely dependent on the tumour grade. A high index of suspicion to improve tumour detection and better treatments of tumours with the same histology at other anatomic sites should enhance the management and outcome of patients with small intestinal malignancies.

Improving resectability and survival in patients with primary duodenal carcinoma

Of 35 patients with primary duodenal carcinoma (PDC), 13 were treated between 1960 and 1974 (group I) and 22 between 1975 and 1990 (group II). PDCs were found in the first 5 portions of the duodenum (14%), second 18 (51%), third 8 (23%), and fourth 4 (12%). Five patients (38%) in group I were deemed to have unresectable disease compared with only one patient (5%) in group II. Eight patients (62%) in group I underwent resection by either pancreatoduodenectomy (4) or segmental resection (4), and 20 patients (95%) in group II had pancreatoduodenectomy (17) or segmental resection (3). Operative mortality was 31% in group I and 0% in group II. Mean survival was 7 months (range: 0 to 22 months) in group I and 48 months (range: 6 to 218 months) in group II. None of the patients in group I survived for 2 years, whereas the 5-year survival for patients in group II was 62%. This experience suggests that resectability, operative mortality, and survival in patients with PDCs have improved markedly in recent years.

Investigations on the significance of the adenoma-carcinoma sequence in the small bowel

In view of the rarity of small-bowel epithelial neoplasms as compared with the case for the large bowel, evidence for an adenoma-carcinoma sequence in the small bowel was studied based on a search for data in the medical literature for the years 1927 through 1986. Sufficiently defined data were found for comparison of 185 benign adenomas, 76 adenoma-with-carcinomas, and 1333 carcinomas in patients without familial polyposis disease and for 63, five, and 30, respectively, in patients with disease. For patients without polyposis, it was found that (1) 29.8% of all small-bowel adenomas (33.6% if those at Vater's ampulla are excluded) showed malignancy; (2) the mean and median ages were lower for benign adenoma than for adenoma-with-carcinoma and carcinoma, although the ratios by sex were the same; (3) there is a nearly identical spatial distribution of the three types of epithelial neoplasms within the small bowel; and (4) both the frequency of finding adenomatous residues existing in continuity with carcinoma and the life history of the adenoma-carcinoma sequence are similar in the small bowel as in the large. In comparing these results with those from patients with familial polyposis disease, it was particularly noted that (1) the only difference was that adenomas in familial polyposis occurred earlier and multiply, and (2) the spatial distributions of adenomas and carcinomas for both cases were closely similar. It is therefore postulated that the adenoma-carcinoma sequence is as significant in the small bowels as in the large. A hypothesis regarding the relationship of epithelial neoplasms in people with and without familial polyposis disease is suggested.

Results of surgical treatment for familial polyposis coli

Seventy-seven patients with polyposis coli operated on at The Mount Sinai Hospital in the last 40 years were studied. Forty-two patients had a subtotal colectomy. Sixteen were found to have colon cancer at the time of operation, and a second rectal cancer developed in 50 percent of the survivors within 1 to 13 years after subtotal colectomy. Rectal cancer subsequently developed in only 3 of 23 patients without colon cancer. Thirty-five patients had total proctocolectomy or total colectomy with mucosal proctectomy and ileoanal anastomosis. Recurrent adenomatous polyps developed in two patients after mucosal proctectomy. A villous adenoma with carcinoma in situ of the ileum developed in one patient 30 years after total proctocolectomy and ileostomy. Another patient died from a periampullary carcinoma 24 years after subtotal colectomy. It seems that as the life expectancy of patients with polyposis improves, the incidence of small bowel and duodenal cancers may be expected to increase.

Unfamiliar aspects of familial polyposis coli

Patients with familial polyposis coli or Gardner's syndrome are at risk for a variety of extracolonic manifestations. In a series of patients followed at the University of Washington, we have found several recurring and unusual manifestations, including upper gastrointestinal polyposis, small bowel obstruction secondary to desmoid tumors or adhesions, recurring pancreatitis, and adenoma of the papilla of Vater. In one family with familial polyposis only, a set of twins had different manifestations; one twin had familial polyposis only, whereas the second had classic extracolonic manifestations of Gardner's syndrome. Multiple rectal adenomas developed in a woman with an ileorectal anastomosis with each of three pregnancies. Spontaneous regression occurred after each delivery. Multiple rectal adenomas developed in her daughter on two occasions while taking birth control pills. Physicians caring for these patients should look for such manifestations.

Ileal adenomas in familial polyposis coli. Differences before and after colectomy

We treated two patients with familial polyposis coli (FPC) who were found to have multiple adenomas in the ileostomy stoma, five and seven years after colectomy, respectively. These adenomas were dense and 3 to 10 mm in diameter. The adjacent ileal mucosa showed a colonic metaplasia. Ileal adenomas detected using intraoperative intestinal endoscopy at the time of colectomy were less than 2 mm in diameter and sparse in density. These findings suggest that ileal adenomas occurring after colectomy for FPC tend to increase in size and number and to resemble colonic adenomas.

Gardner's syndrome associated with periampullary carcinoma, duodenal and gastric adenomatosis. Report of a case

A 48-year-old man with Gardner's syndrome, who had abdominoperineal resection for rectal carcinoma in 1962, was found to have an ulcerating growth of the duodenum, and pancreaticoduodenectomy was performed in 1979. Histologic examination by complete step-serial sectioning disclosed a well-differentiated adenocarcinoma with adenomatous remnants, a large adenoma with focal carcinoma, 256 adenomas of the duodenum, and 91 adenomas of the gastric antrum. The world medical literature was reviewed, and 29 cases of periampullary carcinoma and 12 cases of gastric carcinoma complicating familial polyposis coli or Gardner's syndrome were analyzed.

Adenomas of the small intestine: a clinicopathologic review of 51 cases and a study of their relationship to carcinoma

The authors studied 51 patients who had small bowel tumors that contained adenomatous epithelium. These rare lesions were identified among 392,000 surgical pathology cases seen during a 62-year period. Grossly and histologically, adenomas arising in the mucosa of the small intestine are similar to the adenomas found in the colon. Of the 51 patients, 18 had adenomas, and 33 had tumors that contained both adenoma and carcinoma in the same lesion, including five intramucosal and 28 invasive carcinomas. The location of the tumor usually determined which clinical problems were produced. The data indicate that adenomas originating in the small bowel mucosa probably are premalignant lesions and that many primary adenocarcinomas of the small intestine arise in adenomas. Of the authors' 130 apparently primary small bowel carcinomas (including the papilla of Vater), 33 (25%) histologically demonstrated adenomatous epithelium in the same lesion. Factors associated with an increased chance of finding carcinoma in an adenoma include adenoma type, size of lesion, location, and multicentricity. Carcinomas appear to develop more frequently in papillary (villous) adenomas than in ordinary adenomas. The larger the lesion is, the more likely carcinoma will be identified. Adenomas involving the ampulla contain carcinoma more often than do lesions found elsewhere in the duodenum and small intestine. Three patients had multiple adenomatous polyps of the small bowel; two of these individuals also had duodenal carcinomas. Various problems in pathologic diagnosis and clinical management are discussed.

Gastric and duodenal polyps in familial polyposis coli

Endoscopy with multiple biopsies of the upper gastrointestinal tract was repeated yearly over a two to six year period in nine patients with familial polyposis coli from three families. Adenomatous polyps, one to 20 in number and 2-8 mm in size, were detected in the antrum and the first and second duodenal portions in seven patients, while hyperplastic polyps were detected in four patients in the gastric body. In two patients adenomatous tubules were observed in the biopsies of endoscopically normal mucosa from the same area where adenomatous polyps later developed. Lymphoid polyps were detected in the antrum in three cases. Double contrast radiology correlated poorly with endoscopy in the gastric body; it allowed detection of polyps in the third duodenal portion in two more patients. These results confirm that the incidence of adenomas in the upper gastrointestinal tract in familial polyposis coli may be higher than previously suspected.

Improving survival in adenocarcinoma of the duodenum

The records of 104 patients with primary adenocarcinoma of the duodenum were reviewed. All patients were followed up to the date of this report, 91 for at least 5 years. Melena was an ominous preoperative finding. Survival was directly related to nodal status, the grade of the lesion, and the ability of the surgeon to minimize or eliminate operative mortality. Fifty percent of the lesions were resectable for cure, and the 5 year survival rate for patients with resectable lesions was 46 percent. All eight patients treated with segmental resections for lesions in the third and fourth portions of the duodenum survived at least 5 years. These data are a great improvement over those in previous reports and suggest that this disease may be much more treatable than previously believed.

Gardner's syndrome. Recent developments in research and management

In recent years, a number of comprehensive reviews have been written on inherited intestinal polyposis syndromes (1-7), but none has dealt specifically with Gardner's syndrome and none has focused on basic research being carried out in an attempt to understand this syndrome and to improve the medical management of affected patients. A better understanding of this rare genetic disorder is essential for surgeons, gastroenterologists, cancer researchers, and geneticists alike. To the clinician, it poses difficult challenges in management; to the cancer researcher, it presents a rare opportunity to study very early premalignant transformations; and to the geneticist, it poses exciting questions at the cellular, chromosomal, and molecular levels.

Hypertrophy of the retinal pigment epithelium associated with Gardner's syndrome

Congenital hypertrophy of the retinal pigment epithelium was seen in three affected members of a kindred with Gardner's syndrome. The latter consists of a triad of many intestinal polyps, hard-tissue abnormalities, and soft-tissue abnormalities. Although the appearance of the individual lesions in our patients was typical of hypertrophy of the retinal pigment epithelium, the following atypical features were present: multiple lesions per eye; bilateral occurrence; familial transmission; and association with systemic disease. Ophthalmoscopic examination can help identify children who are at risk of developing polyposis and carcinoma of the colon. In some instances, Gardner's syndrome may be diagnosed in a patient and his family as a result of observing the fundus lesions.

Gardner syndrome and periampullary malignancy

In a family with colonic polyposis and the typical associated findings of Gardner syndrome (osteomas and soft-tissue tumors), two and possibly four of the affected members developed periampullary malignancy. A review indicates that individuals with Gardner syndrome may have a 100- to 200-fold increased risk of developing periampullary carcinoma when compared to the general population. While certain families and certain individuals (those with other duodenal involvement, males and those with all of the characteristics of Gardner syndrome expressed) may be most susceptible, all patients with Gardner syndrome should be periodically endoscopically evaluated for the presence of upper gastrointestinal tract disease.

Gardner's syndrome with duodenal adenomas, gastric adenomyoma and thyroid papillary--follicular adenocarcinoma

A case of a woman with Gardner's syndrome, originally manifested by multiple adenomatous polyps of the colon, is presented. She underwent subtotal colectomy at 14 years of age. Over the next 15 years she had a composite odontoma, an impacted supernumerary tooth, two epidermal inclusion cysts, multicentric paillary-follicular adenocarcinoma of the thyroid, two tubulovillous adenomas of the duodenum in which argyrophilic cells were a prominent feature, and an adenomyoma of the gastric antrum. The presence of all of these lesions in one patient expands the spectrum of lesions seen with Gardner's syndrome and supports the concept of a generalized abnormality of growth regulation as the cause of the syndrome.

Small-intestinal involvement in familial polyposis diagnosed by operative intestinal fiberscopy: report of four cases

Operative intestinal fiberscopy, in which the duodenal fiberscope was introduced during laparotomy for colectomy in familial polyposis via the enterotomy opening, permitted the demonstration of small intestinal polyps in six of seven consecutive cases. Four of the six patients had adenomatous polyps in the proximal jejunum, including one patient with the concomitant presence of ileal adenomas. Polyposis due to lymphoid hyperplasia in the terminal ileum was found in three patients. Preoperative upper gastrointestinal surveys revealed adenomas in the duodenums of all seven patients, adenomas in the gastric antrum in three, and multiple hamartomas in the gastric corpus in two. Thus, in familial polyposis or Gardner's syndrome, more or less the entire gastrointestinal tract seems to be involved and the term "gastrointestinal polyposis" seems to describe these conditions.

Penetrance and expressivity of the gene responsible for the Gardner syndrome

The Gardner syndrome is an autosomal dominant condition characterized by multiple polyposis of the colon, associated with various soft- and hard-tissue tumors. Our original kindred, first reported in the early 1950's has been updated and serves as the basis for a discussion of the penetrance and expressivity of the gene responsible for the syndrome. The family consists of 188 members spread over six generations, with 28 individuals clearly documented as having the syndrome. Using two different methods of calculating penetrance, the responsible gene was found to be fully penetrant. This observation was confirmed by an analysis of 160 additional sibships from the literature. This estimation of penetrance is considerably higher than has been previously reported. The expressivity of the gene, however, is quite variable, and this is illustrated using examples from both our kindred and the literature.

Lesions associated with familial polyposis coli: studies of lesions of lesions of the stomach, duodenum, bones, and teeth

The entire gastrointestinal tract and bones were examined systematically in 24 patients (10 pedigrees) in whom familial polyposis coli was diagnosed. Polypoid lesions were observed in the stomach in as high as 68.2% of the cases, and in the duodenum in 90%. Abnormalities were noted in the skeleton in 50% and in the mandible in 81.3%. The authors emphasize the possibility that familial polyposis coli is substantially the same entity as Gardner's Syndrome.