Primary malignant tumors of the small intestine: analysis of 40 Japanese patients

Leiomyosarcoma of the abdomen and retroperitoneum; a systematic review

Background

Intraabdominal and retroperitoneal leiomyosarcomas are rare cancers, which cause significant morbidity and mortality. Symptoms, treatment and follow up differs from other cancers, and proper diagnosis and treatment of intraabdominal and retroperitoneal leiomyosarcomas is of utmost importance. We performed a systematic review to collect and summarize available evidence for diagnosis and treatment for these tumours.

Methods

We performed a systematic literature search of Pubmed from the earliest entry possible, until January 2021. Our search phrase was (((((colon) OR (rectum)) OR (intestine)) OR (abdomen)) OR (retroperitoneum)) AND (leiomyosarcoma). All hits were evaluated by two of the authors.

Results

Our predefined search identified 1983 hits, we selected 218 hits and retrieved full-text copies of these. 144 studies were included in the review.

Discussion

This review summarizes the current knowledge and evidence on non-uterine abdominal and retroperitoneal leiomyosarcomas. The review has revealed a lack of high-quality evidence, and randomized clinical trials. There is a great need for more substantial and high-quality research in the area of leiomyosarcomas of the abdomen and retroperitoneum.

Systematic Review Registration

PROSPERO, identifier, CRD42023480527.

Clinicopathologic features, surgical treatments, and outcomes of small bowel tumors: A retrospective study in China

BACKGROUND

Small bowel tumors are relatively rare. Accumulation of data regarding their clinical presentation, pathologic features, prognostic factors, treatment modalities, and outcome has been an issue. We summarize the clinicopathologic features and evaluate the long-term outcome of patients with small bowel tumors who underwent surgery.

METHODS

This is a retrospective study of medical records of 456 patients with small bowel tumors treated surgically at a Cancer Hospital between 1999 and 2016.

RESULTS

The study included 275 males (60.3%) and 181 females (39.7%). Small bowel tumors were difficult to diagnose because of non-specific symptoms. The most common symptoms were alimentary symptoms (56.8%) and abdominal pain (37.3%). Final histopathology revealed 241 adenocarcinomas (52.9%), 153 gastrointestinal stromal tumors (GISTs; 33.6%), 16 neuroendocrine tumors (NETs; 3.5%), and 46 other types of tumors (10.1%). The 456 surgeries performed included 153 pancreaticoduodenectomies, 241 limited duodenum resections, 60 palliative bypass surgeries, and 2 abdominal explorations. The 5-year overall survival and progression-free survival rates for patients with small bowel tumor were 57.2% and 44.6%, respectively. Adenocarcinomas resulted in the worst overall survival compared to GISTs or NETs, and tumors with duodenal location resulted in a worse survival compared to those with non-duodenal location.

CONCLUSION

Surgery is the mainstay of treatment for small bowel tumors. Adenocarcinomas and duodenal involvement seem to contribute to poor outcomes.

Recurrence of primary squamous cell carcinoma of the ileum diagnosed by elevation of serum SCC: report of a case

Primary squamous cell carcinoma of the intestine is extremely rare. This report describes a patient with primary squamous cell carcinoma of the small intestine. A 72-year-old Japanese woman was referred to our hospital because of a diagnosis of intestinal obstruction. She underwent laparotomy owing to the diagnosis of mechanical intestinal obstruction due to a pelvic mass after conservative treatment. The affected ileum was resected, and histopathological examination revealed proliferation of differentiated squamous cell carcinoma at the submucosal area with no adenocarcinoma component. At the 4th month after the operation, the level of serum squamous cell carcinoma (SCC) antigen was elevated. At 6 months after the operation, the serum SCC value was further elevated, and enhanced CT revealed two new pelvic tumors with enhancement at the mesentery and free space. A second laparotomy was performed 8 months after the operation. Histopathological examination showed differentiated squamous cell carcinoma as in the first operation. The level of serum SCC decreased at the 28th postoperative day. Chemotherapy including carboplatin and paclitaxel was performed as an adjuvant regimen. The patient has experienced no recurrence of squamous cell carcinoma for 55 months.

Primary small intestine tumour as the cause of gastrointestinal tract occlusion

The following paper presents the case of a 40-year-old patient staying in our Clinic between 2 March 2010 and 12 March 2010 due to the symptoms of permeable occlusion of gastrointestinal tract. This is a patient with a several weeks' history of non-specific abdominal pain, vomiting and significant weight loss (ca 20 kg). Until recently he has not suffered from any serious illnesses. In the performed abdominal ultrasound, gastroscopy and colonoscopy no pathology was affirmed. CT scan with intravenous and oral contrast showed significantly widened intestinal loops with residual liquid matter in the stomach, duodenum and a part of the jejunum without any distinguishing pathological mass, and also single mesenteric lymph nodes and para-aortic nodes enlarged to the size of 12 mm. The patient was qualified for laparatomy. During the surgery, a 4-cm tumour of the jejunum, concentrically narrowing intestinal lumen was found. Segmental resection of the small intestine was performed with side to side anastomosis with the use of a linear stapler. Currently the general condition of the patient is good, without any ailments, and the patient is undergoing systemic treatment.

Irinotecan-based combination chemotherapy for metastatic small intestinal adenocarcinoma

Metastatic small intestinal adenocarcinoma (SIA) is rare among digestive tract malignancies, and a standard therapy has yet to be established. The present study described a patient who was treated with irinotecan-based chemotherapy. A 67-year-old woman with a long history of anemia was diagnosed as having SIA using small bowel endoscopy. Tumor invasion of the mesentery and multiple metastases to the lungs and peritoneal lymph nodes were detected. Nine courses of chemotherapy, each consisting of bolus infusion of 5-fluorouracil at 500 mg/m(2), plus infusion of irinotecan at 100 mg/m(2) with l-leucovorin at 20 mg/m(2) on days 1, 8 and 15, were administered at 4-weekly intervals postoperatively. After two courses, the metastatic nodules in the lungs showed a decrease in number and size, and this response continued for over 6 months. Adverse events were manageable during this period. The patient succumbed to the disease 12 months after the initial diagnosis. The present results therefore suggest that irinotecan-based chemotherapy is a potential treatment for metastatic SIA.

Small bowel tumors: clinical presentation, prognosis, and outcome in 33 patients in a tertiary care center

Introduction. Small bowel cancers are rare. Accumulation of data regarding their clinical presentation, pathologic features, prognostic factors, treatment modalities, and outcome is difficult. Methods. This is a retrospective study of the medical records of 33 patients with small bowel cancers treated at the American University of Beirut-Medical Center over a 20-year period. Results. The study included 25 males (76%) and 8 females (24%). Median age at presentation was 56 years. Most common symptoms were abdominal pain (66.7%) and weight loss (57.6%). Thirteen patients presented with abdominal emergencies (39.3%). Lymphoma was the most common malignant tumor (36.4%), followed by adenocarcinoma (33.3%), leiomyosarcoma (15.2%), gastrointestinal stromal tumors (12.1%), and neuroendocrine tumors (3.0%). Tumors were located in the duodenum in 30% of patients, jejunum in 33%, and ileum in 36%. Resectability rate was 72.7% and curative R0 resection was achieved in 54.1% (13/24) of patients. 5-year survival of the 33 patients was 24.2%. Conclusion. Small bowel cancers are difficult to diagnose because of the nonspecific symptoms. Most patients present with advanced disease and have poor prognosis. Adenocarcinoma and duodenal location have the worst 5-year survival in contrast to stromal tumors and those with ileal location which have the best survival.

Primary jejunal adenocarcinoma as part of multiple primary cancers of the digestive tract

Multiple primary cancers including small intestinal tumors are rare. We describe the first curative resection case of metachronous triple early cancers involving the jejunum as well as the stomach and esophagus. The patient had undergone total gastrectomy for a gastric adenocarcinoma and subsequent esophagectomy for an esophageal squamous cell carcinoma. A jejunal adenocarcinoma, the third primary, occurred at the blind stump of the jejunal limb of a Roux-en-Y esophagojejunostomy reconstructed previously. This tumor was removed by partial resection of the limb with the preservation of the esophagojejunostomy. The patient died from complications of acute pancreatitis 3 years after the last operation, without overt clinical signs of cancer recurrence. Immunohistochemistry of the specimen showed the increased expression of p53 and cyclin D1 proteins in all three cancers, suggesting their involvement in metachronous carcinogenesis in this case. Early diagnosis of each cancer was made possible by regular endoscopic follow-up and favorable anatomical location of each tumor, which were considered to allow less invasive surgery as well as to contribute to the favorable outcome. This case suggests the importance of regular surveillance for metachronous carcinogenesis, especially when the preceding cancers carry genetic abnormalities that may potentially increase the risk for subsequent carcinogenesis.

Primary small intestinal malignant tumors: survival analysis of 48 postoperative patients

BACKGROUND

Primary small intestinal malignant tumor is relatively uncommon compared to gastric and colorectal cancer. It is difficult to make an early diagnosis due to the atypical primary symptoms and lack of effective diagnostic methods.

GOALS

To analyze the relationship between the prognoses, histologic type, and therapeutic strategy in postoperative patients with small intestinal tumor.

STUDY

The parameters that affect survival were evaluated using multivariate Cox analysis in 48 cases of small intestinal tumor (confirmed by operation and pathology) for the past 10 years.

RESULTS

The overall survival (OS) of all 48 cases after surgery was 28 months. The 5-year postoperative survival rate for all of the 48 cases was 27.1%. The median OS for all the 20 stage II/III patients who received adjuvant chemotherapy was 28 months, whereas the median OS for the 15 patients who did not receive the therapy was 37 months (P=0.276). The median time to progression for 8 patients with adenocarcinoma who received 5-fluorouracil or platinum-based palliative chemotherapy was 7 months, whereas for the patients who did not receive the therapy it was 3 months (P=0.06). The result of multivariate analyses showed that only the clinical stage was significantly correlated with OS (P<0.001).

CONCLUSIONS

The prognosis for small intestinal malignancies is associated with clinical stage, and palliative chemotherapy with a 5-fluorouracil or platinum-based regimen offers a potential benefit to patients with adenocarcinoma. Postoperative adjuvant chemotherapy seems to hold no therapeutic or survival benefit for patients with primary small bowel malignancies.

Obscure gastrointestinal bleeding

Obscure GI bleeding is a relatively common problem facing internists, gastroenterologists, and surgeons in a typical clinical practice. The etiology is occasionally suggested by the patient's age, history, and medications. Management is complicated and typically requires a team-oriented approach, with input from the internist, gastroenterologist, radiologist, and surgeon alike. SBFT and enteroclysis seem to have a limited role, unless there is a high suspicion of a small bowel mass lesion or Crohn's disease. Scintigraphy may be performed in patients with active bleeding in whom endoscopy has failed oris contraindicated. Angiography may be used in patients with an early positive nuclear imaging or failed endoscopic therapy. Provocative angiography probably has a lower diagnostic yield than previously reported, and should be performed only in experienced centers. Helical CT is a new and potentially important option in patients with obscure bleeding, but is currently considered experimental. All patients with obscure GI bleeding should undergo repeat upper endoscopy and perhaps colonoscopy to rule out missed lesions. SBE seems to be complementary to capsule endoscopy, and it is unknown whether this should be performed before capsule endoscopy or only if capsule endoscopy yields a positive proximal small bowel finding. Double balloon enteroscopy seems promising, but the technique requires further study. Surgery should be reserved for patients who have a positive capsule endoscopy requiring surgical therapy or patients who have persistent GI bleeding requiring recurrent blood transfusions in whom all other modalities have failed. Treatment for vascularectasias, the most common cause of obscure GI bleeding, is currently inadequate,and typically requires a combination of multiple management approaches.

Cytoreductive surgery and intraperitoneal hyperthermic chemotherapy for peritoneal carcinomatosis from small bowel adenocarcinoma

INTRODUCTION

Peritoneal carcinomatosis (PC) is associated with a dismal prognosis. Small bowel adenocarcinoma is a rare etiology for PC. Due to the rarity, poor prognosis, and lack of standard treatment, we chose to review our experience with this disease process treated with cytoreductive surgery (CS) and intraperitoneal hyperthermic chemotherapy (IPHC).

METHODS

From a prospective database of IPHC patients, six patients diagnosed with PC from adenocarcinoma of the small bowel were identified. Between 1995 and 2004 these patients underwent CS and IPHC with Mitomycin C. A retrospective review was performed on these patients with mortality as the primary outcome measure.

RESULTS

Three of the six patients in this series are still alive, with a mean follow-up of 19.7 months after treatment with CS and IPHC. Three patients died of disease progression 29, 30, and 45 months after IPHC. Median survival after diagnosis of small bowel adenocarcinoma was 54 months, while median survival after CS and IPHC for PC was 30.1 months.

CONCLUSIONS

Small bowel adenocarcinoma with PC remains an unusual therapeutic challenge. Treatment with CS and IPHC is an attractive option for patients in this setting.

'Metachronous' adenocarcinoma of the small intestine

Adenocarcinoma of the small intestine accounts for less than 1% of primary gastrointestinal malignancies (1). Small intestine contains 75% of the length of the gastrointestinal tract with 90% of the surface mucosal area, and yet carcinoma is rare. Symptoms of small bowel adenocarcinoma are vague and non-specific, and this region is relatively inaccessible which together contributes to their late diagnosis and poor prognosis. The authors report a case of two primary adenocarcinomas of the small intestine in the same patient.

Mucinous adenocarcinoma of the small bowel with peritoneal seeding

AIMS

Small bowel adenocarcinoma has an extremely poor prognosis because of delayed diagnosis and the presence of advanced disease. Carcinomatosis associated with a small bowel primary cancer has not been reported to be successfully treated in the past.

METHODS

The clinical information prospectively recorded on six patients with carcinomatosis from small bowel adenocarcinoma was reviewed. All of these patients were treated with an aggressive local--regional strategy that utilized cytoreductive surgery plus peri-operative intraperitoneal mitomycin C and 5-fluorouracil.

RESULTS

Disease control in the abdomen and pelvis was achieved in four of these patients. Their median survival was 12 months with one patient alive and well at 4.5 years.

CONCLUSIONS

Small bowel adenocarcinoma continues to provide a surgical challenge. Complete resection of all visible disease combined with intraperitoneal chemotherapy to eradicate microscopic residual disease should be considered as an option in patients with carcinomatosis.

Adenocarcinoma of the small bowel

Cancer of the small bowel is a rare entity but its incidence is rising. Historically, outcome is poor despite apparent curative resection. At present surgery remains the only treatment modality of proven benefit in the management of this disease. Recent data would suggest 5-year survival rates in the order of 40-50% at all sites of small bowel cancer. To improve upon this, earlier diagnosis with a high index of suspicion and multicentre adjuvant therapy trials are required.

Malignant Tumors of the Small Intestine: A Review of 144 Cases

Cancer of the small intestine represents less than two per cent of all the malignant tumors of the gastrointestinal tract. Because they are infrequent tumors, a review of a tumor registry was performed to analyze response to treatment of the disease and prognostic factors. A retrospective review of patients with primary cancer of the small intestine was performed using the Department of Defense Tumor Registry. The registry was accessed to determine stage, types of cancer, intervention, and patient outcomes. TNM staging and follow-up were available on 144 patients from 1970 to 1996. Median follow-up was 38.9 months. There were 92 (64%) males and 52 (38%) females. The median age was 55.7 years. The types of small intestinal cancer included 68 patients (47%) with adenocarcinoma, 41 patients (28%) with carcinoid, 18 patients (13%) with leiomyosarcoma, and 17 patients (12%) with lymphoma. The overall 5-year survival was 57 per cent and the median survival was 52 months. Survival of patients with adenocarcinoma was not dependent on location within the small bowel. Survival was best for early-stage tumors and when lesions could be completely resected.

Pediatric intestinal leiomyosarcomas: case report and review of the literature

Primary intestinal leiomyosarcomas in children are rare tumors. Twenty-seven previous cases are documented in the literature with little information available on the treatment, survival, and prognostic factors surrounding these tumors. The authors report the 28th case of pediatric intestinal leiomyosarcoma and its follow-up, that of a newborn presenting with intestinal obstruction. Follow-up from all previously reported cases is not recorded and is needed. Our patient, like most children with this tumor, underwent complete excision with no evidence of recurrence at 5 years. Visceral metastases from these neoplasms are atypical, and recorded long-term prognosis may be favorable, unlike their counterpart in the adult population.

Prognostic factors for primary gastrointestinal lymphoma

The gastrointestinal tract is a common primary extranodal site for non-Hodgkin's lymphoma. There is however no uniform consensus on its pathological classification, clinical staging system and management. This paper reports the experience in the management of 425 Chinese patients with primary gastrointestinal lymphoma in Hong Kong from January 1975 to June 1993. There were 230 (54 per cent) males and 195 (46 per cent) females. Their median age was 53 years. The primary sites were: the esophagus in three (1 per cent), stomach in 238 (56 per cent), small intestine in 131 (31 per cent) and large intestine in 53 (12 per cent). According to the Working Formulation, there were 20 (4.7 per cent) small lymphocytic, 10 (2.4 per cent) follicular small cleaved cell, 15 (3.5 per cent) follicular mixed, five (1.2 per cent) follicular large cell, 40 (9.4 per cent) diffuse small cleaved cell, 50 (12 per cent) diffuse mixed, 181 (43 per cent) diffuse large cell, 30 (7.1 per cent) immunoblastic, five (1.2 per cent) lymphoblastic, 10 (2.4 per cent) diffuse small non-cleaved cell and 50 (14 per cent) unclassifiable lymphoma. Immunophenotyping was performed in 199 (47 per cent) patients: 90 per cent B-cell, 7 per cent T-cell and 3 per cent uncertain. According to a Manchester system, 81 (19 per cent) patients had stage I disease, 44 (10 per cent) stage II, 85 (20 per cent) stage III and 215 (51 per cent) stage IV. B symptoms were present in 275 (65 per cent) patients and bulky disease in 104 (25 per cent). Surgery followed by chemotherapy was the mainstay of treatment. Of the 408 patients treated, 63 per cent had a complete remission with relapse rate of 42 per cent. For those with complete remission, 47 per cent were free from disease at 5 years. The overall median survival of all patients was 45 per cent at 5 years. Multivariate analysis revealed that significant independent prognostic factors predicting better survival were young age of < 60 years, low grade histology, stage I and II disease and absence of bulky tumour. For gastric lymphoma, aggressive surgery did not significantly improve their outcome. Chemotherapy appears to play an important role in the management of gastrointestinal lymphoma. Better classification of the primary gastrointestinal lymphoma and more refined stratification of the patients according to the prognostic variables may allow individualization of treatment. Prospective randomized studies are essential to define the relative roles of surgery, chemotherapy and radiotherapy.

Surgical treatment of primary duodenal carcinoma: a personal series

In a personal series, 22 patients (11 men, 11 women) of median age 60 (range 25-81) years with primary duodenal adenocarcinoma underwent operation between 1979 and 1993. Tumours arising from bile duct, ampullary or pancreatic tissue were excluded. Principal presenting symptoms were jaundice (12 patients), pain (seven), anaemia (six) and vomiting (six). A pre-existing villous adenoma was seen in 11 patients and adjacent duodenal dysplasia in 13. Sites of origin were mostly the second part of the duodenum (18 patients) but also the third and fourth parts (two each). Seventeen patients underwent 'curative' resection with one hospital death at 25 days; the 5-year survival rate thereafter was 40 per cent. Five patients who received palliative surgery survived for a median of 7 months. Primary duodenal carcinoma is a distinct entity with a better prognosis than pancreatic cancer after radical resection. It favours the descending duodenum and is closely linked with villous adenoma and epithelial dysplasia.