Primary small-bowel malignancy: update in tumor biology, markers, and management strategies. J Gastrointest Cancer. 2014;45:421-430. [PMID: 25339426 DOI: 10.1007/s12029-014-9658-z]

Vascular endothelial growth factor-A is an Immunohistochemical biomarker for the efficacy of bevacizumab-containing chemotherapy for duodenal and jejunal adenocarcinoma

BACKGROUND

The efficacy and safety of bevacizumab-containing chemotherapy for patients with metastatic duodenal and jejunal adenocarcinoma (mDJA) are unclear. The present study aimed to evaluate the efficacy of bevacizumab and to explore immunohistochemical markers that can predict the efficacy of bevacizumab for patients with mDJA.

METHODS

This multicentre study included patients with histologically confirmed small bowel adenocarcinoma who received palliative chemotherapy from 2008 to 2017 at 15 hospitals. Immunostaining was performed for vascular endothelial growth factor-A (VEGF-A), TP53, Ki67, β-catenin, CD10, MUC2, MUC5AC, MUC6, and mismatch repair proteins.

RESULTS

A total of 74 patients were enrolled, including 65 patients with mDJA and 9 with metastatic ileal adenocarcinoma. Patients with mDJA who received platinum-based chemotherapy with bevacizumab as first-line treatment tended to have a longer progression-free survival and overall survival than those treated without bevacizumab (P = 0.075 and 0.077, respectively). Multivariate analysis extracted high VEGF-A expression as a factor prolonging progression-free survival (hazard ratio: 0.52, 95% confidence interval: 0.30-0.91). In mDJA patients with high VEGF-A expression, those who received platinum-based chemotherapy with bevacizumab as a first-line treatment had significantly longer progression-free survival and tended to have longer overall survival than those treated without bevacizumab (P = 0.025 and P = 0.056, respectively), whereas no differences were observed in mDJA patients with low VEGF-A expression.

CONCLUSION

Immunohistochemical expression of VEGF-A is a potentially useful biomarker for predicting the efficacy of bevacizumab-containing chemotherapy for patients with mDJA.

CT Texture Analysis for Preoperative Identification of Lymphoma from Other Types of Primary Small Bowel Malignancies

Objectives

To explore the application of computed tomography (CT) texture analysis in differentiating lymphomas from other malignancies of the small bowel.

Methods

Arterial and venous CT images of 87 patients with small bowel malignancies were retrospectively analyzed. The subjective radiological features were evaluated by the two radiologists with a consensus agreement. The region of interest (ROI) was manually delineated along the edge of the lesion on the largest slice, and a total of 402 quantified features were extracted automatically from AK software. The inter- and intrareader reproducibility was evaluated to select highly reproductive features. The univariate analysis and minimum redundancy maximum relevance (mRMR) algorithm were applied to select the feature subsets with high correlation and low redundancy. The multivariate logistic regression analysis based on texture features and radiological features was employed to construct predictive models for identification of small bowel lymphoma. The diagnostic performance of multivariate models was evaluated using receiver operating characteristic (ROC) curve analysis.

Results

The clinical data (age, melena, and abdominal pain) and radiological features (location, shape, margin, dilated lumen, intussusception, enhancement level, adjacent peritoneum, and locoregional lymph node) differed significantly between the nonlymphoma group and lymphoma group (p < 0.05). The areas under the ROC curve of the clinical model, arterial texture model, and venous texture model were 0.93, 0.92, and 0.87, respectively.

Conclusion

The arterial texture model showed a great diagnostic value and fitted performance in preoperatively discriminating lymphoma from nonlymphoma of the small bowel.

Ileal Signet Ring Cell Carcinoma Masked by Crohn Disease

Background: Signet ring cell carcinoma (SRCC) is a rare, highly malignant adenocarcinoma that generally involves the stomach; ileal involvement is uncommon. Crohn disease (CD) is associated with long-standing inflammation that may predispose to small intestine adenocarcinoma.

Case Report: A 67-year-old male with ileal CD since age 23 years, maintained in remission by mesalamine, presented with mild intermittent attacks of abdominal cramping, an increase in bowel movements from 3 to 5 daily, and bloating for 3 months. Computed tomography enterography with contrast enhancement demonstrated 2 segments of ileal wall thickening. Colonoscopy performed 7 years prior was unremarkable. The patient received oral prednisone with mild symptomatic improvement; he declined biologics. Ileocolonoscopy 1 month later revealed a nontraversable terminal ileal stricture 15 cm from the ileocecal valve. Biopsy demonstrated signet ring cells infiltrating the lamina propria. The patient underwent laparoscopic ileocecectomy and ileocolic anastomosis. Histopathology of a 2.5-cm ileal mass showed poorly differentiated adenocarcinoma with mucin production and signet ring cell features. One metastatic mesenteric lymph node was identified. Adjuvant chemotherapy was initiated.

Conclusion: This case of metastatic ileal SRCC occurred in the setting of long-standing, clinically controlled CD. Although the absolute risk of small-bowel adenocarcinoma in CD is low, active surveillance for small-bowel adenocarcinoma in patients with longstanding CD may be prudent, given the overlapping symptomology of SRCC and CD, the aggressiveness of SRCC, and the association of SRCC with subclinical inflammation.

Misdiagnosis of multiple synchronous small bowel adenocarcinomas as intestinal tuberculosis: a case report

BACKGROUND

Small bowel adenocarcinoma (SBA) is a rare malignancy that primarily occurs in the duodenum. Multiple synchronous SBA is unique rare and difficult to diagnose due to non-specific disease presentation. Protocols to identify multiple synchronous SBA during early disease stages are urgently required.

CASE PRESENTATION

An elderly man experienced left lower abdominal pain and melena for 3 months. Abdominal CT showed thickening of the multiple segmental small intestinal walls. As the patient had pulmonary tuberculosis simultaneously, he was misdiagnosis as intestinal tuberculosis and received anti-spasm therapy. The treatment delayed radical resection surgery and the patient underwent palliative segmental resection of the jejunum after 4 months due to intestinal obstruction. Resected specimens showed multiple synchronous SBA (five tumors). The patient accepted chemotherapy postoperatively. Six months postoperatively, the patient died of brain metastasis.

CONCLUSIONS

We highlight how multiple synchronous SBA is rare and easily misdiagnosed. We should rule out multiple synchronous SBA when diagnosing intestinal diseases (e.g. inflammatory bowel disease, IBS). Intestinal tuberculosis may also be one of the risk factors for multiple synchronous SBA. High-risk patients should be assessed for known tumor makers, and receive gastroscopy, enteroscopy or capsule endoscopy. Doctors should obtain the pathology under endoscopy to the greatest possible degree. For suspected patients, laparotomy should be performed.

Clinical characteristics of small bowel tumors diagnosed by double-balloon endoscopy: Experience from a Chinese tertiary hospital

BACKGROUND/AIMS

To determine the characteristics of small bowel tumors (SBTs) in patients underwent double balloon endoscopy (DBE) and to compare the clinical value of DBE with other diagnostic tools.

MATERIALS AND METHODS

A retrospective study was conducted in patients underwent DBE procedures from March 2008 to April 2017.The demographic, clinical and pathological characteristics of patients with SBTs were recorded, while the diagnosis of SBTs was achieved either by DBE biopsy or surgical specimens.

RESULTS

One thousand one hundred and two patients (761 males, range 3-85 years) were enrolled in this study, with 1140 procedures completed in total. 99/1102 patients (9.0%) had SBTs, including benign polyps (20, 20.2%), gastrointestinal stromal tumors (GISTs) (24, 24.2%), lymphomas (13, 13.1%), adenocarcinoma (39, 39.4%), and neuroendocrine tumors (3, 3.0%). The most common clinical symptom for benign polyps was obscure gastrointestinal bleeding (OGIB) (75.0%). But among patients with malignant SBTs, the main indication for DBE was chronic abdominal pain (43.8%), followed by OGIB (36.3%), vomit (10.0%), abnormal images (6.3%) and diarrhea (3.8%) (P<0.001). Moreover, SBTs were primarily located in the jejunum alone (40/99, 40.4%). DBE had better sensitivity (89.2%), specificity (95.2%), positive predictive value (PPV) (90.0%), and negative predictive value (NPV) (94.8%) than other tools for suspected SBTs.

CONCLUSION

Small bowel tumor is mainly located in jejunum and with OGIB and abdominal pain as major complaints. DBE is a reliable method for the diagnosis of SBTs compared with other diagnostic tools.

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.

Adenocarcinoma in a Blind Loop of the Ileum 53 Years After an Ileotransversostomy Procedure

BACKGROUND Primary small bowel cancer is a rare malignancy; the common histopathological types are carcinoid and adenocarcinoma. Inflammatory bowel diseases and familial adenomatous polyposis are known risk factors for small bowel cancer. Additionally, cases of surgery-induced small bowel adenocarcinoma are sometimes reported after ileostomy. CASE REPORT A 84-year-old woman, who had undergone ileotransversostomy for intestinal obstruction due to postoperative adhesion following appendectomy at the age of 31 years, was referred to our hospital for further examination after experiencing abdominal pain in the right lower quadrant for 2 weeks. Laboratory data showed elevated serum levels of carcinoembryonic antigen (CEA, 102.9 ng/ml) and carbohydrate antigen 19-9 (CA19-9, 104 U/ml). Enhanced computed tomography (CT) revealed a 10-cm mass in the terminal ileum and a distention of the ileum and colon in the blind loop, with retention of feces. The patient was suspected of having ileal cancer by preoperative examination; therefore, right hemicolectomy with en bloc resection was performed. The tumor was histopathologically diagnosed as a well-differentiated and mucinous adenocarcinoma of the ileum. At over 12 months after surgery, tumor recurrence had not been observed. CONCLUSIONS Difficulties in diagnosis can cause delays in treatment and lead to poor prognosis, mainly because tumors in the small bowel rarely cause clinical symptoms. Adenocarcinoma of the ileum should be considered in postoperative patients with ileotransversostomy.

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.

A 17-year-old male with a Small Bowel Neuroendocrine Tumor: flushing differential diagnosis

Background

Neuroendocrine tumors (NETs) are heterogeneous neoplasms that originate from cells with a secretory function. Small bowel NETs (SB-NETs) are related to serotonin hypersecretion which causes: flushing, diarrhea, abdominal pain, bronchoconstriction and heart involvement, also known as carcinoid syndrome (CS). CS can be confused with an allergic reaction and thus should be considered as a differential diagnosis in the allergy consult. We present the case of a pediatric patient initially referred under the suspicion of food allergies.

Case presentation

We present the case of a 17-year-old male with evanescent non-pruriginous erythematous lesions- flushing that appeared with food consumption, associated with conjunctival injection, warmth and diaphoresis after the lesions disappeared. He denied abdominal pain, diarrhea, cough or wheezing. The 24-h urinary 5-hydroxyindoleacetic acid (5-HIAA) excretion was elevated. The CT scan showed thickening of the distal ileum and multiple lesions on both hepatic lobules and the colonoscopy revealed a tumor in the ileocecal valve. Hepatic and intestinal biopsies reported a well-differentiated NET of the ileocecal valve with hepatic metastasis. He was started on octreotide and underwent a wide hepatectomy and right hemicolectomy with improvement of symptoms.

Conclusions

NETs can present as carcinoid syndrome (flushing, diarrhea, abdominal pain, wheezing), which constitutes vague symptomatology and represents a challenging diagnosis for physicians. They can be confused with an allergic reaction and the allergist should consider it as a differential diagnosis. Accurate diagnostic tests will help to diagnose NETs earlier and potentially prevent carcinoid heart disease, bowel obstruction, and improve quality of life and mortality in these patients.

Trends in incidence, treatment and survival of small bowel adenocarcinomas between 1999 and 2013: a population-based study in The Netherlands

BACKGROUND

We conducted a population-based study to establish the incidence, treatment and overall survival over time of patients with small bowel adenocarcinoma.

MATERIAL AND METHODS

All patients diagnosed with small bowel adenocarcinoma in the Netherlands between 1999 and 2013 were included (n = 1775). Age-standardized incidence rates were calculated per 100 000 person-years using the European standardized population rate. The influence of patient and tumor characteristics on the administration of chemotherapy was analyzed by means of a multivariable logistic regression analysis. The Cochran-Armitage trend test was conducted to evaluate trends in treatment and survival and the Cox proportional hazards model was used to identify prognostic factors of overall survival.

RESULTS

The incidence of small bowel adenocarcinomas increased, mainly due to an almost twofold increase of duodenal adenocarcinomas. Patients with locoregional duodenal tumors were less likely to undergo surgery (58%), towards 95% of the locoregional jejunal and ileal tumors (p < 0.0001). The use of chemotherapy doubled for adjuvant (7-15%) and palliative chemotherapy (19-37%). Median overall survival of patients with locoregional disease increased from 19 to 34 months (p = 0.0006), whereas median overall survival of patients with metastatic disease remained 4-5 months. Favorable prognostic factors for prolonged survival in locoregional disease, identified by multivariable survival analysis, included age <60 years, tumor stage I or II, diagnosis in 2009-2013, surgical treatment and chemotherapy. Favorable prognostic factors for prolonged survival in metastatic disease were age <50 years, jejunal tumors, surgical treatment and chemotherapy.

CONCLUSION

Small bowel adenocarcinomas are rare tumors with an increasing incidence. The administration of adjuvant and palliative chemotherapy doubled, but median overall survival only increased for patients with locoregional disease. Given the rarity and dismal prognosis, it is important to develop international studies to determine the optimal treatment for these patients.

Genetic risks and familial associations of small bowel carcinoma

Adenocarcinoma of small intestines (SBA) is a relatively rare malignancy with poor outcomes due to delayed diagnosis. Fifty percent of patients have metastases on presentation and therefore early detection and treatment offers the best long term outcomes. Certain genetic polyposis syndromes and familial diseases are associated with increased risks for SBA. These include familial adenomatous polyposis (FAP), Lynch syndromes (LS), Juvenile polyposis syndrome, Peutz-Jeghers syndrome, Crohn’s disease (CD) and celiac disease. Mutations in APC gene, Mismatch repair genes, STK11 gene, and SMAD4 gene have been implicated for the genetic diseases respectively. While there are no specific inherited genetic mutations for CD, genome-wide association studies have established over 140 loci associated with CD. CpG island mutations with defects in mismatch repair genes have been identified in celiac disease. Significant diagnostic advances have occurred in the past decade and intuitively, it would seem beneficial to use these advanced modalities for surveillance of these patients. At present it is debatable and no clear data exists to support this approach except for established guidelines to diagnose duodenal polyps in FAP, and LS. Here we discuss the genetic alterations, cancer risks, signaling mechanisms and briefly touch the surveillance modalities available for these genetic and clinical syndromes. English language articles from PubMed/Medline and Embase was searched were collected using the phrases “small-bowel adenocarcinoma, genetics, surveillance, familial adenomatous polyposis, lynch syndromes, Peutz-Jeghers syndrome, juvenile polyposis syndrome, CD and celiac disease”. Figures, tables and schematic diagram to illustrate pathways are included in the review.

A potential association between exposure to hepatitis B virus and small bowel adenocarcinoma

Chronic infection with hepatitis B virus (HBV) has never been described as a risk factor for small bowel adenocarcinoma, although infection is a known risk factor for hepatocellular carcinoma. From May 2009 to December 2014, we implemented an institution-wide screening program for hepatitis B viral serologies prior to starting chemotherapy. Evidence of exposure [hepatitis B core antibody (anti-HBc) positivity in the absence of hepatitis B surface antigen (HBsAg) positivity] was highest in patients with hepatocellular carcinoma (21.1%), followed by small bowel cancer (12.5%). The small bowel adenocarcinoma cases with anti-HBc positivity were reviewed. Special attention was paid to known risk factors for small bowel cancers. One patient had a diagnosis of hereditary nonpolyposis colorectal cancer (HNPCC). However, the other patients had no genetic syndromes, history of inflammatory bowel disease or other chronic inflammation to explain their risk. We postulate exposure to bile acids, tumorigenesis of hepatocytes and cholangiocytes, and/or damage to the intestinal mucosa secondary to HBV exposure/infection as potential mechanisms for development of small bowel adenocarcinoma. More research is warranted to further elucidate this association.

Most small bowel cancers are revealed by a complication

Objective

To characterize the pattern of primary small bowel cancers in a tertiary East-European hospital.

Methods

A retrospective study of patients with small bowel cancers admitted to a tertiary emergency center, over the past 15 years.

Results

There were 57 patients with small bowel cancer, representing 0.039% of admissions and 0.059% of laparotomies. There were 37 (64.9%) men, mean age of 58 years; and 72 years for females. Out of 57 patients, 48 (84.2%) were admitted due to an emergency situation: obstruction in 21 (38.9%), perforation in 17 (31.5%), upper gastrointestinal bleeding in 8 (14.8%), and lower gastrointestinal bleeding in 2 (3.7%). There were 10 (17.5%) duodenal tumors, 21 (36.8%) jejunal tumors and 26 (45.6%) ileal tumors. The most frequent neoplasms were gastrointestinal stromal tumor in 24 patients (42.1%), adenocarcinoma in 19 (33.3%), lymphoma in 8 (14%), and carcinoids in 2 (3.5%). The prevalence of duodenal adenocarcinoma was 14.55 times greater than that of the small bowel, and the prevalence of duodenal stromal tumors was 1.818 time greater than that of the small bowel. Obstruction was the complication in adenocarcinoma in 57.9% of cases, and perforation was the major local complication (47.8%) in stromal tumors.

Conclusion

Primary small bowel cancers are usually diagnosed at advanced stages, and revealed by a local complication of the tumor. Their surgical management in emergency setting is associated to significant morbidity and mortality rates.

Adenocarcinoma of the ileum: A rare and challenging entity

Introduction

Primary small bowel malignancy is unusual and accounts for 1–3% of all gastrointestinal tract neoplasms. Adenocarcinoma is one of the most common histologic types, but its frequency decreases with more distal locations. Its clinical presentation is nonspecific and is usually associated with advanced disease, which contributes to delayed diagnosis.

Presentation of case

A 66-year-old woman was admitted to the hospital with a 6-day history of progressively worsening abdominal pain localized in the right lower quadrant, nausea, and vomiting. Investigation revealed an inflammatory appendiceal tumor. The patient underwent surgery and an unexpected tumor involving the distal ileal segment and ileocecal appendix was found. Right radical hemicolectomy with en bloc resection of the distal ileum was performed. Histopathological examination revealed adenocarcinoma of the ileum.

Discussion

This rare entity is associated with a nonspecific clinical presentation that contributes to delayed diagnosis and treatment, and consequently to a worse prognosis. Approximately half of the cases are only diagnosed at surgery. Primary treatment consists of wide resection with locoregional lymphadenectomy. The role of adjuvant chemotherapy has yet to be determined.

Conclusion

This case demonstrates an unusual condition characterized by late and challenging diagnosis. We highlight the importance of an earlier diagnosis and optimal treatment for improved patient outcomes.

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Small bowel adenocarcinoma is a rare tumor with a late and challenging diagnosis.

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Primary treatment consists in wide resection with locoregional lymphadenectomy.

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The role of adjuvant chemotherapy has yet to be determined.

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It is crucial an earlier diagnosis and optimal treatment to improve the outcome.