Primary adenocarcinoma of the small intestine: presentation, prognostic factors and clinical outcome

Clinicopathological features and prognosis of primary small bowel adenocarcinoma: a large multicenter analysis of the JSCCR database in Japan

BACKGROUND

The clinicopathological features and prognosis of primary small bowel adenocarcinoma (PSBA), excluding duodenal cancer, remain undetermined due to its rarity in Japan.

METHODS

We analyzed 354 patients with 358 PSBAs, between January 2008 and December 2017, at 44 institutions affiliated with the Japanese Society for Cancer of the Colon and Rectum.

RESULTS

The median age was 67 years (218 males, 61.6%). The average tumor size was 49.9 (7-100) mm. PSBA sites consisted of jejunum (66.2%) and ileum (30.4%). A total of 219 patients (61.9%) underwent diagnostic small bowel endoscopy, including single-balloon endoscopy, double-balloon endoscopy, and capsule endoscopy before treatment. Nineteen patients (5.4%) had Lynch syndrome, and 272 patients (76.8%) had symptoms at the initial diagnosis. The rates for stages 0, I, II, III, and IV were 5.4%, 2.5%, 27.1%, 26.0%, and 35.6%, respectively. The 5-year overall survival rates at each stage were 92.3%, 60.0%, 75.9%, 61.4%, and 25.5%, respectively, and the 5-year disease-specific survival (DSS) rates were 100%, 75.0%, 84.1%, 59.3%, and 25.6%, respectively. Patients with the PSBA located in the jejunum, with symptoms at the initial diagnosis or advanced clinical stage had a worse prognosis. However, multivariate analysis using Cox-hazard model revealed that clinical stage was the only significant predictor of DSS for patients with PSBA.

CONCLUSIONS

Of the patients with PSBA, 76.8% had symptoms at the initial diagnosis, which were often detected at an advanced stage. Detection during the early stages of PSBA is important to ensure a good prognosis.

Outcomes of Metastatic and Unresectable Small Bowel Adenocarcinoma in Japan According to the Treatment Strategy: A Nationwide Observational Study

PURPOSE

Limited information is available regarding the characteristics and outcomes of stage IV small bowel adenocarcinoma (SBA) in Japan. This study examined the clinical and pathological characteristics and outcomes according to the treatment strategies in patients with stage IV SBA.

METHODS

This retrospective observational study used the data of patients with jejunal or ileal adenocarcinoma collected by the Small Bowel Malignant Tumor Project of the Japanese Society for Cancer of the Colon and Rectum. Descriptive statistics were expressed as the mean (standard deviation) or median (range). Survival analysis was performed using Kaplan-Meier curves and pairwise log-rank tests.

RESULTS

Data from 128 patients were analyzed. The treatment strategies were chemotherapy alone (26 of 128, 20.3%), surgery alone (including palliative surgery; 21 of 128, 16.4%), surgery + chemotherapy (74 of 128, 57.8%), and best supportive care (7 of 128, 5.5%). The median (range) overall survival was 16 (0-125) months overall, and 11 (1-38) months, 8 (0-80) months, 18 (0-125) months, and 0 (0-1) months for the chemotherapy, surgery, surgery + chemotherapy, and best supportive care groups, respectively. Three main categories of chemotherapeutic regimen were used: a combination of fluoropyrimidine and oxaliplatin (F + Ox), fluoropyrimidine and irinotecan (F + Iri), and single-agent fluoropyrimidine. Among patients treated with chemotherapy, the median (range) OS was 16 (1-106) months overall, and 17 (1-87) months, 29 (7-39) months, and 16 (1-106) months in patients treated with fluoropyrimidine, F + Iri, and F + Ox, respectively.

CONCLUSION

Patients treated with surgery, chemotherapy, or both had a better prognosis than those who received best supportive care. Among patients who received chemotherapy, survival did not differ according to the chemotherapeutic regimen.

Evaluation of Systemic Treatments of Small Intestinal Adenocarcinomas: A Systematic Review and Meta-analysis

Importance

Although small intestinal adenocarcinomas (SIAs) are rare, they have a poor prognosis, and the optimal treatment strategies are largely unknown. Because of the lack of high-quality evidence, guidelines for colorectal cancer are often followed in the treatment of SIAs.

Objective

To review the current evidence regarding survival benefit of systemic therapies, including chemotherapy, targeted agents, and immunotherapy, for patients with SIAs.

Data Sources

Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses, MEDLINE and Embase were searched for articles published from January 1, 2005, until June 1, 2022.

Study Selection

Retrospective cohort studies and prospective phase 2 or 3 trials describing survival after systemic therapies for patients with SIAs were eligible for inclusion. Assessment of study eligibility was blinded and performed by 3 reviewers.

Data Extraction and Synthesis

The reviewers independently extracted data. Random effects, inverse variance, pairwise meta-analyses were performed.

Main Outcomes and Measures

Primary outcomes were overall survival (OS) and progression-free survival (PFS) of patients with SIAs after systemic therapies. Measures of interest included hazard ratios for survival and median survival times.

Results

Overall, 57 retrospective cohort and phase 2 studies of 35 176 patients were included. Adjuvant chemotherapy, generally fluoropyrimidine-based, was associated with increased OS in stage I to III SIAs (hazard ratio [HR], 0.60; 95% CI, 0.53-0.68), especially in stage III tumors (HR, 0.55; 95% CI, 0.48-0.64), irrespective of tumor localization. Palliative chemotherapy was also associated with an OS benefit (HR, 0.48; 95% CI, 0.40-0.58). Fluoropyrimidine-oxaliplatin combinations were superior to other regimens (OS: HR, 0.54; 95% CI, 0.30-0.99; PFS: HR, 0.46; 95% CI, 0.30-0.71). Furthermore, bevacizumab added to chemotherapy compared with chemotherapy alone was associated with significantly prolonged PFS (HR, 0.62; 95% CI, 0.43-0.89). Immunotherapy showed a 50% overall response rate in previously treated defective mismatch repair tumors.

Conclusions and Relevance

In this systematic review and meta-analysis, adjuvant and palliative chemotherapy were both associated with improved survival of patients with SIAs, especially fluoropyrimidine-based regimens and fluoropyrimidine-oxaliplatin combinations. Adding bevacizumab to chemotherapy appears to prolong PFS and deserves further investigation. Immunotherapy seems beneficial and should be considered for patients with defective mismatch repair tumors. International collaborations should be undertaken to confirm and improve efficacy of systemic therapies for patients with SIAs.

Characteristics and outcomes of small bowel adenocarcinoma: 14 years of experience at a single tertiary hospital in Saudi Arabia

Small bowel adenocarcinoma (SBA) is an extremely rare cancer type. In the present study, the patient characteristics and clinical outcomes of patients diagnosed and treated for SBA at a single tertiary hospital were reported. All patients diagnosed and managed between 2007 and 2020 were reviewed. Regression analysis was used to assess variables associated with the metastatic stage at diagnosis. The Kaplan-Meier method was used to estimate survival and the log-rank test was used to determine factors associated with survival outcomes. Out of 137 cases of small bowel primary tumor, 43 consecutive patients with SBA were diagnosed with a median age of 53 years and the majority (76.7%) were males. The common initial presenting symptoms were abdominal pain (58.8%) and bowel obstruction (30.2%). The most common primary site was the duodenum (60.5%) and the majority (65.1%) were diagnosed with stage III/IV disease. Patients with a high neutrophil-lymphocyte ratio (NLR) (≥0.85) were more likely to be in the metastatic stage at diagnosis (P=0.01). The 3-year overall survival (OS) rates based on stage were 100% (I), 85% (II), 53% (III) and 33.9% (IV) (P=0.001). In addition to the stage, the Eastern Cooperative Oncology Group Performance Status (P<0.001), NLR (P<0.001), hypoalbuminemia (P=0.02) and chemotherapy in a metastatic setting (P=0.02) were prognostic factors for OS. In conclusion, NLR is a potential prognostic biomarker for a metastatic stage at diagnosis. Advanced stage, lower performance status score, low albumin level and high NLR are associated with short OS.

Clinical practice guidelines for duodenal cancer 2021

Duodenal cancer is considered to be a small intestinal carcinoma in terms of clinicopathology. In Japan, there are no established treatment guidelines based on sufficient scientific evidence; therefore, in daily clinical practice, treatment is based on the experience of individual physicians. However, with advances in diagnostic modalities, it is anticipated that opportunities for its detection will increase in future. We developed guidelines for duodenal cancer because this disease is considered to have a high medical need from both healthcare providers and patients for appropriate management. These guidelines were developed for use in actual clinical practice for patients suspected of having non-ampullary duodenal epithelial malignancy and for patients diagnosed with non-ampullary duodenal epithelial malignancy. In this study, a practice algorithm was developed in accordance with the Minds Practice Guideline Development Manual 2017, and Clinical Questions were set for each area of epidemiology and diagnosis, endoscopic treatment, surgical treatment, and chemotherapy. A draft recommendation was developed through a literature search and systematic review, followed by a vote on the recommendations. We made decisions based on actual clinical practice such that the level of evidence would not be the sole determinant of the recommendation. This guideline is the most standard guideline as of the time of preparation. It is important to decide how to handle each case in consultation with patients and their family, the treating physician, and other medical personnel, considering the actual situation at the facility (and the characteristics of the patient).

Small Bowel Adenocarcinoma: A Rare Case of Iron Deficiency Anemia

Neoplasms of the small bowel are relatively rare, with less than 5% occurrence among other GI cases. Primary adenocarcinoma, an aggressive sub-type of small bowel cancers, usually presents with vague blood loss and abdominal pain symptoms, causing a delayed diagnosis at an advanced stage of the disease and a poor prognosis. The preferable treatment of choice is surgical resection with chemotherapy, which has shown to have survival benefits. Here we present a case of a 66-year-old male patient with persistent iron deficiency anemia requiring multiple blood transfusions and an unexplained weight loss. A series of diagnostic tests, including upper and lower GI endoscopy, Tc-99 RBC scintigraphy, barium follow-through, CT scans, bone marrow biopsy, esophagogastroduodenoscopy and colonoscopy were inconclusive. He was later diagnosed with a small bowel adenocarcinoma on exploratory laparotomy and surgically treated. Adjuvant chemotherapy was also started. Our case report highlights the course of SBA presenting in an unusual way which was challenging to diagnose with the standard investigations to help physicians/surgeons suspect it at an early stage in the future. This may save patients and help avoid delayed diagnosis or misdiagnosis, especially in patients with an unusual presentation like our patient who presented only with iron deficiency anemia.

Small bowel adenocarcinoma in Crohn's disease: a systematic review and meta-analysis of the prevalence, manifestation, histopathology, and outcomes

BACKGROUND AND AIMS

Small bowel adenocarcinoma (SBA) is a rare neoplasm that is associated with Crohn's disease (CD). This study aims to quantify the prevalence of CD-SBA, review the current evidence of histopathology and molecular analysis findings, and identify the clinical presentation and outcomes of CD-SBA.

METHODS

Electronic databases Medline and Embase were searched for articles describing SBA in inflammatory bowel disease patients. The histopathology, molecular analysis findings, clinical presentation, prevalence, and outcomes of CD-SBA were extracted, and results were pooled with random effects.

RESULTS

In total, 33 articles were included in the analysis. Prevalence of SBA was 1.15 (CI: 0.31-2.33) per 1000 CD patients. Only 11% (CI: 0.04-0.21) of CD-SBA patients had observable radiological features. CD-SBA was most commonly found in the ileum (84%), diagnosed at stage 2 (36%), with main presenting complaints including obstruction, weight loss, and abdominal pain. Significant histopathological findings included adjacent epithelial dysplasia, and an equal distribution of well-differentiated (49%) and poorly differentiated subtypes (46%). Most prevalent genetic mutation was KRAS mutation (18%), followed by mismatch repair deficiency (9.7%). The 5-year overall survival for CD-SBA patients was 29% (CI: 0.18-0.41), and 33% (CI: 0.26-0.41) for de novo SBA. No statistically significant increase in risk for CD-SBA was noted for treatment with thiopurines, steroids, and 5-ASA.

CONCLUSION

Our meta-analysis found the prevalence of CD-SBA to be 1.15 per 1000 CD patients. The 5-year overall survival for CD-SBA was poor. The presenting symptoms were non-specific, and therefore the diagnosis requires a high index of suspicion.

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

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

Prognostic implication of SOX2 expression in small intestinal adenocarcinoma

The presence of KRAS mutation enhances the stem cell features of colorectal carcinoma cells containing mutant adenomatous polyposis coli (APC). However, their potential role in small intestinal adenocarcinoma remains elusive. Here, we aimed to investigate the clinical significance of cancer stem cell markers expression in the context of small intestinal adenocarcinoma with the KRAS genotype. SOX2, NANOG, and OCT4 expression were assessed by immunohistochemistry and digital image analysis, and their potential association with KRAS was further examined in 185 Korean patients with small intestinal adenocarcinomas, which were collected from 22 institutions in South Korea. Positive expression of SOX2, NANOG, and OCT4 was detected in 65 (35.1%), 94 (50.8%), and 82 (44.3%) of patients, respectively. Patients with high SOX2 (SOX2+) expression displayed worse overall survival compared to those with low SOX2 (SOX2-) expression (P < 0.001). Patients with SOX2+/mutant KRAS (KRAS^MT) (11.1 months) had significantly shorter overall survival than those with SOX2-/KRAS^WT (53.6 months) (P < 0.001). In multivariate analysis, SOX2+, distal location, high pT and pN categories, microsatellite stable, and absence of predisposing diseases were independent prognostic factors for worse overall survival. These results suggest that SOX2 expression has the potential to predict clinical outcomes in patients with small intestinal adenocarcinomas.

The risk of small bowel adenocarcinoma in patients with Crohn's disease

Introduction

Small bowel adenocarcinoma (SBA) is an unusual complication of Crohn’s disease (CD).

Aim

To describe the incidence rate, clinical features, and outcomes of SBA in a group of subsequent patients with CD.

Material and methods

We retrospectively analysed outpatient and hospital records and identified a group of patients with diagnosed CD. Then we reviewed all medical records of patients who reported for follow-up visits in a 14-year period. We identified a group of 103 patients, whose medical records were evaluated for the presence of SBA.

Results

Long-term follow-up carried out in the group of consecutively treated patients with CD revealed an 0.97% incidence rate of SBA. Cancer was located in the ileum and the clinical presentation was subileus and anaemia. The patient underwent ileocaecal resection, and the postoperative period was uneventful.

Conclusions

SBA is a rare complication of CD. Although the authors are aware that the number of patients enrolled in the study is insufficient to draw far-reaching conclusions, the results obtained are significant for determination of the incidence rate of SBA in the Caucasian population of patients with CD. The key issue of effective treatment of patients with SBA was early detection of the lesion and R0 resection with proper lymphadenectomy. However, it is worth noting that in more advanced stages of SBA the future belongs to, and outcome improvement depends on, new regimes of adjuvant personalised chemotherapies. Further studies on the mechanisms of carcinogenesis in patients with CD are essential.

Loss of HES-1 Expression Predicts a Poor Prognosis for Small Intestinal Adenocarcinoma Patients

Objective: Hairy and enhancer of split-1 (HES-1), which is a downstream target of the Notch signaling pathway, has been linked to KRAS mutations. HES-1 has been proposed as harboring oncogenic activity in colorectal cancer but has not been investigated in adenocarcinoma of the small intestine, where the drivers of oncogenesis are not as well-understood. Materials and Methods: To investigate the clinicopathologic and prognostic implications of HES-1, HES-1 immunohistochemical expression was analyzed in digital images along with clinicopathological variables, including survival and KRAS genotype, in 185 small intestinal adenocarcinomas. Results: The loss of HES-1 expression (HES-1^Loss) was observed in 38.4% (71/185) of the patients, and was associated with higher pT category (P = 0.018), pancreatic invasion (P = 0.005), high grade (P = 0.043), and non-tubular histology (P = 0.004). Specifically, in tumors with mutant KRAS (KRAS ^MT), HES-1^Loss was related to proximal location (P = 0.024), high T and N categories (P = 0.005 and 0.047, respectively), and pancreatic invasion (P = 0.004). Patients with HES-1^Loss showed worse overall survival compared to those with intact HES-1 (HES-1^Intact) (P = 0.013). Patients with HES-1^Loss/KRAS ^MT (median, 17.3 months) had significantly worse outcomes than those with HES-1^Intact/KRAS ^WT (39.9 months), HES-1^Intact/KRAS ^MT (47.6 month), and HES-1^Loss/KRAS ^WT (36.2 months; P = 0.010). By multivariate analysis, HES-1^Loss (hazard ratio = 1.55, 95% confidence interval (CI), 1.07-2.26; P = 0.022) remained an independent prognostic factor. Conclusion: HES-1expression can be used as a potential prognostic marker and may aid in the management of patients with small intestinal adenocarcinomas.

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.

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.

Adenocarcinoma of jejunum

Although gastrointestinal malignancy is still the major concern of health problems in Worldwide and Thailand, but small intestinal malignancy is extremely rare. The location of small intestinal malignancy is duodenum (73.6%), jejunum (13.2%) and ileum (13.2%). The diagnosing of small intestinal malignancy usually delays due to inaccessible of esophagogastroduodenoscopy especially jejunum and ileum causing poor prognostic outcomes. We reported our case of jejunal adenocarcinoma.

Prognostic factors of non-ampullary duodenal adenocarcinoma

Background

Non-ampullary duodenal adenocarcinoma, excluding carcinoma in the ampulla of Vater, is a rare disease. Although several prognostic factors have been reported, they remain controversial due to the rarity of non-ampullary duodenal adenocarcinoma. The aims of this study were to investigate prognostic factors in patients with non-ampullary duodenal adenocarcinoma and to assess chemotherapy in patients with recurrence.

Patients and methods

Records of 25 patients who underwent surgical treatment for non-ampullary duodenal adenocarcinoma from 2004 to 2016 were retrospectively reviewed. The relationship between the clinicopathological factors and outcomes was investigated.

Results

Serum level of CA19-9, gross appearance, tumor size, tumor invasion, lymph node metastases, TNM stage and lymphatic and vascular invasion were significant risk factors of recurrence. Patients with recurrence who received chemotherapy according to regimens used to treat colorectal cancer had a better prognosis than those without chemotherapy (P = 0.016).

Conclusion

Advanced non-ampullary duodenal adenocarcinoma has a poor prognosis, but chemotherapy possibly improves the prognosis in the patients with recurrent non-ampullary duodenal adenocarcinoma.

Primary small bowel adenocarcinoma: current view on clinical features, risk and prognostic factors, treatment and outcome

Small bowel adenocarcinoma (SBA) is a rare but increasing cause of gastrointestinal malignancy, being both a diagnostic and therapeutic challenge. The goal of treatment is margin negative resection of a lesion and local lymphadenectomy, followed by modern adjuvant chemotherapy combinations in selected cases. Improved outcomes in patients with SBA are encouraging, but elucidation of mechanisms of carcinogenesis and risk factors as well as improved treatment for this malignancy is very needed.

The characteristics and outcomes of small bowel adenocarcinoma: a multicentre retrospective observational study

Background:

Small bowel adenocarcinoma (SBA) is a rare malignancy that accounts for 1–2% of gastrointestinal tumours. We investigated the clinical characteristics, outcomes, and prognostic factors of primary SBA.

Methods:

We retrospectively analysed the characteristics and clinical courses of 205 SBA patients from 11 institutions in Japan between June 2002 and August 2013.

Results:

The primary tumour was in the duodenum and jejunum/ileum in 149 (72.7%) and 56 (27.3%) patients, respectively. Sixty-four patients (43.0%) with duodenal adenocarcinoma were asymptomatic and most cases were detected by oesophagogastroduodenoscopy (EGD), which was not specifically performed for the detection or surveillance of duodenal tumours. In contrast, 47 patients (83.9%) with jejunoileal carcinoma were symptomatic. The 3-year survival rate for stage 0/I, II, III, and IV cancers was 93.4%, 73.1%, 50.9%, and 15.1%, respectively. Multivariate analysis revealed performance status 3–4, high carcinoembryonic antigen, high lactate dehydrogenase (LDH), low albumin, symptomatic at diagnosis, and stage III/IV disease were independent factors for overall survival (OS). Ten patients (18.5%) with stage IV disease were treated with a combination of resection of primary tumour, local treatment of metastasis, and chemotherapy; this group had a median OS of 36.9 months.

Conclusions:

Although most SBA patients were diagnosed with symptomatic, advanced stage disease, some patients with duodenal carcinoma were detected in early stage by EGD. High LDH and symptomatic at diagnosis were identified as novel independent prognostic factors for OS. The prognosis of advanced SBA was poor, but combined modality therapy with local treatment of metastasis might prolong patient survival.

Small bowel adenocarcinoma of the jejunum: a case report and literature review

Background

In practice, small bowel cancer is a rare entity. The most common histologic subtype is adenocarcinoma. Adenocarcinoma of the small bowel (SBA) is challenging to diagnose, often presents at a late stage and has a poor prognosis. The treatment of early-stage SBA is surgical resection. No standard protocol has been established for unresectable or metastatic disease.

Case presentation

We report here on a 26-year-old man with SBA in the jejunum, lacking specific symptoms and with a delay of 6 months in diagnosis. The diagnosis was finally achieved with a combination of balloon-assisted enteroscopy, computed tomography scans, positron emission computed tomography scans and the values of carcino-embryonic antigen and carbohydrate antigen 19-9. The patient underwent segmental intestine with lymph node resection, followed by eight cycles of FOLFOX palliative chemotherapy with good tolerance. As of the 11-month postoperative follow-up, there has been no evidence of recurrent disease.

Conclusions

This case is reported to arouse a clinical suspicion of SBA in patients with abdominal pain of unknown cause. We also provided evidence in this case of a response to palliative chemotherapy with FOLFOX. Because the incidence of SBA is very low, there is a need for further studies to evaluate the possible application of newer investigative agents and strategies to obtain a better outcome within the framework of international collaborations.

[Primary adenocarcinoma of the terminal ileum, synchronous]

BACKGROUND

Among the rarest types of cancer found are the small intestine malignancies, representing only 2% of all gastrointestinal cancer and 0.1-0.3% of all malignancies. The most common subtype of this tumour is the adenocarcinoma, which is located mainly in the duodenum, jejunum and, rarely, in ileum.

CLINICAL CASE

A 75 year-old male, with no any surgical history, who in the previous three months, referred to two clinical episodes of partial bowel obstruction and unquantified weight loss. When admitted into the surgical service, the patient referred to a partial bowel obstruction of more than one week onset. A laparotomy was performed, finding 3 stenosis rings at the ileum end portion, carrying out an intestinal resection and enteral-enteral anastomosis. On the seventh day there was dehiscence of the anastomosis and abdominal sepsis. New surgery was performed with the resection of the intestinal anastomosis and an ileostomy. The pathologist report indicated a small bowel adenocarcinoma moderately differentiated, ulcerated, and multifocal. It was classified as stage III or T3N1M0. The patient progress was satisfactorily, managed as outpatient with postoperative chemotherapy with 5 fluorouracil and cisplatin. The patient died a year later due to liver metastases.

CONCLUSIONS

Due to the extreme rarity of the case, is very likely that general surgeons may find one or two cases of adenocarcinoma of the ileum in their professional career. Thus, they must suspect this pathology when faced with an episode of intestinal obstruction in the adult.

Synchronous mucinous colonic adenocarcinoma and multiple small intestinal adenocarcinomas: report of a case and review of literature

With the wide use of diagnostic imaging modalities, multiple primary malignancies frequently occur; different associations of malignancies have been reported. We describe the case of a primary mucinous adenocarcinoma of large bowel synchronous with three primary poorly differentiated adenocarcinomas of ileum. This type of association has not been described yet; since computed tomography increasingly is proving to be highly accurate in detection of colon cancer, this technique is recommended in such patients.

Small bowel adenocarcinoma (SBA) three years after colonic adenocarcinoma in an elderly patient: Case report in a National Institute of Health and Aging (INRCA) and review of the literature

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Only early diagnosis and resection are factors that can prolong patient survival.

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Physician's suspicion and early detection are crucial to increase resecability of SBA.

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Multi institutional cooperation is essential because of the rarity of this tumor.

INTRODUCTION

Adenocarcinoma of the small intestine is a rare malignancy (the annual incidence in the USA is approximately 3.9 cases per million persons with median age between 60 and 70 years) with limited data available to guide therapeutic decisions. Nonspecific signs and symptoms associated with difficulty in performing small bowel examination is the cause of delayed diagnosis made between 6 and 9 months after appearance of symptoms with the majority of patients presenting with late stage disease and either lymph node involvement or distant metastatic disease.

PRESENTATION OF CASE

An 87-year-old man treated 3 years previously for colonic adenocarcinoma with left colectomy, was brought to our attention with a 4.5 cm × 3.5 cm mass in the proximal jejunum associated with another abdominal wall enhancing mass of 5 cm in diameter in the rectus muscle. Diagnosis on gross examination after surgical resection was adenocarcinoma stage III (T4N1M0) with involvement of lymph nodes.

DISCUSSION

According to an analysis of the Surveillance, Epidemiology and End Results (SEER) database, patients who develop either a small or large intestine adenocarcinoma are at increased risk for a second cancer at both intestinal sites. The role of adjuvant therapy in patients who undergo curative resection is unclear. Recent retrospective and prospective studies have helped to clarify the optimal chemotherapy approach for advanced small bowel adenocarcinoma.

CONCLUSION

With our work, we present our personal case of metachronous primary carcinoma of small bowel following resected colorectal carcinoma and review the literature.

Adenocarcinoma with adenoma in the jejunum suggesting an adenoma-carcinoma sequence in the small bowel: A case report

Other than that in the duodenum, adenocarcinoma in the small bowel is rare. The present study describes a case of adenocarcinoma with adenoma in the jejunum. A 70-year-old male was admitted to hospital due to dehydration induced by abdominal discomfort and difficulty with oral intake. Computed tomography revealed a tumor in the upper side of the jejunum, which was subsequently resected. The tumor contained adenocarcinoma and adenoma. The protein expression of p53 and Ki-67 was analyzed in the normal mucosa, adenoma and adenocarcinoma. The number of epithelial cells expressing p53 and Ki-67 was found to increase in the adenoma tissue compared with that in the normal mucosa. In the adenocarcinoma tissue, the number of cells expressing p53 and Ki-67 further increased, suggesting that an adenoma-adenocarcinoma sequence may occur in the small bowel, similar to that observed in the large bowel.

Small bowel adenocarcinoma - terra incognita: A demand for cross-national pooling of data

To date, due to the rarity, tumor biology and carcinogenesis of small bowel adenocarcinoma (SBA), the disease has been explored insufficiently and immunophenotyping and molecular characterization have not been finalized. This knowledge gap consecutively leads to an overt lack of diagnostic and therapeutic recommendations. In the current study, we provide our experience with the treatment of SBA, and demand for cross-national data pooling to enable unlimited information transfer and higher powered study. A comprehensive database of all patients with SBA was established and consecutively reviewed for clinicopathohistological data, information concerning preoperative evaluation, surgical and chemotherapeutical treatment, as well as outcome parameters. Patients underwent curative intended surgery (42.4%; n=14), adjuvant chemotherapy (CTX) following resection (36.4%; n=12) or palliative care (21.2%; n=7). The majority of patients were diagnosed at an advanced disease stage (pT3, 36.4%; pT4, 39.4%) and the duodenum was the most common tumor site (57.1%; n=20). Complete surgical resection was achieved in 88.5% of patients, while postoperative complications occurred in 19.4%. Within a mean follow-up period of 31.4 months, 17 patients succumbed to the disease following a median survival time of 11 months. Mean overall survival (OS) was 47.4, 25.3 and 9.8 months for surgically, surgically and chemotherapeutically and palliatively treated patients, respectively. Early surgical resection remains the mainstay in the treatment of localized SBA, since it is associated with a prolongation of OS. The role of neoadjuvant and adjuvant CTX has not yet been defined. Thus, since no consensus exists on the adequate treatment of these malignancies, we demand an international collaboration and cross-national data pooling to pave the way for the implementation of evidence-based standard care operating procedures.

Challenging diagnosis of a jejunal adenocarcinoma with ovarian metastasis: report of an unusual case

We report the first documented case of ovarian metastasis from a jejunal primary adenocarcinoma in an Australian patient. The presentation was unusual, initially a suspicious abdominal nodule in the epigastric area, which turned out to be an adenocarcinoma of possible intestinal origin. Gastroscopy and colonoscopy were performed with no suspicious lesion identified. Abdominal and pelvic ultrasound imaging showed a complex pelvic mass suspicious of ovarian cancer. Laparoscopy was performed to exclude possibility of ovarian cancer and small bowel cancer. The ovarian mass showed similar features from the epigastric nodule, again suggestive of intestinal primary. Definitive diagnosis was obtained when the patient represented 2 months later with malignant bowel obstruction requiring palliative resection of the proximal jejunum. This case demonstrates the difficulty in diagnosing ovarian metastasis from a small bowel primary, which has the potential to mimic an ovarian primary tumour clinically, and a large bowel or ovarian primary pathologically.

An elderly woman with triple primary metachronous malignancy: A case report and review of literature

INTRODUCTION

Prevalence of multiple primary malignancies is slowly increasing due to prolonged survival of cancer patients with advances in diagnostic and therapeutic modalities. The reasons may be environmental modifications, genetic predisposition or therapy induced. We describe a case of a 64-year-old woman with three different metachronous primary malignancies managed at our center since 4 years.

PRESENTATION OF CASE

First primary diagnosed in our patient was adenocarcinoma of small intestine which is a rare gastrointestinal malignancy. For this she underwent surgical resection followed by chemotherapy. After 21 months she developed infiltrating duct carcinoma of breast which was managed with modified radical mastectomy and chemotherapy. Again after latent period of 10 months patient had papillary adenocarcinoma of ovary for which she was administered chemotherapy. During follow up tumor was found to be chemoresistant and again she underwent cytoreductive surgery followed by chemotherapy.

DISCUSSION

In present case patient did not have significant risk factors for development of carcinoma of small intestine, breast and ovary. Our patient underwent surgical excision three times and received total 16 chemotherapy cycles of different regimens during management of all three primary malignancies. Development of second and higher order primary malignancy after successful management of previous one should be always kept in mind.

CONCLUSION

Awareness, suspicion of multiple primary malignancy and aggressive diagnostic work up plays crucial role in their detection at earlier stage for better outcome. In addition choice of appropriate chemotherapeutic agents and their regimens remains the cornerstone while managing the patients with multiple primary malignancies.

[Adenocarcinoma of small bowel. An underdiagnosed disease]

BACKGROUND

Small bowel adenocarcinoma is a rare disease. The diagnosis is often disguised by nonspecific and varied presenting symptoms. Adenocarcinoma of the small bowel is typically detected at a late stage and with a poor prognosis.

PATIENTS AND METHODS

The records of 42 patients with small bowel adenocarcinomas diagnosed in 2 surgical clinics between 1995 and 2009 were reviewed for patient and tumor characteristics, treatment effects and survival.

RESULTS

The tumor locations were the duodenum (50%), jejunum (38%) and ileum (12%). In comparison to patients seen before 2004 the observed frequency of emergency operations or palliative procedures as well as stage distribution did not change. The median overall survival was 19 months with a 5-year overall survival of 20%. For patients with resections, reduced performance status, higher stage and residual disease after resection predicted decreased overall survival in univariate analysis. Residual disease and pT category were predictive of survival in multivariate analysis.

CONCLUSION

Complete resection provides the only means of a cure. In cases where curative resection cannot be performed the prognosis remains poor. Further study on the methods for early detection and effective adjuvant chemotherapy should be investigated, however, the available data are limited.

A phase II study of modified FOLFOX as first-line chemotherapy in advanced small bowel adenocarcinoma

This study aimed at assessing the efficacy and safety of biweekly oxaliplatin in combination with continuous infusional 5-fluorouracil and leucovorin (modified FOLFOX regimen) in patients with advanced small bowel adenocarcinoma (SBA). Thirty-three eligible patients with previously untreated SBA received 85 mg/m(2) of oxaliplatin intravenously over a 2-h period on day 1, together with 400 mg/m(2) of leucovorin over 2 h, followed by a 46-h infusion of 5-FU 2600 mg/m(2) every 2 weeks. All patients were evaluable for efficacy and toxicity. A median of nine cycles (range 3-18) was administered. The objective response rate was 48.5% [95% confidence interval (95% CI): 31-67%], with one complete response, 15 partial responses, 12 stable diseases, and five progressions. The median time to progression was 7.8 months (95% CI: 6.0-9.6) and the median overall survival was 15.2 months (95% CI: 11.0-19.4). Toxicity was fairly mild. Grade 3 toxicities included neutropenia (12.1%), thrombocytopenia (3.0%), nausea (6.1%), vomiting (3.0%), diarrhea (3.0%), peripheral neuropathy (9.1%), and fatigue (3.0%), and grade 4 toxicities occurred in none of the patients. The modified FOLFOX regimen is highly active and well tolerated as first-line chemotherapy for advanced SBA patients.

Multicenter retrospective study of 132 patients with unresectable small bowel adenocarcinoma treated with chemotherapy

BACKGROUND

No standard chemotherapy regimen has been established for unresectable or recurrent small bowel adenocarcinoma (SBA).

METHODS

Clinical courses of 132 patients with unresectable or recurrent SBA who received chemotherapy at 41 institutions in Japan were reviewed retrospectively. Patients were classified into five groups according to first-line chemotherapy regimens: fluoropyrimidine monotherapy (group A), fluoropyrimidine-cisplatin (group B), fluoropyrimidine-oxaliplatin (group C), fluoropyrimidine-irinotecan (group D), and other regimens (group E).

RESULTS

The number of patients in each group was as follows: groups A, 60 patients; group B, 17 patients; group C, 22 patients; group D, 11 patients; and group E, 22 patients. Median progression-free survival (PFS) times were as follows: group A, 5.4 months; group B, 3.8 months; group C, 8.2 months; group D, 5.6 months; and group E, 3.4 months. Median overall survival (OS) times were as follows: group A, 13.9 months; group B, 12.6 months; group C, 22.2 months; group D, 9.4 months; and group D, 8.1 months. Patients in group C achieved significantly longer PFS times and substantially (but not significantly) longer OS times than patients in group A. After adjusting for clinical background characteristics, fluoropyrimidine-oxaliplatin therapy was a significant positive prognostic factor for PFS and OS times.

CONCLUSION

The results suggest that fluoropyrimidine-oxaliplatin combination therapy is the most promising first-line chemotherapy regimen for unresectable or recurrent SBA.

Small bowel adenocarcinoma presenting with refractory iron deficiency anemia - case report and review of literature

Cancers of the small bowel are relatively rare and account for approximately 1–2% of all gastrointestinal neoplasms. The most common histologic subtype – adenocarcinoma – constitutes 40% of all cases. These cancers generally present with vague abdominal discomfort and are often diagnosed at a late stage and carry a poor prognosis. The treatment of choice of early-stage small bowel adenocarcinoma is surgical resection. No standard treatment protocol has been defined for unresectable or metastatic disease. Here, we report a case of a 56-year-old woman who presented with unexplained iron deficiency anemia. Extensive initial studies with serial CT scans of the abdomen, esophagogastroduodenoscopy, small bowel capsule endoscopy and colonoscopy were noncontributory. She was later found to have a metastatic small bowel adenocarcinoma and treated with palliative chemotherapy. She achieved a modest response to the treatment. Interestingly, in our case, the sole presentation was unexplained iron deficiency anemia. Physician's awareness regarding the possibility of small bowel cancer especially in the setting of iron deficiency and its workup has been emphasized. This enhances the chance of early detection and hence better survival.

Systemic chemotherapy for treatment of advanced small bowel adenocarcinoma with prognostic factor analysis: retrospective study

Background

We sought to evaluate prognostic factors affecting overall survival (OS), and to investigate the role of palliative chemotherapy using propensity score-based weighting, in patients with advanced small bowel adenocarcinoma (SBA).

Methods

Data from a total of 91 patients diagnosed with advanced SBA at the Asan Medical Center between January 1989 and December 2009 were retrospectively analyzed. Patients were split into two groups, those who did and did not receive palliative chemotherapy.

Results

Overall, 81 patients (89.0%) died, at a median survival time of 6.6 months (95% confidence interval [CI], 5.5 - 7.5 months). The 40 patients receiving chemotherapy showed overall response and disease control rates of 11.1% and 37.0%, respectively, with OS and progression-free survival (PFS) of 11.8 months (95% CI, 4.6 - 19.0 months) and 5.7 months (95% CI, 3.5 - 8.0 months), respectively. The 41 patients who did not receive chemotherapy had an OS of 4.1 months (95% CI, 3.1 - 5.1 months) and a PFS of 1.3 months (95% CI, 0.8 - 1.7 months). Multivariate analysis showed that lack of tumor resection, non-prescription of chemotherapy, liver metastasis, and intra-abdominal lymph node metastasis, were all independently associated with poor survival outcomes. After inverse probability of treatment weighting (IPTW) adjustment, the group that did not receive chemotherapy was at a significantly higher risk of mortality (HR 3.44, 95% CI 2.03 - 5.83, p < 0.001) than were patients receiving chemotherapy.

Conclusion

Palliative chemotherapy may improve survival outcomes in patients with advanced SBA.

Small bowel tumors

Although rare, small bowel tumors may cause significant morbidity and mortality if left undetected. New endoscopic modalities allow full examination of the small bowel with improved diagnosis. However, isolated mass lesions may be missed by capsule endoscopy or incomplete balloon-assisted enteroscopy. Therefore the use of radiologic imaging and intraoperative enteroscopy for diagnosis should not be forgotten. Endoscopic resection of small bowel polyps and certain vascular tumors is possible but requires proper training. Advances in endoscopic tools are likely to broaden the endoscopic management of small bowel tumors. This article describes the general features of small bowel tumors, clinical presentation, and diagnostic tests followed by a description of the more common tumor types and their management.