Duodenal neoplasms: role of CT

Tubulovillous adenoma of the duodenal papilla: radiological-endoscopic and anatomopathological correlation in the surgical proposal

Tubulovillous adenomas of the duodenal ampulla are rare neoplasms. The present report describes a case with radiological-endoscopic and pathological correlation in which the patient underwent duodenal pancreatectomy with good postoperative progression. With advanced imaging methods, especially magnetic resonance and endoscopic ultrasound, locoregional aspects and extraluminal, lymphovascular, and metastatic invasion have been increasingly discussed as contributors to therapeutic decision making. This progression improves lesion staging and is especially useful in selecting eligible candidates for endoscopic treatment.

Villous Gastrointestinal Tumors: Multimodality Imaging with Histopathologic Correlation

Villous lesions are advanced adenomas that manifest most commonly in the colon; however, they can develop throughout the gastrointestinal tract. The duodenum is the most common small-bowel site of these lesions. Although in most cases these are isolated lesions that occur sporadically, patients with certain specific colorectal cancer syndromes, including familial adenomatous polyposis and hereditary nonpolyposis colorectal cancer, may develop multiple advanced adenomas. Villous lesions are important because although they are histologically benign, they may harbor dysplasia and have potential for malignancy. These characteristics make them a primary target for colorectal cancer screening with optical and virtual colonoscopy. However, these lesions can also be symptomatic and detected at diagnostic imaging when patients present for examination. They have characteristic features at a variety of imaging examinations, including barium fluoroscopy, CT, MRI, and endoscopic US. It is important for radiologists to be aware of these lesions, their potential morphologies, and their typical appearances at multimodality imaging. Although villous tumors can be detected at imaging and confirmed with biopsy, owing to limitations in identifying dysplasia and foci of malignancy with the above modalities alone and the potential for malignancy, referral for surgical resection of these lesions ultimately is required. ^©RSNA, 2018.

Large Tubullo-villous Adenoma of Duodenum Presenting as Gastric Outlet Obstruction

Tubullo-villous adenoma of duodenum is a rare entity. These are potentially malignant tumours and therefore, complete excision is the treatment of choice. However, at times preoperative diagnosis could not be always achieved posing difficulty in choosing the optimal surgical method of excision. We report a 40-year-old male patient presented with vague upper abdominal pain and vomiting for last 6 months. His computed tomography and endoscopy demonstrated intraluminal polypoidal mass. Endoscopic biopsies were negative for malignancy. Local surgical excision with tumour free margin was performed and histology revealed tubullo-villous adenoma.

Variant on Manifestation of Duodenal Metastasis 26 Years after Initial Diagnosis of Primary Cutaneous Melanoma

Malignant duodenal neoplasms are relatively rare, and the diagnosis is often delayed because of their vague and nonspecific symptoms. We report the case of a 79-year-old female who had a medical history of malignant melanoma of the cheek that had initially been diagnosed at 53 years of age. Work-up revealed severe stenosis of the duodenum caused by a large mass with ulceration at the tip of its mucosal surface. Tumor biopsy led to a histological diagnosis of extremely poorly differentiated carcinoma, but it was impossible to determine whether the lesion was a primary neoplasm or represented secondary involvement. Pancreatoduodenectomy was performed, and the surgical specimen showed a protuberant tumor in the nonampullary region of the second portion of the duodenum. Final diagnosis of metastatic duodenal melanoma was made by immunohistological examination. She is currently alive without recurrence 28 months after the surgical treatment.

Tumor and tumor-like lesions of duodenum: CT and barium imaging features

Neoplasms of the duodenum, either primary or secondary, are uncommon. However, imaging diagnosis for presurgical evaluation is extremely important due to complex regional anatomy. Computed tomography (CT) and barium-based double contrast examination (UGI series) are most frequently employed to evaluate the tumor invasion and intraluminal mucosal pattern. In this pictorial review, the CT and UGI series imaging features of benign and malignant duodenal tumors and tumor-like lesions are demonstrated and discussed.

Role of computerized tomography in the staging of gastrointestinal neoplasms

Gastrointestinal neoplasms are very common diseases, and the first challenge for clinicians is to define the extent of the tumor in order to plan the best treatment. The role of computerized tomography in assessing this kind of patient is well established worldwide. This article reviews the capabilities and the limits of this imaging technique in the staging of the tumors of the digestive tract (liver, gallbladder, biliary tract, pancreas, esophagus, stomach, small bowel, and colon).

Pictorial review: Radiological diagnosis of duodenal abnormalities

This article depicts the radiological findings of many common gastrointestinal entities. Specifically, examples of disease processes that affect the stomach, gall bladder, small intestine, pancreas and colon are shown. In most cases there is correlation between ultrasound, computed tomography (CT) and fluoroscopic imaging. The major emphasis of the article, however, is to demonstrate classic barium imaging of a large number of gastrointestinal disease processes.

The accuracy of CT staging of small bowel adenocarcinoma: CT/pathologic correlation

PURPOSE

Several studies have documented the use of CT in the evaluation of small bowel neoplasms, but few have addressed the CT staging of adenocarcinoma. We retrospectively correlated CT and pathologic staging to evaluate the accuracy of CT for staging small bowel adenocarcinoma using American Joint Committee on Cancer criteria.

METHOD

The preoperative CT scans of 15 patients with pathologically proven small bowel adenocarcinoma were analyzed. Two blinded readers separately interpreted extent of invasion, presence of lymphadenopathy, and distant metastases. Pathologic and CT staging were compared.

RESULTS

The overall accuracy of CT staging was 47% (14/30). The sensitivity of detection of mesenteric infiltration was 88%. The sensitivity and specificity for detection of distant metastases were 58 and 63% and for lymphadenopathy 75 and 20%, respectively. Errors occurred in patients with Crohn disease, adenomas, Peutz-Jegher syndrome, small bowel obstruction, and perforation and on suboptimal studies.

CONCLUSION

The accuracy of CT staging of small bowel adenocarcinoma is 47%. CT is highly sensitive but not specific for the detection of mesenteric infiltration and regional lymphadenopathy. Since spiral CT may offer improved detection of distant metastases and increased accuracy in the evaluation of patients with concomitant bowel disease, further research is needed to determine the maximal utility of CT in the staging of adenocarcinoma of the small bowel.

CT of small-bowel neoplasms

The diagnosis of neoplasms of the small intestine remains a difficult challenge owing to their nonspecific clinical presentation. CT is an efficient and contributive tool in their diagnosis and preoperative staging. Enabled by CT, the evaluation of the intramural and extramural portions of such tumors complements the mucosal analysis allowed by barium examination. Strict technical rules should be applied to minimize pitfalls mainly resulting from insufficient bowel opacification. Although characteristic appearances are rare, typical CT findings may suggest a specific diagnosis where lipomas and carcinoid tumors are concerned.

Case report: obstructive jaundice secondary to an intussuscepting duodenal villous adenoma

Small intestinal tumours are rare, forming 1% of all gastrointestinal tumours; most occur in the duodenum. Villous adenomas form only a very small proportion of the duodenal tumours. They usually occur in the periampullary region and show a marked propensity for malignant change. The usual mode of presentation is with non-specific pain, jaundice or occult bleeding. Obstruction and pancreatitis are infrequent clinical presentations. Intussusception secondary to a duodenal tumour of any histological type is rarer still. A case of intussusception of a villous adenoma resulting in obstructive jaundice is described.

Diagnosis and categorization of small bowel neoplasms: role of computed tomography

A retrospective study of 35 patients with small bowel neoplasms studied by computed tomography (CT) was performed. The tumor detection rate was 80%. Using the findings reported in the literature, an adequate histological diagnosis could be performed in 69% of the cases by CT. Lipomas, leiomyomas, leiomyosarcomas, and carcinoid tumors were well-recognized, but adenocarcinomas and lymphomas were often mistaken one for the other. An accurate preoperative staging was performed in 61% of the cases. CT failed to detect 75% of the invaded lymph nodes, 25% of the liver metastases, and 25% of the tumoral growth beyond the bowel wall. Despite major limitations in preoperative staging, a good detection rate and some features allowing a specific diagnosis advocate using CT along with the barium examination when clinical history suggests a small bowel tumor.

Duodenectomy without pancreatectomy for extensive benign villous adenoma of the duodenum

Villous adenomas of the duodenum are uncommon, but two have been treated recently in Blenheim. One of these was an extensive benign tumour involving most of the second part of the duodenum but causing no biliary tract obstruction. It was treated by pyloric sphincter-sparing duodenectomy without pancreatectomy, with repair by Roux loop to the bile and pancreatic ducts and proximal duodenum. This procedure does not appear to have been described previously.

Duodenal pseudotumour: a silent impacted common bile duct calculus

We report the case of a man with mild dyspeptic symptoms referred for barium meal, who was initially thought to have a duodenal tumour. Subsequent investigation showed this to be a pseudotumour caused by impaction of a gallstone in the distal common bile duct, and endoscopic sphincterotomy effected a cure. This readily treatable condition should be remembered when filling defects are demonstrated in the duodenal loop.