Small bowel tumors: an overview

Spontaneous expulsion of a duodenal lipoma after endoscopic biopsy: A case report

BACKGROUND

Gastrointestinal (GI) lipomas are benign submucosal tumors of mature adipocytes that arise mainly in the colon and stomach, sometimes in the ileum and jejunum, and rarely in the duodenum. Patients with symptomatic lipomas require endoscopic or surgical treatment. Spontaneous expulsion of lipomas after biopsy is a rare condition that has limited case reports.

CASE SUMMARY

A 56-year-old man presented to our hospital with intermittent postprandial epigastric fullness. Esophagogastroduodenoscopy (EGD) revealed a 10-mm soft yellowish submucosal lesion with the “pillow sign,” located in the second portion of duodenum. Endoscopic ultrasonography (EUS) using a 12-MHz catheter probe showed a hyperechoic, homogenous, and round solid lesion (OLYMPUS EUS EU-ME2, UM-DP12-25R, 12-MHz radial miniprobe, Olympus Corporation, Tokyo, Japan). Deep biopsy was performed using the bite-on-bite technique with forceps. Histological examination was compatible with submucosal lipoma. The lesion spontaneously expelled 12 d after the biopsy. Follow-up EUS performed after 2 mo confirmed this condition.

CONCLUSION

Deep biopsy could lead to spontaneous GI lipoma expulsion. This might be the first step in lipoma diagnosis and treatment.

Facing the unexpected: unusual causes of mechanical small bowel obstruction in adults

Mechanical small bowel obstruction in adults is a common emergency condition that typically requires hospitalisation and usually acute surgical intervention. The majority of the cases are due to adhesive obstruction or common abdominal wall hernias or relevant related past history. However, the surgeons might face unexpected challenges in this concept due to rare causes of this condition. This paper explores in depth the challenges encountered by the emergency general surgeons in the concept of management of rare causes of mechanical small bowel obstruction in adults through a systematic review and critical analysis of the available evidence, and summarises the essential intra-operative steps that are needed to be taken accordingly. In conclusion, the emergency surgeons should be familiar with the uncommon/rare causes of mechanical small bowel obstruction in adults to avoid serious complications. Successful outcomes are based on the combination of high index of clinical suspicion, familiarity with the standard anatomy and its variations, the use of the appropriate radiological investigations and surgical intervention in a timely manner.

Ileocolonic Intussusception Caused by Epithelioid Leiomyosarcoma of the Ileum: A Report of Case and Review of the Literature

Small intestinal malignant tumor accounts for about 3% of all malignant tumors in the gastrointestinal tract, among which 13% are leiomyosarcoma (LMS). In addition, epithelioid LMS is of very rare occurrence. As small intestinal malignant tumors are initially asymptomatic and nonspecific, diagnosis is often delayed, and this can lead to large tumor at the time of detection and lead to intussusception. We observed ileocolonic intussusception in an 80-year-old male patient who was admitted to the hospital with a complaint of abdominal pain and palpable mass on right lower quadrant. The laparoscopic ileocecectomy was performed by the emergency operation because of obstruction. The pathologic examination revealed that the epithelioid LMS developed in the terminal ileum was the leading point of intussusception. To the best of our knowledge, laparoscopic surgery for ileocolonic intussusception with epithelioid LMS has not yet been reported.

Small Intestinal Adenocarcinoma in a Patient With Celiac Disease

Celiac disease (CD) is a systemic immune-mediated disorder against gluten, leading to an autoantibody response causing damage to the small intestinal mucosa. CD has been associated with gastrointestinal malignancies, most commonly gastrointestinal lymphoma. Rare malignancies have also been reported, such as small intestinal adenocarcinoma. In this report, we present a case of a 91-year-old male with a history of CD, noncompliant with a gluten-free diet, who presented with weight loss, abdominal pain, and gastrointestinal bleeding secondary to a newly discovered adenocarcinoma of the jejunum.

Long, Pedunculated, Large Hyperplastic Polyp of the Terminal Ileum Protruding Through the Ileocecal Valve: A Case Report

Small-bowel tumors, both benign and malignant, are rare lesions that clinicians often do not encounter, accounting for less than 2% of gastrointestinal malignancies. Usually, benign small-bowel tumors, including polyps, are asymptomatic. The diagnosis of small-bowel tumors is difficult because of an often-delayed presentation and nonspecific signs and symptoms. We report an incidentally detected case of a long, pedunculated, large polyp of the terminal ileum, which protruded through the ileocecal valve into the cecum that was removed by colonoscopy in a 41-year-old male with intermittent right-sided lower-abdominal pain. The polyp was resected through snare polypectomy without complications. The histopathology of the resected polyp was confirmed as an ileal hyperplastic polyp. Two years later, there was no recurrence observed via postpolypectomy surveillance colonoscopy.

A Case of a Bleeding Duodenal Lipoma Successfully Controlled by Endoscopic Resection

This is a case report of successful endoscopic resection (ER) of a bleeding duodenal lipoma. An 85-year-old woman who was diagnosed with asymptomatic subepithelial tumor of the duodenum 3 years ago visited the emergency room with hematemesis and was admitted to our hospital. Emergent esophagogastroduodenoscopy revealed bleeding from an ulcer on the superior aspect of a subepithelial tumor measuring about 20 mm in diameter, at the superior duodenal angle. The ulcer was in the active stage (A1), with a visible vessel. The bleeding was controlled by ER of the tumor using a snare. The final pathological diagnosis was duodenal lipoma with mucosal ulceration. The patient showed no signs of bleeding for 10 days after the procedure; subsequently, she was discharged and followed up for regular checkups.

Isolated Splenic Recurrence of Treated Jejunal Cancer: A Case Report with Brief Review of Literature

Spleen is a very infrequent site of metastasis despite the fact that it is the most vascular organ in the body. Even if systemic metastasis occurs, splenic metastasis largely remained asymptomatic due to its large functional reserve, and most often, the metastasis is detected incidentally on follow-up scan. Many cases of asymptomatic splenic metastasis detected on follow-up scans are reported in literature from different primary sites. Herein, we report a similar case of a 33-year-old male who presented with isolated splenic recurrence after a long treatment-free interval following curative treatment of adenocarcinoma jejunum. As stated, there are few previous reports of isolated splenic metastasis from carcinoma colon, but considering small intestinal adenocarcinoma, this is the first unique case reported to the best of our knowledge. Due to rarity of clinical scenario and lack of established guidelines, the treatment of such cases varies from patient to patient, and the knowledge, whatever we owe, is on the basis of case reports only.

Multimodality imaging of small bowel neoplasms

Although the small intestine accounts for over 90% of the surface area of the alimentary tract, tumors of the small intestine represent less than 5% of all gastrointestinal tract neoplasms. Common small bowel tumors typically are well evaluated with cross-sectional imaging modalities such as CT and MR, but accurate identification and differentiation can be challenging. Differentiating normal bowel from abnormal tumor depends on imaging modality and the particular technique. While endoscopic evaluation is typically more sensitive for the detection of intraluminal tumors that can be reached, CT and MR, as well as select nuclear medicine studies, remain superior for evaluating extraluminal neoplasms. Understanding the imaging characteristics of typical benign and malignant small bowel tumors is critical, because of overlapping features and associated secondary complications.

Small bowel tumours: update in diagnosis and management

PURPOSE OF REVIEW

The aim of this study was to summarize the role of recently developed diagnostic techniques in the diagnosis and management of patients with small bowel tumours (SBTs).

RECENT FINDINGS

Recent studies show that the overall SBT incidence is increasing. The introduction of small bowel dedicated diagnostic tools [i.e. capsule endoscopy, device-assisted enteroscopy (DAE), computed tomography (CT) and MRI-enterography] might partially explain this trend. In patients with SBT, DAE might represent an ideal tool by coupling careful mucosal inspection with sampling capability. Unfortunately, DAE is an invasive procedure and seldom allows complete small bowel evaluation in a single setting. Therefore, DAE is more often used in clinical practice as confirmatory tool, when other less invasive and readily available tests (i.e. capsule endoscopy or radiological tests) identify relevant findings. Nevertheless, in patients with SBT, capsule endoscopy is burdened by an increased risk of capsule retention and/or missing proximal small bowel lesions, whereas dedicated cross-sectional imaging techniques often identify nonspecific findings of limited clinical significance.

SUMMARY

Despite recent technical improvements, in patients with SBT, the result of a single diagnostic procedure is often insufficient to provide a definite diagnosis. A balanced combination of different tests allows reaching a final diagnosis and drive further management.

Surgical Management and Prognostic Prediction of Adenocarcinoma of Jejunum and Ileum

We conducted a retrospective study based on the Surveillance, Epidemiology, and End Results Program (SEER) database to establish a novel nomogram prognostic prediction system and to estimate the association between overall survival and prognostic factors, as well as to explore surgical treatment strategies for adenocarcinoma of the jejunum and ileum. A total of 883 patients from the SEER database were included in this study. Eight potential prognostic factors were included in a nomogram model and discriminatory power and accuracy were examined using the Harrell's C-index and Akaike Information Criterion (AIC) index. In comparison with the AJCC TNM staging system, the nomogram prediction system was more accurate and homogeneous (Harrell's C-index, 0.731 vs. 0.667; AIC index, 4852.9 vs. 4913.723). For surgical management, resection of more than 12 local lymph nodes could improve the likelihood of survival. This study demonstrates that our nomogram model is more accurate and homogeneous than the traditional AJCC TNM staging system, and proper surgical strategies for mesenteric lymphadenectomy improve overall survival.

Diagnosis and Treatment of Duodenal Lipoma: A Systematic Review and a Case Report

INTRODUCTION

Duodenal lipoma is very rare with limited case reports present in literature. Owing to recent advances in endoscopy and modern imaging techniques, more cases are being diagnosed and treated. However, no systematic study of duodenal lipomas has been reported.

AIM

To study the diagnosis and treatment of duodenal lipoma in a female patient and review the relative literatures to enhance the knowledge of it.

MATERIALS AND METHODS

A literature search for 'duodenal lipoma' was performed on PubMed. Papers published from 1948 to 2016 in the English language were identified. Each article was then read in detail and analysed for clinical data, imaging features, diagnosis and therapy. Also, we hereby present a case of upper gastrointestinal obstruction secondary to multiple duodenal lipomas in a 67-year-old woman. The patient underwent a limited bowel resection with an uneventful recovery.

RESULTS

Literature review demonstrated 59 cases of duodenal lipoma, which indicate that duodenal lipomas are rare to occur but commonly found in the second part. The peak of incidence seems to be around the fifth and seventh decade of life. Duodenal lipomas may present as gastrointestinal bleeding, abdominal pain, obstruction or upper abdominal fullness. CT, MRI, Endoscopic Ultrasound (EUS), endoscopy are highly accurate diagnostic tools. The disease could be managed by endoscopy or surgery.

CONCLUSION

Our review of literature indicated duodenal lipoma is extremely rare. The symptoms are nonspecific and CT is the first choice for diagnosis. The treatment depends on the patient's condition as well as the size and position of the tumour.

Neoplastic Diseases of the Small Bowel

The incidence of small bowel tumors is increasing over time. Until recently, their diagnosis was delayed and it was often reached only at the time of surgery. New diagnostic tools, such as capsule endoscopy, device-assisted enteroscopy, and dedicated small bowel cross-sectional imaging techniques, have been introduced recently in clinical practice. The combination of these tools allows medical practitioners to detect small bowel tumors at an early stage and to reach a definite diagnosis before surgery, thus enabling minimally invasive treatments.

A very rare case of a small bowel leiomyosarcoma leading to ileocaecal intussusception treated with a laparoscopic resection: a case report and a literature review

Background

Small bowel tumours are rare and comprise less than 2 % of all primary gastrointestinal neoplasms. Among these tumours, a leiomyosarcoma belonging to soft tissue sarcomas is extremely rare and accounts for about 1 % of malignant mesenchymal lesions in the gastrointestinal tract. Due to its aggressive nature and slow growth, it is often diagnosed at the late stage when curative treatment is impossible. Authors report a first case of leiomyosarcoma with chronic recurrent ileocaecal intussusception and literature review to analyse diagnosis and treatment features of the ileum mesenchymal tumours.

Case presentation

We present a case of an 87-year-old Caucasian man suffering from cramp-like abdominal pain for months. Due to lack of clinical signs and unspecific complaints, a diagnosis was delayed. Despite a detailed in-hospital examination, a proper diagnosis was established as late as during an operation. The patient was treated by surgery with good results. An uncommon laparoscopic resection of the small bowel with a tumour was performed. A histopathological investigation confirmed a very rare mesenchymal lesion of the distal ileum. The patient is under control with no recurrence for 1 year of the follow-up period.

Conclusions

Reported case indicates that a usually asymptomatic tumour can cause uncommon chronic recurrent ileus signs. CT and MRI scans are investigation of choice in such cases, but they are sometimes inconclusive. It might be worth highlighting the good results of laparoscopic leiomyosarcoma lesion resection with a very good outcome.

Clinical Efficacy of Various Diagnostic Tests for Small Bowel Tumors and Clinical Features of Tumors Missed by Capsule Endoscopy

Background. We aimed to evaluate the efficacy of various diagnostic tools such as computerized tomography (CT), small bowel follow-through (SBFT), and capsule endoscopy (CE) in diagnosing small bowel tumors (SBTs). Additionally, we aimed to evaluate the clinical features of SBTs missed by CE. Methods. We retrospectively studied 79 patients with histologically proven SBT. Clinical data were analyzed with particular attention to the efficacy of CT, SBFT, and CE in detecting SBT preoperatively. We also analyzed the clinical features of SBTs missed by CE. Results. The most common symptoms of SBT were bleeding (43%) and abdominal pain (13.9%). Diagnostic yields were as follows: CT detected 55.8% of proven SBTs; SBFT, 46.1%; and CE, 83.3%. The sensitivity for detecting SBTs was 40.4% for CT, 43.9% for SBFT, and 79.6% for CE. Two patients with nondiagnostic but suspicious findings on CE and seven patients with negative findings on CE were eventually found to have SBT. These nine patients were eventually diagnosed with gastrointestinal stromal tumor (4), small polyps (3), inflammatory fibroid polyp (1), and adenocarcinoma (1). These tumors were located in the proximal jejunum (5), middle jejunum (1), distal jejunum (1), and proximal ileum (1). Conclusion. CE is more efficacious than CT or SBFT for detecting SBTs. However, significant tumors may go undetected with CE, particularly when located in the proximal jejunum.

The clinical pathological features, diagnosis, treatment and prognosis of small intestine primary malignant tumors

The aim of the study was to describe and analyze the clinicopathological features and diagnosis of Chinese patients with small intestine primary malignant tumors and to explore the best therapy to small bowel adenocarcinoma (SBA). More than 26,000 patients with digestive tract malignant tumors received treatment in PLA hospital from 2000 to 2011, and among them, there were 887 patients who had small intestine primary malignant tumors, and 666 of 887 patients had the completed basic clinical documents. We retrospectively analyzed the correlation between clinical and pathological features of the 666 patients and analyzed the survival and prognosis of 173 SBA patients with follow-up data. Both the number of patients with primary malignant tumors of the small intestine and the number of patients who received chemotherapy showed an increasing trend. The ratio of male to female was 1.58:1. The male patients significantly exceed the female patients with tumors of non-ampullary duodenum, jejunum and duodenal ampulla; and most of the patients are over 60 years of age. For patients burdened with either of the pathological types of tumors, the males exceeded the females, but there was no significant difference. Abdominal pain was the main clinical manifestation for patients with tumors of non-ampullary duodenum, jejunum and ileum, and the most common clinical manifestations were jaundice and abdominal pain for patients with ampullary duodenal tumors, adenocarcinoma, neuroendocrine tumors and sarcoma. In addition, patients with stromal tumors were prone to gastrointestinal bleeding. Gastrointestinal endoscopy was the most common examinational procedure. Patients under 60 years of age were prone to surgery and chemotherapy after surgery, and patients over 60 years of age were prone to supportive treatment and chemotherapy without surgery. The medium overall survival of patients who received surgery without chemotherapy, chemotherapy after surgery, chemotherapy without surgery and supportive treatment were 40.0, 35.0, 9.0 and 7.5 months, respectively. For the 173 SBA patients with follow-up data, treatment, age and distant metastasis were important prognostic factors; 149 of 173 SBA patients received only surgery, and the depth of tumor invasion, lymph node metastasis and surgical approach were important prognostic factors. Adjuvant chemotherapy had not provided significant benefit to prolong OS in patients with adenocarcinoma. The incidence of small intestine primary malignant tumors is very low, and it is difficult to diagnose. The patients should be aggressively treated and regularly followed up with related clinical and pathological features. Currently, surgery is the most effective treatment, and the role of chemotherapy needs further large-scale clinical studies.

Small intestinal tumours

Objective. Balloon enteroscopy (BE) and capsule enteroscopy (CE) are enteroscopy methods that allow examination and treatment of the small bowel. Before the CE and BE era, the small intestine was difficult to access for investigation. Small intestinal tumours are infrequent conditions, but about half of them are malignant. Materials and Methods. A total of 303 BEs were performed in 179 patients. Oral insertion was performed in 240 and anal in 63 BEs. Indications for the procedure in our patients with small bowel tumours were anaemia and/or bleeding, obstruction, suspicion of carcinoid tumour, or suspicion of Peutz-Jeghers syndrome. Results. In 50 of our 179 patients (28%), we diagnosed some small intestinal tumours: hamartomas in Peutz-Jeghers syndrome in 16 patients, adenocarcinoma in 7, lymphoma in 6, carcinoid tumour in 4, melanoma and stromal tumour in 3, adenoma, lipoma, and inflammatory polyps in 2, and granular cell tumour, cavernous lymphangioma, fibrolipoma, Cronkhite-Canada polyps, and metastatic involvement in individual cases. Conclusion. BE facilitates exploration and treatment of the small intestine. The procedure is generally safe and useful. BE and CE are essential modalities for the management of small intestinal diseases.

Multiphase CT enterography evaluation of small-bowel vascular lesions

OBJECTIVE

By use of multiphase CT enterography (CTE), small-bowel vascular lesions associated with gastrointestinal bleeding can be classified into three categories--angioectasias, arterial lesions, and venous abnormalities--on the basis of common morphology and enhancement patterns. This article will review the unique patterns of enhancement and lesion morphology seen on multiphase CTE and how those findings enable detection and characterization of specific lesions in many cases.

CONCLUSION

Because of the high prevalence in nonbleeding patients and frequent multiplicity of angioectasias, determining the clinical benefit from their detection by multiphase CTE and endoscopy is problematic. Although arterial lesions are less commonly encountered clinically, their detection is critically important because of a high risk of life-threatening bleeding. Along with wireless capsule endoscopy and balloon-assisted endoscopy, multiphase CTE is a useful tool for the evaluation of patients with obscure gastrointestinal bleeding due to small-bowel vascular lesions.

Lessons from korean capsule endoscopy multicenter studies

Since its development, video capsule endoscopy (VCE) introduced a new area in the study of small bowel disease. We reviewed and discussed current issues from Korean capsule endoscopy multicenter studies. Main results are as follows: First, there was no significant difference in diagnostic yield according to the method of bowel preparation. Second, VCE represents a reliable and influential screening measure in patients with chronic unexplained abdominal pain and this technique could successfully alter the clinical course especially for patients with small bowel tumor. Third, the inter-observer variation in the expert group was lower than that in trainee group. Fourth, studies about the spontaneous capsule passage after retention showed 2.5% of retention rate and the size of lumen was an important factor of spontaneous passage. We need larger scale studies on the effect of bowel preparation methods on the diagnostic yield and further studies about the learning curve or unique capsule endoscopic findings for small intestinal diseases in Korean patients.

Enterovesical fistula caused by non-Hodgkin's lymphoma of the ileum: report of a case

We herein present a rare case of enterovesical fistula caused by ileal non-Hodgkin's lymphoma. A 75-year-old Japanese male presented with macrohematuria at Kosei General Hospital in December 2010. An egg-sized mass was palpable in his right lower abdominal region, and computed tomography (CT) revealed that the ileal tumor had invaded the right posterior wall of the urinary bladder (UB). A histopathological examination of a CT-guided needle biopsy specimen revealed diffuse large B-cell lymphoma involving the ileum and the UB. Thereafter, fecaluria appeared. A transurethral catheter was put in place, and there were no symptoms of cystitis. The patient received chemotherapy for the lymphoma, which produced a partial response. However, the fecaluria continued, and an examination of the small intestine with contrast revealed a thick and irregular wall of the ileum and a fistula between the ileum and UB. A partial resection of the ileum and a partial cystectomy were carried out in April 2011. The surgical specimen demonstrated two tumors 5 cm apart in the ileum, measuring 4.5 × 7 and 4 × 3 cm in size. The proximal tumor had directly invaded the UB and formed an ileovesical fistula. The patient made a good recovery and was doing well 5 months after the surgery without any evidence of recurrence.

Small bowel tumors: what is the contribution of video capsule endoscopy?

BACKGROUND

Intestinal tumors represent less than 6% of digestive tumors and, because of the limitations of intestinal investigations, these tumors are difficult to diagnose. In this context, capsule endoscopy (CE) has proven effective especially in patients with obscure digestive bleeding. The aim of the present study was to calculate the frequency, and evaluate the diagnostic and therapeutic impact of CE in cases of small bowel tumors.

PATIENTS AND METHODS

A total of 95 patients (57 males and 38 females, mean age of 56 years) with negative endoscopy and colonoscopy results were directed to undergo CE examination.

RESULTS

Of the 95 patients, 13 (13.7%) were diagnosed with small bowel tumors. The main indications for CE were obscure (occult and overt) gastrointestinal bleeding. The mean duration of symptoms before diagnosis was 10 months. The final histological diagnosis was established through surgery. In our patients, this included gastrointestinal stromal tumor (nine cases), adenocarcinoma (two cases) and carcinoid tumor (two cases).

CONCLUSION

This study revealed that the prevalence of intestinal tumors appears to be higher than expected in patients through the use of CE.

First Case of Small Bowel Sarcomatoid Carcinoma Found by Video Capsule Endoscopy

Sarcomatoid carcinoma of the small bowel is extremely rare. We report the first case of sarcomatoid carcinoma identified by video capsule endoscopy in a patient referred for obscure gastrointestinal bleeding. Computed tomography and small bowel follow through failed to identify the tumor. The tumor was visualized initially on video capsule endoscopy examination and a 6 x 3 cm polypoid, fungating mass with irregular borders was retrieved on surgical resection. Microscopic examination showed sheets of pleomorphic spindled to epitheliod cells staining positive for cytokeritin and vimentin, indicative of sarcomatoid carcinoma. Forty-one months after surgical resection the patient continued to be free of metastatic disease.

A population-based comparison of adenocarcinoma of the large and small intestine: insights into a rare disease

BACKGROUND

Because of its rarity, adenocarcinoma of the small intestine is frequently compared to adenocarcinoma of the colon, although the validity of this comparison is not known.

METHODS

Patients with small and large bowel adenocarcinoma (SBA and LBA) diagnosed between 1988 and 2007 were identified from the Surveillance, Epidemiology, and End Results registry. Age-standardized incidence and mortality rates were determined. Cancer-specific survival (CSS) stratified by stage and by number of assessed lymph nodes was calculated.

RESULTS

A total of 4518 and 261,521 patients with SBA and LBA, respectively, were identified. In comparison to LBA, patients with SBA were younger and presented with disease of higher stage and histologic grade. The age-standardized incidence rates decreased for LBA (-1.24% per year) but increased for SBA (+1.47% per year). Although age-standardized mortality rates decreased for both LBA and SBA, the decreases were more pronounced for LBA. Five-year CSS was worse for resected SBA compared with resected LBA, although this difference diminished when comparing cases having eight or more lymph nodes assessed. The relative reduction in CSS when selecting eight or more lymph nodes was much greater for duodenal as opposed to jejunal/ileal subsite of the small bowel. With nodal selection the absolute difference in CSS between LBA and SBA for stages I, II, and III was 13, 15.9, and 18.5%, respectively.

CONCLUSIONS

Adequate nodal assessment is much less common in SBA than LBA; and it appears that SBA, in particular duodenal adenocarcinoma, is understaged. Even after corrections to minimize the effect of stage migration and inadequate lymph node evaluation, SBA demonstrated distinctly worse CSS than LBA.

CT-enterography may identify small bowel tumors not detected by capsule endoscopy: eight years experience at Mayo Clinic Rochester

BACKGROUND

Capsule endoscopy (CE) is widely accepted as the preferred diagnostic test in the evaluation of small bowel diseases. However, small bowel tumors (SBT) are sometimes missed by CE. Preliminary studies suggest that CT-enterography (CTE) may play a role in detecting SBT.

AIMS

The purpose of this study was to compare the performance of CE and CTE in detecting SBT METHODS: This was a single center, retrospective study. Patients treated at the Mayo Clinic Rochester between January 2000 and December 2008 with a discharge diagnosis of SBT and negative initial esophagogastroduodenoscopy (EGD) and colonoscopy were identified through a search of the electronic medical records. Among 103 identified patients, 41 had undergone CE, CTE or both, and comprised our study group. The exact binomial sensitivity of CE and CTE in detecting SBT was calculated. Demographic characteristics, clinical presentation, results of diagnostic tests, and tumor characteristics were recorded for each patient.

RESULTS

CTE and CE detected 38/41 (sensitivity 92.7%; 95% CI 80.1-98.5) and 8/27 (sensitivity 29.6%; 95% CI 13.8-50.2) of the SBT identified at Mayo Clinic Rochester, respectively. Seventeen patients had both CTE and CE. In this subgroup of patients, CTE detected SBT in 16/17 (sensitivity 94.1; 95% CI 72.7-99.9) and CE in 6/17 (sensitivity 35.3%; 95% CI 13.3-59). The matched paired difference in the sensitivity of two techniques in detecting SBT was statistically significant (P = 0.004).

CONCLUSION

CTE may identify SBT not diagnosed by CE.

Current advance in small bowel tumors

Small intestinal tumors are difficult challenge to gastroenterologists. The difficulty in making a diagnosis of small intestinal tumor lies in the relative inaccessibility and absence of typical presentation. New endoscopic and radiologic technologies provide clear and fine anatomical visualization of the small bowel and are approved to improve the diagnostic sensitivity and accuracy. Patients at risk of small intestinal tumors might gain a benefit from proper surveillance with this new technology. Minimally invasive therapy is now available with advance of balloon assisted enteroscopy. This review describes the general aspect of the small intestinal tumors, focusing on the new modalities for diagnosis.

[Surgical interventions for small bowel tumors at our department in the last 3 years]

Adenocarcinoma of the small intestine is a rare type of cancer in Hungary as well as in the world. It is more commonly found in patients with coeliac disease (lymphoma) and in hereditary bowel cancer syndromes (hereditary non-polyposis colorectal cancer, familial adenomatous polyposis, and Peutz-Jegher syndrome). Due to the relatively featureless presentation there is usually a few months delay in diagnosis of the disease In addition, small bowel cancer is frequently diagnosed on laparotomy only. We analyzed the small bowel malignancies treated in our department in the last 3 years from the point of view of incidence, preoperative evaluation, surgical intervention, and pathology. All patients were admitted as emergencies, so they underwent rapid investigations, and emergency or semi-emergency surgical interventions. Importantly, preoperative investigations helped to establish operative indication only rather than providing exact diagnosis. The operative procedure was small bowel resection in all cases. Pathological diagnosis included GIST, adenocarcinoma, and non-Hodgkin lymphoma as well.

Morphological and molecular evidence for functional organization along the rostrocaudal axis of the adult zebrafish intestine

BACKGROUND

The zebrafish intestine is a simple tapered tube that is folded into three sections. However, whether the intestine is functionally similar along its length remains unknown. Thus, a systematic structural and functional characterization of the zebrafish intestine is desirable for future studies of the digestive tract and the intestinal biology and development.

RESULTS

To characterize the structure and function of the adult zebrafish intestine, we divided the intestine into seven roughly equal-length segments, S1-S7, and systematically examined the morphology of the mucosal lining, histology of the epithelium, and molecular signatures from transcriptome analysis. Prominent morphological features are circumferentially-oriented villar ridges in segments S1-S6 and the absence of crypts. Molecular characterization of the transcriptome from each segment shows that segments S1-S5 are very similar while S6 and S7 unique. Gene ontology analyses reveal that S1-S5 express genes whose functions involve metabolism of carbohydrates, transport of lipids and energy generation, while the last two segments display relatively limited function. Based on comparative Gene Set Enrichment Analysis, the first five segments share strong similarity with human and mouse small intestine while S6 shows similarity with human cecum and rectum, and S7 with human rectum. The intestinal tract does not display the anatomical, morphological, and molecular signatures of a stomach and thus we conclude that this organ is absent from the zebrafish digestive system.

CONCLUSIONS

Our genome-wide gene expression data indicate that, despite the lack of crypts, the rostral, mid, and caudal portions of the zebrafish intestine have distinct functions analogous to the mammalian small and large intestine, respectively. Organization of ridge structures represents a unique feature of zebrafish intestine, though they produce similar cross sections to mammalian intestines. Evolutionary lack of stomach, crypts, Paneth cells and submucosal glands has shaped the zebrafish intestine into a simpler but unique organ in vertebrate intestinal biology.

Capsule endoscopy in small bowel tumors: a multicenter Korean study

BACKGROUND AND AIM

Capsule endoscopy (CE) has proven to be highly effective at detecting small bowel lesions in a variety of clinical conditions, but studies concerning the practical impact of CE on small bowel tumors are still scarce, especially in the Asian population. The aim of this study was to evaluate the diagnostic and therapeutic impact of CE in the field of small bowel tumors.

METHODS

CE records consecutively pooled from the beginning of use of CE in Korea, October 2001 until April 2008, in 14 centers throughout Korea were reviewed. Clinical information and CE video images of small bowel tumors were analyzed.

RESULTS

A total of 1332 cases undergoing CE were reviewed with all clinical indications. Small bowel tumors were diagnosed with CE in 57 (4.3%) of 1332 patients. The tumors were malignant in 33 cases, and included three adenocarcinomas, eight lymphomas, 20 gastrointestinal stromal tumors, and two metastatic cancers. The most frequent indications for CE in malignant tumors were obscure gastrointestinal bleeding, followed by abdominal pain and weight loss. Thirty of 57 tumors were identified exclusively by CE (diagnostic impact = 30/57), and they were smaller in size (mean, range: 14.3 mm, 2-35 mm) compared to the other tumors detected in radiological studies (48.7 mm, 10-110 mm). Seven patients underwent surgical resection (therapeutic impact = 7/57).

CONCLUSION

CE effectively identifies small bowel tumors that are undetectable by conventional radiological studies (diagnostic impact = 52.6%) and can critically change the therapeutic course (therapeutic impact = 12.3%).

Immunophenotype and molecular characterisation of adenocarcinoma of the small intestine

Background:

Despite having a dramatically larger surface area than the large intestine, the small intestine is an infrequent site for the development of adenocarcinoma. To better understand the molecular abnormalities in small bowel adenocarcinoma (SBA), we characterised a number of candidate oncogenic pathways and the immunophenotype of this rare cancer.

Methods:

Tissue microarrays were constructed from tumour samples from 54 patients with all stages of the disease. Immunohistochemistry and microsatellite instability (MSI) testing were conducted.

Results:

The profile of cytokeratin 20 and 7 coexpression was variable, but expression of caudal type homeobox transcription factor 2 (CDX2) was present in 70% of cases. In this young population (median age 54 years), loss of mismatch repair (MMR) proteins occurred in 35% of patients, with confirmed MSI in 100% of tested cases. Expression of vascular endothelial growth factor-A (VEGF-A) and epidermal growth factor receptor (EGFR) was common, occurring in 96 and 71% of patients, respectively. Only one case showed HER2 expression and none showed loss of phosphatase and tensin homologue mutated on chromosome 10 (PTEN).

Conclusions:

These results suggest that alterations in DNA MMR pathways are common in SBAs, similar to what is observed in large bowel adenocarcinomas. Furthermore, the high percentage of tumours expressing both EGFR and VEGF suggests that patients with this rare cancer may benefit from therapeutic strategies targeting EGFR and VEGF receptor (VEGFR).

Adenocarcinoma of the small bowel: a surgical dilemma

Malignant tumors of the small intestine are among the rarest types of gastrointestinal cancers. Due to their infrequent occurrence and the multitude of tumor types (viz, adenocarcinomas, carcinoids, sarcomas, and lymphomas), not much is known about their natural history and presentation, and there is often delay in the diagnosis. Adenocarcinoma is the commonest histologic type of small bowel cancer. There are no prospective randomized trials that have elucidated the best diagnostic and therapeutic options for this rare condition. In this article, a case of adenocarcinoma of the jejunum presenting as an abdominal lump is presented, along with a review of the literature.

Adenocarcinoma of the small bowel: a surgical dilemma

Malignant tumors of the small intestine are among the rarest types of gastrointestinal cancers. Due to their infrequent occurrence and the multitude of tumor types (viz, adenocarcinomas, carcinoids, sarcomas, and lymphomas), not much is known about their natural history and presentation, and there is often delay in the diagnosis. Adenocarcinoma is the commonest histologic type of small bowel cancer. There are no prospective randomized trials that have elucidated the best diagnostic and therapeutic options for this rare condition. In this article, a case of adenocarcinoma of the jejunum presenting as an abdominal lump is presented, along with a review of the literature.

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.

The role of surgical intervention in the management of duodenal lymphoma

BACKGROUND AND OBJECTIVES

The role of surgical management in duodenal lymphoma is controversial due to the rarity of this tumor subtype. A retrospective review of a provincial cancer registry was performed to assess the rationale for surgical management in duodenal lymphoma.

METHODS

Patient demographics, presentations, pathologies, surgical interventions, treatment, and associated disease-specific survival were assessed and descriptively presented.

RESULTS

From 1985 to 2005, 23 patients (mean age 58 years [22-82]) were diagnosed. The most common histology was large B-cell lymphoma (74%). A significant proportion presented in a complicated fashion: obstruction (30%), perforation (17%), and hemorrhage (4%). Eight patients (35%) were treated with surgery alone, eight (35%) with surgery and chemotherapy, five (22%) with chemotherapy alone, and two (9%) with supportive care. Of those treated with surgery, indications were mostly emergent conditions including obstruction (58%), perforation (33%), and hemorrhage (8%). Overall median follow-up was 14 months (1-168 months) and overall median survival was 12 months (1-168 months). There were no significant differences in survival by histology, stage, or treatment type.

CONCLUSIONS

Chemotherapy continues to represent the therapeutic mainstay for GI lymphomas. However, in duodenal lymphoma, a high proportion of patients require surgery mainly because of complicated presentations.

[Capsule endoscopy for the diagnostics of small intestine tumours]

Three to six percent of all gastrointestinal tumours and one to two percent of all malignant gastrointestinal tumours develop in the small intestine. These occur more frequently in men than in women and the peak of occurrence is at the age of 50 to 60 years. According to epidemiological investigations to date the most frequently developing primary tumours in the small intestine are adenocarcinomas, carcinoid tumours, lymphomas and small bowel gastrointestinal stromal tumours. Clinical appearance of the tumours is the same, independent of their histological type. Fifty percent of the benign tumours is asymptomatic and is only discovered incidentally at autopsy. In comparison, 80% of malignant tumours is symptomatic. The prognosis of small intestine malignant tumours is very poor as at the time of diagnosis they have already formed metastases in 45-75% and at the time of surgery they are in 20-50% irresectable. The reason for the late diagnosis is on the one hand the non-specific nature of the symptoms, on the other hand, the limited visualisation of the entire small intestine via traditional radiological and endoscopic methods. Capsule endoscopy (CE) revolutionised the diagnostics of the small intestine by enabling non-invasive, pain-free investigation of the entire small intestine. The timely application of CE may replace a range of expensive assays with limited diagnostic value. Initial results indicate a higher prevalence of small intestine tumours than it had been estimated based on earlier epidemiological investigations. The new method provides an early diagnosis, enabling a definitive therapy, eventually significantly improving patient survival.

Capsule endoscopy in neoplastic diseases

Until recently, diagnosis and management of small-bowel tumors were delayed by the difficulty of access to the small bowel and the poor diagnostic capabilities of the available diagnostic techniques. An array of new methods has recently been developed, increasing the possibility of detecting these tumors at an earlier stage. Capsule endoscopy (CE) appears to be an ideal tool to recognize the presence of neoplastic lesions along this organ, since it is non-invasive and enables the entire small bowel to be visualized. High-quality images of the small-bowel mucosa may be captured and small and flat lesions recognized, without exposure to radiation. Recent studies on a large population of patients undergoing CE have reported small-bowel tumor frequency only slightly above that reported in previous surgical series (range, 1.6%-2.4%) and have also confirmed that the main clinical indication to CE in patients with small-bowel tumors is obscure gastrointestinal (GI) bleeding. The majority of tumors identified by CE are malignant; many were unsuspected and not found by other methods. However, it remains difficult to identify pathology and tumor type based on the lesion’s endoscopic appearance. Despite its limitations, CE provides crucial information leading in most cases to changes in subsequent patient management. Whether the use of CE in combination with other new diagnostic (MRI or multidetector CT enterography) and therapeutic (Push-and-pull enteroscopy) techniques will lead to earlier diagnosis and treatment of these neoplasms, ultimately resulting in a survival advantage and in cost savings, remains to be determined through carefully-designed studies.

Occult intestinal haemorrhage due to lipoma of the small bowel detected with the combined use of the new endoscopic techniques. A report of two cases

We report two unusual cases of occult intestinal bleeding due to lipoma of the small bowel. Both the patients underwent several inconclusive endoscopic and radiological procedures before the diagnosis of these lesions that was possible using video capsule endoscopy and double balloon enteroscopy. In the first case, the finding of capsule endoscopy was confirmed using enteroscopy, allowing us to diagnose the ileal mass. In the second and more recent case, we used double balloon enteroscopy for the further characterisation and management of the ileal lipoma. Lipoma is a very rare cause of intestinal bleeding and we describe the management and the outcome of our patients.

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.

Resection of Benign Duodenal Neoplasms

Primary small bowel neoplasms (PSBN) are uncommon, accounting for less than 15 per cent of all gastrointestinal tumors. Benign duodenal neoplasms (BDN) are rare, comprising only 10 to 20 per cent of all PSBN. The treatment is generally surgical resection ranging from local excision to pancreaticoduodenectomy depending on size, location, and number of lesions. Patients undergoing surgical treatment for BDN at Vanderbilt University Medical Center from July 1984 to April 2006, were identified and reviewed retrospectively. Medical records were examined for demographics, operative details, results, and complications. Twenty-six patients were identified of which 56 per cent were male and the mean age was 56 ± 14 years. Lesions were found throughout the duodenum, but the majority (62%) were ampullary. Nearly 75 per cent were adenomas, including over half with dysplasia. Operative interventions and complication rates were: duodenal resection with primary anastomosis (n = 3, 0%), local excision (n = 6, 50%), ampullary resection (n = 10, 30%), and pancreaticoduodenectomy (n = 7, 86%). There were no reoperations or mortalities. Mean followup was 14 months. BDN are an increasingly common problem in an era of frequent use of upper endoscopy. The surgical management of these lesions must be tailored to their size, number, location, and malignant potential. A wide variety of surgical procedures can be performed with acceptable morbidity.

CT features of jejunal pathology

The imaging of duodenal and ileal diseases is well documented in radiological literature but the jejunum has been relatively neglected. The aim of this review is to outline the current methods of investigation of the jejunum, and provide a comprehensive review of common pathologies affecting the jejunum, with particular emphasis on investigation by computed tomography.

Adjuvant chemotherapy for small intestine adenocarcinoma

BACKGROUND

Although the small intestine represents 75% of the length and over 90% of the mucosal surface of the alimentary tract, it is the site of only about 2% of malignant gastrointestinal tumours. Adenocarcinoma is the most common histological subtype, accounting for about 40% of all malignant small intestinal tumours. The infrequent occurrence when compared with malignancies of the stomach and colon is accompanied by non-specific clinical symptoms. The consequences are a significant delay in diagnosis and the finding of advanced, incurable disease at operation. Wide surgical resection of early lesions is the only potentially curative treatment, but it is possible only in a minority of patients. The rare nature of adenocarcinomas of the small intestine has led to a paucity of information about the benefits of adjuvant chemotherapy but there are reports of overall better survival for those patients that receive combination treatment. Most chemotherapy regimens consist of 5-fluorouracil (5-FU), alone or in combination with a variety of other agents like doxorubicin, cisplatin, mitomycin C, cyclophosphamide and oxaliplatin.

OBJECTIVES

To determine the role of adjuvant chemotherapy in the management of adenocarcinoma of the small intestine compared to another adjuvant treatment, a placebo or no other adjuvant treatment.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 to 2006), EMBASE (1974 to 2006), PubMed and CINHAL using the Cochrane highly sensitive search strategy for randomised controlled trials.

SELECTION CRITERIA

Phase III randomised controlled trials comparing post-operative adjuvant chemotherapy for adenocarcinoma of the small intestine with other adjuvant therapies, placebo or no adjuvant treatment.

DATA COLLECTION AND ANALYSIS

No suitable trials were identified.

MAIN RESULTS

No studies fulfilled the inclusion criteria.

AUTHORS' CONCLUSIONS

There is a need for high quality randomised controlled trials to evaluate the effectiveness of adjuvant chemotherapy in the management of adenocarcinoma of the small intestine.

Small-bowel tumors detected by wireless capsule endoscopy

Small bowel tumors are difficult to diagnose because of their endoscopic inaccessibility. This has been overcome by the use of the Pillcam SB capsule (Given Imaging, Yoqneam, Israel). The purpose of this report is to describe the largest series of patients with small bowel tumors detected by capsule endoscopy. Eighty six patients were derived from the Given Imaging clinical database on a survey of Pillcam SB capsule users who were diagnosed with 87 small bowel tumors, 1 cecal tumor, and 1 gastric tumor. The population consisted of 55 males and 31 females. 69% of patients were referred for capsule endoscopy for obscure gastrointestinal bleeding (59/86 patients) and 31% (27/86 patients) were referred for other indications including anemia, polyposis, and abdominal pain. All patients have histologically confirmed tumors. Eighty six patients reported 395 previous negative procedures (average of 4.6 per patient). Malignant tumors comprised 61% (54/89) and benign 39% (35/89). Of the 87 reported small bowel tumors, 4 were identified in the duodenum, 43 tumors were identified in the jejunum, 18 tumors were identified in the ileum, and 22 tumors were located in the mid to distal small bowel. The most common malignant tumors were adenocarcinoma, carcinoids, melanomas, lymphomas, and sarcomas. The most common benign tumors were GIST, hemangiomas, hamartomas, adenomas, and granulation tissue polyps. Capsule endoscopy is the diagnostic procedure of choice in patients with suspected small bowel tumors.

Small-bowel tumors detected by wireless capsule endoscopy

Small bowel tumors are difficult to diagnose because of their endoscopic inaccessibility. This has been overcome by the use of the Pillcam SB capsule (Given Imaging, Yoqneam, Israel). The purpose of this report is to describe the largest series of patients with small bowel tumors detected by capsule endoscopy. Eighty six patients were derived from the Given Imaging clinical database on a survey of Pillcam SB capsule users who were diagnosed with 87 small bowel tumors, 1 cecal tumor, and 1 gastric tumor. The population consisted of 55 males and 31 females. 69% of patients were referred for capsule endoscopy for obscure gastrointestinal bleeding (59/86 patients) and 31% (27/86 patients) were referred for other indications including anemia, polyposis, and abdominal pain. All patients have histologically confirmed tumors. Eighty six patients reported 395 previous negative procedures (average of 4.6 per patient). Malignant tumors comprised 61% (54/89) and benign 39% (35/89). Of the 87 reported small bowel tumors, 4 were identified in the duodenum, 43 tumors were identified in the jejunum, 18 tumors were identified in the ileum, and 22 tumors were located in the mid to distal small bowel. The most common malignant tumors were adenocarcinoma, carcinoids, melanomas, lymphomas, and sarcomas. The most common benign tumors were GIST, hemangiomas, hamartomas, adenomas, and granulation tissue polyps. Capsule endoscopy is the diagnostic procedure of choice in patients with suspected small bowel tumors.

Immunohistochemical investigation of tumorigenic pathways in small intestinal adenocarcinoma: a comparison with colorectal adenocarcinoma

Small intestinal adenocarcinoma is an uncommon neoplasm morphologically similar to or indistinguishable from colorectal adenocarcinoma. Although much has been learned about genetic pathways critical to colorectal tumorigenesis, little is known about molecular alterations involved in the development of small intestinal adenocarcinoma. In this study, we immunohistochemically compared non-ampullary small intestinal adenocarcinomas with sporadic colorectal adenocarcinomas for the expression of several proteins known to serve pivotal roles in colorectal tumorigenesis. These included adenomatous polyposis coli and beta-catenin involved in the Wnt signaling pathway, and DNA mismatch repair enzymes hMLH1, hMSH2 and hMSH6 involved in the microsatellite instability pathway. The expression of two important tumor suppressors, p53 and RB, was also examined. The results show that complete loss of adenomatous polyposis coli immunoreactivity, presumably resulting from its gene mutations, was observed in eight of 26 (31%) small intestinal adenocarcinomas and 36 of 51 (71%) colorectal adenocarcinomas (P = 0.0008). Nuclear localization of beta-catenin, an indirect evidence of deregulated Wnt signaling pathway, was observed in 5 (19%) small intestinal adenocarcinomas and 36 (71%) colorectal adenocarcinomas (P<0.0001). Total lack of nuclear staining for one or more of the DNA mismatch repair enzymes occurred in a similar low frequency in both small intestinal and colorectal adenocarcinomas, seen in two of 25 (8%) and 10 of 47 (21%) cases, respectively (P = 0.1958). The frequencies of aberrant p53 and RB expression were also similar between small intestinal and colorectal adenocarcinomas. These observations indicate that defects in the Wnt and microsatellite instability pathways occur in over 90% of colorectal adenocarcinomas, but in only 40% of small intestinal adenocarcinomas. Small intestinal tumorigenesis appears to follow a distinct, yet unidentified, molecular pathway(s) from its colorectal counterpart despite their morphologic similarity.

An unusual presentation of a malignant jejunal tumor and a different management strategy

Background

Malignant small bowel tumors are very rare and leiomyosarcoma accounts for less than 15% of the cases. Management of these tumors is challenging in view of nonspecific symptoms, unusual presentation and high incidence of metastasis. In this case report, an unusual presentation of jejunal sarcoma and management of liver metastasis with radiofrequency ablation (RFA) is discussed.

Case presentation

A 45-year-old male presented with anemia and features of small bowel obstruction. Operative findings revealed a mass lesion in jejunum with intussusception of proximal loop. Resection of bowel mass was performed. Histopathological findings were suggestive of leiomyosarcoma. After 3-years of follow-up, the patient developed recurrence in infracolic omentum and a liver metastasis. The omental mass was resected and liver lesion was managed with radiofrequency ablation.

Conclusion

Jejunal leiomyosarcoma is a rare variety of malignant small bowel tumor and a clinical presentation with intussusception is unusual. We suggest that an aggressive management approach using a combination of surgery and a newer technique like RFA can be attempted in patients with limited metastatic spread to liver to prolong the long-term survival in a subset of patients.

Alteration of Cytokeratin 7 and Cytokeratin 20 Expression Profile Is Uniquely Associated With Tumorigenesis of Primary Adenocarcinoma of the Small Intestine

Twenty-four cases of primary nonampullary small intestinal adenocarcinoma were immunohistochemically examined for the expression of cytokeratin (CK) 7 and CK20 and compared with 23 colorectal adenocarcinomas secondarily involving the small intestine by direct extension or metastasis. While normal small intestinal mucosa was diffusely positive for CK20 and completely negative for CK7 expression, all small intestinal adenocarcinomas (24 of 24) showed a variable degree of CK7 expression. Specifically, the CK7 staining pattern was diffuse in 13 cases (54%) and focal in the remaining cases. Sixteen small intestinal adenocarcinomas (67%) coexpressed CK7 and CK20, and 8 (33%) completely lost CK20 immunoreactivity when compared with adjacent non-neoplastic small intestinal mucosa. In the latter cases, the loss of CK20 immunoreactivity with a reciprocal emergence of CK7 expression was evident. This was in contrast to secondary colorectal adenocarcinomas where 22 cases (96%) expressed CK20, among which only 1 case showed focal CK7 expression. The remaining 1 case was negative for both CK7 and CK20. Interestingly, adenomatous epithelium associated with small intestinal adenocarcinomas identified in 18 cases also exhibited CK7 positivity with a sharp transition from CK7-negative normal-appearing epithelium. Taken together, these observations delineate an alteration of CK7 and CK20 expression profile that occurs early in small intestinal tumorigenesis. This unique pattern may be of diagnostic value in distinguishing primary small intestinal adenocarcinoma from secondary colorectal adenocarcinoma.

Differentiation pathways in duodenal and ampullary carcinomas: a comparative study on mucin and trefoil peptide expression, including gastric and colon carcinomas

Duodenal carcinomas, such as ampullary tumors, may be a heterogeneous group of neoplasms that share differentiation features with gastric or colorectal carcinomas. Because of the cell- and tissue-specific expression patterns of mucins and trefoil peptides, these markers were used to investigate the differentiation status of duodenal and ampullary carcinomas in comparison with gastric and colorectal carcinomas. Adenocarcinomas (14 duodenal, 10 gastric, 11 ampullary and 10 colorectal) were examined immunohistochemically for the mucin gene products MUC1, MUC2, MUC5AC, MUC6 and the trefoil peptides TFF1 and TFF2. The tumors' expression profile for MUC5AC, MUC6 and TFF1 was used to distinguish between gastric- and intestinal-directed differentiation. The mucins that were most often expressed in the individual tumor types were MUC1 (duodenal and ampullary carcinomas), MUC2 (colorectal carcinomas) and MUC5AC (gastric carcinomas). Further classification focusing on the expression profile for MUC5AC, MUC6 and TFF1 revealed that 21% of the duodenal and 45% of the ampullary carcinomas demonstrated mainly gastric differentiation (positivity for all three markers or only two of them). The remaining duodenal and ampullary carcinomas showed nongastric, i.e., intestinal differentiation (all three markers negative or only one marker positive). The gastric differentiation pattern characterized 60% of gastric carcinomas. Colorectal carcinomas showed intestinal differentiation in 100% of cases. Duodenal carcinomas have a heterogeneous mucin expression pattern that is mainly related to either gastric differentiation or intestinal differentiation. This also holds for ampullary carcinomas. Among the markers used, MUC5AC, MUC6 and TFF1 are most useful for revealing differentiation pathways in duodenal and ampullary carcinoma.