Duodenal carcinoma at the ligament of Treitz. A molecular and clinical perspective

A rare case of duodenal adenocarcinoma

Duodenal adenocarcinoma is very rare. Its clinical picture is nonspecific and the diagnosis is often accidental. The factors that affect survival are difficult to determine because the number of patients is not high. The common site of duodenal tumors and surgical removal are also debatable. The treatment guidelines published so far have mostly been evaluated in retrospective studies conducted over a 20-year period with relatively small sample sizes. The author presents a case of duodenal adenocarcinoma in a 62-year-old male patient with a clinical manifestation of melena. Duodeno-cephalo-pancreatectomy was the surgical option.

Ligament of Treitz: Anatomy, Relevance of Radiologic Findings, and Radiologic-Pathologic Correlation

OBJECTIVE. The objective of this article is to discuss the anatomy, embryonic origin, normal variants, and various attachments of the ligament of Treitz. We also describe the pathologic processes that develop along the ligament of Treitz and the role of cross-sectional imaging in identifying these conditions. CONCLUSION. The ligament of Treitz, also known as the suspensory ligament of the duodenum, is an important anatomic landmark in the abdomen. It is essential that radiologists understand the anatomic attachments, normal variants, and various pathologic conditions involving the ligament of Treitz as well as the role of cross-sectional imaging in the assessment of these conditions.

Tubulovillous Adenoma in the Bladder in a Dual Pancreas-Kidney Transplant Patient

Background: A rare report of a tubulovillous adenoma arising in the setting of a dual pancreas-kidney transplant patient.

Case Presentation: This adenoma was discovered in a 60-year-old male with a dual pancreas-kidney transplant that presented with urinary retention and gross hematuria. Management of this patient required both transurethral resection of the tumor as well as a laparotomy after recurrence. Follow-up with cystoscopy has shown no further recurrence of the tumor.

Conclusion: This case adds to the few cases documented of adenomas arising in bladders augmented with gastrointestinal tract tissue. The tumor may reflect growth from donor duodenal graft tissue, however, the metaplasia of urothelial tissue cannot be fully ruled out. Based on this case, our understanding of these rare tumors and their clinical course is deepened.

A case of primary adenocarcinoma of the third portion of the duodenum resected by laparoscopic and endoscopic cooperating surgery

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Laparoscopic and endoscopic cooperating surgery (LECS) enabled en bloc resection with adequate surgical margins and secure intra-abdominal suturing for duodenal neoplasms.

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Thorough mobilization of the mesocolon and pancreas head is essential for this procedure because it facilitates correct resection and suturing.

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LECS is a feasible treatment option for duodenal neoplasms.

Introduction

We report a case of primary adenocarcinoma in the third portion of the duodenum (D3) curatively resected by laparoscopic and endoscopic cooperating surgery (LECS).

Presentation of case

A 65-year-old woman had a routine visit to our hospital for a follow-up of rectal cancer resected curatively 2 years ago. A routine screening gastroduodenal endoscopy revealed an elevated lesion of 20 mm in diameter in the D3. The preoperative diagnosis was adenoma with high-grade dysplasia; however, suspicion about potential adenocarcinoma was undeniable. Curative resection was performed by LECS. Pathological examination revealed intramucosal adenocarcinoma arising from normal duodenal mucosa. The tumor was stage I (T1/N0/M0) in terms of the tumor, nodes, metastasis (TNM) classification. LECS for duodenal tumor has seldom been reported previously, and this is the first report of LECS for primary adenocarcinoma in the D3. The transverse mesocolon was removed from the head of pancreas to expose the duodenum, and the accessory right colic vein was cut; this was followed by the Kocher maneuver for mobilization of the lesion site.

Discussion

LECS enabled en bloc resection with adequate surgical margins and secure intra-abdominal suturing. Thorough mobilization of the mesocolon and pancreas head is essential for this procedure because it facilitates correct resection and suturing.

Conclusion

LECS is a feasible treatment option for duodenal neoplasms, including intramucosal adenocarcinoma, even though it exists in the D3.

Wilkie's Syndrome and Left Adnexal Mass: Unusual Presentation of Duodenal Adenocarcinoma

Duodenal adenocarcinoma (DACa) is a rare malignancy, the presenting symptoms of which are vague and nonspecific. We report the case of a patient presenting with symptoms of subacute small bowel obstruction whose CT scan revealed i) left adnexal mass and ii) compression of 3(rd) portion of duodenum with reduced aortomesentric angle consistent with Wilkie's syndrome (WS). Laparatomy in addition revealed a distal duodenal stricture, which showed a well differentiated DACa causing subtotal intestinal obstruction. The ovarian mass revealed adenocarcinoma with similar morphology. Immunophenotypic analysis revealed positive expression of CK 20 and CDX 2 and absence of CK 7 staining in the tumours consistent with Primary DACa with ovarian metastasis. We further concluded that the WS resulted from reduced mesenteric fat pad caused by DACa induced cachexia. The case highlights the elusive nature of duodenal malignancy and emphasises the importance of meticulous small bowel examination during exploration of ovarian masses.

Tumors of the angle of Treitz: A single-center experience

AIM: To explore the feasibility and oncologic outcomes of segmental jejunal resection on the left side of the mesenteric vessels in patients with tumors of the angle of Treitz using data from a single center.

METHODS: Thirteen patients with tumors of the angle of Treitz who underwent surgery at our institution were prospectively followed. A segmental jejunal resection on the left side of the mesenteric vessels was performed in all patients. Formalin-fixed and paraffin-embedded tumor samples were examined. The primary end point of this analysis was disease-free survival.

RESULTS: In this study, there were 8 males and 5 females (mean age, 50.1 years; range, 36-74 years). The mean tumor size was 8.1 cm (range, 3.2-15 cm). Histologic examination showed 11 gastrointestinal stromal tumors (GISTs) and 2 adenocarcinomas. Five of the GIST patients presented with potential low risk, and 6 presented with intermediate and high risk, according to the National Institutes of Health criteria. One potentially high-risk patient showed tumor progression at 46 mo and died 52 mo after surgery. One patient with locally advanced adenocarcinoma received neoadjuvant chemotherapy and adjuvant radiotherapy, but the disease progressed, and the patient died 9 mo after surgery. One GIST patient without progression died 16 mo after surgery because of a postoperative intestinal obstruction. The median overall survival rate was 84.6 mo, and the median disease-free survival rate was 94.5 mo.

CONCLUSION: The overall survival of patients with tumors of the angle of Treitz was encouraging even when the tumor size was relatively large. A segmental resection on the left side of the mesenteric vessels is considered to be a reliable and curative option for tumors of the angle of Treitz.

SOX9 Is Highly Expressed in Nonampullary Duodenal Adenoma and Adenocarcinoma in Humans

BACKGROUND/AIMS

SOX9 is a marker for stem cells in the intestine, and overexpression of SOX9 is found in gastric and colon cancer; however, the expression of SOX9 in nonampullary duodenal adenoma and adenocarcinoma has not yet been evaluated. This study aimed to investigate SOX9 expression in nonampullary duodenal adenoma and adenocarcinoma by immunohistochemistry.

METHODS

We evaluated SOX9 expression in 43 clinical samples (nonampullary duodenal adenoma in 22 lesions and nonampullary duodenal adenocarcinoma in 21 lesions) resected under endoscopic mucosal resection or endoscopic submucosal dissection.

RESULTS

SOX9 was expressed in part of the base of the normal duodenal mucosa surrounding adenomas and adenocarcinomas. In contrast, SOX9-positive cells were found in more than half of the crypts from the bottom part of the crypt in all of the 43 samples. Moreover, in 15 adenoma samples (68.2%) and 19 carcinoma samples (90.5%), SOX9 was expressed in more than three-quarters of the crypts from the bottom part of the crypt.

CONCLUSIONS

SOX9 is overexpressed in nonampullary duodenal adenoma and adenocarcinoma in humans.

Recurrent Adenocarcinoma of Colon Presenting as Duodenal Metastasis With Partial Gastric Outlet Obstruction: A Case Report With Review of Literature

Colorectal cancer is one of the leading causes of cancer related deaths in western world. While most common site for metastasis for colon cancer is liver, lung, and the peritoneum, metastasis to various other organs such as brain, bones and thyroid has been reported. Metastatic lesions to the small bowel are more common than primary lesions and most common primary neoplasms that metastasize to the duodenum are lung cancer, renal cell carcinoma, breast cancer, and malignant melanoma. We report a very rare case of recurrent adenocarcinoma of colon metastasizing to duodenum after 2 years of curative resection of primary cancer. Surgical resection for curative intent as well as palliative management is recommended.

[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.