Malignant tumours of the small intestine: a review of histopathology, multidetector CT and MRI aspects

Radiomics analysis based on CT for predicting lymph node metastasis and prognosis in duodenal papillary carcinoma

OBJECTIVES

Radiomics has been demonstrated to be strongly associated with TNM stage and patient prognosis. We aimed to develop a model for predicting lymph node metastasis (LNM) and survival.

METHODS

For radiomics texture selection, 3D Slicer 5.0.3 software and the least absolute shrinkage and selection operator (LASSO) algorithm were used. Subsequently, the radiomics model, computed tomography (CT) image, and clinical risk model were compared. The performance of the three models was evaluated using receiver operating characteristic (ROC) curves, decision curve analysis (DCA), calibration plots, and clinical impact curves (CICs).

RESULTS

For the LNM prediction model, 224 patients with LNM information were used to construct a model that was applied to predict LNM. According to the CT data and clinical characteristics, we constructed a radiomics model, CT imaging model and clinical model. The radiomics model for evaluating LNM status showed excellent calibration and discrimination in the training cohort (AUC = 0.926, 95% CI = 0.869-0.982) and the validation cohort (AUC = 0.872, 95% CI = 0.802-0.941). DeLong's test demonstrated that the difference among the three models was significant. Similarly, DCA and CIC showed that the radiomics model has better clinical utility than the CT imaging model and clinical model. Our model also exhibited good performance in predicting survival-in line with the findings of the model built with clinical risk factors.

CONCLUSIONS

CT radiomics models exhibited better predictive performance for LNM than models built based on clinical risk characteristics and CT imaging and had comparative clinical utility for predicting patient prognosis.

CRITICAL RELEVANCE STATEMENT

The radiomics model showed excellent performance and discrimination for predicting LNM and survival of duodenal papillary carcinoma (DPC).

KEY POINTS

LNM status determines the most appropriate treatment for DPC. Our radiomics model for evaluating the LNM status of DPC performed excellently. The radiomics model had high sensitivity and specificity for predicting survival, exhibiting great clinical value.

Current landscape of primary small bowel leiomyosarcoma: cases report and a decade of insights

The incidence of leiomyosarcoma (LMS) is about 4-5/100,000 individuals per year. LMSs occurring in the small bowel are even rarer, and their preoperative diagnosis is very difficult. We described two patients with pathologically confirmed small bowel LMS and analyzed their clinical and medical imaging features. Similar cases reported in English in Pubmed database over the past decade were reviewed and summarized. These tumors were categorized by the growth direction and relationship with the intestinal lumen into three types: intraluminal (n = 10), intermural (n = 3), and extraluminal (n = 7). Notably, among the three types of LMS, the intramural leiomyosarcoma stands out as a noteworthy subtype. Emerging evidence suggests that smaller tumor size (< 5 cm) and the intraluminal type may serve as favorable prognostic indicators, while the extraluminal type is associated with relatively poor prognosis. Furthermore, the integration of imaging features with CA125 and LDH biomarkers holds promise for potential diagnostic value in LMS.

Risk factors, prognostic factors, and nomograms for distant metastasis in patients with diagnosed duodenal cancer: A population-based study

BACKGROUND

Duodenal cancer is one of the most common subtypes of small intestinal cancer, and distant metastasis (DM) in this type of cancer still leads to poor prognosis. Although nomograms have recently been used in tumor areas, no studies have focused on the diagnostic and prognostic evaluation of DM in patients with primary duodenal cancer.

AIM

To develop and evaluate nomograms for predicting the risk of DM and personalized prognosis in patients with duodenal cancer.

METHODS

Data on duodenal cancer patients diagnosed between 2010 and 2019 were extracted from the Surveillance, Epidemiology, and End Results database. Univariate and multivariate logistic regression analyses were used to identify independent risk factors for DM in patients with duodenal cancer, and univariate and multivariate Cox proportional hazards regression analyses were used to determine independent prognostic factors in duodenal cancer patients with DM. Two novel nomograms were established, and the results were evaluated by receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA).

RESULTS

A total of 2603 patients with duodenal cancer were included, of whom 457 cases (17.56%) had DM at the time of diagnosis. Logistic analysis revealed independent risk factors for DM in duodenal cancer patients, including gender, grade, tumor size, T stage, and N stage (P < 0.05). Univariate and multivariate COX analyses further identified independent prognostic factors for duodenal cancer patients with DM, including age, histological type, T stage, tumor grade, tumor size, bone metastasis, chemotherapy, and surgery (P < 0.05). The accuracy of the nomograms was validated in the training set, validation set, and expanded testing set using ROC curves, calibration curves, and DCA curves. The results of Kaplan-Meier survival curves (P < 0.001) indicated that both nomograms accurately predicted the occurrence and prognosis of DM in patients with duodenal cancer.

CONCLUSION

The two nomograms are expected as effective tools for predicting DM risk in duodenal cancer patients and offering personalized prognosis predictions for those with DM, potentially enhancing clinical decision-making.

A comprehensive survey of intestine histopathological image analysis using machine vision approaches

Colorectal Cancer (CRC) is currently one of the most common and deadly cancers. CRC is the third most common malignancy and the fourth leading cause of cancer death worldwide. It ranks as the second most frequent cause of cancer-related deaths in the United States and other developed countries. Histopathological images contain sufficient phenotypic information, they play an indispensable role in the diagnosis and treatment of CRC. In order to improve the objectivity and diagnostic efficiency for image analysis of intestinal histopathology, Computer-aided Diagnosis (CAD) methods based on machine learning (ML) are widely applied in image analysis of intestinal histopathology. In this investigation, we conduct a comprehensive study on recent ML-based methods for image analysis of intestinal histopathology. First, we discuss commonly used datasets from basic research studies with knowledge of intestinal histopathology relevant to medicine. Second, we introduce traditional ML methods commonly used in intestinal histopathology, as well as deep learning (DL) methods. Then, we provide a comprehensive review of the recent developments in ML methods for segmentation, classification, detection, and recognition, among others, for histopathological images of the intestine. Finally, the existing methods have been studied, and the application prospects of these methods in this field are given.

Prediction of distant metastasis and specific survival prediction of small intestine cancer patients with metastasis: A population-based study

BACKGROUND

Small intestine cancer (SIC) is difficult to diagnose early and presents a poor prognosis due to distant metastasis. This study aimed to develop nomograms for diagnosing and assessing the prognosis of SIC with distant metastasis.

METHODS

Patients diagnosed with SIC between 2010 and 2015 were included from the Surveillance, Epidemiology and End Results database. Univariate and multifactor analysis determined independent risk factors for distant metastasis and prognostic factors for overall and cancer-specific survival. We then constructed the corresponding three nomograms and assessed the diagnostic accuracy of the nomograms by net reclassification improvement, receiver operating characteristic curves and calibration curves, assessed the clinical utility by decision curve analysis.

RESULTS

The cohort consisted of 6697 patients, of whom 1299 had distant metastasis at diagnosis. Tstage, Nstage, age, tumor size, grade, and histological type were independent risk factors for distant metastasis. Age, histological type, T stage, N stage, grade, tumor size, whether receiving surgery, number of lymph nodes removed, and the presence of bone or lung metastases were predictors of both overall survival and cancer-specific survival. The nomograms showed excellent accuracy in predicting distant metastasis and prognosis.

CONCLUSION

Nomograms were developed and validated for SIC patients with distant metastasis, aiding physicians in making rational and personalized clinical decisions.

Case Report: Small intestinal metastatic breast cancer: A case report and literature review

Breast cancer is considered a malignant tumor with the highest incidence among women and is prone to develop distant metastasis. Small intestinal metastasis of breast cancer, however, is relatively rare. This case report describes a 49-year-old Chinese female patient who presented with small intestinal obstruction and was diagnosed with lobular breast cancer with small intestinal and contralateral breast metastasis. Clinical manifestations, clinicopathological features and potential mechanisms of metastasis, along with diagnosis and treatment, are discussed with a review of the relevant literature. Although small intestinal metastasis is rare in breast cancer, we should keep high alert on the possibility of gastrointestinal metastasis when treating lobular breast cancer patients.

Malignant Small Bowel Neoplasms:a review of post-contrast multiphasic multidetector computed tomography

Small bowel neoplasms are rare and account for 3-6% of all gastrointestinal neoplasms. For the diagnosis of small bowel neoplasms, differentiating normal bowel tissue from tumor is critical and depends on imaging modality and scanning techniques. The detection and characterization of small bowel neoplasms have recently improved with the advance of computed tomography (CT) technology. Post-contrast multiphasic CT is an aid to detection and recognition of the vascular nature of small bowel neoplasms. Understanding the typical post-contrast multiphasic CT features of small bowel neoplasms is important because of overlapping features and the necessity of evaluating associated complications and metastases to lymph node and other organs. However, accurate classification of pathologies is still challenging in clinical practice. Texture analysis can quantify complex mathematical patterns within the gray-level distribution of the pixels and voxels of digital images, and texture analysis of the post-contrast multidetector CT data of various tumors has been attracting attention in recent years. The aim of this article is to provide a comprehensive guide to the relevant imaging features for different types of malignant small bowel neoplasms. J. Med. Invest. 69 : 19-24, February, 2022.

Small bowel adenocarcinoma: An overview

Small bowel adenocarcinoma (SBA) is a rare malignancy of the gastrointestinal tract. However, these tumors are among those with worst prognosis. Vague clinical signs and symptoms and radiological diagnostic challenges often delay treatment, which negatively impacts the prognosis of the patients. However, recent advances in imaging technology, like multidetector computed tomography, magnetic resonance imaging, and capsule endoscopy, have made earlier and accurate diagnosis possible. Surgery is the treatment of choice followed by adjuvant therapy. However, there are no strict treatment guidelines available for the management of SBA. Most of the available evidence from colorectal and gastric carcinoma has been extrapolated to adequately manage SBA. Prognosis for SBA is better than gastric carcinoma but worse than colorectal carcinoma. Currently, there is not enough information on the molecular characteristics and tumor pathogenesis. 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.

Small intestine leiomyosarcoma mimicking gastrointestinal stromal tumour

Small bowel malignant tumours make only 2% of all gastrointestinal (GI) malignancies. Small bowel leiomyosarcoma (LMS) is further rare, accounts for only 0.1%-3% fraction of these tumours. These cases can present as asymptomatic intra-abdominal mass, anaemia due to GI bleed or acute abdomen such as perforation peritonitis, intussusception and bowel ischaemia. Standard of care is surgical resection. Our case presented as large lobulated exophytic ileal LMS measuring 10.8×11×14.7 cm involving multiple small bowel loops and abutting right iliac vessels and uterus. Patient's clinical course was complicated with COVID-19 positivity, deep vein thrombosis and pulmonary thromboembolism. She was managed by preoperative anticoagulation followed by resection of the tumour with end ileostomy.

Mimicking conditions of intestinal Crohn's disease: magnetic resonance enterography findings

Crohn's disease is a chronic inflammatory condition characterized by a transmural involvement of intestinal walls. Its diagnosis comes from a combination of clinical data, imaging findings and, above all, endoscopy with biopsy results, which are mandatory for achieving a definitive diagnosis. Even so, endoscopy information may be unavailable, for instance due to technical impairments or patient intolerance. On the radiological side, Magnetic Resonance Enterography is currently considered the imaging technique of choice for Crohn's disease assessment, either at first diagnosis or follow-up. Nevertheless, the lack of radiation exposure as well as invasiveness has made this imaging approach suitable also for the evaluation of a number of small and large bowel diseases over recent years. However, it is important to remember that Magnetic Resonance Imaging findings are non-specific and that a wide overlap exists among Crohn's disease and other intestinal conditions. The aim of this work was to provide a series of intestinal affections evaluated through Magnetic Resonance Enterography that resemble Crohn's disease and that can be helpful in avoiding misinterpretation, especially when endoscopy data are missing.

De novo distal terminal ileum adenocarcinoma mimicking Crohn's disease and diagnostic challenges in imaging: a case series

De novo small bowel adenocarcinoma (SBA) in the terminal ileum is the least common of the SBA types. However, its highest prevalence is found in the presence of Crohn's disease (CD). As patients with SBA and CD present with similar symptoms, there is a high chance of misdiagnosing SBA as CD. This can lead to delay in proper diagnosis and can affect prognosis. In this article, we discuss two cases of de novo SBA mimicking CD, in the absence of CD, on conventional CT, CT enteroclysis and magnetic resonance imaging (MRI) enteroclysis. Moreover, it underlines the importance of suspecting SBA in cases where there is a lack of response to long-term medical treatment.

Primary Gastro-Intestinal Lymphoma and Gastro-Intestinal Adenocarcinoma: An Initial Study of CT Texture Analysis as Quantitative Biomarkers for Differentiation

BACKGROUND

To explore the potential role of computed tomography (CT) texture analysis and an imaging biomarker in differentiating primary gastro-intestinal lymphoma (PGIL) from gastro-intestinal adenocarcinoma (GIAC).

METHODS

A total of 131 patients with surgical pathologically PGIL and GIAC were enrolled in this study. Histogram parameters of arterial and venous phases extracted from contrast enhanced modified discrete cosine transform (MDCT) images were compared between PGIL and GIAC by Mann-Whitney U tests. The optimal parameters for differentiating these two groups were obtained through receiver operating characteristic (ROC) curves and the area under the curve (AUC) was calculated.

RESULTS

Compared with GIAC, in arterial phase, PGIL had statistically higher 5th, 10th percentiles (p = 0.003 and 0.011) and statistically lower entropy (p = 0.001). In the venous phase, PGIL had statistically lower mean, median, 75th, 90th, 95th percentiles, and entropy (p = 0.036, 0.029, 0.007, 0.001 and 0.001, respectively). For differentiating PGIL from GIAC, V-median + A-5th percentile was an optimal parameter for combined diagnosis (AUC = 0.746, p < 0.0001), and the corresponding sensitivity and specificity were 81.7 and 64.8%, respectively.

CONCLUSION

CT texture analysis could be useful for differential diagnosis of PGIL and GIAC.

Duodenal tumors on cross-sectional imaging with emphasis on multidetector computed tomography: a pictorial review

Duodenal tumours are uncommon, but they can cause significant morbidity and mortality. As stomach and colon are a more common site of gastrointestinal malignancies, radiologists sometimes neglect the duodenum. Multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) can accurately locate and characterize mass-forming duodenal lesions, making them invaluable for the differential diagnosis and determining management strategies such as biopsy or surgery. Although conventional endoscopy continues to play an important role in the diagnosis of duodenal tumors, MDCT and MRI are very useful for evaluating the duodenal wall, extraduodenal space, and surrounding viscera, as well as the intraluminal content seen on endoscopy. This pictorial review aims to illustrate the most common benign and malignant mass-forming duodenal lesions and to focus on the imaging features that are most helpful in reaching the correct diagnosis.

Small Bowel Neoplasms: A Pictorial Review

Small bowel tumors are rare and account for approximately 3% of all gastrointestinal tumors in the United States. The incidence of small bowel neoplasms is rising-in particular, there is a rising incidence of small bowel carcinoid tumors. This may in part be due to small bowel lesion identification in an increasing number of cross-sectional imaging studies performed for other indications as well as increased use of advanced imaging techniques to assess specifically for small bowel disease. Diagnosis is a challenge owing to nonspecific clinical manifestation, rare occurrence, and low index of clinical suspicion. Yet, various small bowel neoplasms have characteristic imaging features at CT and MRI when optimal distention of the small bowel is achieved, correlating well with features seen in gross specimens. Understanding the imaging features of small bowel neoplasms is important to improve the radiologist's ability to diagnose and characterize small bowel neoplasms. Most small bowel tumors are clinically silent for long periods, and nearly half of the benign tumors are found incidentally during surgery or at cross-sectional imaging performed for other reasons. The authors review the imaging features of common benign and malignant small bowel neoplasms to aid the radiologist in diagnosis of small bowel tumors. ^©RSNA, 2020.

Workup of Gastroenteropancreatic Neuroendocrine Tumors

Neuroendocrine tumors of the gastrointestinal tract or pancreas are rare. Their presentation overlaps with other intra-abdominal neoplasms, but can have unique features. The workup involves recognition of unusual clinical features associated with the tumors, imaging, analysis of blood or urine concentrations, and biopsy. Functional imaging takes advantage of the neuroendocrine tumor-specific expression of somatostatin receptors. There are characteristic features supporting the diagnosis on contrast-enhanced cross-sectional imaging. The use of tumor markers for biochemical diagnosis requires an understanding of the confounding variables affecting these assays. There are unique and specific immunohistochemical staining and grading requirements for appropriate diagnosis of these tumors.

Magnetic Resonance of Small Bowel Tumors

Tumors of the small intestine represent less than 5% of all gastrointestinal tract neoplasms. Magnetic resonance (MR) imaging is rapidly increasing clinical acceptance to evaluate the small bowel and can be the initial imaging method to investigate small bowel diseases. MR examinations may provide the first opportunity to detect and characterize tumors of the small bowel. Intraluminal and extraluminal MR findings, combined with contrast enhancement and functional information, allow accurate diagnoses and consequently characterization of small bowel neoplasms. This article describes the MR findings of primary small bowel neoplasms and the MR findings for the differential diagnosis are discussed.

Surgical Management of Jejunal Tumors: Experience from Tertiary Care Centre

INTRODUCTION

Small bowel is an uncommon site for primary neoplasm in the gastrointestinal tract. Traditionally, duodenum has been combined with jejunum and ileum in analysing the presentation and management of these tumors. Given the different presentation pattern, diagnostic difficulties and anatomical considerations, jejunal tumors may differ from duodenal tumors.

METHODOLOGY

Retrospective analysis of a prospectively maintained database of patients with histology proven jejunal tumors was done. Clinico-radiological characters, histological findings, surgical procedures and the outcomes in these patients were studied.

RESULTS

Sixteen patients were included in the study. Median age at presentation was 42 years (26-76 years) and majority were males (n = 11, 68.8%). Seven (43.7%) patients presented with emergencies. Endoscopic tissue diagnosis could be obtained in 5 (31.3%) patients. Histology of tumors were adenocarcinoma, gastrointestinal stromal tumor and lymphoma in 6 (37.5%), 5 (31.3%) and 3 (18.8%) respectively. Sarcoma (myxofibroma) and metastasis (urothelial origin) were present in one patient each. Two patients with adenocarcinoma had neoadjuvant chemotherapy. Curative resection was feasible in 14 patients. Resection of tumor-bearing segment with anastomosis was performed in 9 patients. Among these, 5 had duodenojejunostomy. One patient had resection and double-barrel jejunostomy. One patient with jejunal GIST had sleeve resection. Multi-visceral resection was performed in 3 patients. There were no mortality and median postoperative hospital stay was 11 days (range 7-33 days).

CONCLUSION

Histology spectrum of jejunal tumors are distinct. Difficulty in obtaining preoperative tissue diagnosis of these lesions need to be addressed by improved endoscopic and image-directed biopsy techniques.

Clinical time course and CT detection of metastatic disease to the small bowel

PURPOSE

The purpose of this study was to identify the CT characteristics of metastatic disease of the small bowel and define the clinical time course between primary tumor diagnosis and small bowel metastasis detection.

METHODS

A retrospective search of a pathologic database for metastases to small bowel identified 242 cases. Exclusion criteria were cases without CT (N = 49), serosal or mesenteric metastases (N = 114), or cases of direct invasion to small bowel (N = 63). The clinical records and imaging were reviewed for 16 patients.

RESULTS

Melanoma was the most common malignancy to metastasize to small bowel (7 of 16 patients). Only one of the 16 cases was detected at the time of initial diagnosis of their primary malignancy. The average time from diagnosis of the primary malignancy or remission to the time of detection of the small bowel metastasis was 7.2 and 8.3 years, respectively. The most common symptoms were gastrointestinal bleeding (N = 5) and small bowel obstruction (N = 5). In 3 cases, the masses were not identified on pre-operative CT.

CONCLUSION

Metastases to the small bowel often occur many years after the initial diagnosis of the primary malignancy or entering remission and may be symptomatic. Attention to the small bowel is particularly important in melanoma patients, who may have multiple small bowel metastases, even after many years of being disease free. As oncology patients undergo numerous surveillance scans and improved therapies allow for longer survival, detection of these masses at a small size can facilitate elective resection to avert urgent surgical intervention.

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.

Multimodality Imaging of Ileal Neuroendocrine (Carcinoid) Tumor

OBJECTIVE. The purpose of this article is to provide a multimodality imaging review of ileal carcinoid tumor. CONCLUSION. Ileal carcinoid tumors display a variety of radiologic findings. Delay in diagnosis is common because of initial nonspecific symptoms and subtle imaging findings. Reviewing the multimodality imaging appearance of the primary tumor, metastatic disease, and associated ancillary findings can help improve patient care.

Adult multicentric burkitt lymphoma with bowel obstruction due to intussusception

Primary malignant tumors of the small intestine are very rare, accounting for 2%-3% of all gastrointestinal malignancies. Lymphoma constitutes about 15%-20% of all small intestine neoplasms and 20%-30% of all primary gastrointestinal lymphomas. The ileum is the most common site for gastrointestinal lymphomas. Because the symptoms and physical findings are non-specific, the preoperative diagnosis is usually difficult. In this case report, we describe the highly unusual case of sporadic Burkitt lymphoma with complete intestinal obstruction due to intussusception of the proximal jejunum and discuss the treatment options.

Correlation between clinical symptoms and pathological types in 197 cases of primary small intestinal tumors

AIM

To improve the primary and preoperative diagnosis of different pathological types of primary small intestinal tumors.

METHODS

The clinical and pathological data of 197 cases of primary intestinal tumors confirmed by surgery and pathology were retrospectively analyzed at the First Affiliated Hospital of Zhengzhou University from August 2011 to February 2017.

RESULTS

The most common clinical symptoms of different types of primary small bowel tumors were different. Abdominal mass was the most common symptom of high risk stromal tumors (38/63). Gastrointestinal bleeding was the most common symptom of low/middle risk stromal tumors (35/60). Abdominal pain was the most common symptom of malignant lymphomas (25/32) and polyps (6/6), and abdominal distension (3/5) was the most common symptom of adenocarcinoma patients. The primary diagnosis rate of primary small bowel tumors was 11.2% (22/197), of which 90.91% (20/22) were confirmed by CT examination.

CONCLUSION

The most common symptoms of different pathological types of primary small intestine tumor are different. Combining the imaging features of different pathological types of tumor and selecting the way of examination reasonably can improve the primary and preoperative diagnosis of tumor pathology, help choose the treatment plan reasonably, and improve the survival of the patients.

Detecting a rare composite small bowel lymphoma by Magnetic Resonance Imaging coincidentally: A case report with radiological, surgical and histopathological features

INTRODUCTION

Diagnosing lymphoma continues to prove challenging in the clinical practice. Composite lymphoma (CL) is defined by the coexistence of different lymphoma subtypes in the same anatomical location. This condition has seldom been witnessed in the gastrointestinal (GI) tract. We weren't able to find previous cases in the literature about small bowel CL with follicular lymphoma (FL) and classical Hodgkin lymphoma (CHL). Surgery is the treatment of choice to obtain accurate histology, to manage and prevent acute complications. We state that this work has been reported in line with the SCARE criteria.

CASE PRESENTATION

We describe an extremely rare case of small bowel CL, presenting as an intestinal bulky mass with circumferential infiltration of bowel loops. The small bowel tumor was incidentally detected by abdominal Magnetic Resonance Imaging (MRI) in a 64-year-old man who suffered from rectal discomfort and non-specific clinical symptoms. After this radiological finding, the patient underwent multiphase contrast computed tomography (MDCT) for initial staging and to study vascular involvement. Surgery was recommended to obtain an accurate diagnosis both due to initial symptoms of the intestinal obstruction and to avoid small bowel complications. The histopathological examination revealed a small bowel CL composed mainly of B cells FL with also CHL components.

CONCLUSION

It is important to note that involvement of the proximal ileal loops is very rare in small bowel lymphoma. MRI represents a precious diagnostic tool to evaluate the intra and extramural extent of the tumor.

Accuracy of Whole-Body DWI for Metastases Screening in a Diverse Group of Malignancies: Comparison With Conventional Cross-Sectional Imaging and Nuclear Scintigraphy

OBJECTIVE

The purpose of this study is to assess the role of whole-body (WB) DWI as a screening modality for the detection of metastases and to compare it to conventional cross-sectional imaging modalities or nuclear scintigraphy in a population with various histopathologic malignancies.

SUBJECTS AND METHODS

WB DWI and conventional imaging (CT, MRI, or scintigraphy) were performed for patients with known malignancies for metastatic workup, and these patients were followed up for a period of 1 year. Two radiologists assessed WB DW images separately, and conventional images were assessed by the senior radiologist. The metastatic lesions were classified into four regions: liver, lung, skeletal system, and lymph nodes. The reference standard was considered on the basis of histopathologic confirmation or clinical follow-up of the metastatic lesions.

RESULTS

WB DWI was slightly inferior to conventional imaging modalities for the detection of hepatic metastases (sensitivity, 86.6% vs 93.3%; specificity, 91.6% vs 95.8%; and accuracy, 89.7% vs 94.8%) and skeletal metastases (sensitivity, 81.8% vs 89.4%; specificity, 86.4% vs 94.3%; and accuracy, 85.2% vs 93.0%); however, the differences were not statistically significant (p = 0.625 for hepatic metastases and p = 0.0953 for skeletal metastases, McNemar test). WB DWI was statistically significantly inferior to conventional imaging for the detection of lymph node metastases (sensitivity, 74.0% vs 81.5%; specificity, 87.9% vs 90.1%; accuracy, 81.4% vs 86.0%; p = 0.0389). WB DWI was statistically significantly inferior to conventional imaging for the detection of pulmonary metastases (sensitivity, 33.3% vs 100.0%; specificity, 90.9% vs 100.0%; accuracy, 60.8% vs 100.0%; p = 0.045).

CONCLUSION

WB DWI can be used for screening hepatic and skeletal metastases, but its reliability as the sole imaging sequence for the detection of lymph nodal and pulmonary metastases is poor and, at present, it cannot replace conventional imaging modalities.

Impact of CT enterography on the diagnosis of small bowel gastrointestinal stromal tumors

OBJECTIVE

Our purpose is to determine the impact of CT enterography on small bowel gastrointestinal stromal tumor (GIST) detection and biologic aggressiveness, and to identify any imaging findings that correlate with biologic aggressiveness.

METHODS

Records of patients with histologically confirmed small bowel GISTs who underwent CT imaging were reviewed. Biologic aggressiveness was based on initial histologic grading (very low, low, intermediate, high grade; or malignant), with upgrade to malignant category if local or distant metastases developed during clinical follow-up. Imaging indications, findings, and type of CT exam were compared with the biologic aggressiveness.

RESULTS

111 small bowel GISTs were identified, with suspected small bowel bleeding being the most common indication (45/111; 40.5%). While the number of malignant GISTs diagnosed by CT remained relatively constant (2-3 per year), the number of non-malignant GISTs increased substantially (mean 1.5/year, 1998-2005; 8.4/year, 2006-2013). In patients with suspected small bowel bleeding, CT enterography identified 33 GISTs (7/33, 21% malignant) compared to 12 GISTs by abdominopelvic CT (6/12, 50% malignant; p < 0.03). Tumor size (p < 0.0001), internal necrosis (p = 0.005), internal air or enteric contrast (p ≤ 0.021), and ulceration (p ≤ 0.021) were significantly associated with high-grade and malignant tumors, and irregular or invasive tumor borders (p < 0.01) was associated with malignant tumors.

CONCLUSION

The detection of small bowel GISTs can increase due to the use of CT enterography in patients with suspected small bowel bleeding. The large majority of small bowel GISTs detected by CT enterography are not malignant.

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.

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

BACKGROUND

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Computed Tomographic presentation of obstructive jejunal adenocarcinoma associated with celiac disease and incomplete intestinal malrotation

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Celiac disease is a risk factor for adenocarcinoma and lymphoma.

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Small bowel adenocarcinoma occurs most often in the proximal intestine.

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Intestinal malrotation can be complete or incomplete. Prophylactic surgery for incomplete malrotation in asymptomatic patient is not required .

Introduction

Small bowel adenocarcinoma is a rare entity most frequently observed with celiac disease. This is the first case report on the association of celiac disease, small bowel adenocarcinoma and intestinal malrotation.

Case report

A 40 year-old male patient diagnosed with celiac disease since the age of 5 years complained of epigastric pain and vomiting for three days. Computed tomography (CT) showed a significant gastroduodenal dilatation with thickened intestinal wall proximal to the duodenojejunal flexure. The lumen contained a food bezoar in the center. The duodenojejunal angle was abnormally on the right side of the abdomen and the superior mesenteric vein was anterior to the superior mesenteric artery. Endoscopy after aspiration found a hemi-circumferential and irregular mass which bled at the contact of fibroscope. Biopsies showed an adenocarcinoma and small bowel resection was performed.

Discussion

Celiac disease is associated with a high risk of small bowel cancer. The association of incomplete intestinal malrotation, duodenojejunal flexure tumor and celiac disease made the surgery challenging.

Conclusion

Patients with celiac disease should be carefully monitored and endoscopic or radiologic investigations should be carried out in patients with any doubtful symptoms.

Magnetic resonance enterography: the test of choice in diagnosing intestinal "zebras"

Small bowel tumors and other rare intestinal disorders are often exceedingly difficult to identify. Even cutting-edge technologies, such as push enteroscopy and capsule endoscopy, can fail to determine the cause of a patient's symptoms. At our institution magnetic resonance enterography (MRE) has become an increasingly reliable tool in the difficult-to-diagnose or difficult-to-monitor patient. In this retrospective case series, we discuss four patients with four rare intestinal disorders that were successfully diagnosed using MRE after failing to be diagnosed using more routine technologies, such as CT scans and flexible sigmoidoscopies. With the discussion of these four cases we demonstrate that MRE is a useful diagnostic modality in patients whose surveillance is difficult or to diagnose rare colorectal disease phenomena, colloquially referred to as “zebras.”

Diagnostic value of electronic enteroscopy in small bowel diseases

AIM: To evaluate the diagnostic value of electronic enteroscopy in small bowel diseases by comparing with enterocolonic double phase computed tomography (CT).

METHODS: A retrospective analysis of 273 electronic enteroscopy procedures were carried out in 170 patients with suspected small bowel diseases, 129 of whom received enterocolonic double phase CT scan at the same time. The indications, detection rate, positive findings, and diagnostic yield of electronic enteroscopy were compared with those of CT. The diagnostic accuracy of electronic enteroscopy and CT was determined by comparing with pathological diagnosis.

RESULTS: Obscure gastrointestinal bleeding (OGIB) was the most common indication (60.6%, 103/170) for electronic enteroscopy. Inflammatory lesions, polyposis or tumors, and vascular lesions made up the first three positive findings of electronic enteroscopy in patients with suspected small bowel diseases. The detection rate and diagnostic yield of electronic enteroscopy were higher than those of CT [89.4% (152/170) vs 63.6% (82/129), 67.6% (115/170) vs 34.1% (44/129), both P < 0.05]. In patients with OGIB, the detection rate and diagnostic yield of electronic enteroscopy were also higher than those of CT [95.1% (98/103) vs 52.6% (41/78), 68.9% (71/103) vs 21.8% (17/78), both P < 0.05].

CONCLUSION: The diagnostic capacity of electronic enteroscopy is better than that of CT. Suspected OGIB is the most common indication for electronic enteroscopy, which has a relatively high detection rate and diagnostic yield. Electronic enteroscopy is a safe and effective diagnostic modality for small bowel diseases.

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.

Small bowel carcinoid: Location isn’t everything!

AIM: To investigate the prognostic significance of the primary site of disease for small bowel carcinoid (SBC) using a population-based analysis.

METHODS: The Surveillance, Epidemiology and End Results (SEER) database was queried for histologically confirmed SBC between the years 1988 and 2009. Overall survival (OS) and disease-specific survival (DSS) were analyzed using the Kaplan-Meier method and compared using Log rank testing. Log rank and multivariate Cox regression analyses were used to identify predictors of survival using age, year of diagnosis, race, gender, tumor histology/size/location, tumor-node-metastasis stage, number of lymph nodes (LNs) examined and percent of LNs with metastases.

RESULTS: Of the 3763 patients, 51.2% were male with a mean age of 62.13 years. Median follow-up was 50 mo. The 10-year OS and DSS for duodenal primaries were significantly better when compared to jejunal and ileal primaries (P = 0.02 and < 0.0001, respectively). On multivariate Cox regression analysis, after adjusting for multiple factors, primary site location was not a significant predictor of survival (P = 0.752 for OS and P = 0.966 DSS) while age, number of primaries, number of LNs examined, T-stage and M-stage were independent predictors of survival.

CONCLUSION: This 21-year, population-based study of SBC challenges the concept that location of the primary lesion alone is a significant predictor of survival.

Multiple carcinoid tumors of the small intestine preoperatively diagnosed by double-balloon endoscopy

Background

Multiple carcinoid tumors of the small intestine are rare and are very difficult to detect preoperatively.

Case Report

A 75-year-old woman in whom the bleeding focus could not be found by upper and lower endoscopy and abdominal CT was admitted for evaluation of anemia. We examined the patient with total double-balloon endoscopy (DBE) and located multiple submucosal tumors. The multiple carcinoid tumors were resected successfully under laparoscopy.

Conclusions

We report a case of a successful laparoscopic operation for multiple carcinoid tumors in the small intestine without intraoperative endoscopy. Total digestive tract observation using DBE is very useful for laparoscopic operation for multiple tumors in the small intestine.

Double-balloon enteroscopy in small bowel tumors: A Chinese single-center study

AIM: To analyze the clinical characteristics of small bowel tumors detected by double-balloon enteroscopy (DBE) and to evaluate the diagnostic value of DBE in tumors.

METHODS: Four hundred and forty consecutive DBE examinations were performed in 400 patients (250 males and 150 females, mean age 46.9 ± 16.3 years, range 14-86 years) between January 2007 and April 2012. Of these, 252 patients underwent the antegrade approach, and 188 patients underwent the retrograde approach. All the patients enrolled in our study were suspected of having small bowel diseases with a negative etiological diagnosis following other routine examinations, such as upper and lower gastrointestinal endoscopy and radiography tests. Data on tumors, such as clinical information, endoscopic findings and operation results, were retrospectively collected.

RESULTS: Small bowel tumors were diagnosed in 78 patients, of whom 67 were diagnosed using DBE, resulting in a diagnostic yield of 16.8% (67/400); the other 11 patients had negative DBE findings and were diagnosed through surgery or capsule endoscopy. Adenocarcinoma (29.5%, 23/78), gastrointestinal stromal tumor (24.4%, 19/78) and lymphoma (15.4%, 12/78) were the most common tumors. Among the 78 tumors, 60.3% (47/78) were located in the jejunum, and the overall number of malignant tumors was 74.4% (58/78). DBE examinations were frequently performed in patients with obscure gastrointestinal bleeding (47.4%) and abdominal pain (24.4%). The positive detection rate for DBE in the 78 patients with small bowel tumors was 85.9% (67/78), which was higher than that of a computed tomography scan (72.9%, 51/70). Based on the operation results, the accuracy rates of DBE for locating small bowel neoplasms, such as adenocarcinoma, gastrointestinal stromal tumor and lymphoma, were 94.4%, 100% and 100%, respectively. The positive biopsy rates for adenocarcinoma and lymphoma were 71.4% and 60%, respectively.

CONCLUSION: DBE is a useful diagnostic tool with high clinical practice value and should be considered the gold standard for the investigation of small bowel tumors.

Surgery for metastatic neuroendocrine tumors with occult primaries

INTRODUCTION

Neuroendocrine tumors (NETs) frequently metastasize prior to diagnosis. Although metastases are often identifiable on conventional imaging studies, primary tumors, particularly those in the midgut, are frequently difficult to localize preoperatively.

MATERIALS AND METHODS

Patients with metastatic NETs with intact primaries were identified. Clinical and pathologic data were extracted from medical records. Primary tumors were classified as localized or occult based on preoperative imaging. The sensitivities and specificities of preoperative imaging modalities for identifying the primary tumors were calculated. Patient characteristics, tumor features, and survival in localized and occult cases were compared.

RESULTS

Sixty-one patients with an intact primary tumor and metastatic disease were identified. In 28 of these patients (46%), the primary tumor could not be localized preoperatively. A median of three different preoperative imaging studies were utilized. Patients with occult primaries were more likely to have a delay (>6 mo) in surgical referral from time of onset of symptoms (57% versus 27%, P = 0.02). Among the 28 patients with occult primary tumors, 18 (64%) were found to have radiographic evidence of mesenteric lymphadenopathy corresponding, in all but one case, to a small bowel primary. In all but three patients (89%), the primary tumor could be identified intraoperatively.

CONCLUSION

The primary tumor can be identified intraoperatively in a majority of patients with metastatic NETs, irrespective of preoperative localization status. Referral for surgical management should not, therefore, be influenced by the inability to localize the primary tumor.

[Radiological diagnostics of the small bowel]

The barium meal with plain X-ray films of the small intestine has for decades been the undisputed gold standard in imaging of the small intestine. More recently, X-rays and fluoroscopy with an overall accuracy of 73% have been replaced by multislice computed tomography (MSCT) or modern magnetic resonance imaging (MRI). Ultrasound is suitable for the orienting investigation of the small intestine in the context of general abdominal sonography as well as for dedicated examinations with a sensitivity of 67-96% and a specificity up to 97%. The endoscopic examinations of the small bowel, such as video capsule endoscopy and double-balloon enteroscopy are expensive and time-consuming techniques, which provide valuable information in special indications. Other than with the stomach or colon, the diagnostics of primary small intestine tumors plays a relatively subordinate role due to the low incidence of 3-5% of all gastrointestinal (GI) neoplasms but with a high sensitivity of 84% and a specificity of up to 97% for computed tomography (CT) and MRI. Predominant questions are those concerning ileus or the diagnostics of passage disturbances after preceding operations, to depict bowel obstructions, adhesions or the involvement of the small bowel in peritoneal carcinomatosis. The sensitivity per lesion in the initial evaluation of Crohn's disease (CD) is 47-68% for capsule endoscopy, 43% for MRI and 21% for CT enterography. In cases of known CD, the sensitivity is 70% for capsule endoscopy and 79% for MRI. A further indication is the evaluation of acute or occult gastrointestinal bleeding.

Small bowel adenocarcinoma: a case of atypical CT scan appearance

A 73-year-old man presented to the surgical assessment unit with recurrent episodes of central abdominal pain and vomiting for 18 months. He has the past medical history (PMH) of hypertension and has been using his denture for 35 years; he had no past surgical history; he drinks alcohol socially and not a smoker. This patient was investigated for iron deficiency anaemia with upper and lower gastrointestional endoscopy, as the patient had positive faecal occult blood; rectal biopsy showed no sign of inflammation and no evidence of malignancy; blood investigation showed Hb 9.8 g/dl, white cell count 14.8, mean cell volume 86.3, mean cell haemoglobin 26.9 and C reactive protein 13. This patient underwent a CT scan of the chest, abdomen and pelvis; the latest one showed that there is a short segment of the middle part of the small bowel that looks thickened and within which there is a high-density calcified shadow which is reported as an ingested foreign body or a tooth fragment; the patient underwent laparotomy and the histology results revealed 30 mm well differentiated/moderately differentiated adenocarcinoma.

Untreated celiac disease in a patient with dermatitis herpetiformis leading to a small bowel carcinoma

Usually, celiac disease has a benign course, though the overall morbidity and mortality have increased. Treatment with a gluten-free diet restores the damaged intestinal mucosa. In rare cases a small bowel adenocarcinoma develops. Unfortunately, the clinical presentation is not always recognized and prognosis is bad. We present a 69-year-old man with a history of dermatitis herpetiformis who presented to our tertiary center for a second opinion for a suspected gastric motility disorder. This diagnosis was based on the combination of upper abdominal pain for over 2 years and repetitive episodes of vomiting. Immediately after referral, celiac disease was diagnosed and a gluten-free diet was started. In the next half year of follow-up, additional anemia and weight loss developed and eventually a small bowel adenocarcinoma was diagnosed. Revision of a small bowel follow-through, which had been performed 2 years earlier, showed that the tube had been positioned just distal from the process. Therefore, this diagnosis had not been made at that time. Unfortunately, curative therapy was not possible and the patient died a few months later. In conclusion, all patients with dermatitis herpetiformis have a gluten-sensitive enteropathy and should be treated with a gluten-free diet. Next to this it is important to notice that patients with celiac disease have an increased risk of developing a small bowel malignancy. Unexplained upper abdominal pain, weight loss and anemia should lead to additional investigations to exclude a small bowel malignancy in these patients. At last, the diagnosis of a small bowel carcinoma is difficult. Together with the radiologist, the optimal techniques for visualization of this malignancy should be considered.

Clinicopathological features and treatment of primary small intestinal lymphoma: recent advances

Primary small intestinal lymphoma (PSIL) is an extra-nodal lymphoma whose clinical and histological presentations are usually heterogeneous depending on the site of the lesion. Proper staging criteria are important for clinicopathological diagnosis. Although there is no consensus regarding the role of surgery and chemotherapy in the treatment of PSIL, surgery followed by chemotherapy and radiotherapy is still the main treatment. This review summarizes the clinicopathological features, diagnosis, therapy and prognosis of PSIL.