Primary segmental and multiple adenocarcinomas of the small bowel

Multiple Adenocarcinomas of the Small Bowel in a Patient with Brunner’s Glands Agenesia: A Previously Unreported Association

Adenocarcinoma of the small bowel is rather uncommon and several etio-pathogenic factors have been proposed. We report a case of multiple synchronous adenocarcinomas arising in the non-ampullary duodenum and first tract of the jejunum in a background of Brunner’s glands agenesia, chronic duodenitis, and extensive dysplasia in a 64 year-old woman. To the best of our knowledge such association has not been reported so far.

Clinical significance of cancer specific methylation of the CDO1 gene in small bowel cancer

Although small bowel cancer (SBC) is extremely rare, its prognosis is poor, and molecular mechanism of the SBC development remains unclear. The aim of our study is to elucidate whether DNA methylation of the promoter region of the cancer-specific methylation gene, cysteine dioxygenase 1 (CDO1), contributes to the carcinogenic process in SBC. The study group comprised patients with 53 patients with SBC, 107 colorectal cancer (CRC), and other rare tumors of the small intestine such as 4 malignant lymphomas, 2 leiomyosarcomas, and 9 gastrointestinal stromal tumors. We analyzed the extent of methylation in each tissue using quantitative TaqMan methylation-specific PCR for CDO1. Significantly higher CDO1 methylation was observed in cancer tissues compared with non-cancerous mucosa of the small intestine (ROC = 0.96). Among the various clinicopathological factors, positive correlation of CDO1 methylation with tumor diameter was observed (R = 0.31, p = 0.03), and the CDO1 methylation level was a possible prognostic factor for relapse-free survival (p = 0.09). Compared with CRC, SBC had a significantly poorer prognosis (p = 0.007) and displayed a significantly higher CDO1 methylation level (p < 0.0001). Intriguingly, especially in pStage I/II, there were robust prognostic difference between SBC and CRC (p = 0.08 / p < 0.0001), which may reflect CDO1 methylation status (p = 0.02 / p = 0.001). Among small bowel tumors, CDO1 methylation in SBC was higher in order of malignant lymphoma, cancer, and leiomyosarcoma/GIST (p = 0.002) by ANOVA. The CDO1 gene shows extremely cancer-specific hypermethylation, and it can be a prognostic marker in SBC.

Multiple synchronous adenocarcinomas of the small bowel in a young patient: A case report

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This case report represents one of the youngest patients ever presented with this condition without any risk factors, and her follow up for three years.

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Multiple adenocarcinomas of the small bowel is an extremely rare disease with no standardized treatment.

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Its clinical presentation can vary from abdominal pain, mass, obstruction and bleeding, requiring a high index of suspicion.

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Its treatment is predominantly surgical and adjuvant therapies are now being studied in randomized controlled studies.

Introduction

Adenocarcinoma of the small bowel is a rare neoplasm presented usually in elder patients as a single tumor. Its presentation as multiple tumors and in young patients is exceptional and there aren't any guidelines to orient its therapy.

Presentation of case

We present the rare case of a sixteen-year-old woman that presents to the emergency department with an intussusception due to a small bowel tumor. The resected specimen showed multiple adenocarcinomas. A complete endoscopic and PET-CT study showed other 5 lesions from the duodenum to the ileum that were resected. Genetic counseling showed no pathogenic changes. The final staging was T2N0M0 and only surveillance was indicated. The patient is now 3 years without any recurrence.

Discussion

Multiple adenocarcinomas of the small bowel are a very infrequent presentation of the disease. Most common risk factors include Crohn disease and adenomas. Its presentation is usually vague with a delay in its diagnosis. The treatment remains mainly surgical with limited use of adjuvant therapy. The most important prognostic factor is lymph node involvement with 5-year survival that can range from 3%-60% depending on the stage.

Conclusion

This case represents an exceptional presentation of a very rare pathology with few cases described in the literature. There isn’t one single best study to stage the patient and surgery is still the standard of treatment while adjuvant therapies studies are being conducted. The young age and lack of predisposing factors or mutations leaves an open field for investigation.