Small bowel cancer in the United States: changes in epidemiology, treatment, and survival over the last 20 years. Ann Surg. 2009;249:63-71. [PMID: 19106677 DOI: 10.1097/sla.0b013e31818e4641]

Prognostic value of lymph node evaluation in small bowel adenocarcinoma: analysis of the surveillance, epidemiology, and end results database

BACKGROUND

The presence of distant metastases and the completeness of resection are important prognostic factors in patients with small bowel adenocarcinoma (SBA); however, the influence of lymph node metastasis on patient outcome has not been well characterized. The objective of the current study was to evaluate the impact of the number of positive and negative lymph nodes on survival after curative resection.

METHODS

Patients who had SBA diagnosed between 1988 and 2005 were identified from the Surveillance, Epidemiology, and End Results (SEER) registry. Cox proportional hazards regression analyses were performed after adjusting for age, sex, race, tumor stage, tumor grade, and primary site. Five-year disease-specific survival (DSS) was determined, all patients were categorized according to the total lymph nodes (TLNs) assessed, and patients with stage III disease also were categorized according to the number of positive lymph nodes (PLNs) and the PLN-to-TLN ratio (the lymph node ratio [LNR]).

RESULTS

In total, 1991 patients (n=1216 with stage I/II SBA and n=775 with stage III SBA) were analyzed. Survival depended on the TLNs assessed. The 5-year DSS rate for patients with stage II disease was associated with the TLNs assessed (44%, 69%, and 83% for 0 TLNs, 1-7 TLNs, and>7 TLNs, respectively). The 5-year DSS for patients with stage III disease was associated with the number of PLNs (58% and 37% for <3 PLNs and ≥3 PLNs, respectively). Among patients with stage III disease, the LNR was even more predictive of survival than stratification by the number of PLNs.

CONCLUSIONS

Survival after surgical resection for stage I, II, and III SBA was associated with the TLNs assessed. Stratifying patients with stage III disease into those with <3 PLNs and ≥3 PLNs significantly improved prognostication.

Small intestinal cancer: a population-based study of incidence and survival patterns in the United States, 1992 to 2006

BACKGROUND

The etiology of cancers of the small intestine is largely unknown. To gain insight into these rare malignancies, we evaluated contemporaneous incidence and survival patterns.

METHODS

Using small intestine cancer data from 12 population-based registries of the Surveillance, Epidemiology and End Results Program, we calculated age-adjusted and age-specific incidence rates (IRs), IR ratios, and relative survival (RS) rates.

RESULTS

In total, 10,945 small intestine cancers (IR = 2.10/100,000 person-years) were diagnosed during 1992 to 2006, including carcinomas (n = 3,412; IR = 0.66), neuroendocrine cancers (n = 4,315; IR = 0.83), sarcomas (n = 1,084; IR = 0.20), and lymphomas (n = 2,023, IR = 0.38). For all histologic groups, males had significantly higher IRs than females, and distinct age-specific gender patterns were limited to intermediate-/high-grade lymphomas. Neuroendocrine cancer rates varied significantly by race, with rates highest among blacks and lowest among Asians/Pacific Islanders. Carcinoma IRs were highest among blacks; sarcoma IRs were highest among Asians/Pacific Islanders; and lymphoma IRs were highest among whites. Age-specific IR patterns were similar across racial/ethnic groups. During 1992 to 2006, duodenal cancer IRs increased more markedly than those for other subsites. RS varied little by gender or race. Neuroendocrine cancers had the most favorable RS, and carcinomas had the least favorable. The greatest improvement in 5-year RS from 1992 to 1998 to 1999 to 2005 was observed for sarcomas and lymphomas.

CONCLUSIONS

Distinct small intestine cancer IR patterns according to histologic subtype suggest different underlying etiologies and/or disease biology, with susceptibility varying by gender, racial/ethnic groups, and subsite. Temporal patterns support a possible role for diagnostic bias of duodenal cancers.

IMPACT

Future epidemiologic studies of small intestine cancer should consider histologic subtype by gender, race/ethnicity, and subsite.

[Small bowel adenocarcinoma]

Small bowel adenocarcinoma is a rare tumor. These tumors are more often sporadic but there is some predisposing disease (Crohn disease, genetic syndrome and rarely celiac disease). Diagnosis is usually performed at an advanced stage because of non-specific nature of clinical manifestations. New methods of radiological and endoscopic exploration of small intestine should allow earlier diagnosis. Surgical resection remains the only potentially curative treatment for non-metastasic tumors. The main prognosis factor is lymph nodes involvement. The role of adjuvant chemotherapy is unclear. For metastatic tumors, 5-fluorouracil and platinum salt combination appears to be the most effective chemotherapy despite of the absence of randomized studies. A national prospective cohort study is currently evaluating the results of chemotherapy (recommended protocol: FOLFOX) as adjuvant and palliative treatment of small bowel adenocarcinoma.

Is there a role for adjuvant therapy in resected adenocarcinoma of the small intestine

BACKGROUND

The benefit of adjuvant therapy for resected small bowel adenocarcinoma has not been proven. We undertook a retrospective analysis to evaluate the benefit of adjuvant therapy in a clearly defined patient population with curatively resected small bowel adenocarcinoma.

MATERIAL AND METHODS

We identified 54 patients with small bowel adenocarcinoma who underwent margin-negative surgical resection and were evaluated after surgery at the University of Texas, M. D. Anderson Cancer Center between 1990 and 2008. Disease-free survival (DFS) and overall survival (OS) were estimated.

RESULTS

Median age was 55 years and primary tumor site was duodenum in 67%, jejunum in 20%, and ileum in 13%. Thirty patients (56%) received adjuvant therapy consisting of systemic chemotherapy with or without radiation in 28 and radiation alone in two. Patients who received adjuvant therapy had significantly higher tumor stage and rate of lymph node involvement. Five-year DFS and OS did not differ between treatment groups. In multivariate analysis, the use of adjuvant therapy was associated with improved DFS (HR 0.27; 95% CI 0.07-0.98, P = 0.05) but not OS (HR 0.47; 95% CI 0.13-1.62, P = 0.23). In patients with a high risk of relapse (defined as a lymph node ratio >or=10%), adjuvant therapy appeared to improve OS, P = 0.04, but not DFS, P = 0.15.

DISCUSSION

The use of adjuvant therapy for curatively resected small bowel adenocarcinoma was associated with an improvement in DFS. This finding strongly supports further investigation of adjuvant chemotherapy in this tumor type.

Adenocarcinoma of the small intestine: a multi-institutional study of 197 surgically resected cases

Small intestinal adenocarcinoma is a rare malignant neoplasm, and its clinicopathologic characteristics have not been well elucidated. A total of 197 small intestinal adenocarcinoma cases were collected from 22 institutions in South Korea and were evaluated for clinicopathologic factors that affect the prognosis of small intestinal adenocarcinoma patients using univariate and multivariate analyses. The mean patient age was 59 years, and the male-to-female ratio was 1.7:1. Tumors were located in the duodenum of 108 cases (55%), the jejunum in 59 (30%), and the ileum in 30 (15%). Predisposing conditions were observed in 23 cases (12%), including 17 cases with sporadic adenomas, 3 with Peutz-Jeghers syndrome, 2 with Meckel diverticulum, and 1 with Crohn disease. Synchronous or metachronous malignant tumors were identified in 31 cases (16%), including 13 colorectal and 10 stomach cancers. About 90% of tumors were classified as either pT3 (63 cases) or pT4 (112 cases). The median survival time for all small intestinal adenocarcinoma patients was 39.7 months. Compared with small intestinal adenocarcinomas without accompanying sporadic adenomas, small intestinal adenocarcinomas with accompanying adenomas were more well differentiated (P < .0001), with a more polypoid growth pattern (P < .0001), a lower pT classification (P < .0001), less perineural invasion (P = .01), and less lymphatic invasion (P = .03). Small intestinal adenocarcinoma patients with associated sporadic adenomas (77%) had a significantly better 5-year survival rate than those without sporadic adenomas (38%, P = .02). By univariate analysis, small intestinal adenocarcinoma patients had significantly different survival based on pT classification (P = .003), lymph node metastasis (P < .0001), distal location (jejunal and ileal carcinomas) (P = .003), retroperitoneal tumor seeding (P < .0001), vascular invasion (P = .007), lymphatic invasion (P = .001), peritumoral dysplasia (P = .004), and radiation therapy (P = .006). By multivariate analysis, lymph node metastasis (P = .01) and distal location (P = .003) were independent predictors of a worse prognosis. In conclusion, (1) small intestinal adenocarcinomas are diagnosed at an advanced disease stage; therefore, the development of strategies for detection at an earlier stage is needed. (2) Small intestinal adenocarcinoma patients with an adenomatous component had a better survival than those without an adenomatous component. (3) Lymph node metastasis and distal location (jejunum and ileum) of tumor are the most important independent prognostic factors.

Adenocarcinoma of the small bowel at a single Korean institute: management and prognosticators

PURPOSE

Small bowel adenocarcinoma (SBA) is a rare malignancy with a poor outcome. We evaluated the natural history of SBA at a single Korean institute.

METHODS

Medical records of 100 patients with SBA were reviewed for clinical characteristics, treatment patterns, outcomes, and prognostic factors.

RESULTS

The most common primary tumor site was the duodenum (82%). Seventy-four patients were diagnosed with stage III/IV disease (28/46 patients, respectively). Sixty-six patients had surgery (R0/R1/R2 in 32/2/32) without operation-related mortality. Of 34 R0/R1-resected patients, 16 received adjuvant chemotherapy. The dominant pattern of recurrence following R0/R1 resection was distant metastasis (29%; 10 of 34 patients). Thirty-four patients with advanced SBA received palliative chemotherapy, showing a response rate of 27.6% and a median progression-free survival of 3.8 months. The median overall survival for all patients and R0/R1-resected patients was 10.5 and 42.1 months, respectively. In multivariate analysis, lower stage, nonduodenal location, and R0/R1 resection were good independent prognostic factors.

CONCLUSIONS

Early diagnosis is crucial to improve outcomes of SBA with respect to increasing resectability. Distant metastasis as a dominant pattern of recurrence suggests a potential role for adjuvant chemotherapy. Newer antitumor agents in advanced SBA should be evaluated considering the poor efficacy of current palliative chemotherapy.

High-resolution array comparative genomic hybridization in sporadic and celiac disease-related small bowel adenocarcinomas

PURPOSE

The molecular pathogenesis of small intestinal adenocarcinomas is not well understood. Understanding the molecular characteristics of small bowel adenocarcinoma may lead to more effective patient treatment.

EXPERIMENTAL DESIGN

Forty-eight small bowel adenocarcinomas (33 non-celiac disease related and 15 celiac disease related) were characterized for chromosomal aberrations by high-resolution array comparative hybridization, microsatellite instability, and APC promoter methylation and mutation status. Findings were compared with clinicopathologic and survival data. Furthermore, molecular alterations were compared between celiac disease-related and non-celiac disease-related small bowel adenocarcinomas.

RESULTS

DNA copy number changes were observed in 77% small bowel adenocarcinomas. The most frequent DNA copy number changes found were gains on 5p15.33-5p12, 7p22.3-7q11.21, 7q21.2-7q21.3, 7q22.1-7q34, 7q36.1, 7q36.3, 8q11.21-8q24.3, 9q34.11-9q34.3, 13q11-13q34, 16p13.3, 16p11.2, 19q13.2, and 20p13-20q13.33, and losses on 4p13-4q35.2, 5q15-5q21.1, and 21p11.2-21q22.11. Seven highly amplified regions were identified on 6p21.1, 7q21.1, 8p23.1, 11p13, 16p11.2, 17q12-q21.1, and 19q13.2. Celiac disease-related and non-celiac disease-related small bowel adenocarcinomas displayed similar chromosomal aberrations. Promoter hypermethylation of the APC gene was found in 48% non-celiac disease-related and 73% celiac disease-related small bowel adenocarcinomas. No nonsense mutations were found. Thirty-three percent of non-celiac disease-related small bowel adenocarcinomas showed microsatellite instability, whereas 67% of celiac disease-related small bowel adenocarcinomas were microsatellite unstable.

CONCLUSIONS

Our study characterized chromosomal aberrations and amplifications involved in small bowel adenocarcinoma. At the chromosomal level, celiac disease-related and non-celiac disease-related small bowel adenocarcinomas did not differ. A defect in the mismatch repair pathways seems to be more common in celiac disease-related than in non-celiac disease-related small bowel adenocarcinomas. In contrast to colon and gastric cancers, no APC nonsense mutations were found in small bowel adenocarcinoma. However, APC promoter methylation seems to be a common event in celiac disease-related small bowel adenocarcinoma. Clin Cancer Res; 16(5); 1391-401.

Carcinoid tumors of the gastrointestinal tract

The gastrointestinal tract is the largest neuroendocrine system in the body. Carcinoid tumors are amine precursor uptake decarboxylase (APUD) omas that arise from enterochromaffin cells throughout the gut. These tumors secrete discrete bioactive substances producing characteristic immunohistochemical patterns. Most tumors are asymptomatic and detected at late stages. Hepatic metastases are commonly responsible for carcinoid syndrome. The small bowel is the most common location of carcinoids. Computed tomography scan and magnetic resonance imaging are useful in the detection of these tumors. The measurement of bioactive amines is the initial diagnostic test. Various treatment options, including somatostatin analogs, interferon, chemotherapy, surgery, hepatic artery chemoembolization, and surgery have emerged in the past two decades. However, the incidence and prevalence of carcinoid tumors has increased, while mean survival time has not changed significantly. The lack of standardized classification, federal support, and an incomplete understanding of the complications of this disease are some of the impediments to progress in treatment.

Cytoreductive surgery and perioperative intraperitoneal chemotherapy for peritoneal carcinomatosis from small bowel adenocarcinoma

BACKGROUND

Small bowel adenocarcinoma is a rare malignancy that presents both a diagnostic and therapeutic challenge. The late presentation is often associated with disseminated carcinomatosis which is regarded a terminal event. We review our experience with small bowel peritoneal carcinomatosis following treatment with cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy (PIC).

METHODS

From a prospective database of CRS and PIC, seven patients were identified to have undergone treatment for small bowel peritoneal carcinomatosis with CRS and hyperthermic intraperitoneal chemotherapy (Mitomycin C) and early postoperative intraperitoneal chemotherapy (5FU). A retrospective review was undertaken to describe the clinicopathological characteristics and survival outcomes.

RESULTS

The median follow-up was 17 months (range, 5-46 months). Six of seven patients have died. The disease-free survival was 12 months and the overall median survival was 25 months. The 1-, 2-, and 3-year survivals were 57%, 38%, and 20% respectively. Tumor histology of poorly differentiated adenocarcinoma with signet ring, lymphovascular invasion and perineural invasion appeared to be associated with a poor outcome.

CONCLUSION

Cytoreductive surgery and perioperative intraperitoneal chemotherapy is a treatment option for small bowel cancer peritoneal carcinomatosis with encouraging survival results.

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.