Duodenal adenocarcinoma: Advances in diagnosis and surgical management

A Rare Case of Duodenal Adenocarcinoma Presenting as a Subepithelial Lesion in a Patient Undergoing Investigation for Iron Deficiency Anaemia

Introduction

Adenocarcinomas account for approximately 40% of small bowel cancers. They are typically mucosal lesions with distinctive features on endoscopy. We describe a rare case of duodenal adenocarcinoma presenting as a subepithelial lesion which posed a diagnostic challenge.

Case

An 85-year-old male patient presented for investigation of iron deficiency anaemia. Initial upper endoscopy found a subepithelial duodenal lesion with central depression but otherwise normal appearing mucosa. Superficial biopsies of the duodenal lesion were unremarkable. Subsequent antegrade single balloon enteroscopy revealed active bleeding from the lesion which was refractory to endoscopic treatment. A complete local excision of the lesion via laparotomy was necessary to achieve haemostasis. Histopathology from the lesion showed a moderately differentiated duodenal adenocarcinoma with invasion into the submucosa but no evidence of lymphovascular spread.

Conclusion

Duodenal adenocarcinomas are rare gastrointestinal tumours associated with a poor prognosis. This case report outlines a rare presentation of duodenal adenocarcinoma and highlights the importance of judicious assessment of lesions found on endoscopy. Advances in endoscopic diagnostic modalities could facilitate early diagnosis and improve therapeutic outcomes.

Feasibility and Safety of a Novel Laparoscopic and Endoscopic Cooperative Surgery Technique for Superficial Duodenal Tumor Resection: How I Do It

BACKGROUND

Pancreatoduodenectomy is considered to be a very invasive treatment for early superficial duodenal tumors (SDTs), which have a lower risk of lymph node metastasis. Partial resection of the duodenum with endoscopic submucosal dissection for SDT resection is an attractive technique but it is associated with a high risk of complications. We describe our technique for SDT resection.

METHOD

It includes the following elements: freeing the transverse mesocolon, exposing and mobilizing the second part of the duodenum and the head of the pancreas (Kocher maneuver), confirming the location of the ulcer bed for endoscopic submucosal dissection, and laparoscopic suturing by hand in the seromuscular layer of the duodenum. We performed this technique in 10 patients between March 2015 and March 2017.

RESULTS

The median tumor diameter and resected tissue diameter were 36 (20-54) and 41 (25-60) mm, respectively. Curative resection (R0) with negative margins was achieved for all patients. There were no conversions to open surgery in this series. No postoperative complications were above grade 2 in the Clavien-Dindo classification system. No recurrences were observed during the medium-term follow-up period.

CONCLUSION

This technique is safe and feasible and can be an option for surgical SDT resection.

Duodenal adenocarcinoma: Surgical results of 27 patients treated at a single center

INTRODUCTION

Duodenal adenocarcinoma is a rare malignancy. Given the rarity of the disease, there is limited data related to resection results. The objective is to analyze results at our hospital after the curative resection of duodenal adenocarcinoma (DA).

METHODS

The variables were retrospectively collected from patients operated on between 1990 and 2017 at our hospital.

RESULTS

A total of 27 patients were treated. Twenty-three patients (85%) underwent pancreaticoduodenectomy, and 4 patients (15%) with tumors located in the third and fourth portions of the duodenum underwent segmental duodenal resection. The overall postoperative morbidity was 67% (18 patients). Postoperative mortality was 7% (2 patients); however, postoperative mortality related to surgery was 4% (1 patient). All patients had negative resection margins. A median of 18 lymph nodes (range, 0-38) were retrieved and evaluated, with a median of 1 involved node (range, 0-8). Median follow up was 23 (9-69.7) months. Actuarial overall survival was 62.2 (25.2-99.1) months. Actuarial disease-free survival was 49 (0-133) months.

CONCLUSIONS

The surgical treatment of duodenal adenocarcinoma is associated with a high morbidity, although it achieves considerable survival. Depending on the tumor location and if there is no pancreatic infiltration, segmental duodenal resection with negative margins is an alternative to cephalic pancreaticoduodenectomy.

Effect of marital status on duodenal adenocarcinoma survival: A Surveillance Epidemiology and End Results population analysis

Numerous studies have shown that marital status may be a prognostic factor in various malignancies, but little is known about its effect on duodenal adenocarcinoma. The aim of the present study was to determine the association between marital status and survival in patients with duodenal adenocarcinoma. The Surveillance, Epidemiology and End Results database was utilized to analyze 2,018 patients who had been diagnosed with duodenal adenocarcinoma between January 2004 and December 2015. Kaplan-Meier and Cox regression analyses were also used to determine the impact of marital status on overall survival (OS) and cause-specific survival (CSS). The 5-year OS rate was higher in married patients (32.6%) compared with unmarried (26.8%) patients (P<0.001), as was the 5-year CSS rate (38.8 vs. 33.7%; P<0.001). Multivariate analysis demonstrated that marital status was an independent prognostic factor for duodenal adenocarcinoma, with married patients having improved OS (P<0.001) and CSS (P=0.001) compared with unmarried patients. Subgroup analysis showed that marital status played a role in the survival of patients at American Joint Committee on Cancer Tumor-Node-Metastasis stage I, but not of patients at stages II, III or IV. The survival outcomes for duodenal adenocarcinoma are improved in married patients compared with those in unmarried patients. Therefore, attention should be paid to the impact of social factors and socio-economic factors on unmarried patients, in order to improve their survival outcomes.

Molecular alterations and PD-L1 expression in non-ampullary duodenal adenocarcinoma: Associations among clinicopathological, immunophenotypic and molecular features

Non-ampullary duodenal adenocarcinoma (NADC) is extremely rare. Little is known about its clinicopathological and molecular features or its management. Herein we retrospectively analyzed the cases of 32 NADC patients, focusing on microsatellite instability (MSI), genetic mutations, CpG island methylator phenotype (CIMP), and immunostaining including mucin phenotype and PD-L1 expression. The incidence of MSI, KRAS/BRAF/GNAS mutations and CIMP was 51.6%, 34.4%/3.1%/6.5% and 28.1%, respectively. PD-L1 expression was seen in 34.4% of patients. No significant associations between clinicopathological features and KRAS/BRAF/GNAS genetic mutations or CIMP were found. Histologically non-well-differentiated-type NADCs and those in the 1st portion of the duodenum were significantly associated with later stages (stages III–IV) (P = 0.006 and P = 0.003, respectively). Gastric-phenotype NADCs were frequently observed in the 1st portion and in late-stage patients; their cancer cells more frequently expressed PD-L1. Histologically, the non-well-differentiated type was an independent predictor of PD-L1 expression in cancer cells (OR 25.05, P = 0.04) and immune cells (OR 44.14, P = 0.02). Only late-stage disease (HR 12.23, P = 0.01) was a prognostic factor for worse overall survival in a Cox proportional hazards regression model. Our observation of high proportions of MSI and PD-L1 expression may prompt the consideration of immune checkpoint inhibitors as a new treatment option for NADCs.

The Small Bowel Cancer Incidence Enigma

Although the small bowel is a vast organ with a highly proliferative epithelium, the incidence of small bowel cancers is surprisingly low. Many factors could be involved in this unexpected cancer incidence, including difficult access to the exploration of the small bowel mucosa, which might lead to missed diagnoses of non-obstructive and non-bleeding small tumours. Moreover, possible factors that influence the low incidence include more efficient machinery of DNA replication and DNA repair enzymes, peculiarities in microbiota components, competence of the immune system, and the speed of intestinal transit. Importantly, the answer for the enigmatic risk of driver mutations caused by replication errors may be hidden in the small bowel, which is an obscure part of digestive tract that is usually inaccessible by endoscopic or colonoscopic conventional investigations. These observations warrant the necessity of an urgent exploration of small bowel features, including the evaluation of DNA replication controls and expression of DNA repair genes, in order to shed light on these obscure events.

Tumour stage and resection margin status are independent survival factors following partial pancreatoduodenectomy for duodenal adenocarcinoma

INTRODUCTION

There is limited published evidence on duodenal carcinoma due to its rarity. This study aimed to evaluate gastric outlet obstruction and obstructive jaundice along with pathological variables as survival factors in patients with duodenal adenocarcinoma following resection.

METHODS

Survival factor analysis was undertaken in patients undergoing duodenal cancer surgery from 1997 to 2015 in a single centre.

RESULTS

There were 57 patients of whom 18 had gastric outlet obstruction and 14 had obstructive jaundice. Fifty-three had a partial pancreatoduodenectomy and four had palliative bypass. Perioperative mortality and morbidity were 4% (2/53) and 47% (25/53) respectively in resected patients. With a median (95% confidence interval, CI) follow-up of 72 (57-86) months, median overall and recurrence-free survival was 38 months (95% CI 28-113) and 27 months (95% CI 18-83) respectively. The 1 and 3-year overall survival rates were 84% (95% CI 74-95) and 52% (95% CI 39-69) respectively. Median overall survival was 19 months in patients with gastric outlet obstruction vs 53 months in those without (p = 0.026) and 28 months in patients with obstructive jaundice vs 38 months in those without (p = 0.611). Univariate analysis revealed that tumour stage, resection margin status, pre-operative albumin status, gastric outlet obstruction and age were associated with poorer overall and recurrence-free survival but multivariate analysis confirmed only tumour stage and resection margin status to be significant.

CONCLUSION

Whereas gastric outlet obstruction in duodenal cancer appeared to be an important survival factor following partial pancreatoduodenectomy, multivariate analysis showed that only tumour stage and resection margin status were the key independent survival factors. Further multicentre studies are required to elucidate further characteristics of duodenal carcinoma and develop neoadjuvant/adjuvant management strategies.

Rare case of small intestine bleeding

We present a case of a healthy 59-year-old woman who presented for a capsule endoscopy to evaluate melaena and iron deficiency anaemia. She had previously underwent an oesophagogastroduodenoscopy and colonoscopy at an outside institution which were unremarkable. Capsule endoscopy showed an ulcerated, bleeding lesion likely in the duodenum. Differential diagnosis included adenocarcinoma, carcinoid tumour, lymphoma, gastrointestinal stromal tumour and metastatic disease. A push enteroscopy was performed after which showed an ulcerated mass in the third portion of the duodenum. Biopsies confirmed adenocarcinoma. Computed tomography of the abdomen showed no signs of distant metastasis and the patient was referred to surgery for evaluation. The patient underwent a pancreaticoduodenectomy, with resection of the mass and negative lymph nodes in all nine that were removed (T3N0). The patient was classified as stage II duodenal adenocarcinoma. Duodenal adenocarcinoma is a rare but clinically significant cause of small bowel bleeding.

Small Bowel Adenocarcinoma

Small bowel adenocarcinoma is a clinically and anatomically distinct gastrointestinal cancer that lacks prospective data to support its optimal management. Patients with inflammatory bowel disease and inherited conditions that cause gastrointestinal polyps are at especially high risk. Due to a lack of effective surveillance programs resulting in missed or delayed diagnoses only when symptoms develop, this disease is generally discovered at an advanced stage. Surgical resection is the only treatment modality with a chance of cure. Currently accepted treatment considerations are often generalized from large bowel and pancreatic-biliary cancers, due to some anatomic and clinical parallels. Additional research, however, is desperately needed to characterize the unique molecular differences of this disease to better prognosticate patients and establish rational clinical trials that would improve their outcomes.

Personalized treatment based on mini patient-derived xenografts and WES/RNA sequencing in a patient with metastatic duodenal adenocarcinoma

Background

Treatment guidelines for a variety of cancers have been increasingly used in clinical practice, and have resulted in major improvement in patient outcomes. However, recommended regimens (even first-line treatments) are clearly not ideal for every patients. In the present study, we used mini patient-derived xenograft (mini-PDX) and next-generation sequencing to develop personalized treatment in a patient with metastatic duodenal adenocarcinoma.

Methods

Resected metachronous metastatic tumor tissues were implanted into SCID mice to determine the sensitivity to a variety of drug regimens. Mutation profiles were assessed using both DNA whole-exome sequencing (DNA–WES) and RNA sequencing. The results of the analyses were used to select optimal treatment for the patient with metastatic duodenal adenocarcinoma.

Results

Assessment with mini-PDX models took only 7 days. The results showed high sensitivity to S-1 plus cisplatin, gemcitabine plus cisplatin and everolimus alone. The patient received gemcitabine plus cisplatin initially, but the treatment was terminated due to toxicity. The patient was then switched to treatment with S-1 alone. The overall disease-free survival was 34 months. DNA–WES and RNA sequencing identified KRAS mutation (A146T), TP53 (C229Yfs*10) and RICTOR amplification in the metastatic duodenal adenocarcinoma. These findings provided further support to the results of the mini-PDX, and suggest mTOR inhibitors should be used if and when relapse eventually occurs in this patient.

Conclusions

Mini-PDX model combined with WES/RNA sequencing can rapidly assess drug sensitivity in cancer patients and reveal key genetic alterations. Further research on this technology for personalized therapy in patients with refractory malignant tumors is warranted.

Electronic supplementary material

The online version of this article (10.1186/s40880-018-0323-y) contains supplementary material, which is available to authorized users.

Synchronous Duodenal Cancer and Lung Cancer Harboring an Epidermal Growth Factor Receptor Mutation Treated with Erlotinib and Oral Fluoropyrimidine

Chemotherapy for multiple primary cancers is challenging. We describe a case of synchronous duodenal cancer with lung cancer harboring an epidermal growth factor receptor (EGFR) mutation treated with erlotinib and S-1, an oral fluoropyrimidine agent. A 78-year-old woman with advanced EGFR-mutated lung adenocarcinoma was simultaneously diagnosed with duodenal adenocarcinoma. After the treatment with erlotinib, the lung cancer responded well, but her duodenal cancer showed no response. S-1 was added to erlotinib, and the duodenal cancer demonstrated a good response with tolerable toxicities. The concurrent use of erlotinib and S-1 was safe and efficacious for synchronous lung cancer harboring an EGFR mutation and duodenal cancer.

Duodenal adenocarcinoma successfully diagnosed with transabdominal ultrasonography

Adenocarcinoma arising from the duodenum is relatively rare. Diagnosis of this disease at an early stage is difficult because its symptoms are usually nonspecific. We herein present a case in which duodenal adenocarcinoma was successfully found by transabdominal ultrasonography. Under ultrasonography, the tumor was located in the proximal duodenum apart from the papilla of Vater, and the serosa was intact. Other diagnostic modalities showed no evidence of adjacent organ invasion or distant metastasis. Therefore, pancreatoduodenectomy was performed and the postoperative course was uneventful. The ultrasonographic findings corresponded well with the pathological diagnosis. The following three procedures were essential in this case: systematic scanning of the digestive tract to determine the location of the lesion, graded compression ultrasound to remove air bubbles from the region of interest, and precise observation of the intestinal walls using proper transducers. The precise and skillful performance of transabdominal ultrasonography using a suitable device can help to diagnose duodenal adenocarcinoma, a rare malignancy.

Laparoscopic and endoscopic co-operative surgery for non-ampullary duodenal tumors

AIM

To assess the safety and feasibility of laparoscopic and endoscopic co-operative surgery (LECS) for early non-ampullary duodenal tumors.

METHODS

Twelve patients with a non-ampullary duodenal tumor underwent LECS at our hospital. One patient had two mucosal lesions in the duodenum. The indication for this procedure was the presence of duodenal tumors with a low risk for lymph node metastasis. In particular, the tumors included small (less than 10 mm) submucosal tumors (SMT) and epithelial mucosal tumors, such as mucosal cancers or large mucosal adenomas with malignant suspicion. The LECS procedures, such as full-thickness dissection for SMT and laparoscopic reinforcement after endoscopic submucosal dissection (ESD) for epithelial tumors, were performed for the 13 early duodenal lesions in 12 patients. Here we present the short-term outcomes and evaluate the safety and feasibility of this new technique.

RESULTS

Two SMT-like lesions and eleven superficial epithelial tumor-like lesions were observed. Seven and Six lesions were located in the second and third parts of the duodenum, respectively. All lesions were successfully resected en bloc. The defect in the duodenal wall was manually sutured after resection of the duodenal SMT. For epithelial duodenal tumors, the ulcer bed was laparoscopically reinforced via manual suturing after ESD. Intraoperative perforation occurred in two out of eleven epithelial tumor-like lesions during ESD; however, they were successfully laparoscopically repaired. The median operative time and intraoperative estimated blood loss were 322 min and 0 mL, respectively. Histological examination of the tumors revealed one adenoma with moderate atypia, ten adenocarcinomas, and two neuroendocrine tumors. No severe postoperative complications (Clavien-Dindo classification grade III or higher) were reported in this series, but minor leakage secondary to pancreatic fistula occurred in one patient.

CONCLUSION

LECS can be a safe and minimally invasive treatment option for non-ampullary early duodenal tumors.