Tumors of the small intestine

The Role of Capsule Endoscopy in the Diagnosis and Management of Small Bowel Tumors: A Narrative Review

Small bowel tumors (SBT) are relatively rare, but have had a steadily increasing incidence in the last few decades. Small bowel capsule endoscopy (SBCE) and device-assisted enteroscopy are the main endoscopic techniques for the study of the small bowel, the latter additionally providing sampling and therapeutic options, and hence acting complementary to SBCE in the diagnostic work-up. Although a single diagnostic modality is often insufficient in the setting of SBTs, SBCE is a fundamental tool to drive further management towards a definitive diagnosis. The aim of this paper is to provide a concise narrative review of the role of SBCE in the diagnosis and management of SBTs.

Carcinoids and Capsules: A Case Series Highlighting the Utility of Capsule Endoscopy in Patients With Small Bowel Carcinoids

Background

Neuroendocine tumors (NETs) or carcinoids arise at many different sites of the gastrointestinal tract. The small intestine is the most common site for NETs. Diagnosing small bowel carcinoids remains challenging given their non-specific presentations and the overall low incidence of small bowel tumors. Video capsule endoscopy (VCE) has significanly improved our ability to detect small bowel malignancies. We explore the value of VCE in the initial workup and management of a series of small bowel carcinoid patients.

Methods

We retrospectively analyzed adult patients undergoing surgical management for small bowel lesions from July 2005 to September 2015 at a tertiary care center. Patient characteristics, presenting symptomatology, diagnostic workup and surgical management were analyzed among patients with histologically confirmed small bowel carcinoid tumors.

Results

Our study identified 16 patients treated surgically for small bowel carcinoids. The majority of patients (87.5%) presented with either occult gastrointestinal bleeding or anemia. Most patients (87.5%) were initially evaluated with various endoscopic and imaging modalities before all ultimately undergoing surgery. Seventy-five percent of patients had a VCE, with 83.3% (10/12) having positive findings that correlated with intraoperative findings compared to 62.5% (5/8) with computed tomography scan, 21.4% (3/14) with colonoscopy, 44% (4/9) with deep enteroscopy, and 0% (0/9) with esophagogastroduodenoscopy (EGD).

Conclusions

In the absence of any contraindications, VCE is an effective endoscopic modality in the diagnostic workup of small bowel NETs. Furthermore, positive VCE findings appear to highly correlate with surgical findings, thus suggesting a valuable role for VCE in the initial surgical assessment of patients with small bowel NETs.

Management of small bowel polyps: A literature review

Despite the small bowel comprising 90% of the mucosal surface area of the gastrointestinal tract, it is a rare site for neoplasia and only accounts for a little over 3% of the tumors that arise in the digestive tract. Benign small bowel lesions include lipomas, lymphangiomas, leiomyomas, neurofibromas, nodular lymphoid hyperplasia and adenomas, many of which are precursors to malignant lesions. Several polyposis syndromes are associated with small bowel polyps as well, including familial adenomatous polyposis syndrome, lynch syndrome, Peutz-Jeghers syndrome, Cowden syndrome and juvenile polyposis syndrome. Our aim was to review non-malignant small bowel polyps and discuss the prevalence, typical location, clinical presentation, diagnosis, endoscopic and histologic description and lastly management of each of these lesions.

Adenocarcinoma of the duodenojejunal flexure presenting as a stricturous lesion

A 50-year-old woman was referred with a colicky upper abdominal pain of 3 months duration. She experienced an increase in pain 2 weeks prior to presentation. This was associated with bilious vomiting about 5-6 times/day with no change in bowel habits. She had no history of any abdominal pathology. A review of systems showed she had a weight loss of 20 kg over a period of 4 months with recent onset of loss of appetite. Physical examination revealed a soft distended upper abdomen with non-radiating pain in the epigastrium. CT of the abdomen showed a heterogeneously enhancing stricturous growth in the proximal part of the jejunum with gross dilation of the stomach and duodenum. She underwent resection and anastomosis of the proximal jejunum. Histopathology revealed the lesion to be an adenocarcinoma.

Adenomyoma of the small intestine in an adult: report of a case

We report a case of adenomyoma in the small intestine, which is an extremely rare entity. An 81-year-old woman presented to our hospital with a history of three episodes of vomiting accompanied by abdominal pain. Upper gastrointestinal examination via a long tube found intestinal obstruction caused by a tumor of the small intestine. Laparotomy revealed a hard mass, 160 cm distal to the Treitz ligament. Pathological examinations of the resected tumor confirmed a diagnosis of adenomyoma originating in the small intestine. To our knowledge, this is only the second report of an adenomyoma of small intestine causing intestinal obstruction in an adult.

Best resident poster award: evaluation of anastomotic techniques for laparoscopic resection of isolated small intestine pathology

BACKGROUND

The purpose of this study was to compare perioperative outcomes for intracorporeal versus extracorporeal anastomotic techniques for isolated laparoscopic small-intestine resection.

METHODS

A retrospective database was created for all adult patients who underwent a laparoscopic segmental small-intestine resection. Patients with inflammatory bowel disease or requiring an ileocolectomy were excluded.

RESULTS

Laparoscopic resection was performed in 52 patients (ratio of men:women, 30:22) with a mean age of 47 ± 21 years. A laparoscopic intracorporeal anastomosis was performed in 30 patients (58%), and an extracorporeal anastomosis was performed in 22 patients (42%). There was no difference in mean operating room time, estimated blood loss, perioperative complication rate, or length of stay between the 2 groups. Ten patients had a complication, and 5 patients experienced a Clavien grade II or greater complication.

CONCLUSIONS

Laparoscopic segmental small-bowel resection using either intracorporeal or extracorporeal anastomotic techniques is equally efficacious for pathology isolated to the small bowel.

Clinicopathological features of primary jejunoileal tumors

Purpose

Tumors of the small bowel are rare, accounting for about 3-6% of all gastrointestinal neoplasms, though they cover more than 90% of the intestinal surface. However, diagnosis and treatment are difficult and present an ongoing challenge for both gastrointestinal surgeons and gastroenterologists. The aim of this study was to investigate the clinical features of small bowel tumors.

Methods

Between November 1994 and November 2007, 81 patients underwent treatments for primary tumors in the jejuno-ileal region at the Department of Surgery, Kangnam St. Mary's Hospital, the Catholic University of Korea. A retrospective review of the patients' characteristics and variable tumor factors was performed.

Results

The mean age of the patients was 53.2 years with 48 men and 33 women. The most common symptom was abdominal pain (59.3%), followed by bleeding (22.2%) and an abdominal mass (6.2%). We found that the patients with ileal tumors complained mainly of abdominal pain (72.9%) whereas the patients with jejunal tumors presented with gastrointestinal bleeding (36.4%) (P = 0.048). Seventy-six of the 81 patients (93.8%) had malignant tumors, including 40 (49.4%) gastrointestinal stromal tumors, 26 (32.1%) lymphomas and 5 (6.2%) adenocarcinomas. No postoperative mortalities were observed. The overall 5-year survival rate of the patients with malignant small bowel tumors was 31.8%.

Conclusion

Because the clinical features of a primary tumor of the small bowel are obscure and its diagnosis is difficult, maintaining a high degree of suspicion and recognizing the possibility of a primary small bowel tumor are important.

Gastrointestinal stromal tumuor- case report and a review of the literature

Gastrointestinal stromal tumours (GIST) are rare mesenchymal tumours, comprising 1% of all GI malignancies. This is a report of a middle-aged man diagnosed with GIST of the duodenum. He had gastrojejunostomy and para-aortic lymph node biopsy for histology. He was subsequently commenced on 5-fluorouracil but with little response.

Resection of Benign Duodenal Neoplasms

Primary small bowel neoplasms (PSBN) are uncommon, accounting for less than 15 per cent of all gastrointestinal tumors. Benign duodenal neoplasms (BDN) are rare, comprising only 10 to 20 per cent of all PSBN. The treatment is generally surgical resection ranging from local excision to pancreaticoduodenectomy depending on size, location, and number of lesions. Patients undergoing surgical treatment for BDN at Vanderbilt University Medical Center from July 1984 to April 2006, were identified and reviewed retrospectively. Medical records were examined for demographics, operative details, results, and complications. Twenty-six patients were identified of which 56 per cent were male and the mean age was 56 ± 14 years. Lesions were found throughout the duodenum, but the majority (62%) were ampullary. Nearly 75 per cent were adenomas, including over half with dysplasia. Operative interventions and complication rates were: duodenal resection with primary anastomosis (n = 3, 0%), local excision (n = 6, 50%), ampullary resection (n = 10, 30%), and pancreaticoduodenectomy (n = 7, 86%). There were no reoperations or mortalities. Mean followup was 14 months. BDN are an increasingly common problem in an era of frequent use of upper endoscopy. The surgical management of these lesions must be tailored to their size, number, location, and malignant potential. A wide variety of surgical procedures can be performed with acceptable morbidity.

Inverted cystic tubulovillous adenoma involving Brunner’s glands of duodenum

Benign neoplasia of the duodenum are very rare. Moreover, duodenal tubulovillous adenomas are more uncommon lesions. The microscopic structure of tubulovillous adenoma has frond-like projection of mucosa with branching papillary structure and generally upward growth into the lumen. We describe a 72-year-old man who showed aduodenal tubulovillous adenoma with unusual inverted cystic growth pattern. Interestingly, this tubulovillous adenomatous lesion was interrupted by gastric metaplasia in the deep portion of the cyst and was closely surrounded by Brunner’s glands. Although histogenesis of gastric metaplasia of duodenum is not fully understood, Brunner’s glands has been suggested as a precursor for gastric metaplasia. Therefore, these findings argued that this adenoma arises from Brunner’s glands through gastric metaplasia. This is the first case of inverted cystic tubulovillous adenoma involving Brunner’s glands of duodenum with gastric metaplasia.

Avances en radiología del intestino delgado: enteroclisis por tomografía computarizada

Computed tomography (CT) enteroclysis is a new technique consisting of helical CT of the abdomen and pelvis after administration of water through a nasojejunal tube and intravenous contrast, resulting in adequate distension and visualization of the small bowel wall. The use of this technique is especially recommended in patients with gastrointestinal bleeding of unknown etiology, possible neoplastic processes of the small bowel, partial small bowel obstruction, and inflammatory bowel disease. One-hundred consecutive patients underwent CT enteroclysis (multiple detectors; 8, 16, or 64) over a 1-year period for suspected lesions of the small bowel. Of these, 31 were positive: Crohn's disease (17), tumors (8), partial obstruction (2), radiation enteritis (1), sprue (1), pneumatosis cystoids (1), and dilatation of bowel loops (1). In 28 of the 31 patients, the findings were confirmed by pathology, endoscopy or clinical follow-up.

Increased diagnostic yield of small bowel tumors with capsule endoscopy

BACKGROUND

It is believed that cancers of the small intestine represent <2% of all malignant tumors of the gastrointestinal tract, although the accuracy of this estimate is unknown, because the current methodologies for examining the small bowel have proved inadequate. Capsule endoscopy allows a more detailed inspection of the small intestine and may improve the ability to diagnose small bowel tumors. The objective of this study was to evaluate the effectiveness of capsule endoscopy in diagnosing small bowel tumors and to help establish the true incidence of tumors in obscure gastrointestinal bleeding.

METHODS

A retrospective analysis of the charts of 562 patients who underwent capsule endoscopy from August 2001 to November 2003 for a variety of indications was performed. The indication for the procedure was bleeding (alone or in addition to another indication, such as abnormal imaging) in 443 patients.

RESULTS

A diagnosis was made by capsule endoscopy in 277 patients (49.3%). Of 562 patients who were included in the study, 50 patients (8.9%) were diagnosed with small bowel tumors. The types of tumor diagnosed by capsule endoscopy included 8 adenocarcinomas (1.4%), 10 carcinoids (1.8%), 4 gastrointestinal stromal tumors (0.7%), 5 lymphomas (0.9%), 3 inflammatory polyps, 1 lymphangioma, 1 lymphangioectasia,1 hemangioma, 1 hamartoma, and 1 tubular adenoma. Of the tumors diagnosed, 48% were malignant. It was observed that 9 of 67 patients (13%) younger than age 50 years who underwent capsule endoscopy for obscure bleeding had small bowel tumors. The pathology results were not available for 10 patients.

CONCLUSIONS

Capsule endoscopy diagnosed small bowel tumors in 8.9% of patients who underwent the procedure for a variety of reasons, establishing it as an effective diagnostic modality. This incidence of small bowel tumors suggests an important role for capsule endoscopy in the algorithm for the diagnostic work-up of patients with suspected small bowel lesions. Capsule endoscopy may lead to earlier detection and treatment of small bowel tumors and an improved prognosis for patients with these neoplasms.

Incidence of Small Bowel Cancer in the United States and Worldwide: Geographic, Temporal, and Racial Differences

OBJECTIVE

To examine the demographic and geographic patterns of small bowel cancer incidence in the United States and worldwide.

METHODS

Incidence data from the Surveillance, Epidemiology, and End Results (SEER) program between 1973 to 2000 were used to analyze the four histologic types of small bowel cancer, adenocarcinomas, carcinoid tumors, lymphomas, and sarcomas. International comparisons were made using data from Cancer Incidence in Five Continents (CIVIII). Geographic correlations between small bowel and both large bowel and stomach cancer incidence, were performed.

RESULTS

Men had higher rates than women for all types of small bowel cancer. Blacks had almost double the incidence of carcinomas and carcinoid tumors compared to whites (10.6 vs. 5.6 per million people; 9.2 vs. 5.4 per million people, respectively). Small bowel cancer incidence has risen, with the greatest increase for carcinoid tumors (21%) and black men (120%). A geographic correlation between small and large bowel cancer incidence, but not small bowel and stomach cancer, were observed.

CONCLUSIONS

Small bowel cancer incidence in the U.S. is higher in blacks compared to whites, particularly for carcinomas and carcinoid tumors. Small bowel cancer incidence is rising, particularly in black men. The geographic correlation between large and small bowel cancer suggests shared etiologies.

Imaging of small bowel disease: comparison of capsule endoscopy, standard endoscopy, barium examination, and CT

Capsule endoscopy is a revolutionary new diagnostic tool for the detection of small bowel disease. As the name implies, capsule endoscopy makes use of a swallowable video capsule; as such, it is the only technique that allows noninvasive endoscopic examination of the entire small bowel without sedation. Obscure gastrointestinal bleeding is the most common indication for capsule endoscopy, which commonly depicts arteriovenous malformations, small bowel tumors, and ulcers missed at standard endoscopy and imaging examinations. However, capsule endoscopy is not optimal for the localization of small bowel lesions. In addition, lesions can be missed due to poor bowel preparation, rapid or delayed small bowel transit, or orientation of the camera away from a lesion. Computed tomography and barium examinations are useful for detecting these missed lesions and for localizing lesions detected at capsule endoscopy. Other limitations of capsule endoscopy are the inability to treat lesions and its limited use in patients with small bowel strictures or obstruction. Nevertheless, this new technique is easy to perform, is well tolerated by patients, and, for the first time, allows noninvasive endoscopic evaluation of the entire small bowel.

High-grade B-cell lymphoma arising in mucosa-associated lymphoid tissue of the duodenum

Duodenal mucosa-associated lymphoid tissue lymphoma is a rare neoplasm. We report a case of a 70-year-old man with non-Hodgkin's lymphoma located in the descending duodenum that was not associated with Helicobacter pylori infection of the stomach. A surgical resection due to obstruction of the bowel lumen above the ligament of Treitz was performed. No invasion into the adjacent structure was confirmed at surgery. The pathological examination showed an infiltration of the duodenal mucosa and submucosa with B lymphocytes. Monoclonal proliferation of the lymphoid tissue was demonstrated by polymerase chain reaction. The histological appearance and the demonstration of monoclonality fulfilled the criteria for malignant high-grade B-cell lymphoma arising from mucosa-associated lymphoid tissue.

Radiologic evaluation and staging of small intestine neoplasms

The small intestine is an uncommon location for neoplasms in either clinical or radiological practice. Because of its anatomic location and morphology, diagnosis of the diseases that affect small intestine pose difficulties. Symptoms are nonspecific and endoscopy is commonly unsatisfactory. Since early and definite diagnosis is crucial for prompt therapy, radiological imaging plays an essential role. Enteroclysis is the primary and effective radiologic modality in the evaluation of small bowel neoplasms. On the other hand, computed tomography should be the complementary radiologic method as well as for staging. In this review, the most common neoplasms of the small intestine and their common radiologic findings have been discussed.

Adenocarcinoma of the small bowel

Cancer of the small bowel is a rare entity but its incidence is rising. Historically, outcome is poor despite apparent curative resection. At present surgery remains the only treatment modality of proven benefit in the management of this disease. Recent data would suggest 5-year survival rates in the order of 40-50% at all sites of small bowel cancer. To improve upon this, earlier diagnosis with a high index of suspicion and multicentre adjuvant therapy trials are required.

Myoepithelial hamartoma of the small bowel: report of a case

Benign small bowel tumors seldom cause symptoms, due to the fluid content and distensibility of the small bowel. We herein present the case of a solitary ileal hamartoma causing melena and abdominal pain in a 24-year-old man. The diagnosis of a submucosal ileal tumor was made after performing small bowel barium studies. Surgical treatment was undertaken, and a histological examination of the excised lesion, which showed a partially ulcerated tumor surface and extended from the submucosa to the subserosa, revealed numerous cystic glands of various sizes together with bundles of proliferating smooth muscle cells. Histochemical and immunohistochemical investigations were performed for differential diagnosis, and the tumor features were consistent with a diagnosis of ileal myoepithelial hamartoma. In the literature, small intestinal myoepithelial hamartomas are quite rare and this is the first report of a myoepithelial hamartoma causing melena.

Malignant tumours of the small bowel

Early diagnosis of small intestinal cancers provides the best probability of cure. The astute clinician will include these tumours in the differential diagnosis when vague or non-specific abdominal complaints occur and a more common cause is not discovered. Failure to evaluate the small bowel, which is a blind spot to routine endoscopic and radiological diagnostic tests, constitutes a common error when confronted with occult gastrointestinal blood loss and normal upper and lower gastrointestinal examination. Surgical resection remains the cornerstone of therapy for these malignancies. Advances in effective chemotherapy for large bowel carcinoma may have an impact on the management of small intestinal adenocarcinomas. Substantial palliation can be offered to the patient with metastatic carcinoid tumour, but the long-term outlook for these patients remains poor. Early stage lymphomas of the intestine are readily treated by combined modality therapy while advanced stage disease remains resistant to curative management. The patient prognosis for a small bowel sarcoma is largely dependent on the tumour grade. A high index of suspicion to improve tumour detection and better treatments of tumours with the same histology at other anatomic sites should enhance the management and outcome of patients with small intestinal malignancies.

A dose-escalation study of recombinant interferon-alpha in patients with a metastatic carcinoid tumour

The efficacy of interferon alpha-2b in doses up to 12 x 10(6) IU three times weekly was studied in 21 patients with a metastatic carcinoid tumour. Of these 21 patients, 19 were evaluable for response. Patients were treated with escalating dosages of interferon alpha-2b: 3 x 10(6) IU, 6 x 10(6) IU and 12 x 10(6) IU. The escalation was performed every 8 weeks when no objective tumour regression was observed. Patients were also evaluated for biochemical response and symptomatic improvement. One objective tumour regression was observed. Of the 15 patients with elevated 5-hydroxyindole acetic acid (5-HIAA) excretion, 5 (33%) had a more than 50% decrease in 5-HIAA excretion. Relief of symptoms occurred in 11 patients (58%). This improvement was already apparent during the initial 8 weeks of treatment. Increasing the dose to 6 or 12 x 10(6) IU interferon alpha-2b did not result in further symptomatic improvement. In contrast toxicity was considerable with the higher dosages of interferon alpha-2b. It is concluded that low dose interferon alpha-2b (3 x 10(6) IU) three times weekly is as effective as higher dosages of interferon alpha-2b at ameliorating symptoms of the carcinoid syndrome.

Primary jejunoileal tumors: a review of 45 cases

We reviewed 45 patients who underwent surgery for primary jejunoileal tumors over a 15-year period. There were 16 benign and 29 malignant tumors, which included 13 lymphomas, 7 adenocarcinomas, 7 carcinoid tumors, and 2 leiomyosarcomas. Eighteen patients, 13 of whom had benign tumors, presented with intestinal bleeding and 5 tumors were found incidentally at laparotomy. Benign lesions were more frequently sited in the jejunum while malignant lesions were more common in the ileum (p less than 0.001). Lesions presenting with hemorrhage were more likely to be benign than malignant (p less than 0.001) and were more commonly sited in the jejunum than in the ileum (p less than 0.05). Visceral perforation (31%), intestinal obstruction (21%), and an abdominal mass (17%) were other presenting features in patients with malignant tumors. In spite of a wide variety of investigations, the correct diagnosis was reached preoperatively in only 31% of patients. Surgical management included either limited bowel resection or segmental resection with regional lymphadenectomy. Operative mortality was 13% and morbidity was 36%. Actuarial 5-year survival for all malignant tumors was 24%, being 64% at 5 years for carcinoid tumors, 20% at 30 months for adenocarcinomas, and 10% at 42 months for lymphomas. These results reemphasize the need for a high index of suspicion and early laparotomy in patients with obscure intestinal symptoms if the prognosis of small bowel tumors is to improve.

Gastrointestinal lymphoma

Primary GI lymphoma is a rare clinical entity. A primary nodal tumor should be ruled out. Symptoms may not be localizing and B symptoms are less common. A tissue diagnosis, preferably by transmural biopsy for small intestinal involvement, often reveals a high-grade morphology. The staging work-up should include a bone marrow examination, although formal staging laparatomy is not always required. Patients with Mushoff stage IE or IIE1 disease do better than those with extraregional nodal disease or distant metastatic involvement. Surgical resection with clear margins is required in order to maximize the changes for cure. Chemotherapy or radiotherapy may give a survival advantage when used as adjuvant treatment for selected stage IE and IIE disease. Chemotherapy should be used after surgical debulking in more advanced disease in order to minimize the chance for bleeding or performation. Future randomized, multi-institutional trials will give more direction as to the best modes of management.

Primary adenocarcinoma of the jejunum and ileum: clinicopathological review of 25 cases

Between 1954 and 1988 only a total of twenty five cases of primary adenocarcinoma of the small bowel (excluding periampillary tumours) were recorded at the Department of Histopathology, Belfast City Hospital. Of these, 14 tumours were located in the jejunum: the remainder arose in the ileum. The average age at presentation was 61.3 years and a slight female to male preponderance of 1:7:1 was noted. The adenocarcinoma arose from a preexisting villous adenoma in six cases. The overall prognosis was poor, with a five year survival of 15.7%. All the survivors had tumours located in the jejunum. The single most important prognostic indicator was the depth of tumour invasion or stage at the time of diagnosis. Tumour size and grade did not seem to correlate well with survival. It is concluded that the rarity of these tumours and their inaccessibility hinder detection and treatment and that surgical resection is more effective than chemotherapy.

Villous tumors of the duodenum

Five cases of villous tumors of the duodenum are reported, all of which involve the ampulla of Vater. Three of the five lesions contained either infiltrating carcinoma or carcinoma in situ. Although preoperative endoscopic biopsy was performed on all tumors no malignancy was identified. Frozen sections done at the time of operation on the three patients with carcinoma also failed to identify malignancy. One patient underwent pancreaticoduodenectomy and four patients had local excision of the tumor. Three of the patients treated with local excision developed recurrence and two subsequently had pancreaticoduodenectomy. Because of the difficulty in making an accurate diagnosis and the chance of recurrence when local excision is employed, strong consideration should be given to pancreaticoduodenectomy as the initial form of treatment of these lesions.

Villous tumors of the duodenum

Five cases of villous tumors of the duodenum are reported, all of which involve the ampulla of Vater. Three of the five lesions contained either infiltrating carcinoma or carcinoma in situ. Although preoperative endoscopic biopsy was performed on all tumors no malignancy was identified. Frozen sections done at the time of operation on the three patients with carcinoma also failed to identify malignancy. One patient underwent pancreaticoduodenectomy and four patients had local excision of the tumor. Three of the patients treated with local excision developed recurrence and two subsequently had pancreaticoduodenectomy. Because of the difficulty in making an accurate diagnosis and the chance of recurrence when local excision is employed, strong consideration should be given to pancreaticoduodenectomy as the initial form of treatment of these lesions.

Leiomyomas of the duodenum

Leiomyoma is a neoplasm of smooth muscle relatively common in the stomach, but very rare in the duodenal location. Symptoms are gastrointestinal bleeding or abdominal pain resembling peptic disease. Three cases of duodenal leiomyomas are described, and the importance of endoscopy is emphasized as a diagnostic tool. Surgical resection of the tumor is the recommended therapeutic procedure, and the difficulty in deciding at the pathological examination whether the leiomyoma is benign or malignant demands prompt follow-up of patients after surgery.

Primary adenocarcinoma of the small intestine with emphasis on microvillous differentiation

A detailed ultrastructural study was made of 12 primary adenocarcinomas of the small intestine. A comparative analysis of microvilli identified three characteristic features in various proportions on the apical tumor cell surface. These were; 1) "long rootlets," which are long intravillous filamentous cores penetrating into the cytoplasm and identical to those observed in colonic adenocarcinoma; 2) a regular arrangement of uniform microvilli similar to the brush border of normal intestinal epithelium; and 3) sparse rudimentary microvillous structures. Because of the rarity of adenocarcinoma in the small intestine no previous study defined these ultrastructural characteristics. The results of the present study suggest that the diverse ultrastructural findings may be related to different stages of tumor cell maturation and that the neoplastic state may increase the variation and range of microvillous differentiation regardless of capacity of mucin secretion by the tumor cells. For diagnostic purposes, brush borders as well as two other microvillous features may serve to identify adenocarcinoma of mucosal origin of the small intestine, if an ultrastructural study discloses these three features.

Carcinoid tumor of the biliary system. Case report and literature review

Work-up of a 62-year-old black male, with a complaint of low back pain for three months, revealed a mass in the porta hepatis, narrowing of the common hepatic duct, and dilated intrahepatic bile ducts. A 3 X 4-cm tumor in the common hepatic duct was excised and biliary continuity restored by hepaticojejunostomy. The excised mass was a carcinoid tumor with no evidence of secretory activity. The patient is well 24.5 months after treatment. The literature on carcinoid tumors of the biliary tract is reviewed.

Primary malignant tumors of the small bowel. The Hartford Hospital experience, 1969-1983

The medical records of 51 patients with primary small bowel cancer were reviewed. Twenty patients had carcinoid tumors, 17 had adenocarcinomas, 8 had leiomyosarcomas, and 6 had lymphomas. Presenting complaints were protean in nature and only 33 percent of patients had a correct diagnosis at the time of operation. Curative resection was attempted in 55 percent, but most patients presented late in their illness and only 27 percent had localized tumors. Survival has been poor: at most recent follow-up, 59 percent were dead, 14 percent were alive with disease, and 27 percent were alive and well. Earlier diagnosis may improve survival. Patients at risk for these tumors are usually more than 50 years of age with vague complaints such as weight loss, pain, abdominal fullness, and fatigue. They should undergo complete evaluation centered around exhaustive radiographic studies and liberal use of endoscopy.

Nephrogenic adenoma occurring in an ileal conduit

We report a case in which papillary lesions developed in an ileal conduit that had been constructed for management of nonmalignant disease. Pathological diagnosis was nephrogenic adenoma, an entity previously thought to occur only in the urothelium. The pathogenesis of this unusual tumor is discussed.

Primary neoplasms of the small intestine

Over a 20 year period, 64 patients with primary neoplasms of the small intestine were treated by celiotomy (61 patients) or surgical endoscopy (3 patients). Gastrointestinal bleeding and anemia (38 percent of patients) characterized benign lesions, whereas pain (42 percent), nausea and vomiting (26 percent), weight loss (29 percent), and either gastrointestinal obstruction or jaundice (18 percent) were more indicative of malignancy. Barium studies, duodenal endoscopy, and selective angiography were the most useful diagnostic tools. All 26 patients with benign lesions did well after resection, whereas the 38 patients with malignancies did poorly despite apparently curative wide excision in 19 and pancreaticoduodenectomy in 6. Only the patients with malignant carcinoid lesions treated surgically and by chemotherapy had a good 5 year survival rate (60 percent). All patients with sarcomas and adenocarcinomas died from their disease. Major operations and chemotherapy gave fair outcomes in only a minority of patients who had no evidence of metastasis. These results document the need to suspect small intestinal neoplasms earlier and to perform more aggressive diagnostic workups in patients with vague gastrointestinal symptoms.

Carcinoid of the small intestine

Carcinoid tumour was the most common small bowel tumour found in this series of 179 patients. It occurred in 24% of patients. Forty-six percent of patients were asymptomatic during life, the tumours being found either at autopsy or during other surgical procedures. Of those that were symptomatic, half presented with intestinal obstruction and the rest with long-standing symptoms. An abdominal mass, which occurred in 14% of cases, is an uncommon physical finding since the majority present as small submucosal tumors. Fifty-eight per cent overall and 72% of those having surgery had evidence of regional spread, either by local invasion or in the form of regional nodal involvement. Seven per cent of patients have died of their disease. Excisional surgery should be performed for all cases where feasible, and repeated for recurrent symptoms.

Atypical carcinoid tumor of the small bowel complicating celiac disease

An atypical carcinoid tumor of the small bowel in a patient with celiac disease is described. Although an increased incidence of malignancy has been observed in celiac disease, this seems to be the first report of a carcinoid tumor of the small intestine associated with this condition. Although the significance of this association is unclear, the implications with regard to gastrointestinal endocrine cell proliferation and tumor histogenesis are discussed.

Primary non-Hodgkin's lymphoma of the duodenum. Case report and literature review

A case of primary non-Hodgkin's lymphoma of the duodenum is presented. A review of the English literature documented 95 cases, and the presenting signs, symptoms, and radiographic findings have been abstracted. Attention is also drawn to the treatment of 27 cases, 11 of which (41%) survived for 2 or more years. Ten of the 11 long-term survivors were treated with radiotherapy with or without resection, whereas only one long-term survivor was treated by surgery alone.