Small Bowel Adenocarcinoma

Primitive Resectable Small Bowel Cancer Clinical-Pathological Analysis: A 10-Year Retrospective Study in a General Surgery Unit

Introduction: Small bowel cancer is very rare; although the incidence of adenocarcinoma and other anatomopathological forms has increased recently, the diagnosis and treatment of this disease are still debatable because of the clinical heterogeneity and the absence of studies including a large number of patients. Materials and Methods: We performed a retrospective study over 10 years in which we analyzed the clinical, imaging, and anatomopathological data of 46 patients hospitalized in a surgery clinic and diagnosed with small bowel cancer (duodenum, jejunum, and ileum). Results: After clinical assessment of these patients, including complications (occlusion, bleeding, and perforation), the CT scan established the diagnosis in over 90% of the cases of the complicated form of the disease. Surgery has a curative role in localized cancers; tumor location, local invasion, the presence of locoregional lymph nodes, and the number of multiple tumors influence the type of surgery. The conventional pathological exam was completed via immunohistochemical staining. Adjuvant oncological treatment was performed after surgery (according to the guidelines); in patients with exceptional histopathological forms, the therapy was personalized. Conclusions: Most small bowel cancers were diagnosed with complications (occlusion and bleeding); the tumor type, location, and presence of multiple bowel cancers significantly influenced its management. Independently of the surgical resection (R0/R1 or R2), the prognosis of the disease depends on the tumor aggressivity, location (single/multiple), and locoregional node invasion.

Bibliometrics analysis on the research status and trends of small bowel adenocarcinoma: 1923-2023

Objectives

The aim of this research is to discuss the research status, hotspots, frontiers, and development trends in the field of small bowel adenocarcinoma based on bibliometrics and visual analysis by CiteSpace software.

Methods

The relevant research articles on SBA from 1923 to 2023 were retrieved from the Web of Science Core Collection database. CiteSpace software was used to form a visual knowledge map and conduct analysis for the countries/regions, journals, authors, keywords, clusters, research hotspots and frontiers of the included articles.

Results

There were 921 articles included, and the number of articles published during 1923-2023 is increasing. The country with the highest number of articles published was the United States (443, 38.76%), followed by Japan (84, 9.12%) and France (72, 7.82%). The author with the highest number of publications is Ansell, Overman MJ (33, 3.58%), and the author with the highest co-citation frequency is Overman MJ (218). Journal of Clinical Oncology is the journal with the highest publication frequency. The top five cluster groups were "chemotherapy", "inflammatory bowel disease", "celiac disease", "tumor" and "small intestine". The related disease, chemotherapy drugs, and treatment regimens of SBA form the main research fields, and prognosis and diagnosis are the research hotspots and trends.

Conclusion

The global research field in SBA has expanded in the past 100 years. The prognosis and new diagnosis of SBA are hotspots in this field and require further study in the future.

Enhancing treatment strategies for small bowel cancer: a clinical review of targeted therapy and immunotherapy approaches

Small bowel cancer (SBC) is a rare and aggressive disease with a poor prognosis, necessitating the exploration of novel treatment approaches. This narrative review examines the current evidence on targeted therapy and immunotherapy for SBC, focusing on the two most common subtypes: adenocarcinoma and neuroendocrine tumor. A comprehensive search of PubMed, Scopus, and Google Scholar databases was conducted to identify relevant clinical trials and case reports published in English up to September 2023. The review includes 17 clinical trials and 10 case reports, indicating that targeted therapy and immunotherapy can have the potential to improve survival rates in patients with SBC. Notably, promising targeted medicines include bevacizumab, cetuximab, and trastuzumab, while pembrolizumab and nivolumab show potential as immunotherapies. However, it should be noted that the magnitude of the increase in survival rates with these interventions was small. Further research is needed to determine the optimal combination of targeted therapy and immunotherapy for individual patients with SBC.

Colo-colic intussusception in an adult caused by lipoma: Case report of a rare condition

This report describes the case of a 56-year-old woman who presented at the emergency room with a 3-week history of severe, intermittent abdominal pain. A CT scan revealed colo-colic intussusception caused by a large, substenosing mass with predominant adipose density. Subsequent endoscopic examination with biopsy revealed a necrotic tissue covering the mass, without definitive histological characterization. A second biopsy led to the extremely rare diagnosis of colo-colic lipoma. While intussusception is rare in adults, it's important to consider it as a differential diagnosis, especially when presenting with abdominal pain and signs of bowel obstruction. Timely diagnosis and appropriate treatment are essential to prevent complications.

Small Intestinal Adenocarcinoma Arising at the Anastomotic Site after Kasai Operation for Biliary Atresia: A Case Report and Literature Review

Biliary atresia is an obliterative cholangiopathy of unknown etiology. Hepatic portoenterostomy, in which obliterated extrahepatic bile ducts are resected and bile flow is restored, known as Kasai operation, is performed within 3 months after birth. While this operation enhances long-term survival of patients, the occurrence of primary malignant hepatic tumors has been increasing. We report a case of small intestinal adenocarcinoma arising at the anastomotic site after Kasai operation. A 49-year-old man, who underwent Kasai operation for biliary atresia when he was 2 months old, experienced rapidly progressive jaundice and liver dysfunction. Deceased-donor liver transplantation was performed for liver failure. Macroscopically, there was a white-yellow tumor located at the anastomotic site of hepatic portoenterostomy of the resected liver. Pathological examination revealed a well-differentiated adenocarcinoma with some Paneth cells in the neoplastic lesion. Immunohistochemically, the tumor cells were negative for cytokeratin 7 (CK7) but positive for cytokeratin 20 (CK20) and a homeobox domain-containing transcription factor (CDX2). Mucin expression in tumor cells was negative for mucin 1 (MUC1) and mucin 6 (MUC6) and positive for mucin 2 (MUC2) and mucin 5AC (MUC5AC). The pathological diagnosis was small intestinal adenocarcinoma originating from the jejunum. The patient was discharged 48 days after the operation. The patient had not experienced recurrence at 10 months after the operation. This is the first report of small intestinal adenocarcinoma arising at the anastomotic site after Kasai operation for biliary atresia. Special care should be taken for the patients after Kasai operation with acute progressive jaundice and liver dysfunction because there is a possibility of malignancy in their native liver.

Lipoma-Associated Intussusception of the Transverse Colon

Intestinal intussusception rarely occurs in adults and is challenging to diagnose in the emergency department due to its associated nonspecific symptom of abdominal pain. Most of these incidences are caused by a neoplasm within the bowel acting as a lead point. Lipomas are benign fatty tumors that rarely develop in the colon and are very infrequently a precursor lesion to intussusception. Our present report describes a case of lipoma-associated intussusception in the transverse colon in an adult who presented with complaints of abdominal pain and acutely worsened chronic constipation. Computerized tomography (CT) imaging and barium enema revealed colocolonic intussusception with a lipomatous lead point and complete obstruction. The patient was admitted for same-day intervention and underwent a successful colectomy with no complications.

Primary Adenocarcinoma of the Jejunum: Case Report of Rare Small Bowel Neoplasm

Small bowel adenocarcinoma (SBA) is rare cancer that accounts for less than 2% of all gastrointestinal tract cancers. Usually, the clinical presentation is unspecific, and a patient might complain of nausea, vomiting, abdominal pain, small bowel obstruction, and small bowel bleeding. Because of these unspecific symptoms, the patient might be diagnosed late, from six to ten months, which affects the prognosis. This study contains a case report of a 38-year female with SBA in the jejunum, with unspecific symptoms. She had a history of recurrent admissions due to acute pancreatitis, acute kidney injury, and hyponatremia caused by dehydration. The patient was diagnosed six months after the first symptoms of nausea and vomiting started. The patient underwent exploratory laparotomy for a jejunal stricture mass, and a lymph node was resected. The course after surgery was smooth, and the patient was discharged home on the fourth-day post-surgery. In conclusion, the symptoms of SBA are unspecific and cannot be diagnosed without complete medical histories and lab examinations, making diagnosing SBA challenging.

Small Bowel Adenocarcinoma: From Molecular Insights to Clinical Management

Small bowel adenocarcinoma (SBA) is a rare malignancy, with a rising incidence in recent decades, and accounts for roughly 40% of all cancers of the small bowel. The majority of SBAs arise in the duodenum and are associated with a dismal prognosis. Surgery remains the mainstay of treatment for localized disease, while systemic treatments parallel those used in colorectal cancer (CRC), both in the adjuvant and palliative setting. In fact, owing to the lack of prospective data supporting its optimal management, SBA has historically been treated in the same way as CRC. However, recent genetic and molecular data suggest a distinct profile from other gastrointestinal malignancies and support a more nuanced approach to its management. Herein, we briefly review the state-of-the-art in the clinical management of early-stage and advanced disease and recent discoveries of potentially actionable genetic alterations or pathways along with the most promising ongoing clinical trials, which will hopefully revolutionize the treatment landscape of this orphan disease in the foreseeable future.

Gastrointestinal cancer characteristics in Lebanon

BACKGROUND AND STUDY AIMS

Gastrointestinal (GI) cancer is one of the top five common cancers in Lebanon. To implement a strategy for screening and early diagnosis through the initiation of prevention programs, a detailed study of GI cancers in Lebanon was conducted by focusing on the frequency and characteristics of each type.

PATIENTS AND METHODS

This retrospective study was conducted in Lebanon between 2001 and 2015 and included patients diagnosed with different GI cancer types. Data were collected from the registry of the National Institute of Pathology (NIP). The frequency of each type was calculated according to sex, age at diagnosis, anatomic location, histological type, and stage.

RESULTS

The total number of patients diagnosed with GI cancers who had their histology done at the NIP between 2001 and 2015 was 5239. The sex (male/female) ratio was 1.016, with a mean age of 62.2 years. Colorectal cancer ranked first among GI cancers, with more than half of the cases (53.4%). More than 70% of the cases were located on the left side, followed by gastric (15.5%) and pancreatic (12.7%) cancers. Regarding gastric cancer, cardia became the dominant location. A shift from squamous cell carcinoma to adenocarcinoma in esophageal cancer was found during this period. Also, most GI cancers in Lebanon were diagnosed in the late stages.

CONCLUSION

This study is the first to evaluate GI cancers in Lebanon, which will help in screening strategies and burden studies.

Efficacy and safety of Seprafilm for preventing intestinal obstruction after gastrointestinal neoplasms surgery: a systematic review and meta-analysis

OBJECTIVE

It was controversial that hyaluronate-carboxy-methylcellulose-based membrane (Seprafilm) could prevent intestinal obstruction after gastrointestinal neoplasms operation. This study aimed to evaluate the efficacy and safety of Seprafilm in preventing postoperative intestinal obstruction of gastrointestinal neoplasms patients.

METHODS

A systematic research of multiple databases was performed to identify relevant studies, and the studies satisfying the inclusion criteria were included. Risk ratio (RR), weighted mean difference (WMD), and 95% confidence intervals were calculated using RevMan 5.3.

RESULTS

2937 patients from 10 studies who were enrolled in this meta-analysis were divided into the Seprafilm group (n = 1334) and the control group (n = 1603). The Seprafilm group had lower incidence of intestinal obstruction (RR, 0.52; 95% CI, 0.38-0.70; p < .0001), reoperation rates due to intestinal obstruction (RR, 0.48; 95% CI, 0.28 - 0.80; p = .005), incidence of overall complications (RR, 0.77; 95% CI, 0.61-0.97; p = .03) and higher serum creatinine on postoperative day 5 (WMD, 0.15; 95% CI, 0.05-0.25; p = .003). There were no differences regarding time to intestinal obstruction after operation, aspartate aminotransferase, alanine aminotransferase, blood urea nitrogen, white blood cell count results on day 5 and 7, serum creatinine on day 7, hospital stay, and incidence of intra-abdominal infection, wound infection, anastomotic leakage between the 2 groups.

CONCLUSIONS

This meta-analysis provided valuable evidence-based support for the efficacy and safety of Seprafilm in preventing postoperative intestinal obstruction of gastrointestinal neoplasms patients. However, more multicenter randomized controlled trials from different countries are needed.

An autopsy case of primary jejunal pouch cancer which protruded from the abdominal wall 14 years after total gastrectomy for gastric cancer

Adenocarcinoma which develops in the jejunal pouch has rarely been reported, but most of such cases tend to be a recurrence of primary cancer due to the presence of residual or disseminated cancer cells. Primary jejunal pouch cancer is extremely rare. We experienced an autopsy case of primary jejunal pouch cancer which occurred 14 years after proximal gastrectomy for gastric cancer. A female in her late 60s was admitted because of hypoglycemia with liver dysfunction. She underwent total gastrectomy for fundic cancer and had been reconstructed by jejunal pouch interposition 14 years prior to this presentation. Hypoglycemia recovered by nutritional support. Computed tomography demonstrated severe fatty liver and liver biopsy proved non-alcoholic steatohepatitis, which was supposed to have been induced by malnutrition. Screening esophagogastroduodenoscopy (EGD) revealed no tumorous lesions in the jejunal pouch at this time. However, her anorexia gradually progressed and the symptom of bowel obstruction appeared. EGD performed 5 months after the previous EGD revealed adenocarcinoma which extended from the anastomosis of the interposed jejunum. Then liver metastasis developed and jejunal pouch cancer invaded the abdominal wall and protruded with ulcer formation. Finally, the patient died of malnutrition. An autopsy revealed adenocarcinoma which had developed in the interposed jejunal pouch and protruded through the abdominal wall accompanied with lung and liver metastasis. We herein describe this rare case of primary interposed jejunal pouch cancer and discuss our findings including a review of the pertinent literature.

Clinicopathological Features of Small Bowel Tumors Diagnosed by Video Capsule Endoscopy and Balloon-Assisted Enteroscopy: A Single Center Experience

Background/Aims

Small bowel malignancies often present a diagnostic challenge due to their relative rarity and nonspecific clinical symptoms. However, technical developments in endoscopic instruments, including video capsule endoscopy (VCE) and enteroscopy, have allowed for the visualization of the entire small bowel. This study aimed to investigate the clinicopathological features of small bowel malignant tumors diagnosed by VCE and double-balloon enteroscopy (DBE) in a single tertiary center.

Methods

We retrospectively analyzed VCE and DBE findings from Korea University Guro Hospital from January 2010 through September 2018.

Results

A total of 510 VCE and 126 DBE examinations were performed in 438 patients. Small bowel malignancies were diagnosed in 28 patients (15 males; mean age, 61.0 years; range, 42 to 81 years). Among them, 8 had lymphoma, 8 had primary adenocarcinoma, 7 had gastrointestinal stromal tumor (GIST) and 5 had metastatic cancer. Abdominal pain and obstructive symptoms were the most common findings in metastatic cancers (4/5, 80%). On the other hand, obscure gastrointestinal bleeding was the most common symptom of GIST (6/7, 85.7%) and adenocarcinoma (3/8, 37.5%).

Conclusions

Approximately 6% of the patients who underwent either VCE or DBE were diagnosed with small bowel malignancy. These findings demonstrated the different clinical characteristics among small bowel malignancies and merit further study.

Prognostic relevance of programmed death-ligand 1 expression and microsatellite status in small bowel adenocarcinoma

Background: Small bowel adenocarcinoma (SBA) is a dreadful disease. Patient prognosis is limited due to late presentation and ineffective chemotherapy. PD-1/PD-L1 checkpoint immunotherapy is regarded as a promising approach in several cancer entities. The association of PD-1/PD-L1 expression and its impact on patient prognosis with SBA is unclear. Material and methods: Seventy-five consecutive patients who underwent surgery for SBA were retrospectively analyzed and stained for PD-L1 expression in the tumour or the stroma. Analysis of mismatch repair genes was performed to determine microsatellite status. Kaplan-Meier estimate was used to analyze patient survival. Univariate and multivariable Cox regression-analyses were used to assess the impact of PD-L1 expression and microsatellite status on patient survival.Results: PD-L1 was weakly upregulated within the tumour or the stroma and associated with prolonged survival (p = .0071 and p = .0472, respectively). Fifty-one tumours (68%) revealed microsatellite stability (MSS) and 24 tumours (32%) were microsatellite instable (MSI) without correlating with patient survival (p = .611). Neither PD-L1 expression in the tumour nor in the stroma was identified as an independent risk factor influencing survival (p = .572 and p = .3055).Conclusion: Although PD-L1 expression is associated with prolonged survival, it was not identified as an independent prognostic marker. Microsatellite status did not influence long-term survival.

Clinical Outcomes of Small Bowel Adenocarcinoma

BACKGROUND

Small bowel adenocarcinomas (SBAs) are rare tumors. Management of SBA is extrapolated from colorectal cancer treatments. Recent evidence suggests that the biology and molecular features of SBA differ from colorectal cancer. The aim of this study was to evaluate the management and outcome of SBA patients. PATIENTS AND METHODS: The National Cancer Data Base (NCDB) was queried for patients with SBA between 2004 and 2013 using ICD-O-3 histology code 8140/3 and topography codes C17.0, C17.1, C17.2, C17.8, and C17.9. Univariate and multivariate survival analyses were conducted to analyze the association between SBA location and overall survival (OS) stratified by stage. Treatment outcomes of surgery, radiation, and systemic therapy were compared.

RESULTS

A total of 7954 SBA patients were identified; duodenum (D) 4607 (57.9%), jejunum (J) 1241 (15.6%), ileum (I) 857 (10.8%), and unspecified 1249 (15.7%). A total of 53.6% patients were male, and 76.6% white. Median age was 66 years. D mostly presented as stage IV disease (37.6%), J as stage II (34.5%) and IV disease (33.8%), and I as stage II (32.2%) and III (30.3%) disease (P < .001). Grade distribution was similar among D, J, and I; the majority were moderately differentiated (40.8%-55.0%), followed by poorly differentiated (30.9%-35.8%) and well differentiated (6.0%-12.4%) (P < .001). D underwent surgery (50.2%) less often than J (90.8%) and I (94.5%) (P < .001). Adjuvant radiation was provided in 8.5% of D, 2.6% of J, and 2.1% of I (P < .001). Adjuvant chemotherapy was provided in 21.9% of D, 50.2% of J, and 42.0% of I (P < .001). The rate of adjuvant chemotherapy was the highest in patients with stage III SBA, and was as follows: D (43.4%), J (65.4%), and I (63.6%) (P < .001). In univariate and multivariate analyses of all patients, adjuvant chemotherapy was associated with improved OS in stage II-III SBA patients. J had the best 5-year OS rate (42.0%; 95% confidence interval, 38.8-45.1, P < .001), and D had the worst (23.0%; 95% confidence interval, 21.6-24.2, P < .001). In multivariate analysis stratified by stage, chemotherapy was associated with improved OS in patients with stage II-IV SBA.

CONCLUSION

Most SBA patients present with stage IV disease. D underwent surgery less often than J and I. Stage II and III D received adjuvant chemotherapy less often compared to stage II and III J and I. Adjuvant chemotherapy was associated with improved OS in patients with stage II-III disease. J had the best 5-year OS rate, and D had the worst.