Malignant small bowel neoplasms: histopathologic determinants of recurrence and survival

Small Bowel Adenocarcinoma: 10-Year Experience in a Cancer Center-The Ottawa Hospital (TOH)

(1) Background: Small bowel adenocarcinoma (SBA) is one of the predominant primary small bowel cancers that has a dismal outcome. We aim to report 10 years of experience in SBA management at a regional cancer centre in Canada.; (2) Methods: We retrospectively analysed clinical and pathological data of patients diagnosed with an SBA between 2011 and 2021 at the Ottawa Hospital (TOH), Ottawa, Canada. We describe the clinicopathological features and outcomes, including survival. Potential prognostic factors were analysed using the Cox proportional hazard model for multivariate analysis.; (3) Results: We identified 115 patients with SBA. The duodenum was the most common SBA location representing 61% (70) of the total patients, followed by the jejunum (17%) and ileum (10%). Around 24% (27) of cases presented with bowel obstructions. The majority of patients (56%, 64) had stage IV disease on presentation. Seven patients had MSI-high tumours, while 24% (27) were MS-stable. In terms of management, 48 patients underwent curative surgical resection, 17 of whom received adjuvant chemotherapy. On the other hand, 57 patients (49.5%) with the advanced disease received palliative systemic therapy, and 18 patients (16%) had supportive care only. Over a median follow-up of 21.5 months (range 0-122), the median overall survival was 94, 61, and 34 months for stages II, III, and IV, respectively (p < 0.05). The median recurrence-free survival was 93 and 23 months for stages II and III, respectively. However, there was no statistically significant difference between TNM stages in RFS, p = 0.069. Multivariate Cox regression analysis showed only poor performance status at diagnosis as a predictor for shorter overall survival (p < 0.05). The univariate analysis didn't show any significant correlation between RFS and covariants.; (4) Conclusions: SBA remains one of the most aggressive tumours with a dismal prognosis even after surgical resection. The optimal chemotherapy regimen has not been established. Further studies are needed to explore the role of adjuvant chemotherapy for stages I-III SBA.

Survival outcomes after surgical management of sporadic or familial adenomatous polyposis associated duodenal cancer

BACKGROUND

Duodenal cancer is the second most common cause of cancer death in familial adenomatous polyposis (FAP) patients. In this study, we compare oncologic outcomes between sporadic and FAP-associated duodenal cancer.

METHODS

In this retrospective study, all patients who underwent surgeries between 2000 and 2014 for either sporadic or FAP duodenal cancer were identified. The patients were grouped based on diagnoses and perioperative and survival outcomes were compared.

RESULTS

A total of 56 patients with duodenal cancer (43 sporadic, 13 FAP) who underwent surgery were identified. Pancreatoduodenectomy (PD) was the most common procedure performed. The overall median survival was 7.5 years (1 year: 92%; 5 years: 58.1%). FAP patients had earlier tumor, node, and metastasis stage, less margin involvement, less perineural, and angiolymphatic invasion but had a comparable survival to sporadic patients. The median survival for FAP duodenal cancer was 7.4 vs 9.6 years for sporadic (P = .97) with similar utilization of adjuvant chemotherapy. Although not statistically significant, PD had an improved median survival compared to segmental duodenal resection (SDR) (9.6 years for PD vs 3.6 years for SDR, P = .17). Non-periampullary location and presence of positive lymph nodes were significant predictors of mortality on multivariate analysis.

CONCLUSIONS

FAP duodenal cancer has no survival advantage compared to sporadic duodenal cancer despite an improved stage of resection with extraampullary lesions having a worse survival.

Pancreas-sparing and superior mesenteric artery first approach in duodenal adenocarcinoma of the fourth portion of duodenum: A case report

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Adenocarcinoma of the distal duodenum is uncommon with bad prognosis.

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Pancreas-sparing resection is preferred to avoid pancreatectomy-related morbi-mortality.

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The artery-first approach of the SMA should be considered by surgeons to early identify contra-indications to proceed during operation.

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The aim of surgery is R0 resection with 5-year survival between 25% and 75%.

Introduction

Peroperative assessment of resectability in pancreas-sparing duodenectomy for distal duodenal (D3-D4) adenocarcinoma is challenging for surgeons.

Presentation of case

We report a 68-year-old man with biopsy-proven adenocarcinoma of the fourth portion of duodenum which had been diagnosed with upper endoscopy and CT. A pancreas-sparing duodenectomy with loco-regional lymph node resection using the superior mesenteric artery first approach was performed.

Discussion

Adenocarcinoma of the fourth portion of duodenum is rare. It has non-specific symptoms. The diagnosis is difficult and is frequently delayed. Surgery is the only chance of cure. After peroperative assessment of resectability, with intraoperative ultrasound, complete exposition of the duodenum and entire dissection of the superior mesenteric artery (SMA) using the artery-first approach technique should be done to assess for tumor resectability, which should include the possibility of complete lymphadenectomy of the mesenteric root. If technically feasible, a pancreas-sparing resection should be preferred to avoid pancreatectomy-related morbi-mortality. The aim of the surgery is a R0 resection which has a 5-year survival rate between 25% and 75%.

Conclusion

Artery-first approach of the SMA should be considered by surgeons in adenocarcinoma of the distal duodenum to identify any contra-indications to proceed further.

A Rare Case of Primary Small Bowel Adenocarcinoma with Intussusception

Other than in childhood, intussusception is unusual and nearly always caused by a structural and well demonstrable lesion. In contrast with the colon tract, the incidence of primary malignancies in the small bowel is very low. We report the case of a 51-year-old man presenting with jejunal intussusception due to a primary adenocarcinoma. To our knowledge, only a few similar cases have been reported in the literature to date. The patient was referred to our division for bowel obstruction. A CT scan showed a jejunal intussusception and surgical exploration was hence considered. At laparotomy, jejunal intussusception located just after the ligament of Treitz due to a polypoid lesion was confirmed and resection of the first jejunal loop was carried out. Histological examination of the specimen resulted in a diagnosis of a primary adenocarcinoma of the small bowel. In adult intestinal intussusception, resection without reduction is considered the optimal management if an underlying primary malignancy cannot be excluded.

Clinicopathologic features, surgical treatments, and outcomes of small bowel tumors: A retrospective study in China

BACKGROUND

Small bowel tumors are relatively rare. Accumulation of data regarding their clinical presentation, pathologic features, prognostic factors, treatment modalities, and outcome has been an issue. We summarize the clinicopathologic features and evaluate the long-term outcome of patients with small bowel tumors who underwent surgery.

METHODS

This is a retrospective study of medical records of 456 patients with small bowel tumors treated surgically at a Cancer Hospital between 1999 and 2016.

RESULTS

The study included 275 males (60.3%) and 181 females (39.7%). Small bowel tumors were difficult to diagnose because of non-specific symptoms. The most common symptoms were alimentary symptoms (56.8%) and abdominal pain (37.3%). Final histopathology revealed 241 adenocarcinomas (52.9%), 153 gastrointestinal stromal tumors (GISTs; 33.6%), 16 neuroendocrine tumors (NETs; 3.5%), and 46 other types of tumors (10.1%). The 456 surgeries performed included 153 pancreaticoduodenectomies, 241 limited duodenum resections, 60 palliative bypass surgeries, and 2 abdominal explorations. The 5-year overall survival and progression-free survival rates for patients with small bowel tumor were 57.2% and 44.6%, respectively. Adenocarcinomas resulted in the worst overall survival compared to GISTs or NETs, and tumors with duodenal location resulted in a worse survival compared to those with non-duodenal location.

CONCLUSION

Surgery is the mainstay of treatment for small bowel tumors. Adenocarcinomas and duodenal involvement seem to contribute to poor outcomes.

Loss of intestinal O-glycans promotes spontaneous duodenal tumors

Mucin-type O-glycans, primarily core 1- and core 3-derived O-glycans, are the major mucus barrier components throughout the gastrointestinal tract. Previous reports identified the biological role of O-glycans in the stomach and colon. However, the biological function of O-glycans in the small intestine remains unknown. Using mice lacking intestinal core 1- and core 3-derived O-glycans [intestinal epithelial cell C1galt1(-/-);C3GnT(-/-) or double knockout (DKO)], we found that loss of O-glycans predisposes DKO mice to spontaneous duodenal tumorigenesis by ∼1 yr of age. Tumor incidence did not increase with age; however, tumors advanced in aggressiveness by 20 mo. O-glycan deficiency was associated with reduced luminal mucus in DKO mice before tumor development. Altered intestinal epithelial homeostasis with enhanced baseline crypt proliferation characterizes these phenotypes as assayed by Ki67 staining. In addition, fluorescence in situ hybridization analysis reveals a significantly lower bacterial burden in the duodenum compared with the large intestine. This phenotype is not reduced with antibiotic treatment, implying O-glycosylation defects, rather than bacterial-induced inflammation, which causes spontaneous duodenal tumorigenesis. Moreover, inflammatory responses in DKO duodenal mucosa are mild as assayed with histology, quantitative PCR for inflammation-associated cytokines, and immunostaining for immune cells. Importantly, inducible deletion of intestinal O-glycans in adult mice leads to analogous spontaneous duodenal tumors, although with higher incidence and heightened severity compared with mice with O-glycans constitutive deletion. In conclusion, these studies reveal O-glycans within the small intestine are critical determinants of duodenal cancer risk. Future studies will provide insights into the pathogenesis in the general population and those at risk for this rare but deadly cancer.

Focus on the diagnostic problems of primary adenocarcinoma of the third and fourth portion of the duodenum. Case report

Although the small intestine constitutes over 75% of the length and 90% of the mucosal surface of the gastrointestinal tract, small intestine cancer is rare and accounts for only 1% of gastrointestinal malignancies. Adenocarcinoma together with carcinoid tumours are the most common histological types of primary malignant tumours of the small bowel but others, including lymphoma and leiomyosarcoma, may less frequently be encountered. Adenocarcinomas are predominantly located in the duodenum. Primary adenocarcinoma of the duodenum is a rare malignant tumor, accounting for 0.3-0.5% of all gastroenteral malignancies. The diagnosis of primary adenocarcinoma of duodenum is often delayed because its symptoms and signs are nonspecific. In this work we want to focus on the diagnostic and therapeutic problems of duodenal adenocarcinoma, reporting a case report.

Duodenal adenocarcinoma: Advances in diagnosis and surgical management

Duodenal adenocarcinoma is a rare but aggressive malignancy. Given its rarity, previous studies have traditionally combined duodenal adenocarcinoma (DA) with either other periampullary cancers or small bowel adenocarcinomas, limiting the available data to guide treatment decisions. Nevertheless, management primarily involves complete surgical resection when technically feasible. Surgery may require pancreaticoduodenectomy or segmental duodenal resection; either are acceptable options as long as negative margins are achievable and an adequate lymphadenectomy can be performed. Adjuvant chemotherapy and radiation are important components of multi-modality treatment for patients at high risk of recurrence. Further research would benefit from multi-institutional trials that do not combine DA with other periampullary or small bowel malignancies. The purpose of this article is to perform a comprehensive review of DA with special focus on the surgical management and principles.

Sporadic nonampullary duodenal adenoma/carcinoma is associated with not only colon adenoma/carcinoma but also gastric cancer: association of location of duodenal lesions with comorbid diseases

BACKGROUND

It is well known that in patients with sporadic nonampullary duodenal adenoma/carcinoma (SNADA) with no polyposis syndrome, including familial adenomataous polyposis, the rates of colorectal adenoma/carcinoma are high. However, the prevalence rates of other tumor types, for example, gastric cancer, in SNADA patients remain unknown. In this study, we aimed to analyze the prevalence rate of comorbid diseases in SNADA patients.

METHODS

We retrospectively analyzed 78 patients with SNADA treated by endoscopic resection between May 2005 and September 2014 at our institution.

RESULTS

Overall, 51 of the 78 (65.4%) SNADA patients had comorbid colorectal adenoma/carcinoma. Further, 10 of the 78 (12.8%) SNADA patients had comorbid gastric cancer, and all of them were positive for Helicobacter pylori infection. SNADA lesions were located significantly more frequently at the oral side of the major papilla in patients with H. pylori infection than in those without H. pylori infection (27 of 36 [75.0%] vs. 19 of 42 [45.2%], p = 0.008, chi-square test). In contrast, SNADA lesions were located significantly more frequently at the anal side of the major papilla in patients with colorectal adenoma/carcinoma than in those without colorectal adenoma/carcinoma (27 of 51 [52.9%] vs. 5 of 27 [18.5%], p = 0.003, chi-square test).

CONCLUSION

SNADA patients showed comorbidity with not only colorectal adenoma/carcinoma but also gastric cancer. H. pylori infection is known to cause gastric cancer and may influence tumorigenesis of SNADA lesions at the oral side of the major papilla.

Psoas muscle infiltration masquerading distant adenocarcinoma

Malignant metastasis to the psoas muscle is rare. We report a case that clinically mimicked psoas abscess that was subsequently proven to be from metastatic disease secondary to adenocarcinoma of the duodenum. A 62-year-old male presented with a seven-month history of right lower quadrant abdominal pain and progressive dysphagia. CT scan of abdomen-pelvis revealed a right psoas infiltration not amenable to surgical drainage. Patient was treated with two courses of oral antibiotics without improvement. Repeated CT scan showed ill-defined low-density area with inflammatory changes involving the right psoas muscle. Using CT guidance, a fine needle aspiration biopsy of the right psoas was performed that reported metastatic undifferentiated adenocarcinoma. Patient underwent upper endoscopy, which showed a duodenal mass that was biopsied which also reported poorly differentiated adenocarcinoma. In this case, unresponsiveness to medical therapy or lack of improvement in imaging studies warrants consideration of differential diagnosis such as malignancy. Iliopsoas metastases have shown to mimic psoas abscess on their clinical presentation and in imaging studies. To facilitate early diagnosis and improve prognosis, patients who embody strong risk factors and symptoms compatible with underlying malignancies who present with psoas imaging concerning for abscess should have further investigations.

Tumors of the angle of Treitz: A single-center experience

AIM: To explore the feasibility and oncologic outcomes of segmental jejunal resection on the left side of the mesenteric vessels in patients with tumors of the angle of Treitz using data from a single center.

METHODS: Thirteen patients with tumors of the angle of Treitz who underwent surgery at our institution were prospectively followed. A segmental jejunal resection on the left side of the mesenteric vessels was performed in all patients. Formalin-fixed and paraffin-embedded tumor samples were examined. The primary end point of this analysis was disease-free survival.

RESULTS: In this study, there were 8 males and 5 females (mean age, 50.1 years; range, 36-74 years). The mean tumor size was 8.1 cm (range, 3.2-15 cm). Histologic examination showed 11 gastrointestinal stromal tumors (GISTs) and 2 adenocarcinomas. Five of the GIST patients presented with potential low risk, and 6 presented with intermediate and high risk, according to the National Institutes of Health criteria. One potentially high-risk patient showed tumor progression at 46 mo and died 52 mo after surgery. One patient with locally advanced adenocarcinoma received neoadjuvant chemotherapy and adjuvant radiotherapy, but the disease progressed, and the patient died 9 mo after surgery. One GIST patient without progression died 16 mo after surgery because of a postoperative intestinal obstruction. The median overall survival rate was 84.6 mo, and the median disease-free survival rate was 94.5 mo.

CONCLUSION: The overall survival of patients with tumors of the angle of Treitz was encouraging even when the tumor size was relatively large. A segmental resection on the left side of the mesenteric vessels is considered to be a reliable and curative option for tumors of the angle of Treitz.

Defining the role of adjuvant therapy: ampullary and duodenal adenocarcinoma

Adenocarcinomas of the ampulla of Vater and duodenum are more rare than pancreatic cancer and have a better prognosis. However, studies conducted on the management of these cancers, such as adjuvant chemotherapy and radiation therapy, are limited by small sample sizes and series that are retrospective. This review evaluates ampullary and duodenal adenocarcinomas with regard to incidence, anatomy, prognostic features, patterns of failure, and the available literature studying adjuvant therapy.

Retrospective analysis of 119 small bowel adenocarcinoma in Chinese patients

BACKGROUND

Small bowel adenocarcinoma (SBA) is a rare occurrence and few studies have addressed it adequately, especially in China.

METHODS

Clinicopathological features, survival and prognostic analysis were retrospectively done in SBA patients admitted between 2001 and 2011 in the People's Liberation Army General Hospital.

RESULTS

The study included 68 men and 51 women with a median age of 56.5 year. Tumors mainly occurred in duodenum (93.3%). Abdominal pain was the most frequent symptom (36.8%). Patients (30.3%) who received postoperative adjuvant chemotherapy had an increased, but not significant, median overall survival (MOS) rate compared to those who did not receive chemotherapy (37 vs 35 months, p = .324). One year disease free survival rate was higher in patients receiving postoperative chemotherapy (83.3% vs 71.1%). Patients survived longer in the curative surgery group (median survival time of 49.0 months) than those in the palliative group (7.0 months) (p < .001). Node-negative patients survived longer than node-positive patients (median OS: 49.0 vs 21.0 months, p = .004). Depth (95% CI: 1.013-1.517, p = .037), node involvement (95% CI: 1.234-3.890, p = .007), palliative surgery (95% CI, 2.998-10.555, p = .0005), and the site of tumor (95% CI: 0.052-0.970, p = .045) were independent predictors of OS in a multivariate analysis.

CONCLUSIONS

SBA is rare and there is lack of obvious clinical manifestations. Depth, node involvement, palliative surgery, and the site of tumor are associated with a poor prognosis. Our analysis highlights the need for further studies to find out the exact role of postoperative adjuvant chemotherapy in these patients.

Primary adenocarcinoma of the fourth portion of the duodenum: "A case report and literature review"

INTRODUCTION

Primary adenocarcinoma of the 4th portion of the duodenum is reported less frequently than those other portions of the duodenum. Therefore, few reports discuss the diagnosis and treatment of this malignancy.

PRESENTATION OF CASE

A 54-year-old woman was admitted to our hospital with a complaint of nausea and vomiting after a meal. Upper gastrointestinal examination and a duodenogram revealed a Type 2 tumor of the 4th portion of the duodenum, which was diagnosed as well-differentiated tubular adenocarcinoma by endoscopic biopsy. Partial resection of the duodenum and jejunum was performed on the basis of intraoperative evaluation of negative lymph node metastasis around the pancreas and proximal duodenum with no macroscopic invasion toward the pancreas and proximal duodenal margin. Her postoperative course was uneventful without any sign of recurrence 5 years later.

DISCUSSION

Primary adenocarcinoma in the 4th portion is relatively less common. It is not easy to diagnose this disease. Patients with primary duodenal adenocaricinoma, who are medically fit to undergo surgery, should be given the option of aggressive resection. Duodeno-cephalo-pancreatectomy remains the standard treatment for adenocarcinomas of the 1st and 2nd portion of the duodenum. Partial resection is the preferred surgical method for patients with adenocarcinoma of the 3rd and 4th portions of the duodenum.

CONCLUSION

This report describes a rare case of primary adenocarcinoma of the 4th portion of the duodenum, successfully treated by partial resection of the duodenum and jejunum. However, larger studies are required to clarify the indications for the preferred surgical method for this malignancy.

KRAS G>A mutation favors poor tumor differentiation but may not be associated with prognosis in patients with curatively resected duodenal adenocarcinoma

KRAS mutations have been found in duodenal adenocarcinomas and may have prognostic significance. The purpose of this study was to classify clinicopathological characteristics, microsatellite instability and KRAS mutations and identify possible prognostic role of KRAS mutations in duodenal adenocarcinomas. Demographics, tumor characteristics and survival were recorded for 78 patients with duodenal adenocarcinomas (Stages I-III). KRAS mutations were detected in 27 (34.6%) cases, of which the majority (74.1%) were G>A transitions. Multivariate logistic regression analysis showed that KRAS G>A mutation was significantly associated with late stage (p = 0.025) and poor tumor differentiation (p = 0.035), when compared with wild-type and other than G>A mutations. KRAS G>A mutation carriers were at increased risk for distant relapse (p = 0.022) and had significantly shorter overall survival (OS; log-rank p = 0.045) and a trend toward shorter relapse-free survival (RFS; log-rank p = 0.062) when compared with those who did not carry the KRAS G>A mutation. In multivariate analyses, there was a significant correlation between ≥ 3 positive lymph nodes and poor OS (p < 0.001) and RFS (p = 0.001) and KRAS G>A mutation carriers demonstrated no effect on clinical outcome. In conclusion, KRAS G>A mutation correlates significantly with late stage and poor tumor differentiation in duodenal adenocarcinoma. Among patients who undergo a curative resection of duodenal adenocarcinoma, KRAS G>A mutation carriers will more likely experience distant relapse but may not exhibit a poor prognosis. The number of positive lymph nodes should be incorporated in future staging systems.

Jejunal adenocarcinoma: an elusive diagnosis

Tubercular stricture of small bowel is a common cause of subacute intestinal obstruction in India. In a small subset of patients the cause of the intestinal obstruction could be adenocarcinoma of jejunum. It is difficult to diagnose preoperatively. The point of concern is compared to tubercular stricture, the treatment of jejunal adenocarcinoma is always surgical in the form of cancer directed surgery. The operating surgeon needs to have a very high suspicion for jejunal adenocarcinoma because the timely treatment offers the best survival in otherwise an aggressive disease with bleak prognosis.

Enteroscopic and radiologic diagnoses, treatment, and prognoses of small-bowel tumors

BACKGROUND

Small-bowel tumors (SBTs) represent a diagnostic challenge.

OBJECTIVE

To evaluate the usefulness of contrast-enhanced CT (CECT), fluoroscopic enteroclysis (FE), videocapsule endoscopy (VCE), and double-balloon endoscopy (DBE) and the outcome after treatment.

DESIGN

Single-center, retrospective study.

SETTING

Tertiary-care referral hospital.

PATIENTS

Between June 2003 and May 2011, 159 consecutive patients with SBTs (93 malignant and 66 benign) were enrolled.

MAIN OUTCOME MEASUREMENTS

Comparison of diagnostic yields among CECT, FE, VCE, and DBE and the prognosis.

RESULTS

CECT and FE had significantly lower diagnostic yields of SBTs ≤ 10 mm, but VCE and DBE had high yields of SBTs regardless of size. CECT had a significantly lower diagnostic yield of epithelial tumors compared with subepithelial tumors. When stratified by the site, the diagnostic yield of VCE for SBTs located only in the distal duodenum/the proximal jejunum (73%) was significantly lower than that for SBTs located in other areas (90%). Comparisons among the 4 methods revealed that VCE and DBE had significantly higher diagnostic yields than CECT, and DBE had significantly higher diagnostic yields than VCE, but a combination of CECT and VCE had a diagnostic yield similar to that of DBE. The histologic diagnostic yield of SBTs by DBE was 92%, and 25% of SBTs were enteroscopically treated. Metastatic tumors had the poorest overall survival, followed by adenocarcinomas and malignant lymphomas.

LIMITATIONS

Retrospective comparative study.

CONCLUSION

For the detection of SBTs, a combination screening method by using VCE and CECT is recommended. DBE is useful for histologic diagnosis and endoscopic treatment.

The imaging features of small bowel tumours

OBJECTIVE

Small bowel tumours account for only 2-5 % of gastrointestinal neoplasms but are an important source of morbidity and mortality. This article presents the features demonstrated by a wide range of small bowel tumours across different imaging modalities.

CONCLUSION

Early and accurate diagnosis via radiological means is an important factor in overall survival for malignant tumours and a thorough understanding of the common features is essential for all radiologists.

Primary small intestine tumour as the cause of gastrointestinal tract occlusion

The following paper presents the case of a 40-year-old patient staying in our Clinic between 2 March 2010 and 12 March 2010 due to the symptoms of permeable occlusion of gastrointestinal tract. This is a patient with a several weeks' history of non-specific abdominal pain, vomiting and significant weight loss (ca 20 kg). Until recently he has not suffered from any serious illnesses. In the performed abdominal ultrasound, gastroscopy and colonoscopy no pathology was affirmed. CT scan with intravenous and oral contrast showed significantly widened intestinal loops with residual liquid matter in the stomach, duodenum and a part of the jejunum without any distinguishing pathological mass, and also single mesenteric lymph nodes and para-aortic nodes enlarged to the size of 12 mm. The patient was qualified for laparatomy. During the surgery, a 4-cm tumour of the jejunum, concentrically narrowing intestinal lumen was found. Segmental resection of the small intestine was performed with side to side anastomosis with the use of a linear stapler. Currently the general condition of the patient is good, without any ailments, and the patient is undergoing systemic treatment.

Small bowel emergency surgery: literature's review

Emergency surgery of the small bowel represents a challenge for the surgeon, in the third millennium as well. There is a wide number of pathologies which involve the small bowel. The present review, by analyzing the recent and past literature, resumes the more commons. The aim of the present review is to provide the main indications to face the principal pathologies an emergency surgeon has to face with during his daily activity.

Duodenal carcinoma at the ligament of Treitz. A molecular and clinical perspective

BACKGROUND

There is very small occurrence of adenocarcinoma in the small bowel. We present a case of primary duodenal adenocarcinoma and discuss the findings of the case diagnostic modalities, current knowledge on the molecular biology behind small bowel neoplasms and treatment options.

CASE

The patient had a history of iron deficiency anemia and occult bleeding with extensive workup consisting of upper endoscopy, colonoscopy, capsule endoscopy, upper gastrointestinal series with small bowel follow through and push enteroscopy. Due to persistent abdominal pain and iron deficiency anemia the patient underwent push enteroscopy which revealed adenocarcinoma of the duodenum. The patient underwent en-bloc duodenectomy which revealed T3N1M0 adenocarcinoma of the 4th portion of the duodenum.

CONCLUSIONS

Primary duodenal carcinoma, although rare should be considered in the differential diagnosis of occult gastrointestinal bleeding when evaluation of the lower and upper GI tract is unremarkable. We discuss the current evaluation and management of this small bowel neoplasm.

Borderline cases between benignancy and malignancy of the duodenum diagnosed successfully by endoscopic submucosal dissection

OBJECTIVE. Due to advances in endoscopic equipment, primary duodenal tumors are found more frequently than in the past. We performed endoscopic submucosal dissection (ESD) to diagnose and treat four non-ampullary duodenal tumors. MATERIAL AND METHODS. During endoscopic treatment, marks were placed around the circumference of the tumor and sufficient amounts of physiological saline with epinephrine were injected into the submucosal layer to elevate the lesion. An incision was made around the lesion using a long-type needle knife and the isolated lesion was resected completely "en bloc". In this procedure, a cylindrical transparent hood was attached to the endoscopy apparatus to allow for satisfactory visualization of the procedure. RESULTS. The mean age of the patients was 69 years. The patients consisted of two males and two females. Gross examination showed three flat, elevated lesions and one polypoid lesion. Tumor size ranged from 10 to 31 mm in maximum diameter. Histological examination revealed two cases of well-differentiated adenocarcinomas and two cases of tubular adenomas with severe atypia. Procedure-related complications consisting of perforation occurred in two cases and were resolved under close postoperative observation including antibiotics, use of a nasogastric tube and nil per oral feeding status. The mean follow-up period was 18 months and none of the patients experienced tumor recurrence after the treatment. CONCLUSIONS. Since tissue obtained from endoscopic biopsies can sometimes prove difficult for definitive histological diagnosis, ESD may play an important role in the management of cases appearing to border on malignancy. In addition, ESD allows for minimally invasive treatment without sacrificing the possibility of cure for duodenal carcinoma.

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.

Pancreatic head cancer with distant duodenal metastasis: a case report with rare endoscopic presentations

Metastasis to the duodenum from a primary cancer is rare, but direct extension from pancreatic cancer is much more common. Here, we present a case of multiple duodenal metastases of pancreatic head cancer in a 77-year-old woman with upper gastrointestinal bleeding. An upper gastrointestinal endoscopic examination revealed multiple elevated reddish nodules on a normal mucosa background that extended from the superior duodenal angle to the duodenal second portion. Echo-guided fine needle aspiration biopsies of the pancreatic head tumor and endoscopic biopsies of the reddish duodenal nodules proved the diagnosis of adenocarcinoma. When such endoscopic morphology is found, especially when the locations are distant from the papillae, metastasis should be considered and multiple biopsies are mandatory.

Clinical analysis of primary anaplastic carcinoma of the small intestine

Primary anaplastic carcinoma is a rare variant of small intestinal cancer. Most reports of primary anaplastic carcinoma of the small intestine are isolated case reports, therefore the clinicopathological features, therapeutic management, and surgical outcome of this tumor type remain unclear. This review analyzes the available clinical characteristics of primary anaplastic carcinoma of the small intestine and investigates key differences from differentiated adenocarcinoma of the small intestine. A Medline search was performed using the keywords ‘small intestine’ and ‘anaplastic carcinoma’ or ‘undifferentiated carcinoma’. Additional articles were obtained from references within the papers identified by the Medline search. The literature revealed a poor prognosis for patients who underwent surgical resection for anaplastic carcinoma of the small intestine, which gave a 3-year overall survival rate of 10.8% and a median survival time of 5.0 mo. The literature suggests that anaplastic carcinoma is markedly more aggressive than differentiated adenocarcinoma of the small intestine. Surgical resection with the aim of complete tumor removal provides the only beneficial therapeutic option for patients with anaplastic carcinoma of the small intestine, because chemotherapy and radiation therapy have no significant effect on the rate of survival. However, despite complete tumor resection, most patients with anaplastic carcinoma of the small intestine are at great risk of disease recurrence. Multicenter clinical trials are expected to provide additional therapeutic strategies and establish the efficacy of multimodality adjuvant therapy. This report also highlights the importance of a systematic diagnostic approach for anaplastic carcinoma of the small intestine.

Small bowel tumors: clinical presentation, prognosis, and outcome in 33 patients in a tertiary care center

Introduction. Small bowel cancers are rare. Accumulation of data regarding their clinical presentation, pathologic features, prognostic factors, treatment modalities, and outcome is difficult. Methods. This is a retrospective study of the medical records of 33 patients with small bowel cancers treated at the American University of Beirut-Medical Center over a 20-year period. Results. The study included 25 males (76%) and 8 females (24%). Median age at presentation was 56 years. Most common symptoms were abdominal pain (66.7%) and weight loss (57.6%). Thirteen patients presented with abdominal emergencies (39.3%). Lymphoma was the most common malignant tumor (36.4%), followed by adenocarcinoma (33.3%), leiomyosarcoma (15.2%), gastrointestinal stromal tumors (12.1%), and neuroendocrine tumors (3.0%). Tumors were located in the duodenum in 30% of patients, jejunum in 33%, and ileum in 36%. Resectability rate was 72.7% and curative R0 resection was achieved in 54.1% (13/24) of patients. 5-year survival of the 33 patients was 24.2%. Conclusion. Small bowel cancers are difficult to diagnose because of the nonspecific symptoms. Most patients present with advanced disease and have poor prognosis. Adenocarcinoma and duodenal location have the worst 5-year survival in contrast to stromal tumors and those with ileal location which have the best survival.

[Capsule endoscopy for the diagnostics of small intestine tumours]

Three to six percent of all gastrointestinal tumours and one to two percent of all malignant gastrointestinal tumours develop in the small intestine. These occur more frequently in men than in women and the peak of occurrence is at the age of 50 to 60 years. According to epidemiological investigations to date the most frequently developing primary tumours in the small intestine are adenocarcinomas, carcinoid tumours, lymphomas and small bowel gastrointestinal stromal tumours. Clinical appearance of the tumours is the same, independent of their histological type. Fifty percent of the benign tumours is asymptomatic and is only discovered incidentally at autopsy. In comparison, 80% of malignant tumours is symptomatic. The prognosis of small intestine malignant tumours is very poor as at the time of diagnosis they have already formed metastases in 45-75% and at the time of surgery they are in 20-50% irresectable. The reason for the late diagnosis is on the one hand the non-specific nature of the symptoms, on the other hand, the limited visualisation of the entire small intestine via traditional radiological and endoscopic methods. Capsule endoscopy (CE) revolutionised the diagnostics of the small intestine by enabling non-invasive, pain-free investigation of the entire small intestine. The timely application of CE may replace a range of expensive assays with limited diagnostic value. Initial results indicate a higher prevalence of small intestine tumours than it had been estimated based on earlier epidemiological investigations. The new method provides an early diagnosis, enabling a definitive therapy, eventually significantly improving patient survival.

Impact of capsule endoscopy on outcome in mid-intestinal bleeding: a multicentre cohort study in 285 patients

BACKGROUND

Capsule endoscopy (CE) sensitively detects the bleeding source in the small bowel. However, the influence of CE on long-term outcome is not well established.

METHODS

In five tertiary hospitals, all CE investigations were retrospectively identified dating back to 3 years. Patients with intestinal bleeding and negative bidirectional endoscopy were included, and relapse of bleeding was recorded.

RESULTS

A bleeding source was detected in 219 of 285 patients (76.8%); CE provided the diagnosis in 175 of 219 (79.9%) and other, repeated investigations in 44 cases (20.1%). Follow-up (mean+/-SD=20.7+/-9.4 months) in 240 patients identified rebleeding in 65 (27.1%), and readmission to a hospital in 42 (17.5%). Hospital readmission was most frequent in patients with angiectasias (31.3%, relative risk (RR)=5.0; 95% confidence interval (CI)=2.4-10.4). Other risk factors included patients being older than 60 years of age (RR=3.8; 95% CI=1.5-9.5), and anticoagulant medication (RR=3.0; 95% CI=1.5-6.0). Therapeutic measures had a mean recurrence rate of 3.7% in surgical candidates (Meckel's diverticulum, tumor), 40% in endoscopically treated and 16% in medically treated patients. In case all the detected angiectasias had been cauterized, the relapse rate was low (11.8%), but in incompletely treated patients, it was high (85.7%). Bleeding relapse was never lethal.

CONCLUSION

CE guides therapeutic measures and predicts the risk of recurrent bleeding in small intestinal bleeding. High risk of rebleeding in angiectasias is significantly reduced by the cauterization of all demonstrable lesions.

Adenocarcinoma of the third and fourth portion of the duodenum: a case report and review of the literature

A 65-year-old woman presented with abdominal pain, weight loss, fatigue, and microcytic anemia. Esophagogastroduodenoscopy, until the second part of duodenum, was normal. Ultrasound and computed tomography demonstrated a solid mass in the distal duodenum. A repeat endoscopy confirmed an ulcerative, intraluminar mass in the third and fourth part of the duodenum. Segmental resection of the third and fourth portion of the duodenum was performed. Histology revealed an adenocarcinoma. On the 4^th postoperative day, the patient developed severe acute pancreatitis leading to multiple organ failure and died on the 30^th postoperative day.

Laparoscopically assisted bowel surgery in an era of double-balloon enteroscopy: from inside to outside

BACKGROUND

This report describes an integrated therapeutic method of double-balloon enteroscopy (DBE) and laparoscopically assisted bowel surgery (LABS) for small bowel diseases.

METHODS

In this study, 34 patients with obscure gastrointestinal bleeding (OGIB, n=25) and abdominal pain (n=9) who underwent DBE and LABS were analyzed. Demographics, patient characteristics, diagnostic tests, DBE and LABS findings, surgical results, and long-term outcome were reviewed.

RESULTS

All 34 patients underwent DBE without significant complications. Biopsy was performed for 16 patients, ink mark for 25 patients, and temporary homeostasis during DBE for 5 patients. Laparoscopically assisted bowel resection was performed for 27 patients, converted laparotomy for 6 patients, and laparoscopic diagnosis alone for 1 patient. The pathologic diagnoses included gastrointestinal stromal tumor (GIST) for eight patients, primary adenocarcinoma for three patients, lymphoma for three patients, Meckel's diverticulum for three patients, angiodysplasia for three patients, ulcer for two patients, lipoma for four patients, metastasis for three patients, jejunal diverticulosis for two patients, and tuberculosis ileitis, ileal varix, and lymphangioma for one patient each. No surgical mortalities or significant morbidities were noted. After a follow-up period of 14+/-3 months, 29 patients were well without disease recurrence. Two patients had symptomatic recurrence, and three patients died of cancerous progression.

CONCLUSIONS

The combination of DBE and LABS represents an ideal therapeutic method, especially for OGIB caused by small bleeding neoplasms or vascular lesions.

Diagnosis of marginal cell lymphoma of small intestine by double balloon enteroscopy

A 65-year-old woman with a medical history of diabetes mellitus type 2, hypertension, an old cerebrovascular accident, and seizure disorder presented to the emergency room with lower abdominal pain of 4 weeks duration. Upon physical examination, her abdomen was soft and bowel sounds were present, but there was diffuse tenderness in her lower abdomen with some guarding. A computed tomography scan of her abdomen with oral and intravenous contrast showed significantly thickened small bowel loops with subjacent lymphadenopathy. Biopsies obtained during esophagogastroduodenoscopy and colonoscopy showed acute and chronic inflammation. A double balloon enteroscopy (DBE) was then performed, which showed stricture in the jejunum from which the biopsy was obtained. The biopsy showed marginal cell lymphoma. The patient is presently undergoing chemotherapy. Double balloon enteroscopy is a new elegant endoscopical technique that seems promising, as the endoscopist can reach undiscovered small bowel segments. It seems to be well tolerated and safe. For the first time, it provides the means to endoscopically investigate and treat disorders of the small intestine that have previously been inaccessible to conventional endoscopy.

Primary jejunal adenocarcinoma as part of multiple primary cancers of the digestive tract

Multiple primary cancers including small intestinal tumors are rare. We describe the first curative resection case of metachronous triple early cancers involving the jejunum as well as the stomach and esophagus. The patient had undergone total gastrectomy for a gastric adenocarcinoma and subsequent esophagectomy for an esophageal squamous cell carcinoma. A jejunal adenocarcinoma, the third primary, occurred at the blind stump of the jejunal limb of a Roux-en-Y esophagojejunostomy reconstructed previously. This tumor was removed by partial resection of the limb with the preservation of the esophagojejunostomy. The patient died from complications of acute pancreatitis 3 years after the last operation, without overt clinical signs of cancer recurrence. Immunohistochemistry of the specimen showed the increased expression of p53 and cyclin D1 proteins in all three cancers, suggesting their involvement in metachronous carcinogenesis in this case. Early diagnosis of each cancer was made possible by regular endoscopic follow-up and favorable anatomical location of each tumor, which were considered to allow less invasive surgery as well as to contribute to the favorable outcome. This case suggests the importance of regular surveillance for metachronous carcinogenesis, especially when the preceding cancers carry genetic abnormalities that may potentially increase the risk for subsequent carcinogenesis.

Prognostic factors in primary adenocarcinoma of the small intestine: 13-year single institution experience

Background

Adenocarcinoma of the small bowel is a relatively rare malignancy as compared to the other malignancies of the gastrointestinal tract. Nonspecific presentation and infrequent occurrence often leads to a delay in diagnosis and consequent poor prognosis. Various other factors are of prognostic importance while managing these tumors.

Methods

The medical records of a total of 27 patients treated for adenocarcinoma of the small bowel at Providence Hospital and Medical Centers from year 1990 through 2003 were reviewed retrospectively. Data were analyzed using SPSS software (version 10.0; SPSS, Inc., Chicago, IL). Survival analyses were calculated using the Kaplan Meier method with the log rank test to assess the statistical significance. The socio-demographics (age, gender) were calculated using frequency analyses.

Results

The patients included nine males and eighteen females with a median age at diagnosis of 62 years. Only 48% of the patients had an accurate preoperative diagnosis while another 33% had a diagnosis suspicious of small bowel malignancy. None of the patients presented in stage 1. The cumulative five-year survival was 30% while the median survival was 3.3 years. There was no 30-day mortality in the postoperative period in our series.

Conclusion

The univariate analysis demonstrated that tumor grade, stage at presentation, lymph nodal metastasis and resection margins were significant predictors of survival.

Intussusception in adults: report of four cases and review of the literature

Intussusception in adults is a rare clinical entity. The individual surgeon will not often encounter this condition. A lead-point for adult intussusception exists in 90% of cases and is frequently malignant. We present four cases and discuss treatment and diagnostic modalities. A comprehensive review of the literature is given. All cases were treated by resection according to oncologic principles without previous reduction. Histological examination showed non-Hodgkin lymphoma, lipoma, clear cell sarcoma and adenocarcinoma as the lead-points.

A three-decade analysis of 3,911 small intestinal neuroendocrine tumors: the rapid pace of no progress

OBJECTIVES

Small intestinal neuroendocrine tumors (SI-NETs) are the most common gastrointestinal neuroendocrine tumor, but their natural history and outcome remain poorly defined, which hinders both the prediction of disease progression and appropriate therapeutic options. We examined patterns, incidence, prognosis, and outcomes of these tumors over a 30-yr period.

METHODS

Data were extracted from the NCI's SEER registry (1973-2002). Incidence rates, distribution, and 5-yr survival rates were analyzed and adjusted (U.S. decennial census data).

RESULTS

Of the 18,641 NETs, 3,911 (21.0%) were SI-NETs, of which 1,953 (49.6%) were ileal. Since 1973, both SI-NET and its ileal variant have increased annually by 3.8% and 2.1%, respectively. Ileal tumors, as a percentage of SI tumors, have increased from 52% to 63.6%. The age-adjusted incidence of ileal, small intestinal, and digestive system NETs has increased 225%, 460%, and 720% over 30 yr. Ileal tumors have specifically increased in prevalence in white (274%) and black (500%) men and women (213% and 286%, respectively); an overall increase of fourfold in blacks and 2.4-fold in whites. Although 83.3% of SI-NETs were staged, 83.7% were histologically ungraded. Five-year survival rates for SI-NETs were 62.6 +/- 1% (all stages), 73.8% (localized), 72% (regional), and 43.2% (distant). These have not significantly altered since 1973 (P= 0.11).

CONCLUSIONS

SI-NETs have increased, particularly in men and in the black population, which may be due to in vivo changes, increased clinical and pathological awareness, or increased detection of tumors. SI-NETs are malignant, diagnosed late, and survival rates have remained unchanged over 30 yr.

Surgical management and outcome in primary adenocarcinoma of the small bowel

BACKGROUND

Primary adenocarcinoma of the small bowel is a rare malignancy and is associated with poor survival outcome. Patient, tumor and treatment-related factors were analyzed for their association with recurrence and survival.

METHODS

Between 1971 and 2005, 64 patients with primary adenocarcinoma of the small bowel were treated at our institution. Clinico-pathologic data, operative details, postoperative treatment, recurrence pattern and survival were reviewed.

RESULTS

The most common clinical features at presentation included abdominal pain (n = 33; 51.6%) or bowel obstruction (n = 20; 31.3%). The most frequently involved portion of the small bowel was the duodenum (n = 41; 64%). A segmental bowel resection was performed in 30 patients and pancreaticoduodenectomy in 14 patients. Postoperative mortality and morbidity rates were 3.6% (n = 2) and 14.5% (n = 8), respectively. Of the 55 patients who underwent operative intervention, a curative resection was performed in 30 (54.5%). The most common sites of recurrence following a curative resection were the liver and lung. Median survival for all 64 patients was 18 months with a 5-year survival of 21.1%. On multivariate analysis, absence of distant metastatic disease (5-year survival 30.4%), curative resection (5-year survival 44.8%) and pathological T stage 1-3 (5-year survival 39.2%) were identified as independent predictors of survival.

CONCLUSIONS

A curative resection in the absence of both distant metastases and pathological T4 tumor provides the best survival outcome. Recurrence at distant sites is the predominant pattern of failure following a curative resection, suggesting a role for adjuvant therapy.

Clinical analysis of primary duodenal adenocarcinoma: an 11-year experience

BACKGROUND AND AIM

The impact of obstructive jaundice (OJ) complicated by primary duodenal adenocarcinoma (PDA) on survival, and its treatment options, has rarely been mentioned in literature. The aim of the present study was to review the clinical features of PDA patients in an attempt to determine the prognostic factors and the influence of OJ on survival.

METHODS

From May 1994 to February 2005, all duodenal malignancies treated at Kaohsiung Chang Gung Memorial Hospital were reviewed. Preliminary findings were made on a total of 116 duodenal adenocarcinoma (DA) cases. After excluding metastatic DA and the papilla of Vater cancer, 23 patients (19.8%), confirmed as having PDA, were enrolled.

RESULTS

Among the 23 predominantly male patients with a mean age of 68 years, abdominal pain was the most common symptom. Major tumor origin was the second portion, and the predominantly cytological feature was moderate differentiation. Tumor-node-metastasis (TNM) cancer stage IV accounted for 47.8% of the patients, and cancer-directed surgeries (CDS) were performed on 11 patients. Seven patients experienced complications due to OJ, which could be a sign of grave prognosis predicting survival of less than 1 year. Four of the patients received internal or external biliary drainage before CDS or palliative surgeries. Cigarette smoking, cytology, TNM stage, aspartate aminotransferase (AST), OJ, and CDS were significant factors of overall survival in a univariate analysis. The independent predictors of long-term survival were CDS, TNM stage, cytology, cigarette smoking, and AST using the Cox proportional hazard model.

CONCLUSION

PDA patients who did not smoke and who were eligible for and received CDS had better prognostic outcomes.

Small-bowel tumors detected by wireless capsule endoscopy

Small bowel tumors are difficult to diagnose because of their endoscopic inaccessibility. This has been overcome by the use of the Pillcam SB capsule (Given Imaging, Yoqneam, Israel). The purpose of this report is to describe the largest series of patients with small bowel tumors detected by capsule endoscopy. Eighty six patients were derived from the Given Imaging clinical database on a survey of Pillcam SB capsule users who were diagnosed with 87 small bowel tumors, 1 cecal tumor, and 1 gastric tumor. The population consisted of 55 males and 31 females. 69% of patients were referred for capsule endoscopy for obscure gastrointestinal bleeding (59/86 patients) and 31% (27/86 patients) were referred for other indications including anemia, polyposis, and abdominal pain. All patients have histologically confirmed tumors. Eighty six patients reported 395 previous negative procedures (average of 4.6 per patient). Malignant tumors comprised 61% (54/89) and benign 39% (35/89). Of the 87 reported small bowel tumors, 4 were identified in the duodenum, 43 tumors were identified in the jejunum, 18 tumors were identified in the ileum, and 22 tumors were located in the mid to distal small bowel. The most common malignant tumors were adenocarcinoma, carcinoids, melanomas, lymphomas, and sarcomas. The most common benign tumors were GIST, hemangiomas, hamartomas, adenomas, and granulation tissue polyps. Capsule endoscopy is the diagnostic procedure of choice in patients with suspected small bowel tumors.

Small-bowel tumors detected by wireless capsule endoscopy

Small bowel tumors are difficult to diagnose because of their endoscopic inaccessibility. This has been overcome by the use of the Pillcam SB capsule (Given Imaging, Yoqneam, Israel). The purpose of this report is to describe the largest series of patients with small bowel tumors detected by capsule endoscopy. Eighty six patients were derived from the Given Imaging clinical database on a survey of Pillcam SB capsule users who were diagnosed with 87 small bowel tumors, 1 cecal tumor, and 1 gastric tumor. The population consisted of 55 males and 31 females. 69% of patients were referred for capsule endoscopy for obscure gastrointestinal bleeding (59/86 patients) and 31% (27/86 patients) were referred for other indications including anemia, polyposis, and abdominal pain. All patients have histologically confirmed tumors. Eighty six patients reported 395 previous negative procedures (average of 4.6 per patient). Malignant tumors comprised 61% (54/89) and benign 39% (35/89). Of the 87 reported small bowel tumors, 4 were identified in the duodenum, 43 tumors were identified in the jejunum, 18 tumors were identified in the ileum, and 22 tumors were located in the mid to distal small bowel. The most common malignant tumors were adenocarcinoma, carcinoids, melanomas, lymphomas, and sarcomas. The most common benign tumors were GIST, hemangiomas, hamartomas, adenomas, and granulation tissue polyps. Capsule endoscopy is the diagnostic procedure of choice in patients with suspected small bowel tumors.

Survival trends for small intestinal cancer in England and Wales, 1971-1990: national population-based study

This population-based study examines prognostic factors and survival trends among adults (15–99 years) diagnosed with small intestinal cancer in England and Wales during 1971–1990 and followed up to 1995. During this period, the 1- and 5-year age-standardised relative survival rates for small intestinal cancers combined were 42% and 23%, respectively. Duodenal tumours, adenocarcinomas, men, patients with advanced age and the most deprived patients had the poorest prognosis. For all small bowel tumours combined, the excess risk of death fell significantly by 6–9% every 4 years over the 20-year period (adjusted excess hazard ratio (EHR) 0.91 at 1 year after diagnosis, 0.94 at 5 years). For duodenal tumours, the EHR fell by about 14% (95% CI 5–22%) every 4 years between 1979 and 1990, and a similar trend for jejunal tumours was of borderline significance. Further population-based investigations linking survival data to individual data on diagnostic methods and types of treatment are needed.

Small bowel tumors

WCE is a noninvasive diagnostic technique that visualizes the entire small intestine and identifies lesions in parts of the small bowel not reached by traditional endoscopy. Although further studies are needed to define the exact role of WCE for diagnosing and managing small bowel tumors, its sensitivity has been shown to be superior to PE and small bowel follow-through in regard to diagnosing patients who have obscure GI bleeding, the most common indication for capsule endoscopy in the authors' series of patients with documented small bowel tumors. As more material is published, capsule endoscopy likely will be confirmed to be the diagnostic procedure of choice in patients with suspected small bowel tumors.