Duodenal adenocarcinoma: Advances in diagnosis and surgical management

Primary adenocarcinoma of duodenal bulb mimicking a pancreatic tumor: a case report

Duodenal bulb adenocarcinoma is a rare malignancy of the gastrointestinal tract. This cancer often presents with an insidious onset, making it challenging to diagnose early. A noteworthy case-study involved a 56 year-old-woman complaining from epigastric transfixing pain, jaundice, and overall health decline. The initial diagnosis suspected was a pancreatic tumor. An abdominal CT scan however showed no abnormality in the pancreas but revealed on the other hand an irregular, non-stenosing, heterogeneous fibrous thickening of the lower aspect of the duodenal bulb. An EGD showed a congested infiltrated area in the post-bulbar region, and Pathological exam confirmed the diagnosis of a primary adenocarcinoma of the duodenal bulb. The purpose of this article is to present the case of a primary adenocarcinoma of duodenal bulb mimicking a pancreatic tumor: a rare presentation of a rare tumor itself and to present points differentiating these two neoplasms. Diagnosis relies on a comprehensive assessment involving clinical, radiological, endoscopic, and histologic features. Integration of advanced imaging modalities, such as CT/MRI, coupled with upper gastrointestinal endoscopy, is crucial for accurate evaluation.

Proximal bowel obstruction caused by high-grade duodenal adenocarcinoma: A rare case

Introduction

Duodenal adenocarcinoma is an exceptionally rare malignancy, constituting less than 0.5% of all gastrointestinal cancers. Its nonspecific symptoms often lead to delayed diagnosis and advanced disease at presentation.

Case presentation

A 64-year-old female presented with epigastric pain, nausea, and biliary vomiting. Imaging revealed a proximal small bowel obstruction, and endoscopy identified a high-grade duodenal adenocarcinoma. The patient underwent a successful duodenojejunectomy, side-to-side anastomosis, and lymphadenectomy.

Discussion

Post-operative recovery was uneventful, leading to discharge in stable condition. This case underscores the importance of considering duodenal adenocarcinoma in differential diagnoses for small bowel obstruction and highlights the effectiveness of surgical management.

Conclusion

Duodenal adenocarcinoma, though rare, should be considered in patients with small bowel obstruction. Early diagnosis and prompt surgical intervention are crucial for favorable outcomes.

Duodenal Bulb Adenocarcinoma: A Case Report

The duodenum is thought to be the most prevalent site of primary small bowel adenocarcinoma, and the disease mostly affects the descending part of the duodenum. Although the majority of small intestine adenocarcinomas are caused by duodenal adenocarcinomas, it is extremely uncommon for them to occur in the duodenal bulb. We report the case of an 80-year-old female with a complex medical history who presented with symptomatic anemia secondary to gastrointestinal (GI) blood loss secondary to adenocarcinoma of the duodenal bulb.

Long-term survival outcomes of duodenal adenocarcinoma: A cohort study with 15-year single-center experience

BACKGROUND

Duodenal adenocarcinoma (DA), a rare gastrointestinal malignancy, lacks clear natural history and management strategies. This study aimed to investigate the long-term outcomes of patients with DA, focusing on long-term survival and the impact of tumor characteristics, surgery, and adjuvant therapy.

AIM

To bridge this knowledge gap, we conducted a hospital-based cohort study in our 15-year experience with DA aimed at investigating the long-term outcomes of the patients with DA, along with analyzing the impact of the tumor characteristics, operations and adjuvant therapy on survival outcomes.

METHODS

A retrospective analysis of 208 patients diagnosed with non-ampullary DA at a single institution between 2009 and 2023 was performed. This study used SPSS 26.0 software to make a comprehensive statistical analysis of demographic characteristics, clinical presentation, treatment modalities, and survival outcomes. The effectiveness of surgical resection and adjuvant therapy in 5-year oval survival (OS) and disease-free survival was evaluated using Kaplan-Meier survival curves, the Cox proportional hazards model, and statistical comparisons of survival distributions.

RESULTS

The median OS time for the cohort was 39 months, with 3- and 5-year OS rates of 51.2% and 43.6%, respectively. Radical resection was performed in 82.6% of cases, and was significantly associated with an improved 5-year OS, with a rate of 57.8%. Adjuvant therapy showed a survival benefit in the specific patient subsets, particularly in tumor stage II or III tumors, with an improved OS. Adjuvant therapy (hazard ratio= 2.71, 95% confidence interval: 1.30-5.62, P = 0.008), pancreatic invasion and advanced tumor stage were identified as significant predictors of OS in multivariate analyses.

CONCLUSION

Radical operation for DA is associated with a remarkable improvement in the 5-year OS. Importantly, postoperative adjuvant therapy can significantly prolong the OS time in patients with radical operation, especially in patients with stage III. It highlights the necessity for early diagnosis, tailored surgical approaches, and a nuanced understanding of the role of adjuvant therapy.

Clinicopathologic features and surgery-related outcomes of duodenal adenocarcinoma: A multicenter retrospective study

BACKGROUND

The incidence of duodenal adenocarcinoma is increasing, with limited studies on this disease published. This multicenter retrospective study aimed to analyze the clinicopathologic features of duodenal adenocarcinoma and identify prognostic factors for postoperative survival.

METHODS

Demographic characteristics, clinicopathologic features, treatment outcomes, and survival of patients with duodenal adenocarcinoma undergoing surgical treatment at 16 Chinese medical centers from 2012 to 2023 were retrospectively analyzed.

RESULTS

Among the 2,189 patients with duodenal adenocarcinoma included, 50.07% had extra-ampullary duodenal adenocarcinoma and 49.93% had peri-ampullary duodenal adenocarcinoma. The 1-, 3-, and 5-year overall survival rates for patients who underwent radical surgery were 91.78%, 69.30%, and 55.86%, respectively. The median overall survival was 73 months (range, 64-84), and the median progression-free survival was 64 months (range, 52-76). No differences in survival were observed between the laparotomy and minimally invasive surgery groups (log-rank P = .562); furthermore, no significant between-group differences in operation time, lymph node dissection, postoperative complications, or in-hospital mortality were observed (P > .05). The minimally invasive surgery group experienced less intraoperative blood loss (250 mL vs 100 mL, P < .001), fewer intraoperative blood transfusions (24.97% vs 18.84%, P = .002), and shorter hospital stays (28 days vs 23 days, P < .001). Multivariate Cox regression analysis revealed that advanced age, advanced stage, longer operation time, intraoperative blood transfusion, and postoperative hemorrhage were independent risk factors for poor prognosis.

CONCLUSION

Radical surgery was associated with favorable overall survival among patients with duodenal adenocarcinoma, and no difference in survival was observed between patients with extra-ampullary duodenal adenocarcinoma and peri-ampullary duodenal adenocarcinoma. Minimally invasive surgery is a reliable alternative for duodenal adenocarcinoma treatment.

The Role of Adjuvant Therapy in Duodenal Adenocarcinoma and Intestinal Subtype Ampullary Carcinoma After Curative Resection

OBJECTIVE

To define the role of adjuvant therapy in duodenal adenocarcinoma (DAC) and intestinal subtype ampullary carcinoma (iAC).

BACKGROUND

DAC and iAC share a similar histologic differentiation but the benefit of adjuvant therapy remains unclear.

METHODS

Patients undergoing curative intent surgical resection for DAC and iAC between 2010 and 2021 at 5 high-volume centers were included. Patient baseline, perioperative, and long-term oncological outcomes were evaluated. Statistical testing was performed with SPSS 25 (IBM).

RESULTS

A total of 136 patients with DAC and 171 with iAC were identified. Patients with DAC had more advanced tumors than those with iAC. Median overall survival (OS) in patients with DAC was 101 months versus 155 months for patients with iAC ( P = 0.098). DAC had a higher rate of local (14.1% vs 1.2%, P < 0.001) and systemic recurrence (30.4% vs 3.5%, P < 0.001). Adjuvant therapy failed to improve OS in all patients with DAC and iAC. For DAC, patients with perineural invasion, but not other negative prognostic factors, had improved OS rates with adjuvant therapy (72 vs 44 m, P = 0.044). Patients with iAC with N+ (190 vs 57 m, P = 0.003), T3-T4 (177 vs 59 m, P = 0.050), and perineural invasion (150 vs 59 m, P = 0.019) had improved OS rates with adjuvant therapy.

CONCLUSIONS

While adjuvant therapy fails to improve OS in all patients with DAC and iAC in the current study, it improved OS in patients with DAC with perineural invasion and in patients with iAC with T3-T4 tumors, positive lymph nodes, and perineural invasion.

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.

Groove pancreatitis: From enigma to future directions-A comprehensive review

Groove pancreatitis (GP) is a rare and clinically distinct form of chronic pancreatitis affecting the pancreaticoduodenal groove comprising the head of the pancreas, duodenum, and the common bile duct. It is more prevalent in individuals in their 4-5th decade of life and disproportionately affects men compared with women. Excessive alcohol consumption, tobacco smoking, pancreatic ductal stones, pancreatic divisum, annular pancreas, ectopic pancreas, duodenal wall thickening, and peptic ulcers are significant risk factors implicated in the development of GP. The usual presenting symptoms include severe abdominal pain, nausea, vomiting, diarrhea, weight loss, and jaundice. Establishing a diagnosis of GP is often challenging due to significant clinical and radiological overlap with numerous benign and malignant conditions affecting the same anatomical location. This can lead to a delay in initiation of treatment leading to increasing morbidity, mortality, and complication rates. Promising research in artificial intelligence (AI) has garnered immense interest in recent years. Due to its widespread application in diagnostic imaging with a high degree of sensitivity and specificity, AI has the potential of becoming a vital tool in differentiating GP from pancreatic malignancies, thereby preventing a missed or delayed diagnosis. In this article, we provide a comprehensive review of GP, covering the etiology, pathogenesis, clinical presentation, radiological and endoscopic evaluation, management strategies, and future directions. This article also aims to increase awareness about this lesser known and often-misdiagnosed clinical entity amongst clinicians to ultimately improve patient outcomes.

Pancreas preserving duodenectomy (PPrD)

BACKGROUND

Pancreaticoduodenectomy has been the standard of care for managing duodenal neoplasms, but recent studies show similar overall and disease-specific survival after pancreas-preserving duodenectomy (PPrD) with potentially less morbidity.

METHODS

Retrospective cohort of all adult (age >18) patients who underwent PPrD with curative intent of a neoplasm in or invading into the duodenum at our institution from 2011 to 2022 (n ​= ​29), excluding tumors involving the Ampulla of Vater or the pancreas. Statistical analyses were performed using STATA.

RESULTS

R0 resection was achieved in 93 ​% patients. Ten (34.4 ​%) experienced postoperative complications (13.7 ​% within Clavien-Dindo III-V). PPrD patients had lower rates of pancreatic leak, delayed gastric emptying, and deep surgical site infection.

CONCLUSIONS

In this case series, we demonstrate PPrD is safe and effective, with a high rate of complete resection and lower complication rate than that seen in pancreaticoduodenectomy.

Duodenal adenocarcinoma at stage IV: A critical look at diagnostic pathways and treatment modalities

Duodenal adenocarcinoma is a rare and aggressive gastrointestinal malignancy that frequently presents with symptoms like gastric outlet obstruction and biliary obstruction, leading to delayed diagnosis and challenging prognosis. This case report explores the clinical presentation, diagnostic hurdles, and therapeutic management of late-stage duodenal adenocarcinoma in a 53-year-old woman with no significant prior medical history. The patient presented with severe epigastric pain radiating to the right upper quadrant, nausea, and decreased appetite. Elevated liver enzymes and imaging revealed multiple liver masses and a primary duodenal mass. Biopsies confirmed moderately differentiated adenocarcinoma. Tumor markers were evaluated during the staging phase, showing markedly elevated levels. The patient underwent systemic chemotherapy with FOLFOX but faced complications, including pulmonary emboli and neurological symptoms. Management required a multidisciplinary approach, integrating palliative and supportive care to address symptoms and improve quality of life. The case highlights the necessity of considering duodenal adenocarcinoma when diagnosing persistent gastrointestinal symptoms. It highlights the need for a holistic treatment approach, including tailored chemotherapy regimens and vigilant monitoring of complications. Molecular profiling was crucial in guiding treatment decisions, although MSI, HER2, and PD-1 were negative, and the tumor showed no mismatch repair protein deficiency. This article emphasizes the importance of early integration of palliative care and the value of comprehensive pathological analysis in managing advanced duodenal adenocarcinoma, providing insights into diagnostic and therapeutic strategies for this complex case.

Adenocarcinoma in the Jejunum Presenting as Acute Abdomen and Melena in an Otherwise Healthy Patient: A Case Report

A jejunal adenocarcinoma is a rare form of cancer that is difficult to diagnose due to its vague and non-specific symptoms, often leading to delayed treatment and poor outcomes. In this case, we report a 43-year-old male who presented with acute abdominal pain, weight loss, and melena. A CT scan revealed a mass in the small intestine, and subsequent exploratory laparotomy confirmed the presence of a tumor, which was surgically excised. Histopathological analysis confirmed jejunal adenocarcinoma with positive CDX2 staining, ruling out other adenocarcinoma subtypes. This case underscores the importance of including jejunal adenocarcinoma in differential diagnoses of acute abdomen and highlights the critical role of early surgical intervention in improving patient outcomes.

Celiac Disease Masking Duodenal Adenocarcinoma: A Case Report and Literature Review

Small bowel adenocarcinoma (SBA) is an uncommon gastrointestinal malignancy, with the duodenum being the most commonly affected site. This report describes a 33-year-old woman who initially presented with abdominal pain and vomiting. Initial imaging revealed abnormalities of the proximal jejunum. Endoscopic evaluation initially revealed celiac disease (CD); however, with disease progression, the patient developed bowel obstruction that led to surgical intervention with an open duodenal biopsy. The open duodenal biopsy confirmed the presence of duodenal adenocarcinoma (DA). This case demonstrates the diagnostic complexity of DA in the presence of concurrent CD due to overlapping presentations. Physicians must maintain a high suspicion of DA in the setting of progressive and difficult-to-treat CD, as early diagnosis and management of DA can significantly improve patient outcomes.

A Case Report of Duodenal Malignancy and Its Management With Pancreaticoduodenectomy

Gastrointestinal malignancies, most specifically duodenal malignancy, are uncommon in the population; however, they are tricky to manage because the lesions are diagnosed at a late stage and located in a complex area. This case report focuses on a patient who was diagnosed with a second (descending) part of the duodenum (D2) malignancy; the tumour was localised at the second part of the duodenum, and the management of this patient was through the Whipple procedure or pancreaticoduodenectomy. The patient complained of stinging abdomen pain. Diagnostic examination comprised of CT and biopsy proved the presence of a malignant tumour originating from the D2 area. The tumour's characteristics and the patient's general health status are determined by using Whipple's procedure. Post-operative management entails the use of IV antibiotics, analgesics, multivitamins and nasojejunal (NJ) tube feeding. The case also expounds on the consequences of a multimodal treatment strategy, meticulous planning of the surgical procedure, and adequate post-operative management of D2 malignancies. These data may shed some light on the peculiarities of duodenal cancer management with the Whipple procedure; nonetheless, early diagnosis and proper management should remain the primary goals.

Endoscopic Diagnosis of Epithelial Subtypes of Superficial Non-Ampullary Duodenal Epithelial Tumors using Magnifying Narrow-Band Imaging

INTRODUCTION

Superficial non-ampullary duodenal epithelial tumors (SNADETs) include low-grade adenoma (LGA) and high-grade adenoma or carcinoma (HGA/Ca) and are classified into two different epithelial subtypes, gastric-type (G-type) and intestinal-type (I-type). We attempted to distinguish them by endoscopic characteristics including magnifying endoscopy with narrow-band imaging (M-NBI).

METHODS

Various endoscopic and M-NBI findings of 286 SNADETs were retrospectively reviewed and compared between G- and I-types and histological grades. M-NBI findings were divided into four patterns based on the following vascular patterns; absent, network, intrastructural vascular (ISV), and unclassified. Lesions displaying a single pattern were classified as mono-pattern and those displaying multiple patterns as mixed-pattern. Lesions showing CDX2 positivity were categorized as I-types and those showing MUC5AC or MUC6 positivity were categorized as G-types based on immunohistochemistry.

RESULTS

Among 286 lesions, 23 (8%) were G-type and 243 (85%) were I-type. More G-type lesions were located oral to papilla (91.3 vs. 45.6%, p < 0.001), and had protruding morphology compared to those of I-types (65.2 vs. 14.4%, p < 0.001). The major M-NBI pattern was ISV in G-type (78.2 vs. 26.3%, p < 0.001), and absent for I-type (0 vs. 34.5%, p = 0.003). Three endoscopic characteristics; location oral to papilla, protruding morphology, and major M-NBI pattern (ISV) were independent predictors for G-type. Mixed-pattern was more common in HGA/Ca than LGA for I-type (77.0 vs. 58.8%, p = 0.01); however, there was no difference for those in G-type.

CONCLUSION

Endoscopic findings including M-NBI are useful to differentiate epithelial subtypes.

A rare case of neuroendocrine cell tumor mixed with a mucinous component in the ampulla of Vater

BACKGROUND

A rare case of neuroendocrine cell tumor (NET) having both conventional and mucinous components was reported. Mucinous NET is rarely encountered in the pathological diagnosis of gastrointestinal (GI) tumors. Here we examined the mechanism for transformation of conventional NETs into mucinous NETs.

CASE PRESENTATION

Macroscopic examination revealed a tumor with ulceration in the ampulla of Vater that measured 1.7 cm in its largest diameter. Histologically, the tumor comprised two components: a tubular/ribbon-like feature and small nests floating in a mucinous lake. The tumor nests showed sheet, nest and ribbon-like structures of small cells having eosinophilic cytoplasm as well as small-sized nuclei with dense hyperchromatin. Immunohistochemical analysis showed tumor cells positive for pan-endocrine markers (synaptophysin, CD56, INSM1 and chromogranin). Based on the histological findings, the solid and mucinous components were diagnosed as conventional and mucinous NETs, respectively. Grading was NET G2 based on 12.8% and 13.2% Ki-67-positive cells in the solid and mucinous components, respectively. Immunohistochemically, the mucin phenotype of this tumor was gastric and intestinal. Only the mucinous NET component had cytoplasmic CD10 expression. Examination using a customized gene panel detected only a DPC4 mutation, which was limited to the mucinous component.

CONCLUSIONS

Coexistence of conventional and mucinous NETs could provide important insight into evaluating the NET subtype histogenesis. Moreover, molecular alterations including cytoplasmic expression of CD10 and the DPC4 mutation can contribute to interpretation of tumor pathogenesis.

Safety of Duodenal Endoscopic Submucosal Dissection for Superficial Non-Ampullary Duodenal Epithelial Tumor: A Single-Center Study in the United States

Endoscopic submucosal dissection (ESD) of superficial non-ampullary duodenal epithelial tumors (SNADETs) is associated with a high rate of en bloc resection and low rate of recurrence. However, in the United States, SNADETs are predominantly managed using endoscopic mucosal resection (EMR) or surgery because the feasibility and safety of duodenal ESD have not yet been established. In this study, we analyzed the outcomes of duodenal ESD for SNADETs. This single-center retrospective study reviewed the data of patients who underwent ESD for SNADETs between June 2018 and August 2023. Baseline patient characteristics, histopathology of the resected lesions, adverse events, and recurrence rates were evaluated. The primary outcome measures were en bloc resection, complications, and recurrence rate. Thirty ESD procedures were performed on 24 patients. All 30 lesions were adenomas, with no cancerous lesions. The en bloc resection rate and R0 resection rates were both 53%. There were no cases of procedure-associated perforation. Post-ESD bleeding was observed in six cases. No ESD-related mortality was observed. The recurrence rate was 14% in 1 year follow up, and 28% the during all follow-up period. ESD is a safe option for SNADET in the United States; however further comparative studies are necessary to determine the optimal procedure for North American populations.

An autopsy case of alpha-fetoprotein-producing large duodenal adenocarcinoma

We report an autopsy case of a large duodenal adenocarcinoma that produced alpha-fetoprotein (AFP). The patient was a man in his 70s with diabetes mellitus. He presented with epigastralgia and was referred to our hospital. Upper gastrointestinal endoscopy and abdominal computed tomography revealed a large tumor of 11 cm in diameter in the descending limb of the duodenum. A tumor biopsy showed poorly differentiated adenocarcinoma. Although his carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels were within the normal range, his AFP levels were significantly elevated (42,078.4 ng/mL). Due to vascular invasion, curative resection was not feasible, and chemotherapy was chosen as the treatment option. After gastrojejunostomy was performed to enable oral intake, one cycle of modified leucovorin/5-fluorouracil/oxaliplatin (mFOLFOX6) therapy was administered. However, it proved ineffective, and the patient's anorexia gradually worsened. Ultimately, he succumbed to the progression of cancer cachexia. Autopsy findings revealed a 14-cm-long duodenal carcinoma primarily located in the duodenal bulb, with direct invasion into the stomach, pancreas, and liver. A pathological examination confirmed a diagnosis of poorly differentiated adenocarcinoma with AFP production. Duodenal cancer is rare, and AFP-producing duodenal cancer is even rarer, with only 21 reported cases, including our own. We present this autopsy case of AFP-producing duodenal adenocarcinoma and review the cases reported in the relevant literature.

Distinct approaches (antecolic and retrocolic) according to tumor location in laparoscopic and endoscopic cooperative surgery for non-ampullary duodenum tumors

AIM

Laparoscopic and endoscopic cooperative surgery for early non-ampullary duodenum tumors (D-LECS) is now noted because of its safety and lower invasiveness. Here, we introduce two distinct approaches (antecolic and retrocolic) according to the tumor location during D-LECS.

METHODS

From October 2018 to March 2022, 24 patients (25 lesions) underwent D-LECS. Two (8%), two (8%), 16 (64%), and five (20%) lesions were located in the first portion, in the second portion to Vater's papilla, around the inferior duodenum flexure, and in the third portion of the duodenum, respectively. The median preoperative tumor diameter was 22.5 mm.

RESULTS

Antecolic and retrocolic approaches were employed in 16 (67%) and 8 (33%) cases, respectively. LECS procedures, such as two-layer suturing after full-thickness dissection and laparoscopic reinforcement by seromuscular suturing after endoscopic submucosal dissection (ESD), were performed in five and 19 cases, respectively. Median operative time and blood loss were 303 min and 5 g, respectively. Intraoperative duodenal perforations occurred in three of 19 cases during ESD; however, they were successfully laparoscopically repaired. Median times until start diet and postoperative hospital stay were 4.5 and 8 days, respectively. Histological examination of the tumors revealed nine adenomas, 12 adenocarcinomas, and four GISTs. Curative resection (R0) was achieved in 21 cases (87.5%). In a comparison of the surgical short outcomes between antecolic and retrocolic approaches, there was no significant difference.

CONCLUSION

D-LECS can be a safe and minimally invasive treatment option for non-ampullary early duodenal tumors, and two distinct approaches according to the tumor location are feasible.

Poorly cohesive duodenal carcinoma mixed with signet ring cell carcinoma with systemic metastasis: a case report and literature review

Poorly cohesive duodenal carcinoma mixed with signet ring cell carcinoma is very rare, and no cases have been reported. When distant metastasis occurs, it is very easy to be misdiagnosed. We report the first case of a 52-year-old man with poorly cohesive carcinoma of the duodenum mixed with signet ring cell carcinoma with systemic metastasis. The process of its diagnosis and differential diagnosis is highlighted.

Synthesis and Anticancer Evaluation of Novel 7-Aza-Coumarine-3-Carboxamides

Herein, we report the design and synthesis of novel 7-aza-coumarine-3-carboxamides via scaffold-hopping strategy and evaluation of their in vitro anticancer activity. Additionally, the improved non-catalytic synthesis of 7-azacoumarin-3-carboxylic acid is reported, which features water as the reaction medium and provides a convenient alternative to the known methods. The anticancer activity of the most potent 7-aza-coumarine-3-carboxamides against the HuTu 80 cell line is equal to that of reference Doxorubicin, while the selectivity towards the normal cell line is 9-14 fold higher.

Importance of carbohydrate antigen (CA 19-9) and carcinoembrionic antigen (CEA) in the prognosis of patients with duodenal adenocarcinoma: a retrospective single-institution cohort study

BACKGROUND

Duodenal adenocarcinoma (DA) is a rare malignancy without validated tumor markers. In practice, carcinoembryonic antigen (CEA) and carbohydrate antigen (CA 19-9) are often used in the management of DA, though their prognostic value is unknown.

MATERIALS AND METHODS

A single-institution retrospective review included patients diagnosed with biopsy-confirmed adenocarcinoma of the duodenum between 2006 and 2021. Peri-ampullary tumors were excluded. Levels of CA 19-9 and CEA were collected as continuous variables and were analyzed as binary variables: normal vs. high, using the maximum normal value as a cut-off (normal Ca 19-9 <35 U/ml; CEA <3 ng/ml). Survival analysis was conducted using Kaplan Meier curves, log-rank test and Cox proportional hazards model.

RESULTS

There were 68 patients included in the final analysis. Median age was 67 years old and median follow-up time was 22.2 months. CA 19-9 and CEA were elevated in 36.8% and 48.5% of patients, respectively. A concomitant elevation of both tumor markers was associated with worsened OS (HR 2.140, 95% CI: 1.114-4.112; p = 0.019). After controlling for age and sex on multivariate analysis, elevation in both CA 19-9 ≥35 and CEA ≥3.0 remained significantly associated with increased mortality (HR 2.278, 95% CI: 1.162-4.466; p = 0.016).

CONCLUSIONS

In summary, CA 19-9 and, to a lesser extent, CEA, show promise as prognostic markers in DA. Larger studies are needed to validate their use and to evaluate their performance as markers of recurrence.

A Rare Case of Primary Duodenal Plasmacytoma: An Incidental Finding

Solitary extramedullary plasmacytoma (SEP) is a rare tumor due to the monoclonal proliferation of plasma cells without bone marrow involvement. Plasmacytomas are frequently encountered in bone or soft tissue but rarely occur in the gastrointestinal (GI) tract. They can present with a multitude of symptoms depending on their site. This report describes a case of SEP diagnosed as a duodenal ulcer (DU) during esophagogastroduodenoscopy (EGD) for iron deficiency anemia.

Pancreatoduodenectomy following neoadjuvant chemotherapy in duodenal adenocarcinoma

A 51-year-old male patient had four times of massive hematochezia episode three days before arrival. Carbohydrate antigen (CA) 19-9 level was extremely elevated. Computed tomography, magnetic resonance imaging, and positron emission tomography-computed tomography identified 5.7 cm sized periampullary duodenal cancer with regional metastatic lymph nodes and vascular invasion to aberrant right hepatic artery, main portal vein, and superior mesenteric vein. Diagnosed as duodenal adenocarcinoma through endoscopic biopsy, 16 times of FOLFIRI (5-fluorouracil, leucovorin, irinotecan) was conducted. The regimen changed to XELOX (capecitabine, oxaliplatine), four times of administration was done, and the CA19-9 level dramatically decreased. The tumor decreased to 2.1 cm. After R0 laparoscopic pylorus preserving pancreatoduodenectomy, no adjuvant therapy was given. No sign of recurrence or metastasis was reported, and the patient reached complete remission after five years. We reported a case where neoadjuvant chemotherapy for locally advanced duodenal adenocarcinoma was shown to be effective.

Duodenal Mucinous Adenocarcinoma in a Patient With Immunodeficiency: A Case Report

Duodenal mucinous adenocarcinoma is a rare type of small bowel carcinoma. It is not commonly encountered; hence little knowledge exists about its presentation, diagnosis, and management. The diagnosis is mostly made by either esophagogastroduodenoscopy (EGD) or intra-operatively. Some of the main symptoms are abdominal pain, nausea, vomiting, weight loss, or signs and symptoms of upper gastrointestinal bleeding. Therefore, this is a serious condition that healthcare providers and patients should be aware of to reduce its severity and improve prognosis. We present a case of duodenal mucinous adenocarcinoma in a patient with immunodeficiency virus.

Clinical Outcome of Resected Non-Ampullary Duodenal Adenocarcinoma: A Single Center Experience

(1) Background: This study identified the clinical outcome and prognostic factors of resected non-ampullary duodenal adenocarcinoma (NADA) in a single tertiary cancer center. (2) Methods: The medical records of 109 patients with NADA who underwent curative surgery between 2000 and 2018 were reviewed retrospectively. (3) Results: The mean age was 62.4 years with a male predominance (70.6%). The majority of tumors were located at the 2nd portion (58.7%). Fifty-seven patients (52.3%) had symptoms at diagnosis. CA19-9 was elevated in 32 patients (29.4%). Of this cohort, most patients were diagnosed as stage III (64.2%). The median overall survival was 92.9 months, and the 1-, 3-, and 5-year survival rates were 84.4%, 71.6%, and 53.7%, respectively. In univariate and multivariate analysis, age, symptoms, CA19-9, and margin status were associated with overall survival and symptoms, CA19-9 and margin status were also associated with recurrence. When correlating symptoms with stages, patients with symptoms at diagnosis had more advanced stages (all p < 0.001). (4) Conclusion: Old age, elevated CA19-9, symptoms, and margin status were independent prognostic factors of NADA, and the patients with symptoms at diagnosis tend to have more advanced stages and a poor prognosis.

Role of Endoscopy in Management of Upper Gastrointestinal Cancers

Upper gastrointestinal (GI) malignancy is a leading cause of cancer-related morbidity and mortality. Upper endoscopy has an established role in diagnosing and staging upper GI cancers, screening for pre-malignant lesions, and providing palliation in cases of advanced malignancy. New advances in endoscopic techniques and technology have improved diagnostic accuracy and increased the therapeutic potential of upper endoscopy. We aim to describe the different types of endoscopic technology used in cancer diagnosis, summarize the current guidelines for endoscopic diagnosis and treatment of malignant and pre-malignant lesions, and explore new potential roles for endoscopy in cancer therapy.

Surgical treatment of duodenal adenocarcinoma: ampullary vs. non-ampullary, short- and long-term outcomes

BACKGROUND

The aim of this study was to evaluate symptoms, diagnostic methods, short- and long-term outcomes of surgical treatment in patients with duodenal adenocarcinoma.

PATIENTS AND METHODS

A single center, retrospective, observational study of 52 consecutive patients with duodenal adenocarcinoma operated on with curative intent between 2006 - 2019. Duodenectomy as part of a hemipancreatoduodenectomy or total pancreatectomy procedure was performed for ADAC (ampullary duodenal/intestinal adenocarcinoma) or NADAC (non-ampullary duodenal adenocarcinoma).

RESULTS

Prevailing symptoms were obstructive jaundice in the ADAC group (P<0.0001) and bleeding in the NADAC group (P=0.005), with larger tumor size in patients with NADAC (P=0.001). Complication rate, morbidity and mortality were comparable. Primary total pancreatoduodenectomy predominated in the NADAC group, 16.6% vs. 2.9%, and salvage completion pancreatectomy in the ADAC group, 6% vs. 0%. Significant prognostic factors for OS were perineural invasion (P=0.006) and adjuvant chemotherapy (P=0.045) in the ADAC group, and for DFS the total number of resected lymph nodes (P=0.042) and lymph node ratio (P=0.031) in the NADAC group. Median OS is 21 months and 5-year survival 27.3% in the NADAC group and 41.5 months and 52% in the ADAC group.

CONCLUSION

Ampullary duodenal/intestinal adenocarcinomas are smaller than non-ampullary at diagnosis, with a higher rate of lymph node metastases, but with a better prognosis and long-term outcome in the presented cohort. Oral localisation of NADAC prevailed in the present cohort. Perineural invasion and postoperative oncological therapy are significant prognostic factors for OS in ADAC, but the total number of lymph nodes and lymph node ratio are significant prognostic factors for DFS in NADAC.

Signet-ring cell carcinoma of the duodenal bulb presenting with gastrointestinal hemorrhage: a case report and literature review

Background

Primary duodenal cancer (PDC) is rare, especially signet-ring cell carcinoma (SRCC) of the duodenal bulb, and it is commonly misdiagnosed as an ulceration. Here, we report a rare case of SRCC of the duodenal bulb presenting with gastrointestinal hemorrhage in an 82-year-old man.

Case presentation

An 82-year-old man was admitted for gastrointestinal hemorrhage. Physical examination revealed upper abdominal tenderness and pale appearance, but was otherwise unrevealing. Laboratory workup was significant for anemia. Imaging showed no abnormalities. Two endoscopic evaluations along with interventional embolization were attempted and, unfortunately, adequate hemostasis was not achieved, resulting in distal subtotal gastrectomy, including the duodenal bulb. SRCC of the duodenal bulb was diagnosed based on pathology after surgery. Post-operatively, the patient experienced persistent gastrointestinal bleeding. Family declined further intervention and the patient eventually died one month post-resection.

Conclusions

SRCC in the duodenal bulb is difficult to diagnose. For those with high-risk factors, endoscopic examination and biopsy are recommended. For patients who can receive radical tumor resection, pancreaticoduodenectomy (PD) is considered a first-line option. Early diagnosis and resection have been shown to improve prognosis.

Node negative duodenal adenocarcinoma is associated with long-term patient survival following pancreaticoduodenal resection

BACKGROUND

Duodenal adenocarcinoma (DA) is a rare gastrointestinal malignancy. There is limited data reporting patient outcomes following radical pancreatic resection for DA. We assessed the disease-free (DFS) and overall survival (OS) in patients undergoing pancreaticoduodenectomy for DA in our institution.

METHODS

We retrospectively analysed all patients undergoing pancreatic resection of DA at our institution between January 2009 and March 2020 inclusive.

RESULTS

Ninteen patients underwent pancreatic resection at our institution for DA during the study period. The overall postoperative morbidity and mortality was 37% and 5%, respectively. Nine patients (47%) had no nodal involvement. Median follow up was 25 months (range 1-108 months). Median DFS for our whole cohort was 17 months but was significantly higher in patients with no nodal metastasis [p < 0.001]. Median OS was 9.5 months for the whole cohort but was significantly higher in the patients with no nodal metastasis (60 months) compared to those with nodal metastasis (17.5 months) [p < 0.003].

CONCLUSION

Improved DFS and OS for patients undergoing pancreaticoduodenectomy for DAs is associated with lymph node negative disease.

Small bowel adenocarcinoma: An overview

Small bowel adenocarcinoma (SBA) is a rare malignancy of the gastrointestinal tract. However, these tumors are among those with worst prognosis. Vague clinical signs and symptoms and radiological diagnostic challenges often delay treatment, which negatively impacts the prognosis of the patients. However, recent advances in imaging technology, like multidetector computed tomography, magnetic resonance imaging, and capsule endoscopy, have made earlier and accurate diagnosis possible. Surgery is the treatment of choice followed by adjuvant therapy. However, there are no strict treatment guidelines available for the management of SBA. Most of the available evidence from colorectal and gastric carcinoma has been extrapolated to adequately manage SBA. Prognosis for SBA is better than gastric carcinoma but worse than colorectal carcinoma. Currently, there is not enough information on the molecular characteristics and tumor pathogenesis. Because the incidence of SBA is very low, there is a need for further studies to evaluate the possible application of newer investigative agents and strategies to obtain a better outcome within the framework of international collaborations.

High tumor budding predicts a poor prognosis in resected duodenal adenocarcinoma

PURPOSE

Tumor budding is a histological characteristic defined as the presence of small clusters of cancer cells at the invasion front. Its significance in duodenal adenocarcinoma (DA) has not been fully described.

METHODS

A single-center, retrospective study was conducted. Patients who underwent curative surgery for histologically diagnosed DA from January 2006 to December 2018 at Kansai Medical University Hospital were included. Tumor budding was counted per 0.785 mm² and classified as low (0-4 buds), intermediate (5-9 buds), or high (≥ 10 buds).

RESULTS

In total, 47 patients were included. The 5-year overall survival and relapse-free survival rates were 77% and 72%, respectively. High tumor budding was seen in 15 patients (32%). Excluding patients with superficial type (pT1) DA (n = 22), high tumor budding [hazard ratio (HR) 13.4, p = 0.028], regional lymph node metastasis (HR 19.9, p = 0.039), and adjuvant chemotherapy (HR 0.056, p = 0.036) were independent factors related to the overall survival in multivariate analyses. Distant metastases occurred significantly more often in patients who had high tumor budding than in others (p = 0.039).

CONCLUSION

The data suggest that high tumor budding is a predictor of a poor prognosis in resected DA.

Routine contrast-enhanced CT is insufficient for TNM-staging of duodenal adenocarcinoma

PURPOSE

Adequate TNM-staging is important to determine prognosis and treatment planning of duodenal adenocarcinoma. Although current guidelines advise contrast-enhanced CT (CECT) for staging of duodenal adenocarcinoma, literature about diagnostic tests is sparse.

METHODS

In this retrospective single-center cohort study, we analyzed the real life performance of routine CECT for TNM-staging and the assessment of resectability of duodenal adenocarcinoma. Intraoperative findings and pathological staging served as reference standard for resectability, T-, and N-staging. Biopsies, ¹⁸FDG-PET-CT, and follow-up were used as the reference standard for M-staging.

RESULTS

Fifty-two consecutive patients with duodenal adenocarcinoma were included, 26 patients underwent resection. Half of the tumors were isodense to normal duodenum on CECT. The tumor was initially missed in 7/52 patients (13%) on CECT. The correct T-stage was assigned with CECT in 14/26 patients (54%), N-stage in 11/26 (42%), and the M-stage in 42/52 (81%). T-stage was underestimated in (27%). The sensitivity for detecting lymph node metastases was only 24%, specificity was 78%. Seventeen percent of patients had indeterminate liver or lung lesions on CECT. Surgery with curative intent was started in 32 patients, but six patients (19%) could not be resected due to unexpected local invasion or metastases.

CONCLUSION

Radiologists and clinicians have to be aware that routine CECT is insufficient for staging and determining resectability in patients with duodenal adenocarcinoma. CECT underestimates T-stage and N-stage, and M-stage is often unclear, resulting in futile surgery in 19% of patients. Alternative strategies are required to improve staging of duodenal adenocarcinoma. We propose to combine multiphase hypotonic duodenography CT with MRI.

Transduodenal resection of periampullary neuroendocrine tumor: A case report

Introduction and importance

Periampullary tumors are characterized as tumors that emerge nearby to the major papilla in the duodenum. They are rare lesions with an incidence rate of 0.4–0.48 per 100,000. Neuroendocrine tumors (NETs) constitute only 3% of all duodenal tumors. Their proximity to the major and minor papillae along with the gastric outlet raises a surgical challenge.

Case presentation

Our patient is a 40-year-old, male, medically free. He presented with history of a testicular mass. A CT scan of the abdomen and pelvis was done and showed a large retroperitoneal lymph node. A biopsy of the epididymal mass showed no evidence of malignancy. Excision of the left para-aortic mass revealed a metastatic lymph node of a well-differentiated neuroendocrine tumor. Further evaluation by gallium-68 PET-CT scan showed a periampullary neuroendocrine tumor. The decision to operate was concluded in a multidisciplinary team meeting, and intraoperatively the duodenum showed a well-defined mass between the first and second part of the duodenum which was excised via a trans-duodenal submucosal approach. A frozen section confirmed a negative margin. The final histopathology report showed a grade 2 metastatic well-differentiated neuroendocrine tumor. The latest follow-up was 3 years post-op via fluorine-18 fluorodeoxyglucose PET-CT and it showed no FDG avid disease at the duodenum or pancreases with no FDG avid lymphadenopathy or distant metastasis.

Conclusion

Periampullary tumors that fall under certain parameters could be resected via transduodenal local resection. This procedure yields equivalent results to more invasive surgeries, such as a Whipple's procedure, with less morbidity.

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Ampullary neuroendocrine tumors (NETs) are rare in compare to duodenal NETs, as they are highly metastatic and aggressive regardless of the size.

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These tumors present a diagnostic challenge in addition to being a topic of contention regarding surgical resection options.

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The controversy resides in main surgical options; the first being a pancreaticoduodenectomy (PD), and the second is a transduodenal local resection.

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Certain conditions must be met to achieve a satisfactory outcome for transduodenal local resection in case of periampullary NETs.

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For patients who have met the criteria, transduodenal local resection is believed to be a less invasive, safe, and useful alternative for PD.

A Rare Case of Three Distinct Gastrointestinal Neoplasms Occurring Simultaneously in an Elderly Patient

Duodenal adenocarcinoma (DA), gastrointestinal stromal tumor (GIST), and pancreatic neuroendocrine tumor (PNET) are a set of rare gastrointestinal (GI) cancers characterized by nonspecific symptoms such as anemia, weight loss, and abdominal pain. We report an interesting case of DA, GIST, and PNET in a 79-year-old African American male who presented to the emergency department with syncope. The patient was tachycardic and found to have severe anemia. Further computed tomography (CT) of the abdomen and pelvis with contrast revealed a mass within the duodenal bulb along with a pancreatic cystic lesion. The patient underwent gastroduodenectomy and distal pancreatectomy with incidental findings of GIST in the posterior gastric wall. The patient after surgical removal of all tumors no longer experienced abdominal pain and had hematocrit and hemoglobin (H&H) level of 9.1/31.7 postoperation day (POD) 14. The case unfolds a rare presentation of three neoplasms that were moderate to well-differentiated with no metastases. It highlights the importance of assessment of rare GI neoplasms concurrently with colorectal cancer when geriatric patients present with nonspecific GI symptoms.

Pancreas sparing duodenectomy in the treatment of primary duodenal neoplasms and other situations with duodenal involvement

BACKGROUND

There are no clearly defined indications for pancreas-preserving duodenectomy. The present study aimed to analyze postoperative morbidity and the outcomes of patients undergoing pancreas-preserving duodenectomy.

METHODS

Patients undergoing pancreas-preserving duodenectomy from April 2008 to May 2020 were included. We divided the series according to indication: scenario 1, primary duodenal tumors; scenario 2, tumors of another origin with duodenal involvement; and scenario 3, emergency duodenectomy.

RESULTS

We included 35 patients. Total duodenectomy was performed in 1 patient of adenomatous duodenal polyposis, limited duodenectomy in 7, and third + fourth duodenal portion resection in 27. The indications for scenario 1 were gastrointestinal stromal tumor (n = 13), adenocarcinoma (n = 4), neuroendocrine tumor (n = 3), duodenal adenoma (n = 1), and adenomatous duodenal polyposis (n = 1); scenario 2: retroperitoneal desmoid tumor (n = 2), recurrence of liposarcoma (n = 2), retroperitoneal paraganglioma (n = 1), neuroendocrine tumor in pancreatic uncinate process (n = 1), and duodenal infiltration due to metastatic adenopathies of a germinal tumor with digestive hemorrhage (n = 1); and scenario 3: aortoenteric fistula (n = 3), duodenal trauma (n = 1), erosive duodenitis (n = 1), and biliopancreatic limb ischemia (n = 1). Severe complications (Clavien-Dindo ≥ IIIb) developed in 14% (5/35), and postoperative mortality was 3% (1/35).

CONCLUSIONS

Pancreas-preserving duodenectomy is useful in the management of primary duodenal tumors, and is a technical option for some tumors with duodenal infiltration or in emergency interventions.

A case of duodenal adenocarcinoma treated with primary chemoradiation

Duodenal adenocarcinoma represents <1% of total gastrointestinal malignancies. Given the rarity of the disease, a definitive treatment guideline is lacking. Surgery plays a major role and radiotherapy was not included in the treatment due to the presence of many critical structures near the vicinity of the duodenum such as the liver, kidneys, and bowel. However, with the advent of newer techniques, adjuvant chemoradiation has shown a promising result with improvement in locoregional control by 20%. We are herewith presenting the details of the radiation planning of a patient treated with chemoradiation who had good long-term outcome.

Primary Duodenal Carcinoma with Embryonal Carcinoma Features in a Young Man

We present the case of a 35-year-old man with intractable nausea, vomiting, and severe anemia. A computed tomography (CT) scan of the chest, abdomen, and pelvis showed a circumferential lesion thickening of up to 3.5 cm at the level of the third portion of the duodenum. No aortocaval, retroperitoneal lymphadenopathy, nor secondary lesion was observed. Esophagogastroduodenoscopy (EGD) revealed a circumferential mass within the third portion of the duodenum. Histopathology of biopsy materials from the duodenal mass showed it most likely to be a poorly differentiated adenocarcinoma. The patient underwent a subtotal stomach-preserving pancreaticoduodenectomy with regional lymph node dissection. Histologically, tumor cells with basophilic cytoplasm and pleomorphic nuclei showed a solid pattern, and expressed CD30 and SALL4 immunohistochemically, leading to a diagnosis of embryonal carcinoma-like tumor. No other primary tumor could be identified, and the location of the tumor, mainly on the mucosal surface, suggested a duodenal origin. The UICC TNM staging was T3N2M0, stage IIB. This is a rare case of primary duodenal carcinoma with features of embryonal carcinoma.

Laparoscopic segmental resection for tumours of the Angle of Treitz: a challenging but feasible surgical option. Results from a retrospective case-series analysis

Tumours of the small intestine are rare and account for about 5% of gastrointestinal tract neoplasms. The angle of Treitz (AT) could be defined as the intestinal loop comprised between the third duodenal portion and the first 10 cm of jejunum. A gold standard surgical treatment for AT neoplasm has not yet been well defined. This paper is focused on a very rare disease and at the best of our knowledge this is the largest case series in the literature about the Laparoscopic Segmental Resection (LSR) of AT tumours. Using a prospectively collected database, all data of consecutive patients, from January 2007 to May 2019, who underwent LSR for AT tumours at two different institutions were analysed. Patients' demographics, intra and post-operative data, 30-day mortality and overall survival were collected. A total of 16 patients were retrieved from our database. The mean operative time was 206,5 ± 79 min. Conversion to open surgery was needed in two cases due to tumor size and, respectively, invasion of the transverse colon which required a multivisceral resection. The mean distal and proximal resection margins were 7.4 ± 2.2 and 3.9 ± 1.2 cm. The median number of harvested nodes was 9 ± 3. Pathological diagnosis was GIST in 11 cases, adenocarcinoma in 4 and sarcoma in 1 case. In conclusion, in experienced hands, LSR appears to be a safe and effective treatment option for tumours of the AT. Prospective studies are needed to confirm these findings.

The Role of Neoadjuvant Versus Adjuvant Therapy for Duodenal Adenocarcinoma: A National Cancer Database Propensity Score Matched Analysis

INTRODUCTION

Adjuvant therapy is recommended in duodenal adenocarcinoma (DA), but the role of neoadjuvant therapy remains undefined. We compared the effect of neoadjuvant therapy to adjuvant therapy on overall survival, 30-day, and 90-day mortality following the resection of DA.

METHODS

A retrospective review of the National Cancer Database was performed on patients with DA who received either adjuvant or neoadjuvant therapy in addition to surgical resection. Propensity score matching was done for patient, socioeconomic, and tumor characteristics. Overall survival, 30-day, and 90-day mortality were compared.

RESULTS

A total of 112 patients were identified; 55 received adjuvant therapy; 57 received neoadjuvant therapy. There was no difference in 30-day (0% vs. 1.75%; P = 1.00), 90-day mortality (1.82% vs. 7.02%; P = .36), nor overall survival (1 yr: 86% vs. 76; 3 yr: 49% vs. 46%; 5 yr: 42% vs. 39%; P = .28).

CONCLUSIONS

There was no difference in overall survival after propensity score matched analysis.

Simple Versus Radical Resection for Duodenal Adenocarcinoma: A Propensity Score Matched Analysis of National Cancer Database

BACKGROUND

Duodenal adenocarcinoma treatment consists of either simple or radical surgical resection. Existing evidence suggests similar survival outcomes between the two but is limited by small numbers and single-institution analysis. We aim to compare survival after partial versus radical resection for duodenal adenocarcinoma using the National Cancer Database (NCDB).

METHODS

Using NCDB results from 2004 to 2014, we compared patients with duodenal adenocarcinoma undergoing partial resection (n = 1247) and radical resection (n = 1240) by age, sex, facility type, facility location, cancer stage, cancer grade, lymph node sampling, node status, tumor size, margin status, neoadjuvant therapy, and adjuvant therapy using chi-square analysis. Survival was compared using propensity matching.

RESULTS

Patients undergoing partial resection had overall earlier cancer stage, more favorable tumor grade, and were less likely to undergo lymph node sampling and neoadjuvant therapy. When overall survival was compared between the 2 propensity-matched groups, the median survival was 46.7 months after partial resection and 43.2 months after radical resection (P = .329), and overall survival was similar between the 2 groups (P = .894). The use of adjuvant therapy demonstrated improved survival over either surgery alone (P < .0001, P = .0037).

CONCLUSION

Partial resection did not demonstrate worse survival outcomes than radical resection for duodenal adenocarcinoma. The use of adjuvant therapy in addition to surgery demonstrated improved survival regardless of surgery type and played a larger role in survival than the type of surgery. Our findings provide evidence to support the continued use of both partial and radical surgical resections to treat duodenal malignancy.

Clinical comparative analysis of various duodenal diseases in different age groups

BACKGROUND/AIMS

This study aimed to investigate the differences and relevance of various common duodenal diseases in different parts in the aspects of age, gender, helicobacter pylori (H. pylori) infection, application of nonsteroidal anti-inflammatory drugs (NSAIDs), smoking, or alcohol consumption.

MATERIALS AND METHODS

The medical records of various duodenal diseases were collected and tested for difference using the χ2 test or the Fisher exact probability method.

RESULTS

1) The proportions of duodenal ulcer (DU), inflammation, and duodenal bulb diseases in the adult group (A) (47.98%, 36.70%, and 66.63%) were higher than those in the elderly group (E) (41.38%, 29.83%, and 56.82%), but the proportions of duodenal diverticulum (DD) and tumor diseases in the descending and ascending segments (2.95%, 1.43%, 9.14%, and 0.14%) were lower than those in group E (13.73%, 3.69%, 19.41%, and 0.76%) (p<0.001). 2) The positive rate of H. pylori (63.64%) in the duodenal bulb diseases was higher than that in the bulb-descending segment (53.75%), but the application rate of NSAIDs (16.44%) in the duodenal bulb-descending diseases was lower than that in the descending segment (24.81%) (p<0.001).

CONCLUSION

1) DU, inflammation, and duodenal bulb diseases are common in adults, but DD and tumor diseases in the descending and ascending segments are more common in the elderly. 2) Compared with the duodenal bulb-descending diseases, the application of NSAIDs has greater impact on the diseases in the descending segment, and the rate of H. pylori infection is higher in duodenal bulb diseases.

Immune infiltrating cells in duodenal cancers

Background

Duodenal adenocarcinoma (DA) is a rare yet aggressive malignancy, with increasing incidence in the last decades. Its low frequency has hampered a thorough understanding of the pathogenesis of the disease and of its biology, limiting the identification of tailored therapeutic options. A large body of evidence has clearly shown the clinical relevance of immune cells in solid tumors, correlating immune features with post-surgical prognosis. The aim of this study was to analyze the immune contexture in a cohort of duodenal adenocarcinomas surgically resected at our Institution and define its correlation with clinical variables.

Methods

Tissue slides from paraffin-embedded tumor specimens of 15 consecutive DA and 3 adenomas that underwent a pancreaticoduodenectomy in our center between 2010 to 2018 were immunohistochemically stained. The density (percentage of immune reactive area, IRA%) of immune markers CD45RO, CD8, CD20, IL-17, PD-1, CD68 was quantified by computer-assisted image analysis. Demographic, clinical, histopathological data were collected.

Results

In our population, median IRA % (IQR) of immune subsets was respectively CD45RO-TILs 2.19 (2.14), CD8-TIL 0.42 (0.81), CD20-TILs 0.22 (0.51), CD20-TLT 2.84 (4.64), CD68-TAM 2.19 (1.56), IL17⁺ cells 0.39 (0.39), PD1-TILs 0.19 (0.41). The median follow-up was 47.5 (22.4–63.3) months. At statistical analysis, the density of CD8-TILs inversely correlated with lymph node ratio (p = 0.013), number of metastatic lymph nodes (p = 0.019), and was lower in N+ adenocarcinomas compared to N0 (1.07 vs 0.29; p = 0.093), albeit not significantly. Stratifying patients for the N status, the density of CD8-TILs decreased with the increasing of the N stage (p = 0.065) and was lower in patients who experienced recurrence and died for the disease (0.276 vs 0.641; p = 0.044). Notably, also CD68-TAM distribution was different in patients who had recurrence versus patients who did not (1.028 vs 2.276; p = 0.036).

Conclusions

Immune cells showed variable expression in correlation with common prognostic factors, suggesting T cell infiltration may play a protective role towards lymphatic spread of disease and nodal metastatization. Furthermore, T cell density and macrophage infiltration were associated to a lower risk of recurrence and disease related death. A multicentric approach may be indicated to allow analysis of larger cohorts of patients, potentially increasing the power of our observations.

The role of autofluorescence, photodynamic diagnosis and Photodynamic therapy in malignant tumors of the duodenum

This article presents the current state of knowledge and a review of the literature in terms of the prevalence, etiopathogenesis, differential diagnosis, management, prognosis, and treatment of malignant tumors of the duodenum. The role of autofluorescence and photodynamic diagnosis as an emerging treatment method for rarely o ccurring duodenal malignant neoplasms .. We selected publications which can be found in databases such as The National Center for Biotechnology Information, U.S. National Library of Medicine (PubMed), The American Chemical Society, The American Association of Pharmaceutical Sciences and The American Society for Photobiology and The Canada Institute for Scientific and Technical Information.

Primary Duodenal Adenocarcinoma: Uncommon Tumor, Uncommon Presentation. A Case Report and Review of the Literature

Introduction

The symptoms of primary duodenal adenocarcinoma, which is a rare but aggressive tumor, are vague and nonspecific and often result in a delayed diagnosis or misdiagnosis. This results in a tumor being diagnosed at an advanced stage when it becomes unresectable secondary to local and distant spread.

Case Presentation

A 64-year-old Nepalese female presented to our hospital with epigastric pain, anorexia, and significant weight loss that developed over two-and-a-half months. Upper gastrointestinal endoscopy showed an ulceroproliferative growth in the first part of the duodenum with no features of duodenal stenosis. Contrast-enhanced computed tomography of the abdomen revealed heterogeneously enhancing, circumferential, asymmetrical thickening in the first part of the duodenum and multiple liver metastases. Biopsy of the mass revealed features suggestive of moderately differentiated adenocarcinoma of the duodenum. She was managed with palliative care during her hospital stay. The unique presentation in our case was that the tumor did not cause stenosis and the patient could consume food till the last day of her life.

Conclusion

In patients with primary duodenal adenocarcinoma, the non-stenotic lesion is also a possibility. Clinicians should always maintain a high degree of suspicion to avoid the delay in diagnosis or misdiagnosis.

A case report of paraneoplastic syndrome in β-hCG-secreting duodenal adenocarcinoma

Human chorionic gonadotropin (hCG) is a glycoprotein hormone that is used in clinical practice to detect pregnancy and serves as a sensitive marker for trophoblastic tumors. Other organs besides placental trophoblasts naturally express the hormone at low levels, which can be elevated in nontrophoblastic malignancies. Some studies have suggested that elevated β-hCG levels in nontrophoblastic tumors are a sign of aggressive disease and strongly associated with poor prognosis. We describe a case of a 50-year-old post-menopausal woman with metastatic duodenal adenocarcinoma who presented with a negative pregnancy test that later changed to positive. Biopsy of the primary duodenal mass showed positive immunohistochemical expression of β-hCG. The patient was also found to have multiple brain metastases, which is uncommon in gastrointestinal cancer. This is a rare case of paraneoplastic syndrome in a β-hCG-secreting duodenal adenocarcinoma.

Adenocarcinoma of the duodenum arising from Brunner's gland resected by partial duodenectomy: a case report

Background

Duodenal carcinoma originating in Brunner’s gland is rare. Herein, we report a case of duodenal carcinoma arising from Brunner’s gland in a 63-year-old man.

Case presentation

On diagnostic imaging, the lesion presented as a non-invasive carcinoma; the patient also had uncontrolled diabetes and liver cirrhosis. Hence, we decided to perform partial duodenectomy to reduce operative stress. Pathological examination revealed that the tumor consisted of tissue from Brunner’s gland. Additionally, the carcinoma cells were strongly positive for Mucin-6 protein, which is an epithelial marker of Brunner’s gland. The patient’s post-operative course was uneventful, and he has been well for 2 years after the surgery.

Conclusions

This a rare case of an adenocarcinoma arising from Brunner’s gland of the duodenum that was resected by duodenectomy.