Edit concept Question Editor Create issue ticket

Duodenal Carcinoma

Carcinoma of the Duodenum

Duodenal carcinoma is a very rare tumor of the gastrointestinal tract but is one of the most common arising from the small intestine. Tumors can develop in any duodenal segment, and the nonspecific clinical presentation of gastrointestinal complaints is the primary reason why it is often recognized late and why a poor prognosis is expected in many cases. Both invasive and noninvasive imaging studies are used to confirm the diagnosis.


Presentation

Duodenal carcinoma (also known as duodenal adenocarcinoma, as the tumor arises from the glandular part of the epithelium) comprises less than 1% of all tumors from the gastrointestinal (GI) tract, but up to 55% of all small intestinal adenocarcinomas originate in the duodenum, suggesting its rather important place among neoplastic tumors of the GI tract [1] [2] [3] [4] [5]. Tumors may arise in any of the four duodenal segments - superior (I), descending (II), inferior (III) and ascending (IV), with respective variations in terms of frequency across different reports [3] [5] [6]. The clinical presentation of duodenal carcinoma is nonspecific, which supported by the fact that abdominal pain is the principal complaint [1] [3] [4]. Accompanying features are weakness, fatigue, GI bleeding and obstruction, weight loss, jaundice, nausea and vomiting [1] [3]. Unfortunately, lack of clinical suspicion toward duodenal carcinoma as a result of nonspecific symptoms is the reason why the diagnosis is often made up to 15 months after the appearance of symptoms, leading to a poorer prognosis and inability to perform surgical resection of the tumor, thus requiring more aggressive forms of chemotherapy that are heavily tolerated [2] [3]. Current understanding of the pathogenesis of this tumor is incomplete, but the presence of hereditary GI tract diseases, such as familial adenomatous polyposis and Gardner syndrome, as well as history of duodenal polyps, seem to increase the risk for duodenal carcinoma [1] [3].

Abdominal Pain
  • Due to persistent abdominal pain and iron deficiency anemia the patient underwent push enteroscopy which revealed adenocarcinoma of the duodenum.[ncbi.nlm.nih.gov]
  • The clinical presentation of duodenal carcinoma is nonspecific, which supported by the fact that abdominal pain is the principal complaint.[symptoma.com]
  • There can be signs like abdominal pains, weight loss, bleeding, jaundice or obstruction. There is a different diagnosis for patients who show epigastric discomfort.[duodenal.org]
  • She was apparently alright until October 2014, and thereafter, she complained of abdominal pain and vomiting (3–4 episodes per day).[ccij-online.org]
  • Most of the clinical features are non-specific and include upper abdominal pain and weight loss as the most common presenting symptoms.[radiopaedia.org]
Abdominal Mass
  • Characterize abdominal masses and adenopathy with the aid of diffusion-weighted MR imaging.[books.google.com]
  • Physical examination was unremarkable except for a vague ill-defined abdominal mass.[omicsonline.org]
  • At that point, you may notice an abdominal mass . Duodenal cancer can be classified into five major types: Diagnosing duodenal cancer can be difficult because symptoms occur in later stages of the disease. This can also make it difficult to treat.[healthline.com]
  • A palpable abdominal mass is found in less than 5% of the patients ( 5 ). Diagnosis Barium studies of the upper intestinal tract have been replaced by fiberoptic endoscopy.[ncbi.nlm.nih.gov]
  • Where the disease is advanced , the doctor’s examination may reveal: Abdominal mass/es; Enlarged lymph nodes (lymphadenopathy) Bowel obstruction; Fluid in the abdomen (ascites); Enlarged liver (hepatomegaly); and/or Lower extremity fluid accumulation[myvmc.com]
Persistent Vomiting
  • vomiting, constipation, (isolated stricture ileum) Ileum 5 cm proximal to ileo-caecal junction Histopathology of Rt.Hemicolectomy Synchronous metastases Right Hemicolectomy Recovery 8 Lee, 2011 50 IIa Epigastric pain 2 nd part duodenum Multiple biopsies[wjso.biomedcentral.com]
Conjunctival Pallor
  • On physical examination, she presented conjunctival pallor. Routine blood investigations showed leukocytosis, anemia, hypoalbuminemia, and elevation of C-reactive protein and tumor markers, with carcinoembryonic antigen being confirmed subsequently.[karger.com]
Macrocephaly
  • Further detailed clinical investigations revealed macrocephaly (63 cm), melanotic spots of the penis, small angiomas, millimetric trichilemmomas in the nose and multiple lipomas, which led to the diagnosis of Cowden/Bannayan disease.[ncbi.nlm.nih.gov]
Motor Disturbances
  • Its clinical presentation include GI bleeding, obstructive symptoms such as vomiting and epigastric bloatedness, and rarely intussusception and diarrhea, possibly due to duodenal motor disturbances [ 10 ].[omicsonline.org]

Workup

As mentioned previously, the nonspecific clinical presentation of duodenal carcinoma can be a significant challenge for the physician, but because early recognition dramatically improves overall survival, a meticulous workup should be carried out in all individuals with such complaints. The development of symptoms and their progression must be noted during history taking, and after a complete physical examination, imaging studies, considered as the cornerstone of diagnosis, need to be employed. Standard ultrasonography, computed tomography (CT) or magnetic resonance imaging (MRI) serve as first-line techniques [1] [2] [6]. To confirm duodenal carcinoma, esophagogastroduodenoscopy is the gold-standard in visualizing the tumor, but it is also beneficial because a biopsy sample can be obtained for histopathological examination during this procedure [1] [2] [6]. Upper endoscopic techniques may not always reach the site of the tumor, however, thus being unable to make the diagnosis unless specialized longer scopes are available [3]. For this reason, barium radiography of the GI tract is also recommended, as it carries a very high rate of diagnosis as well [1] [2]. A histological diagnosis is necessary, and together with CT/MRI findings, appropriate clinical staging of the tumor can be performed, which has critical implications for the choice of therapy.

Small Bowel Mass
  • View Article PubMed Google Scholar Ross A, Mehdizadeh S, Tokar J, Leighton JA, Kamal A, Chen A, Schembre D, Chen G, Binmoeller K, Kozarek R, et al: Double balloon enteroscopy detects small bowel mass lesions missed by capsule endoscopy.[doi.org]
  • This patient has multiple intraluminal small bowel masses (yellow arrows), which appeared to be metastases from an unknown primary. Also note the intussusception (red arrow) en soft tissue metastasis in the left gluteus muscle (blue arrow).[radiologyassistant.nl]
Normocytic Anemia
  • Laboratory investigations showed normocytic anemia with hemoglobin 7.1 g/dl. Liver enzymes and serum levels of the tumor markers CA19-9 and carcinoembryonic antigen were within normal range.[jmedscindmc.com]

Treatment

  • Endoscopic resection appears to be a safe and efficient treatment of carefully selected patients with early primary nonampullary duodenal carcinoma.[ncbi.nlm.nih.gov]
  • Especially, cancer-directed treatments improved patient survival.[kjim.org]
  • 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.[ncbi.nlm.nih.gov]
  • In the third and fourth part many doctors are of the opinion to give duodenal segmentectomy treatment.[duodenal.org]

Prognosis

  • Tumors can develop in any duodenal segment, and the nonspecific clinical presentation of gastrointestinal complaints is the primary reason why it is often recognized late and why a poor prognosis is expected in many cases.[symptoma.com]
  • Primary duodenal carcinoma is a distinct entity with a better prognosis than pancreatic cancer after radical resection. It favours the descending duodenum and is closely linked with villous adenoma and epithelial dysplasia.[ncbi.nlm.nih.gov]
  • The cases highlight the advanced state of the disease at presentation, the difficulty in diagnosis, and its poor prognosis. Duodenal carcinoma occurs in both sexes worldwide with no predisposing factors in the majority of cases.[ncbi.nlm.nih.gov]
  • Metastasis, poor tumor differentiation, increased depth of spread and pre-existing Crohn's disease are associated with poor prognosis. Recurrence of the tumor is also a common entity.[radiopaedia.org]

Etiology

  • ., Hammani, L. and Imani, F. (2008) Uncommon Etiological Jaundice. Feuillets de Radiologie, 5, 336-340. [ 12 ] Pilleul, F., Crombe Ternamian, A. and Fouque, P. (2004) Examining the Small Bowel by Cross Sectional Imaging Techniques.[scirp.org]
  • Adenocarcinomas account for 75% of all primary duodenal malignancies, including leiomyosarcoma, lymphoma, and carcinoid tumors. 2 The first case of duodenal adenocarcinoma was described in 1746; since then, more than 800 cases have been reported. 3,4 Etiology[consultant360.com]
  • No definite etiologic factors are apparent in the cases reported. Age incidence averages around fifty years. A casual perusal of the literature discloses about one hundred cases.[pubs.rsna.org]
  • Definition / general By definition, centered in ampulla of Vater, arises from ampullary intestinal mucosa If advanced, cannot distinguish tumor origin between ampulla, distal common bile duct or pancreas Etiology May arise from villous adenoma or villoglandular[pathologyoutlines.com]
  • There is little conclusive information regarding risk factors and the exact etiologies for the duodenal cancer ; however those thought to play an important role are: Diet containing high amount of fat.[health-treatment.com]

Epidemiology

  • As suggested by two recent major epidemiological studies on patients with small bowel neoplasms (SBN) identified from the National Cancer Data Base (NCDB, 1985-2005) and the Surveillance Epidemiology End Results (SEER, 1973-2004) database [ 3 ] as well[doi.org]
  • Department of Epidemiology and Biostatistics Memorial Sloan-Kettering Cancer Center New York USA 4. Department of Surgery Memorial Sloan-Kettering Cancer Center New York USA[doi.org]
  • Small bowel adenocarcinoma: Epidemiology, risk factors, diagnosis and treatment.[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology Approximately 64% of all small-bowel tumors are malignant, and approximately 40% of these tumors are adenocarcinomas. Epidemiologically, small-bowel adenocarcinomas have a striking resemblance to large-bowel adenocarcinomas.[emedicine.medscape.com]
  • PDF Version Xiaodong Feng Anti-Angiogenesis Therapy for Cancer Treatment: An Overview for Clinicians PPT Version PDF Version Muhammad Attique khan Shahid Nuclear Physics PPT Version Aly-Moussa Virology PPT Version PDF Version Sivaramakrishna Koganti Pathophysiological[omicsonline.org]
  • Pathophysiology The periampullary region is anatomically complex, representing the junction of 3 different epithelia, pancreatic ducts, bile ducts, and duodenal mucosa.[emedicine.medscape.com]
  • Pathophysiology Ooi et al identified three oncogenic pathways that are deregulated in the majority ( 70%) of gastric cancers: the proliferation/stem cell, NF-kappaβ, and Wnt/beta-catenin pathways.[emedicine.medscape.com]

Prevention

  • Causes, Risk Factors, and Prevention Learn about the risk factors for small intestine cancer and what you might be able to do to help lower your risk. Early Detection, Diagnosis, and Staging Know the signs and symptoms of small intestine cancer.[cancer.org]
  • For example, drugs can be given to help prevent or reduce nausea and vomiting. For more information about chemo and its side effects, see Chemotherapy .[cancer.org]
  • A prophylactic colectomy is recommended in early adulthood to prevent the development of colorectal cancer.[cebp.aacrjournals.org]
  • The Centers for Disease Control and Prevention (CDC) estimates that approximately two-thirds of the world’s population harbors the bacterium, with infection rates much higher in developing countries than in developed nations.[cancer.gov]
  • Stomach Cancer (Adenocarcinoma of the Stomach) Prevention Preventative measures for gastric cancer include eating a diet high in fruits and vegetables ( 5 serves/day) to provide an adequate intake of antioxidants .[myvmc.com]

References

Article

  1. Cloyd JM, George E, Visser BC. Duodenal adenocarcinoma: Advances in diagnosis and surgical management. World J Gastrointest Surg. 2016;8(3):212-221.
  2. Kumar SP, Pavan Kumar A. Carcinoma in the fourth part of the duodenum. Can J Surg. 2009;52(3):E69-E70.
  3. Usuda D, Hashimoto Y, Muranaka E, Okamura H, Kanda T, Urashima S. Primary Duodenal Adenocarcinoma without Stenosis: A Case Report with a Brief Literature Review. Case Rep Oncol. 2014;7(2):444-451.
  4. Kim MJ, Choi SB, Han HJ, et al. Clinicopathological analysis and survival outcome of duodenal adenocarcinoma. Kaohsiung J Med Sci. 2014;30(5):254-259.
  5. Bandyopadhyay A, Das M, Kundu SK. Metastatic Primary Duodenal Adeno-Carcinoma Responding to Metronomic Oral Cyclophosphamide Chemotherapy. Indian J Palliat Care. 2014;20(3):239-242.
  6. Sista F, Santis GD, Giuliani A, et al. Adenocarcinoma of the third duodenal portion: Case report and review of literature. World J Gastrointest Surg. 2012;4(1):23-26.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2019-06-28 11:36