Incidental Finding of an Asymptomatic Jejunal Schwannoma: A Rare Case Report and Review of Literature.

BACKGROUND Schwannomas are tumors that arise from Schwann cells that surround and support nerve cells. Most common sites for presentations are head, neck, and extremities. Schwannomas of gastrointestinal tract are rare, slow-growing tumors, usually benign, arising from gastrointestinal tract's neural plexus. They are histologically distinguishable from conventional schwannomas that arise in soft tissue or the central nervous system. Preoperative diagnosis of gastrointestinal schwannoma is challenging, requiring immunohistological confirmation of the nature of the tumor. Here, we report a case of 57-year-old woman with an incidental finding of an asymptomatic submucosal jejunal schwannoma. CASE REPORT A 57-year-old woman with a medical history of hematological disorder underwent a contrast abdominal computed tomography as part of medical follow-up. The imaging revealed the presence of a jejunal mass. The patient underwent laparoscopic surgical resection of the lesion, followed by side-to-side jejuno-jejunal anastomosis with 4-cm clear surgical margins. The final pathologic study revealed the presence of jejunal schwannoma, as tested positive for S-100 protein. The patient was discharged home on the fourth postoperative day, having an uneventful recovery. CONCLUSIONS Jejunal schwannoma are usually benign and asymptomatic, and they are often discovered incidentally during diagnostic tests for other conditions; therefore, it should be included in the differential diagnosis of gastrointestinal tumors. Surgical treatment appears to be necessary to achieve a definitive diagnosis through a biopsy of the tumor tissue. Benign jejunal schwannomas have a good prognosis.

Unusual presentation of jejunal adenocarcinoma and ovarian metastasis.

It is rare to find a small bowel tumour presenting as intestinal obstruction. This type of cancer is an extremely unusual condition often misdiagnosed until late stages. We report the case of a patient with persistent vomiting secondary to an obstructing jejunal adenocarcinoma not related to intestinal bowel disease. After resection and chemotherapy treatment a huge mass was detected in the left ovary. The anatomopathological findings confirmed a metastatic cancer consequent to the jejunal adenocarcinoma previously resected. This case illustrates a successful outcome of a jejunal adenocarcinoma with very poor prognosis after a extremely unusual ovarian metastasis. It is highly important to suspect other causes than intestinal bowel disease when doing a differential diagnosis in a young patient presenting with clinical symptoms of intestinal obstruction.

[A Case of Primary Jejunum Cancer Mimicking Superior Mesenteric Artery Syndrome].

In this report, we described a case of jejunum cancer that presented with abdominal pain and vomiting as chief complaints, which mimicked superior mesenteric artery syndrome. An elderly woman in her 70s was referred to our department for prolonged abdominal discomfort. Findings from CT and abdominal echo indicated that superior mesenteric artery syndrome may be responsible for jejunum cancer. Upper gastrointestinal endoscopy revealed a peripheral type 2 lesion in the upper jejunum. Upon biopsy, the patient was diagnosed with adenocarcinoma(papillary type). Surgical resection of the small intestine was performed. Although small intestinal cancer is a fairly rare disease, it should be considered a differential diagnosis. Comprehensive evaluations including medical history and imaging should be considered.

Obscure gastrointestinal bleeding from a large jejunal lipoma treated using an endoscopic unroofing technique with double balloon enteroscopy: a case study.

Small intestinal lipomas are rare, but may cause obscure gastrointestinal bleeding. The endoscopic unroofing technique excises only the upper third of the lipoma and allows both histological confirmation and complete treatment with minimal risk of perforation. We present a rare case of obscure gastrointestinal bleeding caused by a jejunal lipoma. A 75-year-old man on antiplatelet therapy presented to our department with melena and anemia. Computed tomography revealed he had a 45-mm jejunal submucosal tumor with fat attenuation. Endoscopic resection using an endoscopic unroofing technique with double balloon enteroscopy was successfully performed. The tumor was confirmed to be a lipoma.

Current Oncologic Standards for Surgery of Small Bowel Cancers.

PURPOSE: The last 2 decades has witnessed efforts towards standardization of surgery for small bowel cancers. The proposed recent guidelines/recommendations pertaining to choice of procedure and extent of lymphadenectomy are based on analysis of data from high volume centres of excellence. We evaluated whether these recently proposed oncologic recommendations can be replicated in the setting of single centre/team. METHODS: This was a retrospective analysis of consecutive adult patients (age ≥ 18 years) who underwent surgery for tumours of small intestine (duodenum, jejunum, and ileum) by the same team of surgeons from 01/01/2010 to 12/31/2019. The procedure performed and lymph nodes harvested during pathologic examination were compared with recent recommendations. RESULTS: Of the 32 patients (20 males and 12 females), mean age was 52.4 (range 31-77) years. Twenty-nine (90.6%) patients underwent surgery for small bowel cancers. Duodenum was the most common site, while NET was the commonest cancer. Whipple's procedure was performed for tumours of II part of duodenum, while for the rest, segmental resection was performed. The median number of lymph nodes examined for duodenal adenocarcinoma and NET was 14 and 9, respectively. For jejunal/ileal adenocarcinoma, median lymph node number examined was 11. CONCLUSION: Our study shows that these recently proposed standards for surgery of small bowel cancers are achievable if basic principles of oncologic surgery are followed.

Surgical resection of undifferentiated pleomorphic sarcoma (UPS) with jejunal perforation, a suspected case of metastasis of lung cancer.

Undifferentiated pleomorphic sarcoma (UPS) in the gastrointestinal tract is rare. According to the diagnostic criteria after the World Health Organization 2013 reclassification, there has been only one case of UPS with perforation of the gastrointestinal tract. A 71-year-old man who was undergoing outpatient chemotherapy at the department of respiratory medicine of our hospital for lung cancer and brain metastasis, was admitted to our hospital with sudden high fever and abdominal pain. A computed tomography scan showed free air in the abdominal cavity with thickening of part of the jejunal wall. We suspected jejunal metastasis of lung cancer and performed emergency surgery for acute peritonitis due to gastrointestinal perforation in the same area. A Bormann type 2 tumour was found in the jejunum with perforation. The histopathological diagnosis was UPS. Ten months have passed since the surgery, and there has been no recurrence of UPS and no significant change in lung cancer. Primary UPS of the gastrointestinal tract is rare, and cases with perforation are extremely rare. Currently, ten months have passed since the surgery, and no recurrence has been observed. We encountered a case of UPS in which it was difficult to distinguish metastasis from lung cancer to the jejunum, and the emergency surgery gave us the chance to confirm the definitive diagnosis and save the patient's life.

An atypical presentation of small bowel adenocarcinoma; a case report.

Small bowel malignancy (SBM) is a rare malignancy in the gastrointestinal tract. Duodenum is the most commonly involved segment and the most common histological subtype is adenocarcinoma (40%). Due to a lack of screening tools and vague symptoms, its clinical detection is very challenging. A 27-year-old man presented at the surgical emergency of Lahore General Hospital in February 2019 with non-specific gastrointestinal symptoms (vomiting, abdominal pain), for which he had previously visited the hospital multiple times. Later, on further workup, he had been diagnosed as a case of intussusception on CT scan. On exploration, he had an impassable stricture in the jejunum. Resection anastomosis of the jejunum was done, but later, on histopathology it turned out to be adenocarcinoma. Adenocarcinoma of the small bowel is a rare entity, and, particularly in Pakistan, the available literature is limited. SBM should be included in the differentials of patients with vague abdominal symptoms. Future studies for the evaluation of new investigations and treatment modalities should be encouraged to improve the overall outcome of the patients.

Preoperative serum chromogranin-a is predictive of survival in locoregional jejuno-ileal small bowel neuroendocrine tumors.

BACKGROUND: Small bowel neuroendocrine tumors (SB-NET) frequently metastasize to regional lymphatic or distant sites. Although most prognostication of SB-NET focuses on lymph node involvement, findings from studies of neuroendocrine tumors from other primary sites have suggested that preoperative serum chromogranin-A (CgA) levels may provide a more accurate metric. METHODS: Using the National Cancer Database (2004-2016), we analyzed patients with locoregional SB-NET who underwent curative resection including an adequate lymphadenectomy (n = 1,274). A statistically optimized cut-point was used to dichotomize CgA cohort based on preoperative serum CgA levels. RESULTS: We determined that a CgA ≥139 ng/mL identified patients with significantly shorter estimated mean overall survival (6.6 years vs 7.6 years, log-rank P = .00001). These patients were also older (63 vs 57 years, P < .001) and had higher rates of poorly differentiated tumors (2.1% vs 0.7%, P = .04) or primary tumors >1 cm (88.2% vs 79.2%, P = .001). Clinical features associated with shorter overall survival included preoperative CgA ≥139 ng/mL (HR = 2.19, 95% CI 1.22-3.92; P = .009), age at diagnosis (HR = 1.06, 95% CI 1.03-1.09; P < .001), Charlson-Deyo score ≥2 (HR = 3.93, 95% CI 1.71-9.01; P = .001), and poorly differentiated tumors (HR = 11.22, 95% CI 4.16-30.24; P < .001). Neither lymph node metastasis nor T-stage were independently associated with shorter overall survival in patients with locoregional SB-NET. CONCLUSION: Elevated preoperative serum CgA is an adverse prognostic marker associated with shorter overall survival in patients with locoregional SB-NET.

Tumor Microenvironmental Prognostic Risk in Primary Operable Small Intestinal Adenocarcinoma.

The tumor microenvironment (TME) has become an important area of investigation with respect to improving prognosis in malignancies. Here we evaluated TME prognostic risk in small intestinal adenocarcinomas based on histologic assessment of tumor budding at the peritumoral-invasive front (pTB) and stromal tumor-infiltrating lymphocytes (sTILs). pTB and sTILs were analyzed in 230 surgically resected small intestinal adenocarcinomas, as recommended by the International Tumor Budding Consensus Conference (ITBCC) and the International TILs Working Group (ITWG). On the basis of high levels of pTB count (≥10) and sTIL density (≥20%), we combined pTB and sTIL to produce a collective TME-based prognostic risk index: low-risk (pTBLow/sTILHigh; n=39, 17.0%), intermediate-risk (pTBLow/sTILLow or pTBHigh/sTILHigh; n=99, 43.0%), and high-risk groups (pTBHigh/sTILLow; n=92, 40.0%). TME risk index provided better prognostic stratification than the individual pTB and sTIL (14.9 vs. 6.7 vs. 10.3). Tumors with higher TME prognostic risk were associated with an infiltrative growth pattern and nonintestinal immunophenotype (both P=0.001), pancreatic invasion (P=0.010), lymphovascular (P<0.001) or perineural invasion (P=0.006), higher T-category (P<0.001), N-category (P=0.004), and stage grouping (P=0.002), and KRAS mutation (P=0.008). In multivariate analysis, higher TME prognostic risk index (P<0.001), distal tumor location and nonintestinal immunophenotype (both P=0.001), higher N-category (P<0.001), and microsatellite stable (P=0.015) were worse-independent prognosticators. TME prognostic risk index consistently stratified patient survival regardless of tumor location (P<0.001 in proximal; P=0.002 in distal), stages (P<0.001 in lower stages I to II; P=0.028 in stage III), and DNA mismatch repair gene status (P<0.001 in microsatellite stable; P=0.001 in microsatellite instability). TME risk index is a powerful prognostic predictor for risk stratification of patients with small intestinal adenocarcinoma.

[A Case of Primary Jejunal Cancer Treated with Laparoscopic Jejunectomy with Appearance of Ileus].

An 83-year-old man visited our hospital for vomiting. Chest-abdominal computed tomography(CT)revealed that a tumor whose inside was imaged in the jejunum about 15 cm after leaving the Treitz ligament was pointed out, and dilation of the oral intestinal tract of the tumor was observed. Upper gastrointestinal endoscopy showed a type 3 circumferential tumor at the jejunum. He was diagnosed with obstructive ileus due to jejunal cancer. Laparoscopic-assisted partial jejunal resection was performed. Although the patient was followed up without chemotherapy, CT showed multiple lung and liver metastases and a mass lesion was found in the right entire chest, and a biopsy revealed skin metastasis 6 months after the operation. The patient is being followed up 10 months after surgery, there is no progression of liver, lung, and skin metastasis.

A Rare Case of Well-Differentiated Neuroendocrine Tumor Arising From a Jejunal Pancreatic Heterotopia.

Pancreatic heterotopia is a well-described entity occurring at multiple abdominal sites, most commonly the stomach and small intestine. They can develop similar disease processes as the pancreas ranging from acute pancreatitis, cyst formation, or neoplasms, most commonly ductal adenocarcinoma. Neuroendocrine tumors (NETs) arising in pancreatic heterotopias are exceedingly rare with only 3 prior published cases. In this article, we describe the first reported case of a NET arising in a jejunal pancreatic heterotopia in a 59-year-old woman presenting with abdominal pain and diarrhea. The submucosal tumor was composed of a well-differentiated NET (World Health Organization grade 1) directly intermixed with a heterotopic pancreas consisting of acinar cells, islet cells, and ducts. This case illustrates that NETs can occur in association with pancreatic heterotopias at any site. Also, the importance for pathologists to recognize that pancreatic heterotopias can give rise to a variety of neoplasms and is not limited to ductal adenocarcinoma.

Unusual presentation of a giant jejunal gastrointestinal stromal tumor.

AIM: Gastrointestinal stromal tumours (GISTs) are rare tumours. Tumour rupture is an additional adverse prognostic factor and should be recorded, regardless of whether it took place before or during surgery. CASE REPORT: A case report of hemoperitoneum from spontaneous rupture of a gastrointestinal stromal tumor of the jejunum is presented. The patient underwent an urgent laparotomy. An "en bloc" resection was performed. CONCLUSION: The information in the literature is examined. Spontaneous rupture of the tumor with concomitant hemoperitoneum is an important prognostic factor in these patients. The hemoperitoneum contributes to a worse prognosis because of its ability to produce peritoneal seeding KEY WORDS: Gist.

[Inflammatory fibroid polyp in the jejunum - a case report].

Inflammatory fibroid polyps (IFP) are rare type of benign tumours found in the gastrointestinal tract. IFP´s are in most cases small in size and without symptoms but can cause intussuception and haemorrhage. We present a case of a 25 year old female who presented with abdominal pain and symptoms and signs of anemia, hemoglobin was 36 g/L upon arrival. Further workup revealed a large tumor in the small intestine. The patient underwent a partial resection of the proximal jejunum. Pathology of the specimen showed inflammatory fibroid polyp.

Jejunal hemolymphangioma: A case report.

RATIONALE: Hemolymphangioma is a benign tumor comprised of the newly-formed lymph spaces and blood vessels, which can usually be found in the head and neck of the affected children. There are few reports regarding cases with hemolymphangioma in small intestine, spleen, esophagus, and other organs. PATIENT CONCERNS: Herein, a 55-year-old woman was presented in this study, she had complained of discomfort in the right upper abdomen for 2 months, and was discovered with a space-occupying lesion in proximal jejunum on computed tomography (CT). Eventually, the lesions were confirmed through double-balloon enteroscopy (DBE) to be located in the jejunum 60 cm away from the Treitz ligament. DIAGNOSE: Subsequently, the small intestine was partially resected, and postoperative pathology had confirmed the diagnosis of small intestinal hemolymphangioma. INTERVENTIONS: Excisional surgery of the lesion was planned. On surgery, the lesions were discovered to be about 33 cm to 22 cm when engorged the superficial vessels. No enlarged lymph nodes were seen at the root of the mesentery, and no obvious lesion was observed in the remaining small intestine. OUTCOMES: Follow-up for 6 months showed no recurrence. LESSONS: Hemolymphangioma lacks typical clinical symptoms, and the correct preoperative diagnosis of hemolymphangioma remains challenging. Due to the increasing use of endoscopic diagnostic techniques, it is expected that hemolymphangioma in gastrointestinal tract may be detected and endoluminal located before surgery more feasibly. This case report aimed to highlight the contributions of CT and DBE to an accurate preoperative diagnosis and surgical strategy planning.