Metastatic clear cell endometrial carcinoma: an unusual cause of a common clinical presentation.

A 60-year-old woman presented with melena for 2 weeks. She had undergone hysterectomy and bilateral salpingo-oophorectomy to treat clear cell endometrial carcinoma 10 months before the presentation. She was anaemic and tachycardic; abdominal CT scan revealed a large duodenal mass. Her gastrointestinal bleed was not amenable to endoscopic intervention, so she had emergent laparotomy, pancreaticoduodenectomy with duodenal mass excision. Histopathology confirmed that the duodenal mass was a metastatic deposit from her clear cell endometrial cancer. Postoperatively, she was frail and chose hospice care and she died 90 days postoperatively. Clear cell endometrial cancer is a rare subtype of endometrial cancer, that has a worse prognosis compared with the more common endometrioid subtype. The duodenum is a rare site for metastatic endometrial cancer, and we report this case to alert clinicians to the possibility of metastases to the small intestine in patients with clear cell endometrial cancer.

A Rare Presentation of Choledochoduodenal Fistula Due to Ovarian Cancer Metastasis.

Choledochoduodenal fistula (CDF) is an abnormal communication between the common bile duct and the duodenum. It accounts for about 5% to 25% of the total biliary fistulas and is usually due to a perforated duodenal ulcer, choledocholithiasis, and complications secondary to tuberculosis or could be iatrogenic. Primary intrabilliary tumors usually cause obstructive jaundice and rarely biliary metastasis arising from other organs like colon, breast, and lungs can cause obstructive jaundice. There has been a case report of metastasis from ovarian cancer to the major papilla of the duodenum but no reported cases of it causing a CDF. We report a rare case of an 83-year-old female with ovarian cancer who developed a metastatic lesion to the duodenum eventually resulting in a CDF.

Evaluation of duodenal perfusion by contrast-enhanced ultrasonography in dogs with chronic inflammatory enteropathy and intestinal lymphoma.

BACKGROUND: Contrast-enhanced ultrasonography (CEUS) can be used to evaluate intestinal perfusion in healthy dogs. It is helpful for diagnosing and monitoring inflammatory bowel disease in humans and could be useful for dogs with chronic intestinal diseases. OBJECTIVES: To examine duodenal perfusion in dogs with chronic inflammatory enteropathy (CIE) and intestinal lymphoma. ANIMALS: Client-owned dogs with CIE (n = 26) or intestinal lymphoma (n = 7) and dogs with gastrointestinal signs but histopathologically normal duodenum (controls, n = 14). METHODS: In this cross-sectional study, dogs with CIE were classified into remission (n = 16) and symptomatic (n = 10) groups based on clinical scores determined at the time of CEUS. The duodenum was scanned after IV injection of Sonazoid® (0.01 mL/kg). CEUS-derived perfusion parameters, including time-to-peak, peak intensity (PI), area under the curve (AUC), and wash-in and wash-out rates were evaluated. RESULTS: The PI was significantly higher in the symptomatic CIE group (median (range); 105.4 (89.3-128.8) MPV) than in the control group (89.9 (68.5-112.2) MPV). The AUC was significantly higher in the symptomatic CIE group (4847.9 (3824.3-8462.8) MPV.sec) than in the control (3448.9 (1559.5-4736.9) MPV.sec) and remission CIE (3862.3 (2094.5-6899.0) MPV.sec) groups. The PI and clinical score were positively correlated in the CIE group. No significant differences in perfusion parameters were detected between the lymphoma and CIE groups or the lymphoma and control groups. CONCLUSIONS AND CLINICAL IMPORTANCE: The PI and AUC can detect duodenal inflammation and hence are potentially useful for excluding a diagnosis of CIE.

Total robotic surgery for pancreaticoduodenectomy combined with rectal cancer anterior resection: A case report and literature review.

RATIONALE: Synchronous double malignancies, including carcinoma of the ampulla of Vater and rectal carcinoma, are generally uncommon occurrences in the gastrointestinal tract. PATIENT CONCERNS: The present study report a case of a 37-year-old man who was incidentally found to suffer from carcinoma of the ampulla of Vater and rectal carcinoma. DIAGNOSES: The duodenoscopy was performed and revealed an ulcerated and bulky ampulla of Vater, the biopsy from which revealed a moderate-differentiated adenocarcinoma, A local hospital colonoscopy confirmed a tumor located in rectal 7 cm from the anal margin and biopsy-confirmed poorly differentiated adenocarcinoma. INTERVENTIONS: About such patient treatment, both open and laparoscopic surgery are restricted because of operation complexity, large injury, and poor cosmetic effect. surgery performed using Da Vinci robotic surgical system (DVSS). OUTCOMES: No evidence of recurrence or relapses was found in the first year after surgery. LESSONS: Although sporadic double malignancies are uncommon, they should be considered when evaluating cancer patients. Complex surgery performed by robotic surgery may became surgeon's preferred treatment modality.

Primary small bowel adenocarcinoma: current view on clinical features, risk and prognostic factors, treatment and outcome.

Small bowel adenocarcinoma (SBA) is a rare but increasing cause of gastrointestinal malignancy, being both a diagnostic and therapeutic challenge. The goal of treatment is margin negative resection of a lesion and local lymphadenectomy, followed by modern adjuvant chemotherapy combinations in selected cases. Improved outcomes in patients with SBA are encouraging, but elucidation of mechanisms of carcinogenesis and risk factors as well as improved treatment for this malignancy is very needed.

Duodenal plexiform fibromyxoma as a cause of obscure upper gastrointestinal bleeding: A case report.

RATIONALE: We are reporting the first-to our knowledge-case of duodenal Plexiform Fibromyxoma causing obscure upper gastrointestinal bleeding. PATIENT CONCERNS: Plexiform fibromyxoma triggered recurrent upper gastrointestinal bleeding episodes in a 63-year-old man who remained undiagnosed, despite multiple hospitalizations, extensive diagnostic workups and surgical interventions (including gastrectomies), for almost 17 years. DIAGNOSES-INTERVENTIONS: During hospitalization for the last bleeding episode, an upper gastrointestinal endoscopy revealed an intestinal hemorrhagic nodule. The lesion was deemed unresectable by endoscopic means. An abdominal computerized tomography disclosed no further lesions and surgery was decided. The lesion at operation was found near the edge of the duodenal stump and treated with pancreas-preserving duodenectomy (1st and 2nd portion). OUTCOMES: Postoperative recovery was mainly uneventful and a 20-month follow-up finds the patient in good health with no need for blood transfusions.Plexiform fibromyxomas stand for a rare and widely unknown mesenchymal entity. Despite the fact that they closely resemble other gastrointestinal tumors, they distinctly vary in clinical management as well as the histopathology. Clinical awareness and further research are compulsory to elucidate its clinical course and prognosis.

FEATURES OF THE ADAPTATION STATUS OF THE PATIENTS WITH DIFFERENCES IN THE PREVALENCE OF CANCER PROCESS IN BILIOPANCREATICODUODENAL ZONE AND IN THE VOLUME OF A SURGICAL INTERVENTION.

The differences in the type and tension of the general unspecific adaptational reactions in cancer patients with varying prevalence of the process in biliopancreaticoduodenal zone and volume of surgical intervention were revealed. It was shown prognostic significance of the numerical score of the type and tension of the adaptational reaction a day after pancreatoduodenal resection for the development of postoperative complications.

Diagnosis of functioning pancreaticoduodenal neuroendocrine tumors.

Functioning pancreaticoduodenal neuroendocrine tumors (PD-NETs) are popular in a textbook, but they are still unfamiliar to a general clinician, and delay of diagnosis or misdiagnosis has been reported even today. It is a consensus that sporadic functioning PD-NET is cured only by surgical resection. So, early detection and early resection is the gold standard for the treatment of functioning PD-NET. Functioning PD-NETs in patients with multiple endocrine neoplasia type 1 (MEN 1) are often multiple. You should check about MEN 1 whenever you encountered multiple PD-NET. They are diagnosed in younger age than sporadic cases. In most cases they are accompanied with numerous microscopic or macroscopic nonfunctioning P-NETs, which are potentially metastatic and the most common cause of death in MEN 1 patients.

Perioperative Enteral Immunonutrition Modulates Systemic and Mucosal Immunity and the Inflammatory Response in Patients With Periampullary Cancer Scheduled for Pancreaticoduodenectomy: A Randomized Clinical Trial.

OBJECTIVES: Nutritional deficiencies and immune dysfunction in cancer patients may contribute to postoperative septic morbidity. This trial compared the effects of perioperative enteral immunonutrition (EIN) versus standard enteral nutrition (SEN) on systemic and mucosal immunity in patients undergoing pancreaticoduodenectomy for periampullary cancer. METHODS: Thirty-seven patients were randomized (EIN, n = 17; SEN, n = 20) to receive feed for 14 days preoperatively and 7 days postoperatively. Mediators of systemic immunity (interleukin 1α, tumor necrosis factor α, lymphocytes subsets, and complement components) and of mucosal immunity in duodenal biopsies, nutritional markers and parameters were evaluated. RESULTS: The groups were comparable for demographics, the concentrations of mediators of systemic and mucosal immunity at time of recruitment, and for the duration and amount of feed received. Preoperative EIN rather than SEN was associated with significant reductions in plasma tumor necrosis factor α and total hemolytic complement. Enteral immunonutrition-fed patients had significantly higher total lymphocyte count on the third postoperative day and significantly greater rise in CD4/CD8 ratio from day 3 to day 7 postoperatively compared with SEN-fed patients. CONCLUSIONS: The perioperative administration of EIN rather than SEN is associated with a favorable modulation of the inflammatory response and enhancement of systemic immunity in patients undergoing pancreaticoduodenectomy for periampullary cancer.

[The clinical features of 16 cases of primary adenocarcinoma of the third portion of duodenum].

OBJECTIVE: To summarize the clinical features of the third portion of duodenum (PATD) for improving the understanding of PATD. METHODS: Sixteen cases with PATD in Peking Union Medical College Hospital(PUMCH) were retrospectively analyzed. RESULTS: The most common symptoms of PATD were upper abdominal pain (12/16) , vomiting (9/16) and distention (7/16).On average, the disease had progressed 5.5 months (including 2.5 months of diagnostic workup) before the diagnosis was established. Patients with pathologically poorly differentiated PATD had shorter course of disease (6.5 vs 16.6 months, P = 0.56) and lower chance of cancer-directed surgery (1/8 vs 6/8, P = 0.04) than those with well differentiated PATD. The diagnostic rate was 11/14 by CT scan while only 2/7 by upper gastrointestinal radiography. Three cases were misdiagnosed as superior mesenteric artery syndrome by barium examination. CONCLUSIONS: PATD should be considered in patients presenting upper abdominal symptoms with negative gastro endoscopy and barium examination.Overall, CT scan plays a pivotal role in diagnosing PATD. Making a correct diagnosis timely can improve the outcome of PATD patients, particularly, in those with poorly differentiated pathology.

A case of lung cancer metastasized to the gastrointestinal anastomosis site where the primary gastric cancer was resected 17 years ago.

Metastasis from lung cancer, often found in the adrenal glands, bone, liver, brain, and kidneys, have been thought to be rare in the digestive system. When a metastatic tumor is found in the intestine, it is most commonly metastatic melanoma or carcinoma of the cervix uteri, ovary, or breast. Yet, intestinal metastases have been described in 11% of lung cancers at autopsy. These metastases may induce gastrointestinal perforation, obstruction, or bleeding. Patients with bleeding from small intestinal metastases secondary to lung cancer almost uniformly have poor prognoses. The lung cancer metastasized to the gastrointestinal site or location where a first primary cancer was once resected is never reported in the literature. We report the case of a 76-year-old man with a history of gastric adenocarcinoma treated by subtotal gastrectomy seventeen years ago who presented with lung cancer metastatic to the bone. One month later, he developed persistent melena due to duodenal metastases. Upper gastrointestinal endoscopy showed an ulcerative duodenal mass with bleeding. The pathohistological and immunohistochemical examinations of tissue from the pathologic fracture and the endoscopic biopsy specimen revealed metastatic poorly differentiated adenocarcinoma consistent with lung origin. The diagnosis of metastatic lung cancer can be rendered based on pathologic examination and immunohistochemical analysis, even without access to the primary lung tumor. In this case, the anastomosis site where a gastrectomy for gastric cancer was once performed might be a good niche or microenvironment for cancer cells or tumor stem cells to metastasize to.

Clinicopathological evaluation of duodenal well-differentiated endocrine tumors.

AIM: To assess the clinicopathological characteristics of duodenal well-differentiated endocrine tumors. METHODS: We examined clinicopathological characteristics in 11 consecutive patients with duodenal well-differentiated endocrine tumors treated by endoscopic therapy or surgery in our hospital from 1992 through 2007. Patients with well-differentiated endocrine tumors of the papilla of Vater or with gastrinoma were excluded. RESULTS: Three patients received endoscopic treatment, and 8 underwent surgery. In patients who received endoscopic treatment, the tumor diameter was less than 1.0 cm, with no histopathological evidence of lymphovascular invasion or invasion of the muscularis. There were no complications such as late bleeding or perforation after treatment. Among 8 patients with tumors less than 1.0 cm in diameter, 3 underwent partial resection, and 2 underwent radical surgery. Three patients had lymphovascular invasion, 1 had invasion of the muscularis, and 1 had proximal lymph node metastasis. Among 3 patients with tumors 1.0 cm or more in diameter, 1 underwent partial resection, and 2 underwent radical surgery. One patient had lymphovascular invasion, with no lymph node metastasis. After treatment, all patients are alive and have remained free of metastasis and recurrence. CONCLUSION: Duodenal well-differentiated endocrine tumors less than 1.0 cm in diameter have a risk of lymphovascular invasion, invasion of the muscularis, and lymph node metastasis, irrespective of procedural problems.

Features of duodenal cancer in patients with familial adenomatous polyposis.

BACKGROUND & AIMS: Most patients with familial adenomatous polyposis (FAP) develop duodenal adenomas; duodenal cancer is a major cause of mortality in this patient group. We reviewed cases of duodenal cancer in patients with FAP to identify factors that determine long-term cancer risk. METHODS: Twenty FAP patients (12 male) were identified from a registry database search. Data from registry and medical notes and endoscopic and histopathologic reports were evaluated. RESULTS: Of the cancers that developed in these patients, 11 were ampullary and 9 were duodenal. The median age at cancer diagnosis was 53 years. Seventeen patients died (median age at death, 57 y; median survival from diagnosis, 11 mo); the cause of death was metastatic or duodenal/ampullary cancer in 14 patients. Fifteen patients presented symptomatically (including 3 interval cancers while on surveillance). Two were diagnosed at surveillance and 3 were diagnosed during surgery performed for endoscopic features of advanced benign disease. Duodenal cancers were associated with a significantly lower mean colonic polyp count than ampullary cancers (496 +/- 282 vs 1322 +/- 735; P = .025); there appeared to be familial clustering of this cancer. When endoscopic data were available (n = 11 of 20), all ampullary cancers arose from ampullas greater than 1 cm. The Spigelman stage did not predict risk of ampullary cancer but did predict duodenal cancer (median stage 2 vs stage 4 for duodenal cancer). CONCLUSIONS: Once cancer arises in patients with FAP, prognosis is poor, so cancer prevention should be the main goal. Surveillance intervals should reflect both Spigelman staging and ampullary disease.

Functional and morphological changes in pancreatic remnant after pancreaticoduodenectomy.

OBJECTIVES: Pancreatic exocrine insufficiency has been reported to be more common in pancreaticogastrostomy (PG) than in pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD). This study aimed to evaluate the long-term outcome after PD between these 2 groups. METHODS: We evaluated the long-term functional status of 42 surviving patients diagnosed with periampullary lesions who underwent PJ or PG after PD and followed up for more than 1 year. Among these, 23 patients underwent PJ and 19 patients underwent PG. To compare the 2 groups, we analyzed the (1) pancreatic exocrine insufficiency by questioning the presence or absence of steatorrhea, (2) pancreatic endocrine function by measuring glycohemoglobin A1c, fasting blood glucose, and history of new-onset diabetes, (3) nutritional status by measuring serum total protein, albumin, cholesterol, and triglyceride, (4) gastric emptying time, (5) panendoscopic findings, (6) changes of pancreatic duct diameter by computed tomography, and (7) relaparotomy rate. RESULTS: The mean follow-up time for PG and PJ were 37 +/- 23 and 103 +/- 52 months, respectively (P < 0.05). A total of 52.4% patients developed pancreatic exocrine insufficiency, and 11.9% had new-onset diabetes. There was no significant difference between PJ and PG groups. A significantly improved postoperative nutritional state regarding serum total protein and albumin were noticed in both groups. There was no significant difference in terms of gastric emptying time, positive panendoscopic findings, and changes in pancreatic duct diameter. The pancreatic remnant-related relaparotomy rate was higher in the PJ group as compared with the PG group (17.4% vs 0%; P = 0.056). CONCLUSIONS: There is no significant difference in pancreatic exocrine or endocrine insufficiency, gastric emptying time, and positive panendoscopic findings between PJ and PG. Pancreaticojejunostomy was associated with a higher pancreatic remnant-related relaparotomy rate; however, because of a shorter follow-up in the PG group, a continuous long-term follow-up is still needed.

Duodenal MALT lymphoma presenting with obstructive jaundice: report of a case and review of the literature.

BACKGROUND: Mucosa-associated lymphoid tissue (MALT) lymphoma is a rare type of non-Hodgkin's lymphoma. The most common site for MALT lymphoma is the stomach. CASE REPORT: We are reporting a case of a 57-year-old man who presented with obstructive jaundice and was found to have duodenal MALT lymphoma. Unlike gastric MALT lymphoma which is responsive to Helicobacter pylori eradication therapy, duodenal MALT lymphoma does not have a definitive treatment. DISCUSSION: To our knowledge, this is the first report of a duodenal MALT lymphoma presenting clinically as obstructive jaundice. We describe this case to alert physicians to consider this disease in the differential diagnosis of obstructive jaundice.

Primary duodenal cancer: case report.

Primary carcinoma of the duodenum is uncommonly encountered. This is a report of a 64-year-old diabetic/hypertensive who was admitted in our unit with six months history of upper abdominal pain, vomiting on and off and weight loss of greater than 10 kgs. Endoscopy revealed complete obstruction of the third part of the duodenum. Lesion biopsy revealed moderately differentiated adenocarcinoma and associated duodenitis. A staging CT scan showed thickening of the duodenal wall over a span of six centimetres, luminal narrowing, mucosal irregularity and multiple para-vascular large nodes some greater than or equal to two centimetres. Palliative bypass surgery was suggested as the preferred mode of treatment. He underwent cholecysto-jejunostomy/jejunojejunostomy to palliate biliary and intestinal obstruction.