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Small-Bowel Adenocarcinoma
IVAN JOVANOVIC,* LUCIA C. FRY,, and KLAUS MNKEMLLER,
*Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Department of Internal Medicine
and Gastroenterology, Marienhospital, Bottrop, Germany; Otto-von-Guericke University, Magdeburg, Germany

See related article, Seirafi M et al, on page e21

in CGH.

63-year-old man with coronary artery disease and hypertension was admitted to our hospital because of progressive
shortness of breath and chest pain. The patient had several episodes of melena starting 24 hours before presentation. On clinical
examination the patient was pale. His hemoglobin level was 7.5
g/L (reference value, 1114.0) with a hematocrit of 24% (reference value, 36%52%). The remaining laboratory parameters
were within reference ranges. Esophagogastroduodenoscopy
and colonoscopy were unremarkable. An oral double-balloon
enteroscopy disclosed a circumferential, partially stenosing, jejunal tumor 80-cm distal to the pylorus (Figure A). During
surgery, a partially obstructing mass was found (Figure B).
Histology revealed a small-bowel adenocarcinoma (Figure C).
Small-bowel adenocarcinomas historically have been diagnosed
post mortem.1 However, since the introduction of capsule endoscopy and balloon-assisted enteroscopy, the diagnosis of smallbowel tumors is increasing.2 Adenocarcinomas of the small bowel
can be either primary or metastatic.2 The most common metastatic adenocarcinomas originate from the lung, breast, and kidneys.2 Primary small-bowel adenocarcinomas occur more commonly in elderly patients. However, patients with hereditary
conditions such as familial adenomatous polyposis and Peutz
Jeghers syndrome are at increased risk of developing small-bowel
adenocarcinoma in any part of the small bowel.2,3 Indeed, in
patients with familial adenomatous polyposis, jejunal adenocarcinoma is the fourth most common cancer after colon, duodenum,
and papilla of Vater.2 PeutzJeghers syndrome is associated with
specific genetic mutations on chromosome 19 (serine/threonineprotein kinase 11) and an increased lifetime risk of both gastrointestinal and extraintestinal malignancies reaching 85%, including cancer of the pancreas, lung, breast, uterine, ovaries, testis, and
any part of the luminal gastrointestinal tract, including the small
bowel.3

The most common presentation of small-bowel adenocarcinoma is abdominal pain and occult gastrointestinal bleeding.
On endoscopy, small-bowel cancer appears as a stenotic, circumferential, occasionally exulcerated mass.2 When lymphatic
invasion has occurred it is not uncommon to find that the
proximal mucosa surrounding the tumor is engorged and covered by multiple lymphangiectasias.2 The mainstay of treatment
for the small bowel is surgical resection.1 However, the prognosis is poor, with most series reporting a 5-year survival rate of
15% to 35%. Although adjuvant and palliative chemotherapy is
an option to treat these patients, because of the relative rarity of
these tumors, there are no controlled trials showing its utility.
References
1. Stang A, Stegmaier C, Eisinger B, et al. Descriptive epidemiology
of small intestinal malignancies: the German Cancer Registry experience. Br J Cancer 1999;80:1440 1444.
2. Fry LC, Neumann H, Kuester D, et al. Small bowel polyps
and tumours: endoscopic detection and treatment by double-balloon enteroscopy. Aliment Pharmacol Ther 2009;29:135142.
3. Kopacova M, Tacheci I, Rejchrt S, et al. PeutzJeghers syndrome:
diagnostic and therapeutic approach. World J Gastroenterol 2009;
15:53975408.

Conicts of interest
The authors disclose no conicts.
Funding
Ivan Jovanovic is a recipient of the American Society for Gastrointestinal Endoscopy Cook Don Wilson Award 2010. This work was
performed during his award period at the Marienhospital (Bottrop,
Germany).
2011 by the AGA Institute
1542-3565/$36.00
doi:10.1016/j.cgh.2010.11.003
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2011;9:xxviii

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