Small bowel adenocarcinoma: revisited
Keywords:Small bowel malignancy, Small bowel adenocarcinoma, Small bowel resection, FOLFOX
Small bowel malignancies are rare despite it representing 75% of the gastro intestinal (GI) length and 90% of the mucosal surface area. Even then small bowel adenocarcinoma (SBA) accounts for only 30-40% of all small intestine malignancies. Etiology is multifactorial and risk factors include hereditary mutations, inflammatory bowel diseases, coeliac disease. Presenting symptoms are vague and nonspecific and cannot usually be diagnosed by conventional upper and lower GI endoscopy as it is in an inaccessible location. This leads to delayed diagnosis and hence poor prognosis. Mainstay of treatment is surgical resection with adjuvant chemotherapy in advanced disease. We present a case study of a 74 years old woman who presented to the emergency department with small bowel obstruction and radiological features suggestive of underlying small bowel malignancy. She underwent urgent laparotomy with segmental small bowel resection and had intraoperative evidence of wide spread metastasis which was confirmed on subsequent tumor staging scans. She received adjuvant chemotherapy with complete metabolic response at one year post resection. SBA is generally diagnosed at advanced stage due to its anatomical location. Complete surgical resections should always be targeted. However, adjuvant chemotherapy plays a role in advanced disease even though clinical data of evidence is scarce.
Overman MJ. Rare but real: management of small bowel adenocarcinoma. Am Soc Clin Oncol Educ Book. 2013;189-93.
Hutchins RR, Bani Hani A, Kojodjojo P, Ho R, Snooks SJ. Adenocarcinoma of the small bowel. ANZ J Surg. 2001;71(7):428-37.
Howe JR, Karnell LH, Menck HR, Scott‐Conner C. Adenocarcinoma of the small bowel. Cancer. 1999;86:2693-706.
Surveillance, Epidemiology, and End Results (SEER) Program. SEER*Stat Database: Incidence-SEER 18 Regs Research Data+Hurricane Katrina Impacted Louisiana Cases, Nov 2015 Sub (1973-2013 Varying)-Linked To County Attributes-Total U.S., 1969-2014 Counties, National Cancer Institute, DCCPS, Surveillance Research Program, Surveillance Systems Branch, Released April 2016, Based on the November 2015.; Available online: https://seer.cancer.gov/statfacts/html/smint.html. Accessed on 10 Dec, 2020.
Cancer Registration Statistics, England Statistical Bulletins.; Available online: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/cancerregistrationstatisticsengland/previousReleases. Accessed on 10 Dec, 2020.
Shenoy S. Genetic risks and familial associations of small bowel carcinoma. World J. Gastrointest. Oncol. 2016;8:509-19.
Jagelman DG, DeCosse JJ, Bussey HJ. Upper gastrointestinal cancer in familial adenomatous polyposis. Lancet. 1988;1:1149-51.
Vasen HF, Bulow S, Myrhoj T, Mathus-Vliegen L, Griffioen G, Buskens E et al Decision analysis in the management of duodenal adenomatosis in familial adenomatous polyposis. Gut. 1997;40:716-9.
Bernstein CN, Blanchard JF, Kliewer E, Wajda A. Cancer risk in patients with inflammatory bowel disease: A population-based study. Cancer. 2001;91:854-62.
Palascak-Juif V, Bouvier AM, Cosnes J, Flourié B, Bouché O, Cadiot G et al. Small Bowel Adenocarcinoma in Patients with Crohn’s Disease Compared with Small Bowel Adenocarcinoma De Novo. Inflamm. Bowel Dis. 2005;11:828-32.
Shaukat A, Virnig DJ, Howard D, Sitaraman SV, Liff JM, Lederle FA. Crohn’s disease and small bowel adenocarcinoma: A population-based case-control study. Cancer Epidemiol. Biomark Prev. 2011;20:1120-3.
Askling J, Linet M, Gridley G, Halstensen TS, Ekstrom K, Ekbom A. Cancer incidence in a population-based cohort of individuals hospitalized with celiac disease or dermatitis herpetiformis. Gastroenterol. 2002;123:1428-35.
Lowenfels AB, Sonni A. Distribution of small bowel tumors. Cancer Lett. 1977;3:83-6.
Maglinte DD, O'Connor K, Bessette J, Chernish SM, Kelvin FM. The role of the physician in the late diagnosis of primary malignant tumors of the small intestine. Am J Gastroenterol. 1991;86(3):304-8.
Kusumoto H, Takahashi I, Yoshida M, Maehara Y, Watanabe A, Oshiro T et al. Primary malignant tumors of the small intestine: Analysis of 40 Japanese patients. J Surg Oncol. 1992;50:139-43.
Cheung DY, Kim JS, Shim KN, Choi MG. Korean Gut Image Study Group. The Usefulness of Capsule Endoscopy for Small Bowel Tumors. Clin Endosc. 2016;49(1):21-5.
Laurent F, Drouillard J, Lecesne R, Bruneton JN. CT of small-bowel neoplasms. Semin Ultrasound CT MR. 1995;16(2):102-11.
Buckley JA, Siegelman SS, Jones B, Fishman EK. The accuracy of CT staging of small bowel adenocarcinoma: CT/pathologic correlation. J Comput Assist Tomogr. 1997;21(6):986-91.
Faggian A, Fracella MR, D’Alesio G, Alabiso EM, Berritto D, Feragalli B et al. Small-Bowel Neoplasms: Role of MRI Enteroclysis. Gastroenterol Res Pract. 2016;6:2016.
Alexander S, Bourke MJ, Williams SJ, Bailey A, Co J. EMR of large, sessile, sporadic non-ampullary duodenal adenomas: technical aspects and long-term outcome (with videos) Gastrointest Endosc. 2009;69:66-73.
Dabaja BS, Suki D, Pro B. Adenocarcinoma of the small bowel: presentation, prognostic factors, and outcome of 217 patients. Cancer. 2004;101:518-26.
Kaklamanos IG, Bathe OF, Franceschi D. Extent of resection in the management of duodenal adenocarcinoma. Am J Surg. 2000;179:37-41.
Sohn TA, Lillemoe KD, Cameron JL. Adenocarcinoma of the duodenum: factors influencing long-term survival. J Gastrointestinal Surg. 1998;2:79-87.
Bakaeen FG, Murr MM, Sarr MG, Thompson GB, Farnell MB, Nagorney DM et al. What prognostic factors are important in duodenal adenocarcinoma. Arch Surg. 2000;135:635-41.
Bilimoria KY, Bentrem DJ, Wayne JD, Ko CY, Bennett CL, Talamonti MS. Small bowel cancer in the United States: changes in epidemiology, treatment, and survival over the last 20 years. Ann Surg. 2009;249:63-71.
Aparicio T, Zaanan A, Svrcek M, Laurent-Puig P, Carrere N, Manfredi S et al. Small bowel adenocarcinoma: epidemiology, risk factors, diagnosis and treatment. Dig Liver Dis. 2014;46:97-104.
ClinicalTrials.gov. NIH U.S. National Library of Medicine. Available from: http:/clinicaltrials.gov. Accessed on 17 Jan 2020.
Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC cancer staging manual, 7th edition. France: Springer. 2010.
Fishman PN, Pond GR, Moore MJ, Oza A, Burkes RL, Siu LL et al. Natural history and chemotherapy effectiveness for advanced adenocarcinoma of the small bowel: a retrospective review of 113 cases. Am J Clin Oncol. 2006;29:225-31.
Halfdanarson TR, McWilliams RR, Donohue JH, Quevedo JF. A single-institution experience with 491 cases of small bowel adenocarcinoma. Am J Surg. 2010;199:797-803.
Czaykowski P, Hui D. Chemotherapy in small bowel adenocarcinoma: 10-year experience of the British Columbia Cancer Agency. Clin Oncol (R Coll Radiol). 2007;19:143-9.
Koo DH, Yun SC, Hong YS, Ryu MH, Lee JL, Chang HM et al. Systemic chemotherapy for treatment of advanced small bowel adenocarcinoma with prognostic factor analysis: retrospective study. BMC Cancer. 2011;11:205.
Khan K, Peckitt C, Sclafani F, Watkins D, Rao S, Starling N et al. Prognostic factors and treatment outcomes in patients with Small Bowel Adenocarcinoma (SBA): The Royal Marsden Hospital (RMH) experience. BMC Cancer. 2015;15:15.
Aydin D, Ali Sendur M, Kefeli U, Unal OU, Tastekin D, Akyol M et al. Evaluation of prognostic factors and treatment in advanced small bowel adenocarcinoma: report of a multi-institutional experience of Anatolian Society of Medical Oncology (ASMO). J BUON. 2016;21:1242-9.
Zaanan A, Costes L, Gauthier M, Malka D, Locher C, Mitry E et al. Chemotherapy of advanced small-bowel adenocarcinoma: a multicenter AGEO study. Ann Oncol. 2010;21:1786-93.
Locher C, Malka D, Boige V, Lebray P, Elias D, Lasser P et al. Combination chemotherapy in advanced small bowel adenocarcinoma. Oncol. 2005;69:290-4.
Overman MJ, Kopetz S, Wen S, et al. Chemotherapy with 5-fluorouracil and a platinum compound improves outcomes in metastatic small bowel adenocarcinoma. Cancer. 2008;113:2038-45.
Tsushima T, Taguri M, Honma Y, Takahashi H, Ueda S, Nishina T et al. Multicenter retrospective study of 132 patients with unresectable small bowel adenocarcinoma treated with chemotherapy. Oncolog. 2012;17:1163-70.