AJR 2000; 174:1564-1566
© American Roentgen Ray Society
Early Duodenal Cancer
Detection on Double-Contrast Upper Gastrointestinal Radiography
Djenaba Bradford1,
Marc S. Levine1,
Dai Hoang1,2,
Rajeev M. Sachdeva3 and
Eugene Einhorn3
1
Department of Radiology, Hospital of the University of Pennsylvania, 3400
Spruce St., Philadelphia, PA 19104.
2
Present address: Albert Einstein Medical Center, 5501 Old York Rd.,
Philadelphia, PA 19141.
3
Department of Pathology, Veterans Administration Medical Center of
Philadelphia, Philadelphia, PA 19104.
Received August 2, 1999;
accepted after revision November 5, 1999.
Address correspondence to M. S. Levine.
Introduction
A denocarcinoma of the duodenum is a rare malignant tumor that accounts for
less than 1% of all cancers of the gastrointestinal tract
[1]. These tumors most commonly
involve the ampullary or periampullary regions of the descending duodenum
[2]; adenocarcinomas are less
likely to occur in the duodenal bulb, in which benign tumors are much more
common [3].
Many duodenal cancers are diagnosed at an advanced stage because symptoms
of these cancers do not normally develop until the tumors have invaded
adjacent structures, regional lymph nodes, or both. However, occasionally,
early duodenal cancers are incidentally discovered during endoscopy or on
barium studies in patients without symptoms directly attributable to these
lesions
[3,4,5].
We recently encountered an early cancer of the duodenal bulb that was
initially detected on double-contrast upper gastrointestinal radiography and
subsequently proven to be a well-differentiated papillary mucosal
adenocarcinoma. To our knowledge, radiologically detected early duodenal
cancer has not been previously reported in the English-language radiology
literature. Therefore, we present the clinical, radiographic, and pathologic
findings of early duodenal cancer and discuss their significance.
Case Report
An 85-year-old man presented with guaiacpositive stool, iron-deficiency
anemia, and intermittent epigastric pain. The patient was treated with
H2 receptor antagonists. Double-contrast upper gastrointestinal
radiography revealed a sessile slightly lobulated polyp near the base of the
duodenal bulb (Fig. 1A). The
lesion had a diameter of 1.3 cm and was clearly separate from the pylorus.
Subsequent endoscopy revealed a 1.5-cm sessile polyp in the duodenal bulb with
superficial erosion of the overlying mucosa. Endoscopic biopsy specimens of
the lesion revealed a well-differentiated papillary adenocarcinoma.
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Fig. 1A. —85-year-old man with early duodenal cancer. Spot radiograph from
double-contrast barium study shows sessile, slightly lobulated 1.3-cm polyp
(arrows) in duodenal bulb. Note that inferior portion of lesion is
surrounded by barium and is separate from pylorus.
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|
At surgery, the patient had a 1.5-cm slightly lobulated polyp in the
duodenal bulb. A Billroth's II gastroduodenectomy was performed. Pathologic
examination of the resected specimen revealed a well-differentiated papillary
adenocarcinoma near the base of the duodenal bulb (Figs.
1B and
1C). The lesion was confined to
the mucosa (the underlying submucosa and muscularis propria were not
involved), and regional lymph nodes were free of tumor. Therefore, the lesion
was pathologically classified as a mucosal (i.e., early) duodenal cancer. The
patient was discharged from the hospital in satisfactory condition.
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Fig. 1B. —85-year-old man with early duodenal cancer. Photomicrograph of
resected specimen shows papillary configurations comprising exophytic
well-differentiated mucosal carcinoma in duodenal bulb. (H and E,
x50)
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Fig. 1C. —85-year-old man with early duodenal cancer. Photomicrograph shows
well-differentiated adenocarcinoma of duodenal bulb mucosa. Note solid
glandular components lacking intervening stroma. (H and E, x125)
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Discussion
Although uncommon, adenocarcinoma of the duodenum accounts for 45-65% of
small-bowel cancers [1,
2]. These tumors may develop de
novo in the duodenum or may result from the malignant degeneration of
preexisting adenomatous polyps (particularly villous adenomas)
[6]. Duodenal cancers commonly
occur in the ampullary or periampullary regions of the descending duodenum
[2]; however, these tumors are
occasionally found in other portions of the duodenum, including the duodenal
bulb [7]. The most frequent
clinical findings of early duodenal cancer include epigastric pain, nausea,
vomiting, postprandial bloating, weight loss, and signs of upper
gastrointestinal bleeding, such as guaiac-positive stool and iron-deficiency
anemia [1,
2,
7].
Unfortunately, most symptomatic patients with duodenal cancer have advanced
lesions at presentation. As a result, these patients have a poor prognosis,
with overall 5-year survival rates ranging from 20% to 40%
[1,
2]. Factors affecting patient
survival include the histologic grade of the tumor (the degree of
differentiation and the nuclear grade), depth of invasion, presence or absence
of nodal or distant metastases, duration of symptoms, and location of tumor in
the duodenum (distal lesions have a better prognosis)
[2,
8]. The preferred treatment for
resectable lesions in the second and third portions of the duodenum is a
pancreaticoduodenectomy with en bloc resection of adjacent tissues, including
regional lymph nodes [1].
Advanced duodenal cancers may appear on barium studies as polypoid,
ulcerated, or annular lesions
[9]. However, we report a
patient with early duodenal cancer that was revealed on double-contrast
radiography as a sessile, slightly lobulated 1.3-cm polyp in the duodenal bulb
(Fig. 1A). In other reports,
early duodenal cancer has rarely been detected on double-contrast barium
studies or endoscopy
[3,4,5].
These tumors have appeared on radiography as small polypoid lesions
[3] and at endoscopy as sessile
or pedunculated polyps or polypoid lesions with shallow areas of ulceration in
the duodenal bulb or elsewhere in the duodenum
[3,4,5].
Despite the rarity of early duodenal cancer, it is important to be aware of
its radiographic findings because affected individuals have a much better
prognosis when the lesions are detected at an early stage.
Other benign and malignant tumors of the duodenal bulb may also appear on
radiographs as polypoid lesions. Both adenomatous and hyperplastic polyps may
appear on barium studies as smooth rounded nodules in the duodenal bulb
[6]. Small submucosal masses
such as leiomyomas, ectopic pancreatic rests, Brunner's gland hamartomas, and
carcinoids may also be difficult to differentiate from polyps on radiography
[6]. Although prolapsed antral
mucosa or even prolapsed antral tumors may appear as polypoid lesions in the
bulb, these lesions are always contiguous with the pyloric channel
[6]. Occasionally, a redundant
mucosal fold at the superior duodenal flexure may be mistaken for a polypoid
mass; however, this flexural pseudolesion should be recognized by its
characteristic location at the junction of the first and second portions of
the duodenum and its changeable appearance with various degrees of compression
and obliquity [6].
Although benign tumors of the duodenal bulb are more common than malignant
tumors, the findings in our patient suggest that endoscopy and biopsy may be
warranted to rule out early duodenal cancer when barium studies reveal
duodenal polyps that are larger than 1 cm in diameter, particularly if the
lesions are lobulated or ulcerated. When early duodenal cancers are detected,
they may be treated with resection of the duodenal bulb and partial
gastrectomy [3] or, in some
cases, with endoscopic polypectomy or endoscopic strip biopsy without the need
for surgical intervention [4,
5].
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Introduction
Case Report
