Case Report
Early Duodenal Cancer
Detection on Double-Contrast Upper Gastrointestinal Radiography
Audio Available | 
Share
 |
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.
 View larger version (121K) | 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. |
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.
 View larger version (170K) | 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, ×50) |
 View larger version (210K) | 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, ×125) |
| 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].
Address correspondence to M. S. Levine.
| References | |
|---|
