Small bowel adenocarcinoma associated with colorectal cancer: Report of two cases

Adenocarcinoma de intestino delgado asociado con cáncer colorrectal: a propósito de dos casos

A. Ocaña Fernández; G. Marcos García; E. Ceballos Barbancho; C. Rodríguez Sánchez; M. Ruiz Martín; J. J. Cruz Hernández

Servicio de Oncología Médica. Hospital Universitario de Salamanca

Correspondence

SUMMARY

PURPOSE: To point out the difficult therapeutic management of small bowel adenocarcinoma and its rare association with colorectal cancer.
MATERIAL AND METHODS: We present two cases of patients having small bowel adenocarcinoma associated with colorectal cancer.
RESULTS AND CONCLUSIONS: The role of postoperative adjuvant chemotherapy is not well established. The association between the two mentioned tumors is rare, and the genetic pathogenesis is unknown.

Key words: Small bowel adenocarcinoma. Colorectal cancer. Adjuvant chemotherapy.

RESUMEN

PROPÓSITO: destacar el difícil manejo terapéutico de los tumores de intestino delgado y su poco frecuente asociación con el cáncer de colon.
MATERIAL Y MÉTODOS: se presenta el caso de dos pacientes con un tumor de intestino delgado que también desarrollaron un cáncer de colon. ]]> CONCLUSIONES: la quimioterapia adyuvante en el cáncer de intestino delgado no está claramente establecida. La asociación de ambos tumores es poco frecuente y se desconocen los mecanismos genéticos.

Palabras clave: Adenocarcinoma intestinal. Cáncer de colon. Quimioterapia adyuvante.

Introduction

Tumors of the small intestine are rare neoplasms. It has been estimated that small bowell tumors constitute less than 10% of all gastrointestinal tumors¹. Adenocarcinomas constitute 25% of all small bowel tumors and nearly 80% of adenocarcinomas are located in the duodenum or jejunum.

Symptoms related primarily to the size and site of the tumor. The most common symptom is upper abdominal pain related to partial duodenal obstruction.

Histopathogical confirmation can be obtained preoperatively in most patients by upper gastrointestinal endoscopy with total duodenoscopy.

Surgical resection is the first therapeutic approach and the role of postoperative adjuvant therapy has not been clearly defined

Here we report two cases of duodenal adenocarcinoma cancer associated with colorectal cancer.

Case reports of two patients

Case 1

A 49 years-old male was diagnosed in 1993 of having a colorectal adenocarcinoma stage III. He received a right hemicolectomy followed by adjuvant chemotherapy with 5 fluorouracil plus leucovorin. Seven years later in 2000 he came to our hospital with abdominal pain and a blood loss history. Computed tomography (CT) scan showed a duodenal mass, and confirmatory histology resulted in a duodenal adenocarcinoma. Surgical treatment with a pancreaticoduodenectomy was made followed by adjuvant chemotherapy with 5 fluorouracil plus Isovorin. Data on the long-term effect of chemotherapy show no relapse yet.

Case 2

A 59 years-old woman presented to us, in 1997, with a 10 months history of weight loss and nausea. Endoscopy of the small intestine showed a duodenal mass and biopsy was positive for adenocarcinoma. She received a pancreaticoduodenectomy without adjuvant chemotherapy treatment. She continued revisions normally. In July 2001 she came to our institution with asthenia and a weight loss history. Computed tomography (CT) scan showed a lesion in the splecnic angle of the colon. Colonoscopy confirmed a mass and biopsy was positive for adenocarcinoma. Surgical treatment was made with a hemicolectomy procedure. It confirmed a stage III colorectal cancer. Adjuvant chemotherapy treatment with 5 fluorouracil plus Isovorin was administrated.

Discussion

Adenocarcinomas constitute 39% of all malignant small bowel tumors and about 45% of all adenocarcinomas of the small bowel arise within the duodenum².

Small intestine neoplasm usually occur in association with genetic disease or chronic intestinal inflammation³, and the prognosis is generally considered to be poor. Delay in diagnosis is common because of the infrequency and unspecific symptoms.

Surgical resection is the first therapeutic approach and the role of postoperative adjuvant therapy has not been clearly defined.

A complete macroscopic and microscopic tumor resection has to be the aim of any curative surgical approach⁴. And because 22% to 71% of patients have positive nodes at presentation a systemic regional Iymphadenectomy should always be done². Duodenal segmentectomy associated with intestinal derotation is a safe procedure with less morbidity and mortality than pancreaticoduodenectomy⁵.

In patients with unresectable disease palliative radiation therapy can be of some benefit in controlling chronic blood loss⁶.

Postoperative adjuvant chemotherapy is not defined. Since these tumors clinically appear to behave more like gastric and colorectal cancer than pancreatic cancer chemotherapy based 5-fluorouracil regimen is a therapeutic option.

In our cases surgical treatment with pancreaticoduodenectomy was done in both cases but postoperative adjuvant chemotherapy with 5 fluorouracil plus leucovorin was administered in only one case. The association with colorectal cancer show a possible genetic alteration not well known yet.

References

1. Ellis H, et al. Tumours of he small intestine. Semin Surg Oncol 1987; 3:12.        [ Links ]

2. Caniel G. Cancer of the Small Intestine. Cancer: Principles and practice of Oncology, Fifth Edition, edited by Vincent T. De Vita, Jr Samuel Hellman, Steven A. Rosenberg. Lippincott-Raven Publishers, Philadelphia 1997; 1133-4.        [ Links ]

3. Bettini AC et al. Chemotherapy in small bowel adenocarcinoma associated with celiac disease: a report of three cases. Tumori 2003; 89:193-5.        [ Links ]

4. Brucher BL et al. New aspects of prognostic factors in adenocarcinomas of he small bowel. Hepatogastroenterology 2001; 39:727-32.        [ Links ]

5. Tocchi A et al. Adenocarcinoma of he third and fourth portions of he duodenum: results of surgical treatment. Arch Surg 2003; 1:80-5.        [ Links ]

6. Brennan Mf et al. Duodenal cancer. Asian J Surg 1990; 13:204.        [ Links ]

7. Wheeler JMD et al. An insigth into he genetic pathway of adenocarcinoma of he small intestine. Gut 2002; 50:218-23.        [ Links ]

8. Blaker H et al. Genetics of adenocarcinomas of he small intestine: frequent deletions at chromosome 18q and mutations of he SMAD 4 gene. Oncogene 2002, 21:158-64.        [ Links ]

Correspondence to
Dr. A. Ocaña Fernández ]]> Servicio de Oncología Médica
Hospital Universitario de Salamanca
Paseo San Vicente, 58-182
E-37007 Salamanca

Recibido: 16.02.04
Aceptado: 01.03.04