DOUBLE BALLOON ENTEROSCOPY: SMALL BOWEL ADENOCARCINOMA

An 83 year old male with a history of hypertension, type 2 diabetes and ischaemic heart disease sustained an acute myocardial infarction 8 months ago. He had a percutaneous coronary intervention (PCI) and a single coronary stent was inserted. He was commenced on Ticagrelor and was already on Aspirin. Three months ago, he was admitted to hospital with melaena (Hb 9.5 g/dL). An OGD showed duodenitis and colonoscopy to terminal ileum showed sigmoid diverticular disease only. He also had a CT scan of the abdomen and pelvis which confirmed diverticular disease, no bowel masses and no lymphadenopathy. One month ago, he had a video capsule endoscopy showing some blood at 30 minutes of the capsule entering the small bowel. Hence a double balloon enteroscopy (DBE) was undertaken (oral route)… see video. The DBE showed an ulcerated lesion in the jejunum with rolled edges. Biopsies showed adenocarcinoma. My thanks to Dr Jo Chapman, Consultant Pathologist, for the histology slides shown in the video.

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The small intestine is 5 to 7 m long and represents 75% of the length of the entire gastrointestinal tract. However, the incidence rate of small intestinal neoplasms is approximately 11-fold lower than that of colorectal cancer. Cancers of the small bowel are relatively rare, with an annual incidence rate of 5,300 in the United States. Small bowel adenocarcinoma (SBA) (36.9%) and carcinoid tumours (37.4%) are the most commonly observed subtypes. Whereas the incidence rate of carcinoid has increased recently, the incidence rate of SBA has been quite stable.

SBA have a well-established relationship with FAP, HNPCC (Lynch syndrome), and Crohn’s disease. The highest proportion of small bowel adenocarcinomas—approximately 50% to 60%—arise from the duodenum.
Diagnosis is often delayed due to lack of specific symptoms and effective screening methods. The overall staging and pattern of spread is similar to that of colorectal cancer, but on a stage-for-stage basis, prognosis is worse for small bowel adenocarcinoma. Resectability of the primary tumor is the key prognostic factor, along with older age, poor performance status, presence of distant metastasis, and the primary tumor arising in the duodenum.

Surgery is the mainstay of treatment for both localiSed and locally advanced disease. Duodenal primaries are less resectable due to anatomic constraints and usually require pancreacticoduodenectomy, whereas jejunoileal tumoUrs are treated with segmental bowel resection and removal of the mesentery. Several studies consistently report an overall 5-year survival of 30% to 40% when the disease is surgically resectable. Nevertheless, patients with metastatic disease are also likely to benefit from surgery to avoid and/or treat the complications of obstruction and bleeding.

The use of adjuvant chemotherapy for small bowel adenocarcinomas, with or without radiation, has been increasing. Duodenal small bowel adenocarcinomas are usually treated similarly to adenocarcinoma of the pancreas. Adjuvant chemoradiation regimens have been attempted with no clear benefit. Promising results have been reported with neoadjuvant 5-FU and mitomycin-C in duodenal adenocarcinoma, but this treatment is associated with appreciable toxicity.

No randomized prospective trials have assessed the role of palliative chemotherapy for metastatic or recurrent small bowel adenocarcinomas. Small case series have suggested improved survival with the administration of 5-FU, as a single agent or in combined therapy, in patients with metastatic and/or recurrent small bowel adenocarcinomas, as compared with patients receiving supportive care alone. To date, no data are available on the use of 5-FU prodrugs, irinotecan (CPT-11, Camptosar), or oxaliplatin (Eloxatin) for the treatment of patients with small bowel adenocarcinoma.

Fluorouracil-based chemotherapy, with or without radiotherapy, has shown activity in small bowel adenocarcinomas, but due to the lack of prospective, randomized data, the minimal benefit, if any, reported in clinical series, and the associated toxicity, the decision to treat should be individualized, and the risks and benefits carefully explained to the patient. The poor prognosis of patients with locally advanced or metastatic small bowel adenocarcinoma calls for well-designed phase II trials to test new chemotherapy agents and combined-modality regimens.

REFERENCES

[1] Umman P, Adiyodi V and Narayan C, Indian J Surg (March–April 2013) 75(2):123–127, Small Bowel Adenocarcinoma – Report of Two Cases and Review of Literature

[2] Aparicio T et al, Digestive and Liver Disease 46 (2014) 97–104, Small bowel adenocarcinoma: Epidemiology, risk factors, diagnosis and treatment

[3] Duerr D et al, Journal of Cancer, 2016; 7(15): 2290-2295, A Retrospective Review of Chemotherapy for Patients with Small Bowel Adenocarcinoma in British Columbia

• Category

  Small Bowel Cancer