Adenocarcinoma of the duodenum
Duodenal adenocarcinoma is the most common primary malignancy of the duodenum.
Adenocarcinoma is the most common primary malignant neoplasm of the duodenum. It represents 0.3% of all gastrointestinal malignancies. It accounts for 50-70% of small bowel adenocarcinomas occurring either in the duodenum or proximal jejunum.
The peak prevalence is in the 7th decade. More than 50% of them having metastases at the time of diagnosis.1
Most of the clinical features are non-specific which include upper abdominal pain and weight loss as the most common presenting symptoms, in the late phases of the disease a variety of symptoms and signs have been reported, like symptoms of proximal intestinal obstruction and jaundice, haematemesis, melaena, and occult blood in the stool. A variety of other findings, such as low back pain and alteration in bowel habit, have also been described.
Grossly they have napkin ring appearance or polypoidal fungatining mass. Patients with familial adenomatous polyposis and Gardner syndrome are considered to have a higher likelyhood of developing duodenal cancer. Patients who have duodenal polyps without a predisposing family history are also at an increased risk.2
- distal portion( 3rd and 4th parts) - 45%
- second part - 40%
- first part - 15%
According to some publications, upper GI series seem to be the most accurate diagnostic modalities for small-bowel carcinomas. 3 Upper GI shows features of mucosal pattern distortion, obliteration and narrowing. Delayed images may show hold up of barium at the site of the lesion.4
The lesions appear as irregularly hypoechoic masses. Ultrasonography can diagnose and assess vascularity of larger lesions but the smaller tumours (<2 cm) may not be detected.2
CT is the modality of choice for staging of the disease by identifying primary tumour, assessing local, nodal and distant spread3,5.
Demonstration of lesions facilitated by negative contrast agents (water):
- intrinsic mass with a short segment of bowel wall thickening6
- invasion of retroperitoneal fat planes, pancreatic and biliary duct, vascular encasement, lymph nodal and distent metastases is common in later stages7
Treatment and prognosis
Duodenal adenocarcinoma is associated with a delayed diagnosis and poor prognostic and survival outcomes due to non specific clinical presentation.
Metastasis, poor tumour differentiation, increased depth of spread and pre-existing Crohn's disease are associated with poor prognosis.
Recurrence of the tumour is also a common entity. The most common sites of recurrence are the liver, lungs and peritoneum.3
The only way to improve results is early diagnosis of primary tumour, by providing a higher resectability.8
Pancreaticoduodenectomy is required for tumours of the first and second portion of the duodenum. In tumours of distal duodenum, segmental resection may be adequate.9
General imaging differential considerations include
- 1. Jayaraman MV, Mayo-Smith WW, Movson JS et-al. CT of the duodenum: an overlooked segment gets its due. Radiographics. 2001;21 Spec No (suppl 1): S147-60. doi:10.1148/radiographics.21.suppl_1.g01oc01s147 - Pubmed citation
- 2. Markogiannakis H, Theodorou D, Toutouzas KG et-al. Adenocarcinoma of the third and fourth portion of the duodenum: a case report and review of the literature. Cases J. 2008;1 (1): 98. doi:10.1186/1757-1626-1-98 - Free text at pubmed - Pubmed citation
- 3. Kumar SP, Pavan Kumar A. Carcinoma in the fourth part of the duodenum. Can J Surg. 2009;52 (3): E69-70. Free text at pubmed - Pubmed citation
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- 5. Angelelli G, Macarini L, Giordano G et-al. The role of computerized tomography in the study of duodenal carcinoma. Radiol Med. 1992;82 (4): 450-4. Pubmed citation
- 6. Farah MC, Jafri SZ, Schwab RE et-al. Duodenal neoplasms: role of CT. Radiology. 1987;162 (3): 839-43. Pubmed citation
- 7. Zissin R, Osadchy A, Gayer G et-al. Pictorial review. CT of duodenal pathology. Br J Radiol. 2002;75 (889): 78-84. Br J Radiol (full text) - Pubmed citation
- 8. Santoro E, Sacchi M, Scutari F et-al. Primary adenocarcinoma of the duodenum: treatment and survival in 89 patients. Hepatogastroenterology. 1997;44 (16): 1157-63. Pubmed citation
- 9. Bakaeen FG, Murr MM, Sarr MG et-al. What prognostic factors are important in duodenal adenocarcinoma?. Arch Surg. 2000;135 (6): 635-41. Pubmed citation