Alpha-fetoprotein-producing adenocarcinoma in which the metastatic route was determined from calcified lesions

Alpha-fetoprotein (AFP)-producing adenocarcinoma is known for its rapid progression and poor prognosis, and chemotherapy regimens are yet to be standardized. Here we describe the first report of AFP-producing adenocarcinoma with calcification. The metastatic route was visualized from the calcification, and combination chemotherapy was performed. A 77-year-old Japanese man was transferred to our hospital for treatment of liver tumors. Computed tomography (CT) revealed multiple liver tumors with portal vein tumor thrombosis. The tumors were highly attenuated before enhancement, suggesting various degrees of calcification. Serum levels of carcinoembryonic antigen (CEA), AFP, and the proportion of fucosylated AFP were considerably elevated. Gastroduodenoscopy revealed an elevated tumor occupying the duodenal bulb with an ulcerative lesion in the vicinity of the gastroduodenal junction, and biopsy specimens from the duodenum and liver revealed medullary adenocarcinoma with calcification. Three-dimensional reconstruction of CT images clearly showed that the calcified lesions had spread from the gastroduodenal junction to the liver via a route comprising the corresponding local vein, the superior mesenteric vein, and portal vein. The patient was accordingly diagnosed with calcified AFP-producing adenocarcinoma with multiple liver metastases. Combination chemotherapy using TS-1 and cisplatin (CDDP) resulted in a striking response for the initial 4?months in terms of tumor markers and CT findings. This is the first report of AFP-producing adenocarcinoma with calcification. A metastatic route from the primary tumor to the liver was clearly visualized by tracing the calcified lesions. Combination chemotherapy based on 5-fluorouracil and CDDP may have the potential to prolong survival.     

Primary adenocarcinoma of duodenal bulb benefitted by chemotherapy

A 48-year-old man had primary adenocarcinoma of the duodenal bulb. The extensive hepatic metastasis of the patient did not allow any major surgical procedure. Therefore UFTM chemotherapy was performed and was associated with three years of improvement. Subjective symptoms were relieved and test findings indicated normalization of liver biochemistry as well as CEA and CA 19-9. X-ray, endoscopy, and pathological findings indicated the disappearance of the carcinoma of the duodenal bulb. In addition, both ultrasonic examination and CT of the abdomen showed marked reduction of the hepatic metastasis. The authors do not hesitate to recommend the UFTM therapy as a therapeutic modality for inoperable and metastatic primary adenocarcinoma of the duodenum.     

Endoscopic mucosal resection of duodenal bulb adenocarcinoma with neuroendocrine features: An extremely rare case report

Duodenal adenocarcinoma, especially duodenal bulb with neuroendocrine features (NEF), is extremely rare. Here, we report one such case of duodenal bulb adenocarcinoma with neuroendocrine features. A 63-year-old Han Chinese woman was admitted to our department with the diagnosis of a duodenal bulb polyp and underwent an endoscopic mucosal resection. The pathological findings confirmed it as duodenal bulb adenocarcinoma with NEF. The patient remains curative after one and half a years of follow-up. Duodenal adenocarcinoma with NEF might be a low malignant neuroendocrine tumor rather than a conventional adenocarcinoma. Endoscopic treatment, including endoscopic mucosal resection, might be an ideal option for the adenocarcinomas with NEF.     

Resection for hepatocellular carcinoma with duodenal invasion: report of a case

A 73-year-old man was admitted to our hospital on emergency for severe anemia. Upper gastrointestinal endoscopic study revealed a hemorrhagic ulcer in the duodenal bulb. He underwent endoscopic hemostasis. Abdominal ultrasonography and computed tomography showed a huge mass in segment 4 of the liver, growing into the extrahepatic space with direct invasion to the duodenal bulb. Extended left lobectomy and partial gastroduodenectomy was performed, because the endoscopic management of hemostasis was incomplete. He was discharged on the 30th postoperative day. Histopathologically, the tumor cells were moderately differentiated hepatocellular carcinoma with direct invasion to the duodenal mucosa. This report demonstrated the first case with a hepatocellular carcinoma with duodenal invasion, for which hepatic resection was performed successfully.     

Gardner''s Syndrome Associated with Carcinoma of the Duodenal Bulb: Report of a Case

A 49-year-old woman with Gardner's syndrome, who underwent total proctocolectomy in 1982, was found to have a cancer of the duodenal bulb. Subsequently, resection of the stomach and duodenal bulb was performed in 1983. The surgical specimen showed an ulcerating tumor in the duodenal bulb which was a moderately differentiated adenocarcinoma histologically. Multiple adenomas were present in the gastric antrum and the duodenum. Duodenal cancer so far reported has been mostly confined to the periampullary region, and cancer of the duodenal bulb associated with familial polyposis coli has not been reported.     

Deformity of duodenal bulb, gastric metaplasia of duodenal regenerating mucosa and recurrence of duodenal ulcer： A correlated study

AIM: To investigate the correlation among the presence and degree of gastric metaplasia of duodenal regenerating mucosa, the deformity of bulb and the recurrence of duodenal ulcer. METHODS: A total of 99 patients with duodenal ulcer were treated with H2-antagonist with or without antimicrobial therapy. All patients received follow-up endoscopic examinations 6 wk after treatment. When the ulcer(s) were noted to be healed, two biopsies were taken from the ulcer scar for histological study of gastric metaplasia, and 4 biopsies were taken from antrum for Helicobacter pylori (H pylori) study. Out of these cases, 44 received further follow-up endoscopic examinations after 3,6 and 12 mo respectively for studying the recurrence rate of duodenal ulcers. The correlation among ulcer recurrence, degree of gastric metaplasia of regenerating mucosa, bulbar deformity, and colonization of H pylori in the stomach was then studied. RESULTS: The results showed that there was a strong correlation between the deformity of duodenal bulb and the degree of gastric metaplasia of regenerating duodenal mucosa. The recurrence rate of duodenal ulcer had a significant difference between patients with and without H pylori colonization in the stomach (P<0.001). The greater the degree of gastric metaplasia of duodenal regenerating mucosa, the higher the recurrence rate of duodenal ulcer (P= 0.021). The more deformed the duodenal bulb, the higher the incidence of recurrence of duodenal ulcer (P = 0.03). CONCLUSION: There is a correlation among deformity of duodenal bulb, gastric metaplasia of duodenal regenerating mucosa and recurrence of duodenal ulcer. A more severely deformed duodenal bulb is closely related to a greater extent of gastric metaplasia. Both factors contribute to the recurrence of duodenal ulcer.     

Gastric metaplasia of regenerating duodenal mucosa and deformity of duodenal bulb: A correlative study

The correlation between the presence and degree of gastric metaplasia of regenerating duodenal mucosa and the deformity of duodenal bulb was studied. Based on the endoscopically morphological patterns of bulb, the duodenal ulcers were divided into three types: type I, with a normal-shaped bulb; type II, with a mildly deformed bulb; and type III, with a markedly deformed bulb. A total of 159 patients with active duodenal ulcers were scheduled to be treated with H₂-receptor antagonists. Of these patients, 124 proved to have a healed duodenal ulcer 4 weeks after initial treatment upon follow-up endoscopic examinations. Two biopsies were taken from the centre of the ulcer scar when the ulcer was found to be healed for light microscopic study. Histologically, the degree of gastric metaplasia was divided into three grades: grades 0, 1 and 2. The results show that a healed duodenal ulcer with a normal-shaped bulb is not frequently accompanied by gastric metaplasia. However, a healed ulcer with a markedly deformed bulb has a high incidence and degree of gastric metaplasia, which may be easily colonized by Helicobacter pylori and thus develop an environment of easy recurrence. Therefore, a cycle of healing and recurrence may exist in patients with a duodenal ulcer and a markedly deformed bulb. Eradication of H. pylori may be the best way to break this cycle.     

An Endoscopically Resected Case of Early Carcinoma of the Duodenal Bulb

We report here on a case of early carcinoma originating in the duodenal bulb. The patient was a 70-year-old woman who complained of nausea. A gastrointestinal endoscopy disclosed a lesion protruding from the duodenal bulb and a biopsy revealed adenocarcinoma. According to the results of the endoscopy, the tumor was subpedunculated and probably confined in the mucosal layer. Based on these findings, we performed an endoscopic tumor resection. A histological examination of the resected specimen revealed a papillotubular adenocarcinoma (1.7 × 1.2 × 0.8 cm) localized in the mucosal layer. No carcinomatous lesion was left in the resected margin. No symptoms of recurrence have been noted during the last 6 months. When considering clinical pathology of the present case, we assessed 39 cases of primary early carcinoma in the duodenal bulb previously reported in the Japanese literature. We considered that our patient was the 14th in Japan with an early carcinoma of the duodenum which was completely excised via endoscopic resection. We expect that endoscopic resection of early duodenal carcinoma will be widely used in the future.     

Abnormalities in the duodenal transit and motility in duodenal ulcer patients: studies with a new isotopic technique.

Abnormalities of duodenal motility have been described in patients with duodenal ulcer and in experimental ulcers in rats and it has been postulated that they could be pathogenic in peptic ulcer disease. We have investigated with an isotopic technique whether duodenal bulb clearance or duodenal transit are abnormal in duodenal ulcer. Six patients with inactive and six with active duodenal ulcers, all men, and six healthy male controls were studied. Motility of the duodenum was simultaneously monitored. A bolus of 99mTcDTPA was injected into the duodenum while water or acid were perfused on different occasions. Duodenal bulb clearance and transit to the ligament of Treitz were calculated. Duodenal transit in duodenal ulcer patients 108.8 (23) sec was faster than in controls, 194.9 (5.1) sec (p less than 0.05) during the quiescent period of the motility cycle. The frequency of duodenal bulb contractions during acid perfusion was higher in duodenal ulcer patients 1.7 (0.4) cont/min, than in controls 0.8 (0.1) cont/min (p less than 0.05). No other significant differences were observed between ulcer patients and controls. These data suggest that patients with duodenal ulcers do not have major abnormalities of duodenal bulb clearance, nor of duodenal transit and that duodenal motility does not play a primary role in the pathogenesis of the ulcer.     

A case of nodal malignant lymphoma presenting with arterial bleeding related to its duodenal penetration

A 62-year-old man with a chief complaint of dysphagia visited our hospital. Enhanced computed tomography showed the tumor near the duodenal wall and lymphadenopathy in the left supraclavicular fossa and para-aortic lymph node. Upper gastrointestinal endoscopy showed an ulcer accompanied with a fistula in the anterior wall of duodenal bulb, suggesting that the tumor penetrated into duodenal wall. Biopsy from the lymph node in the left supraclavicular fossa indicated diffuse large B-cell lymphoma. Although chemotherapy was planned, massive arterial bleeding occurred from the part of duodenal penetration. Endoscopic hemostasis was unsuccessfully performed. Therefore, we performed transcathether arterial embolization for hemostasis. After the procedure, the patient received six cycles of chemotherapy, and he achieved complete response. He has been alive 5 years without recurrence. There were many cases of gastrointestinal bleeding from primary gastrointestinal lymphomas, while there were few cases with nodal involvement by malignant lymphoma resulting in bleeding from gastrointestinal tract. We herein report a case of duodenal bleeding by nodal involvement of diffuse large B-cell lymphoma with review of literature.     

The influence of severe bulb deformity on duodenal ulcer relapse

In order to evaluate the prognostic role of duodenal bulb deformation in the recurrence of peptic ulcer, duodenal bulb morphology and the complete healing of duodenal ulcer were endoscopically evaluated in sixty patients, who were subsequently allocated at random to either maintenance therapy with ranitidine or no treatment. Endoscopic checkups were done at regular intervals, up to the first ulcer recurrence. As expected, long-term ranitidine treatment significantly reduced the relapse rate (12 month cumulative relapse rate was 32% versus 86% in the untreated). A set of prognostic factors which might interfere with this result (sex, age, alcohol consumption, history of ulcerous relatives, duration of the disease, previous H2-blocking treatment, previous complications, smoking and morphology of the duodenal bulb) were evaluated by multivariate analysis using the Cox regression model. Only duodenal bulb morphology appeared to have any independent prognostic value. In the untreated group ulcer recurrence seemed to occur earlier (median relapse time = 2 months) in the patients with severe non-stenosing bulb deformity, and later in those with normal or mildly deformed bulb (median relapse time = 8 months); ranitidine treatment delayed relapse in deformed bulb patients (median relapse time = 14 months) and almost eliminated it in those with normal duodenal bulb morphology. No association was found between the presence of duodenal bulb deformity and the above-mentioned covariates. Our study confirms the primary importance of anti-H2 treatment and suggests that anatomical characteristics of the duodenal bulb also influence the occurrence of ulcer relapse.     

Relationship between Helicobacter pylori infection and gastric metaplasia in the duodenal bulb in the pathogenesis of duodenal ulcer

BACKGROUND: The aim of this study was to determine whether the amount of Helicobacter pylori and the extent of gastric metaplasia in the duodenal mucosa play critical roles in the pathogenesis of duodenal ulcer. METHODS: Duodenal and gastric biopsy specimens were obtained from H. pylori-positive patients with duodenal ulcer, gastric ulcer or chronic gastritis. The extent of gastric metaplasia was evaluated histologically and endoscopically using the methylene blue test. In this study, we performed competitive polymerase chain reaction, a highly sensitive and quantitative method for determining the amount of H. pylori gastric and duodenal mucosa. The prevalence and extent of gastric metaplasia and the amount of H. pylori in the duodenal bulb in the three patient groups were compared. The correlation between the amount of H. pylori in the duodenum and gastric antrum and extent of gastric metaplasia were also determined. RESULTS: The prevalence and extent of gastric metaplasia and the amount of H. pylori in the duodenal bulb in patients with duodenal ulcer were much higher than in patients with gastric ulcer or chronic gastritis. A positive correlation was found between the amount of H. pylori in the duodenum and the extent of gastric bulb and that in the antrum. CONCLUSIONS: The findings of this study indicate that H. pylori colonization in the duodenal bulb may play a critically important role in the pathogenesis of duodenal ulcer and that the amount of H. pylori in the duodenal bulb may be related to the amount of H. pylori in the gastric antrum and the extent of gastric metaplasia in the duodenal bulb.     

Successful treatment of duodenal adenocarcinoma with multiple liver metastases by S-1?+?irinotecan (CPT-11)

Unresectable duodenal adenocarcinoma excluding the ampullary region is rare, and no standard chemotherapy has been defined for this disease. Although S-1-based chemotherapy is widely administered for advanced gastric cancer, few reports have described advanced duodenal cancer treated with S-1-based chemotherapy. We present herein a case of duodenal adenocarcinoma with liver metastases. The patient was a 72-year-old man with chief complaints of epigastralgia and fever. Gastroduodenal endoscopy revealed an ulcerative lesion on the upper wall of the duodenal bulb, and biopsy specimens showed well-differentiated adenocarcinoma. Computed tomography and ultrasonography showed multiple liver metastases. S-1 (80 mg/m² day⁻¹ on days 1–21) + irinotecan (80 mg/m² day⁻¹ on days 1 and 15) were administered in 4-week intervals as first-line chemotherapy. Tumor markers subsequently normalized, and liver metastases were diminished. The progression-free term was 6 months. Grade 3 neutropenia and diarrhea were observed as adverse events. S-1 + cisplatin and S-1 + docetaxel were administered as second- and third-line chemotherapies, respectively. The patient died due to hepatic failure, with an overall survival of 15 months. S-1-based regimens appear effective and well tolerated, and S-1 may thus represent a useful option for advanced duodenal cancer.     

The endoscopic diagnosis of duodenal ulcer disease. A randomized clinical trial of bias and of interobserver variation

In a randomized design we examined whether endoscopists are biased by knowledge of the radiologic diagnosis of duodenal ulcer and deformity of the duodenal bulb when recording the corresponding endoscopic diagnoses. A total of 156 patients had a barium meal and were subsequently randomized into 2 groups. In 74 of the cases the 2 endoscopists knew the result of the X-ray examination when doing the endoscopy; in 82 of the cases they did not. One endoscopist was significantly biased by his knowledge of the radiologic diagnosis of deformity of the duodenal bulb. Neither of the endoscopists was biased by his knowledge of the radiologic diagnosis of duodenal ulcer. In addition, the interobserver variation between the two endoscopists with regard to the endoscopic diagnoses of duodenal ulcer, deformity of the duodenal bulb, and duodenitis was examined. The interobserver variation was expressed by the overall agreement and by the kappa statistics, which adjusts the overall agreement for expected chance agreement. For duodenal ulcer, deformity of the duodenal bulb, and duodenitis, the overall agreements and kappa values were 0.91, 0.78, and 0.75, and 0.54, 0.42, and 0.33, respectively.     

Irradiation-induced duodenal ulcer disease refractory to ranitidine: healing by omeprazole

In two patients duodenal ulcer refractory to high dose H2-blocker treatment started several months after irradiation therapy following right nephrectomy because of renal adenocarcinoma. Established antiulcer drugs like ranitidine, famotidine, sucralfate, pirenzepine, and antacids alone or in combination were unable to control ulcer pain and failed to induce ulcer healing. Initiation of omeprazole treatment at dosages to produce complete achlorhydria were necessary for ulcer healing and maintenance therapy. We suggest that (a) irradiation may cause duodenal ulcer disease indistinguishable from idiopathic duodenal ulcer; (b) radiation-induced ulcers in the duodenal bulb are refractory to various antiulcer drugs but may heal after administration of omeprazole in dosages that completely suppress acid secretion.     

Multiple giant duodenal ulcers associated with duodenal gastrinoma

A 59-year-old Japanese man with a history of chronic hepatitis C and cirrhosis was admitted to hospital because of severe abdominal pain and diarrhea. His discomfort had begun 2 months earlier and was localized to the upper abdomen. Upper gastrointestinal endoscopy showed multiple ulcerative lesions from the duodenal bulb to the descending part of the duodenum, one of which was a giant ulcer that filled half of the intestinal lumen. Despite continuous intravenous lansoprazole therapy, his abdominal symptoms did not improve. Upper gastrointestinal endoscopy was again performed to detect the tumor, but it was difficult to observe the tumor with a conventional endoscope. We then inverted a transnasal endoscope into the duodenum, and this enabled us to detect a 15-mm submucosal tumor in the upper wall of the duodenal bulb. Examination of specimens from endoscopic ultrasonography fine-needle aspiration biopsy of the tumor revealed gastrinoma in the duodenal bulb. We decided to perform an operative resection. The patient’s symptoms resolved after surgery, and he remained asymptomatic at follow-up 18 months later. Therefore, when it is difficult to detect the tumor directly by conventional endoscopy, we recommend that attempts be made to detect the tumor by inverting a transnasal endoscope into the duodenal bulb.     

Helicobacter pylori-associated antibodies in patients with duodenal ulcer, gastric and oesophageal adenocarcinoma

OBJECTIVE: To associate Helicobacter pylori-associated antibodies with clinical disease in groups of patients with duodenal ulcer, gastric adenocarcinoma, oesophageal adenocarcinoma and normal mucosa. DESIGN: Prospective observational sero-epidemiology study. Identification of consecutive in-patients with duodenal ulcer, gastric adenocarcinoma, oesophageal adenocarcinoma and normal mucosa. Analyses of sera for antibodies to whole H. pylori, Cag A and Vac A antigens using ELISA and Western blot. Statistical analyses. SETTING: Walsgrave Hospital, Coventry, a district general hospital that serves a population of 350,000. PARTICIPANTS: Consecutive in-patients with an endoscopic diagnosis of duodenal ulcer (n = 31), gastric adenocarcinoma (n = 31), oesophageal adenocarcinoma (n = 40) and normal mucosa (n = 46). MAIN OUTCOME MEASURES: A profile of antibodies was constructed for each patient group and between-group comparisons were made. A logistic regression model determined the H. pylori-associated antibody that could best predict a patient's diagnosis. A discriminatory power for each antibody was calculated. RESULTS: Whole H. pylori, Cag A and Vac A antibodies are found more commonly in duodenal ulcer patients when compared to oesophageal adenocarcinoma (P < 0.003) and normal mucosa patients (P < 0.015). Similarly, gastric adenocarcinoma patients have antibodies to whole H. pylori, Cag A and Vac A more frequently than oesophageal adenocarcinoma (P< 0.002) and normal mucosa patients (P < 0.006). Vac A antibodies discriminate between duodenal ulcer/gastric adenocarcinoma and oesophageal adenocarcinoma/normal mucosa patients (odds ratio 5.56, log likelihood -90.06, P < 0.001) more effectively than Cag A antibodies (odds ratio 4.17, log likelihood -91.88, P < 0.001). CONCLUSIONS: Similar profiles of H. pylori-associated antibodies are seen in patients with duodenal ulcer and gastric adenocarcinoma, confirming that virulent H. pylori are involved in the pathogenesis of both diseases. Antibodies to Vac A could be used to identify patients at increased risk of developing H. pylori-associated disease.     

The papilla of Vater just below the pylorus presenting as recurrent duodenal ulcer bleeding

The papilla of Vater emptying into the duodenal bulb site is extremely rare and considered an aberrant condition. We report here a case with recurrent duodenal ulcer bleeding associated with this anomaly. A 42-year-old man was admitted to St. Mary Hospital because of tarry stool for three days. Despite no documented etiology to explain recurrent ulceration, the patient had about ten episodes of ulcer bleeding since 1995. On duodenoscopy, 1.0 x 0.6 cm sized active stage duodenal ulcer with oozing was observed at the posterior wall side below the pylorus. The papilla of Vater was bulging just below the pylorus. Bile juice was excreted from its opening. Pancreatic duct and common bile duct, which drained into the bulb site, were observed on ERCP. In this report, we show that recurrent duodenal ulcer can be associated with the papilla of Vater just below the pylorus.     

Choledochoduodenal fistula at the anterior wall of the duodenal bulb: a rare complication of duodenal ulcer

A 38 year-old man was admitted to our hospital with the chief complaint of epigastralgia. His laboratory data revealed leukocytosis and increased serum amylase, and abdominal ultrasonography revealed diffuse swelling of the pancreas. Thus, he was diagnosed as having acute pancreatitis. Moreover, abdominal computed tomography showed pneumobilia in the gallbladder and the common bile duct. Gastroduodenal fiberscopy demonstrated peptic ulcer scars around a foramen with smooth margins at the anterior wall of the duodenal bulb. The bile juice flowed from the bottom of the foramen. Endoscopic retrograde cholangiopancreatography revealed the fistula between the common bile duct and the anterior wall of the duodenal bulb, but not the posterior wall. However, there was no pancreatico-biliary maljunction and no stones in the gallbladder or bile duct. This is a rare case of choledochoduodenal fistula at the anterior wall of the duodenal bulb caused by duodenal peptic ulcer disease.     

35例原发性十二指肠癌的诊断及治疗分析

目的总结原发性十二指肠癌的诊治经验,提高其诊治水平。方法回顾分析2001年1月～2007年12月我院经内镜及手术确诊的35例原发性十二指肠癌患者的临床资料。结果本组病例肿瘤位于十二指肠球部6例;十二指肠降部26例;十二指肠水平部3例。其中乳头状腺癌8例、管状腺癌23例、黏液腺癌2例,类癌1例,恶性间质瘤1例。胃镜确诊率为77.4%;上消化道钡餐造影确诊率为52.4%。CT确诊率为46.7%;B超确诊率为10.3%;MRCP确诊率为6.9%。行胰十二指肠切除术22例,十二指肠乳头切除、乳头成形术6例,胃空肠吻合术3例,单纯肿物切除术1例,姑息性旁路手术2例。结论原发性十二指肠癌发病部位以十二指肠降部尤其乳头周围部为多,病理以腺癌为主;本病诊断首选内镜检查,其次是十二指肠气钡双重造影;手术切除尤其是胰十二指肠切除术是最常用、最可靠的治疗方法。