A 72-year-old man with duodenal adenocarcinoma.

CASE REPORTS Dr. Tamraz: A 72-year-old male patient, previously healthy and had never smoked, presented with intermittent and crampy abdominal pain of about 1-month duration that was occasionally associated with nausea and vomiting. The patient had no fevers, night sweats, or weight loss. He also had no melena or change in bowel habits. His past medical history was significant for hypertension, which was well controlled on angiotensin receptor blockers. Laboratory evaluation showed a mild microcytic anemia, with a Hb of 11 g/dL, Hct 33%, MCV 76 fl, normal WBCs and platelets. Occult blood was positive. Dr. Lowery: With the presence of occult blood positivity, I assume an endoscopy was done. Dr. el-Oubeidi: An upper endoscopy was undertaken and showed a tumor at the apex of the duodenal bulb, which was circumferential, ulcerated, and protruding into the lumen causing partial obstruction. Dr. Zaatari: Biopsy of this tumor was conflicting between carcinoid and adenocarcinoma. Pathologists find it difficult sometimes to differentiate on limited biopsy material between a duodenal, pancreatic, biliary, and ampullary carcinoma due to the closeness of these structures and their overlapping histologic features of carcinomas arising at those sites. Immunohistochemical stains are also of limited value in this context. Molecular profiling may offer an opportunity to better categorize tumors that arise at that site. According to a recent presentation by Overmann et al at the 2011 Gastrointestinal Cancers Symposium, gene expression analysis incorporates carcinomas of ampulla with that of the duodenum and classifies ampullary carcinomas into 2 groups, biliary like and intestinal like, each with a different prognosis and treatment. Dr. Abou-Alfa: Dr. Shamseddine, how often do you see such presentation in Lebanon? Dr. Shamseddine: Duodenal tumors whether carcinoid or adenocarcinoma in origin are very rare, with only a few cases reported in our registry. Dr. O’Reilly: Adenocarcinoma of the small intestine is an uncommon neoplasm that represents up to 42% of all small bowel malignancies and fewer than 0.5% of all gastrointestinal malignancies. The majority of patients present with locoregional disease, stage II or III disease present in 53% of patients. The diagnosis of these tumors is often difficult due to the rarity of these lesions and the nonspecific and variable nature of the presenting signs and symptoms. Thus, delay in diagnosis is common, which may result in discovery of the disease at a late stage and a poor treatment outcome. The etiology of small bowel cancers is unknown, although a number of risk factors and predisposing conditions have been described. The most important of these include hereditary nonpolyposis colorectal cancer, Peutz-Jeghers syndrome, familial adenomatous polyposis, chronic inflammatory disorders such as Crohn’s disease, and autoimmune disorders such as celiac disease. The incidence of adenocarcinoma is highest in the duodenum of any site in the small bowel. In two large single-institution series of patients with small bowel adenocarcinoma 65% and 57% arose in the duodenum. I am curious, though, if any further testing was obtained to help evaluate the extent of disease. Periampullary carcinomas include adenocarcinomas of the ampulla, pancreas, and duodenum as well as the common bile duct. Dr. Al-Kutoubi: A computer tomography (CT) scan with oral and IV contrast was obtained that showed an ill-defined mass at the level of the duodenum measuring 6 5.4 cm, causing distortion of the head of the pancreas, partially obstructing the duodenum with no evidence of biliary ductal dilatation (Figures 1A and 1B). Dr. Tamraz: In view of the resectable nature of the disease and the absence of metastatic disease, the patient underwent an exploratory laparotomy and a Whipple procedure was performed, which I will ask Dr. Faraj to comment on. Dr. Faraj: At laparotomy and following exploration of the peritoneal cavity, the lesser sac was opened and the duodenum was mobilized. The common hepatic duct was divided after cholecystectomy, and a tunnel was created anterior to the portal vein extending to the superior mesenteric vein. The pancreas was divided, and then the specimen was excised. Reconstruction was done in one limb using duct-to-mucosa anastomosis for the pancreaticojejunostomy and about 15 cm distally, and a hepaticojejunostomy was performed in a retrocolic fashion. Then about 70 cm gastro-jejunostomy was done, and a Braun anastomosis was carried by side-to-side jejunojejunostomy (Figure 2). The patient tolerated the procedure well and was transferred to the recovery room in good condition. Dr. Zaatari: There was a large fungating mass at the duodenum in proximity to the head of pancreas, and actually short of looking at the histologic sections, it was very difficult to determine that this was indeed a primary from the duodenum or pancreas because of the proximity of the two structures. But looking at the slides, you can see that most of the pathology was consistent with adenocarcinoma, moderately differentiated with many well-formed glands. You can see as well that the bulk of the tumor was within the wall of the duodenum with extension to the pancreatic head. Based on that, the argument was more in favor of duodenal primary rather than