Journal of Surgical Oncology 34262-263 (1987)

Adenocarcinoma of the Duodenum

DEBA P. SARMA, MD, AND THOMAS C. WEILBAECHER, MD

From the Department of Pathology, Veterans Administration Medical Center, and Louisiana State University Medical School, New Orleans

Three patients with carcinoma of the first and the third part of the duodenum are reported. A review of the literature shows the diagnosis of this rare lesion of the duodenum is usually late. In order for surgical resection to be successful, suspicion of such a lesion and an aggressive workup is needed.

K E Y WORDS: duodenal carcinoma, duodenal malignancy, cancer of duodenum

INTRODUCTION Primary adenocarcinoma of the duodenum is a rare

lesion. In about 500,000 autopsies reviewed by Kleiner- man et a1 [ 11, the incidence of carcinoma of the duo- denum (excluding periampullary carcinomas) was only 0.03 % . We reviewed our autopsy records for a 25-year period (January 1960 to January 1985) and found only three patients with duodenal carcinoma, constituting an autopsy incidence of 0.048% (3 cases out of 6,227 autopsies).

REPORT OF CASES

Case 1 A 58-year-old black man came to the hospital with a

2-month history of fatigue, nausea, belching, and a 15- pound weight loss. Physical examination revealed a cach- ectic man with a 6 X4-cm nontender midline abdominal mass above the umbilicus. Liver and spleen were not enlarged. Results of hematologic and chemical laboratory tests were unremarkable. Gastroduodenoscopy revealed a partial obstruction of the pyloric outlet. An upper gas- trointestinal series showed a large pyloric mass displac- ing the duodenal bulb posteriorly. At abdominal ex- ploration the duodenal lesion was diagnosed as adenocar- cinoma by frozen section. The patient underwent a distal gastrectomy, duodenectomy, and partial pancreatectomy . The first part of the duodenum was occupied by a 5 X 5 x2-cm sessile, exophytic, polypoid mass with lob- ulated focally necrotic surface (Figs. 1,2). Tumor was noted to invade the duodenal wall, with minimal involve- ment of the pylorus and the head of the pancreas. The ampulla of Vater and the pancreatic duct were normal. Microscopically the tumor was a moderately differen-

0 1987 Alan R. Liss, Inc.

tiated adenocarcinoma (Fig. 3). Metastatic was noted in two paraduodenal lymph nodes.

After an uneventful postoperative course

carcinoma

the patient continued losing weight and -expired 3 months later. At autopsy, there was disseminated cancer in the abdominal cavity with extensive metastases in liver.

Case 2 A 90-year-old black man died of fulminating tubercu-

lous pneumonia. He did not have any gastrointestinal symptoms during hospitalization. At autopsy, the third part of duodenum was partially filled by a soft 4 x 8-cm papillary mass completely encircling the duodenal mu- cosa. Microscopically, the tumor was a papillary adeno- carcinoma invading the muscularis propria of the duodenum. There was no involvement of the ampulla of Vater or pancreas. There was no metastasis.

Case 3 A 48-year-old white man was diagnosed to have extra-

hepatic biliary obstruction. At laparotomy the pancreas was found to be indurated and considered to be inoper- able pancreatic carcinoma. A cholecystojejunostomy was performed, The patient expired 2 months later. At au- topsy, an 8 x7-cm ulcerating lesion was noted in the first part of the duodenum involving the complete circumfer- ence. The tumor had extended into the periduodenal soft tissue. The duodenal papilla was normal and was located 3 cm beyond the edge of the ulcer. Microscopically, the lesion was a poorly differentiated adenocarcinoma. The

Accepted for publication May 3, 1985. Address reprint requests to D. Sarma, MD, 1601 Perdido Street, New Orleans, LA 70146.

Adenocarcinoma of the Duodenum 263

Fig. I . Resected specimen showing distal stomach (right), and duo- denum with tumor in the first part.

Fig. 3. Microscopically, the lesion is adenocarcinorna. Hcmatoxylin and eosin, x 80.

denectomy with regional lymph node removal is the most acceptable therapy for duodenal carcinoma 121. For cure, diagnosis must be made before the cancer spreads beyond the primary site. Making an early diagnosis remains a problem for duodenal cancer because the signs and symp- toms are often vague. Also because of the rarity of duodenal carcinoma, physicians may not be highly sus- picious [3]. The patient may be asymptomatic or may have abdonimal discomfort, nausea, vomiting, weight loss, and melena. Anemia and presence of occult blood in stool may be the only laboratory abnormalities. Upper gastrointestinal series and duodenoscopy should be done in all suspicious cases. Among the resectable cases, 5- year survival is less than 30% [3,4].

ACKNOWLEDGMENTS Thanks to Roey Holliday for secretarial assistance.

Fig. 2. Longitudinal section showing the stomach and pylorus (right) separate from the duodenal mass. Tumor is almost limited to the duodenal wall. Note the head of the pancreas @elow).

REFERENCES 1. Kleinerman J, Yardumian K, Tamaki HT: Primary carcinoma of

duodenum. Ann Intern Med 32:451465, 1950. 2. Soira IA. Ghazi A. Wolff WI: Prirnarv adenocarcinoina of the

head of the pancreas was infiltrated by the tumor cells in he

liver and lungs. marked fibrosis. ~~~~~~~~i~ was

dtodenum. Cancer 39: 1721-1726, 1977.’

J Surg 147:66-71, 1984.

29: 1010-1015, 1972.

COMMENT 3. Ouriel K, Adams JT: Adenocarcinoma of the mal l intestine Am

Out of three cases that we have described Only one was 4. Cortese AF, Cornell GN: Carcinoma of the duodenum. Cancer surgically resected with curative intent. Pancreaticoduo-