Transcript PowerPoint Presentation - Slide 1

Small Bowel Tumors
Keith D. Lillemoe M.D.
Dept. of Surgery
Indiana University
School of Medicine
Small Bowel Tumors
Epidemiology
• Exceedingly rare - < 5500 new cases,1200 deaths/year
• Explanations
•
•
•
•
lack of bacteria
rapid transit
role of pancreatic and mucosal enzymes
secretory Ig A / intramural lymphoid tissue
Small Bowel Tumors
Predisposing Conditions
Adenocarcinoma
HNPCC
Familial Adenomatous Polyposis
Crohn’s Disease
Lymphoma
Celiac Disease
Crohn’s Disease
Immunologic Dysfunction
Small Bowel Tumors
Pathology - Benign
Adenomas
(20 – 30%)
simple tubular adenomas
villous adenomas
Brunner’s gland adenomas
Leiomyomas
Lipomas
Hemangiomas
Hamartomas
(30 – 40%)
(15 – 20%)
(<10%)
(<5%)
Small Bowel Tumors
Pathology - Malignant
Distribution (%)
Type of Tumor
Duodenum
Jejunum
Ileum
Adenocarcinoma
35-45
30-40
20-25
40-50
Carcinoid Tumor
10-20
30-40
40-50
20-30
Lymphoma
10-15
5-10
75-85
20-25
1
40-50
50-60
10-15
Gastrointestinal
Stromal Tumors
% of Total
Small Bowel Tumors
Clinical Presentation
Malignant
Benign
Symptom
Pain
Obstruction
Bleeding
Asymptomatic
%
25
20
10-20
<50
Symptom
%
Weight Loss
90-100
Abdominal Pain
80
Obstruction
30
Abdominal Mass
15
Perforation
10
Bleeding
10
Jaundice
2
Small Bowel Tumors
Diagnosis
Radiology
Endoscopy
• Plain films
• Upper
• Contrast Studies
• Lower
• CT
• Enteroscopy
• Laparotomy/Laparoscopy
• Capsule
endoscopy
Small Bowel Tumors
Management – Benign Neoplasms
Adenomas:
Duodenum :
Jejunum/Ileum :
Endoscopic polypectomy
Transduodenal excision
Duodenectomy
Local excision
Small Bowel Tumors
Management – Benign Tumors
Hamartomas – Limited resection of responsible lesion (s)
Hemangiomas – Resection
Electrocautery
Small Bowel Tumors
Management - Adenocarcinoma
Duodenum – Pancreaticoduodenectomy
5 year – survival : 50-60%
Jejunum-ileum – En bloc resection of bowel/mesentery
5 year survival : overall 15-30%
node  15%
node Θ 50-70%
? role for adjuvant therapy
Small Bowel Tumors
Gastrointestinal Stomal Tumors
• formerly leiomyoma / leiomyosarcoma
• arise from mesenchymal tissue
interstital (cell of Cajal)
• grow extrinsically, often to large size
• present with palpable mass, hemorrhage
• associated with mutation of C-kit
Small Bowel Tumors
Management – Gastrointestinal
Stromal Tumors
• Limited surgical resection
• Imatnib Mesylate
(gleevac)
• 5 year survival 60-80%
Small Bowel Tumors
Lymphomas
• vague symptoms – fatigue, malaise, weight loss, pain
• perforation, obstruction – 25%
• palpable mass – 33%
Small Bowel Tumors
Lympoma – Pathology/Staging
• Non-Hodgkin’s, B-cell
• Usually intermediate/high grade with large cell features
• Ann Arbor classification
IE – Tumor continued to SI without lymph nodes
IIE – Regional lymph node involvement
IIIE – Nonresectable lymph nodes
IVE – Spread to nonlymphatic organs
Small Bowel Tumors
Management - Lymphoma
I-E / II-E – Limited resection, ?CTX
5-year survival : 60%
III-E / IV-E – Limited resection + CTX /
Radiation
5-year survival : rare
Small Bowel Tumors
Carcinoid Tumors
• arise from enterochromatin cells
• often present late with nodal/hepatic metastasis
• obstruction due to desmoplastic reaction of
mesentery
• carcinoid syndrome
Small Bowel Tumors
Management – Carcinoid Tumors
• segmental resection with en bloc mesenteric resection
• aggressive treatment of metastatic disease
• treatment of carcinoid syndrome : octreotide
5 year survival :
localized
regional
distant
100%
65%
25-35%
Small Bowel Tumors
Metastatic Neoplasms
• direct extension, carcinomatosis
• Hematogenous metastasis
(melanoma, hypernephroma, breast, lung)