Transcript of noisoi08
DUODENAL TUMORSCME
MEDIC 254 Hoøa Haûo Q. 10 TP. Hoà Chí Minh ÑT: 8357284 8355 136
fax: 8488352543 email: medic@hcm. vnn. vn
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A. INCIDENCE:
10%20% of small bowel tumors. ( #0, 6% all gastrointestinal benign
and malignant neoplasms)
Equal in both men and women.
Approximately 2500 cases of small bowel tumors occur annually in
the US
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The most common duodenal tumor
They appear as both sessile and pedunculated polyps. The surface is
the same collor of the surrounding mucosa.
Histological classify :
+Tubular
+Tubulovillous : if more than 2025% but less than 7580% of the
polyp consists of vilous elements
+Vilous: high degree of malignant potential
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2. Leiomyoma
The most frequently occurring benign tumor in the small intestine.
Most common in the jejunum. 1020% in the duodenum.
Round or ovoid sessile polyp, rarely pedunculate, with a smoothly
tapering border. The central hemorrhagic ulcer should arouse a
suspicion of leiomyoma.
Most leiomyomas arise from the muscularis propria. Leiomyomas are
composed of bundles of spindleshaped smooth muscle cells with
elongated nuclei and abundant cytoplasm arranged in a herringbone
pattern. Differentiation from leiomyosarcomas is difficult. Absence
of cellular pleomorphism, rare mitotic activity, and no invasion of
surrounding tissue are indications of benign status.
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3. Lipoma
They appear in the colon( 6570%), the ileum, the duodenum, and the
jejunum.
stroma.
They arise from the submucosal adipose tissue or serosal fat and
thus are typically extramucosal in location.
Histologically, they are composed of mature adipose tissue
supported by a fibrous
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They make up 3050% of benign lesions of the duodenum.
they are usually smaller than 1cm and often multiple and
polypoid.
Microscopically, they are composed of enlarged aggregates of
glandular tissue often in the form of a polypoid mass. Intersection
of the glandular structure by bands of smooth muscle, cystic
dilatation of the glandular structure, and a fibrous capsule are
characteristic
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They may be solitary or multifocal and may arise from nerve sheaths
(neurilemomas), sympathetic ganglia (ganglioneuromas), and neural
connective tissue (neurofibromas).
They may be associated with cafe au lait spots and cutaneous
neurofibromas (von Recklinghausen ‘s disease).
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6. Angiomas
They can be subdivided into hemangiomas or true vascular tumors (5%
of all small bowel tumors) and telangiectasias or focal angio
dysplasia.
Histologically, hemangioma are bloodfilled sinuses with endothelial
lining.
Telangiectasia may be hereditary or acquired.
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Three subgroups have been described:
+Type I: Commonly found in the right segment of the colon of
elderly people
+Type II: Congenital ( autosomal recessive)and presents as gross
varices in the small intestine of people younger than 20 years of
age.
+Type III: OslerWeberRendu syndrome, is familial, occurs in an
autosomal dominant pattern, and involves the entire gut.
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Mode of transmission:
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0, 35% of all gastrointestinal carcinomas.
The lesion are usually polypoid but can infiltrate the duodenal
wall to produce annular constriction. 2/3 of duodenal
adenocarcinoma are in the region of the ampulla of vater.
Regional lymph nodes and the liver are the most common metastatic
sites.
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2. Carcinoids:
The second most common small bowel malignancy. Most frequently in
the ileum. When arising in the duodenum, they tend to be less
aggressive in terms of inducing desmoplasia and metastasis.
Typically, carcinoids appear as small submucosal nodules, but they
can become polypoid.
Microscopically, they are composed of uniform, small, round cells
that assume a variety of histologic patterns
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3. Sarcoma
The third most common malignancy of the small bowel, of which the
leiomyosarcoma is the most frequent ( most common in the jejunum,
10% in the duodenum).
These tumors tend to grow slowly and may becom quite bulky. They
often outgrow their bloodsupply and thus are subject to ulceration
and necrosis.
Metastasis is usually directly to the peritoneum, less often by
hematogenous spread to the liver, and least often by lymphogenous
extension to regional nodes.
Sarcomas can arise from smooth muscle, connective tissue, fatty
tissue, vascular components, or neural elements.
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4. Lymphoma:
Although rare in the gastrointestinal tract of adults, lymphoma is
the most common digestive tract tumor in children.
Lymphomas may involve the bowel as primary growths or as
expressions of a generalized lymphomatous process. Lymphomas can
appear as fungating ulcerated masses or as diffuse thickening of
the gut wall.
All forms of nonHodgkin ‘s lymphomas have been reported. Most are
of the Bcell type
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III. Metastases and contigious spreadings
The most common sources are breast carcinoma, lung carcinoma, and
melanoma.
Cancers involving the duodenum by contiguous spread are
from pancreas, stomach, biliary tree, right kidney and the hepatic
flexure of the colon.
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1. Bleeding:
Bleeding may be occult to massive and commonly results from
ulceration and necrosis of the tumors.
Leiomyomas, leiomyosarcomas, and hemangiomas bleed more frequently
than do other small bowel tumors.
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C. CLINICAL FEATURES
2. Bowel obstruction
Tumors obstructing the duodenal lumen produce symptoms of abdominal
pain and often anorexia, nausea, and vomiting.
Bowel obstrustion can be caused by intussusception, with the tumors
acting as the lead point, by annular constriction of the bowel, by
volvulus, or by compression from an adjacent tumor mass.
3. Obstructive jaundice
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Unrevealing
A palpable mass often indicates a malignant growth, such as a
lymphoma or a leiomyosarcoma, although benign leiomyomas may
occasionally present as a mass.
Abdominal distention resulting from bowel obstruction is a late
finding, as are hepatomegaly and extensive lymphadenopathy.
Melanin spots on the lips and buccal mucosa suggest the
PeutzJeghers syndrome.
Angiomas visible under the nails and beneath the tongue suggest the
OslerWeberRendu syndrome
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1. Bariumcontrast radiography:.
Barium can be administered by mouth or through a tube passed
through the stomach and into the duodenum (enteroclysis).
Localized filling defects in the opacified intestinal lumen have
been produced by either intraluminal or extraluminal lesions.
Villous tumors: Dappled radiolucency of frondlike projections set
in a matrix of barium (‘’soap bubble’’).
Smoothwalled polypoid defects suggest : Adenoma, Brunner ‘s gland
adenoma, lipoma, leiomyoma (particularly if a central ulcer fleck
is present), or carcinoid.
Luminal stenosis may indicate infiltration of the duodenal wall by
tumor.
At least 15%30% false negative results.
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In most instances routine upper gastrointestinal endoscopy probably
does not include bowel beyond the second portion of the
duodenum.
Oral insertion of a smallcaliber colonoscope allows evaluation of
the small bowel, at least to the proximal jejunum.
Endoscopy provides for photographic documentation and biopsy.
Endosonography permit precise delineation of intramural and
extraluminal tumors, as well as of adjacent structures.
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aids in detection of hepatic metastasis, adenopathy, bowel wall
thickening, extraluminal masses, and biliary onstruction.
Angiography may help define highly vascular tumors or sites of
bleeding
Exploratory laparotomy, on occasion, may be the only method capable
of establishing a diagnosis. This is more commonly the case in the
presence of tumors distal to the duodenum.
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E. TREATMENT
The treatment of benign and malignant tumors of the duodenum is
surgical removal.
1. Benign Polypoid Tumors:
Can often be accomplished by endoscopic snare and cautery. When
involvement of the duodenum is extensive or when the configuration
of the lesion precludes endoscopic removal, duodenotomy or
duodenectomy may be necessary.
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(Whipple’s operation) is the usual procedure.
Malignant lesion of the duodenal bulb and of the third and fourth
portions of the duodenum can often be ttacked successfully without
pancreatectomy.
Except when used for the treatment of lymphomas, radiation and
chemotherapy have not been notably successful
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Adenomas, especially familial polyposis, require careful follow
up.
2. Malignant tumors:
Survival depends in large part on early diagnosis. Unfortunately
3050%of small bowel malignancy have metastasized by the time of
discovery. Endoscopic examination offers the hope of earlier
detection, particularly in the duodenum. Newer supplemental
techniques such as needle biopsy and endoscopic ultrasonography may
further improve diagnostic accuracy
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10%-20% of small bowel tumors
Approximately 2500 cases of small bowel tumors occur annually in
the us
Equal in both men and women
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At least 15%-30% false negative results
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Duodenum
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Oral insertion of a small caliber colonoscope
Photographic documentation and biopsy
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Smoothly tapering border
Central hemorrhagic ulcer
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Angiography
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Malignant tumors:Whipple’s operation
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30%-50% metastasized by the time of discovery
Endoscopic offers the hope of earlier detection
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