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Primary carcinoma of the infrapapillary portion of the duodenum
PRIMARY CARCINOMA OF THE INFRAPAPILLARY PORTION OF THE DUODENUM* RICHARD J. CHODOFF, M.D., JOSEPH STEIN, M.D. AND JACOB SPECTER, M.D. Philadelphia,
Pennsylvania
C
ARCINOMA of the infrapapillary portion of the duodenum is encountered infrequently. However, it is a condition which can be diagnosed preoperativeIy and which is subject to surgical treatment. Up until rg5o Shallow and associates’ could collect only fifteen cases from the literature in which resection was performed. We have recentIy encountered a patient in whom this lesion was diagnosed preoperatively and in whom a resection and primary end-toend anastomosis was performed. CASE
REPORT
M. T., a forty-one year old white woman, was admitted to Mount Sinai Hospital on September zg, 1950, because of weight loss and easy fatigue. She had been told she was anemic in rg42. In March, 1949, she noticed that she tired easily and was found to have a Iow hemoglobin. She received iron and liver therapy and her condition improved. In May, 1950, there was a recurrence of symptoms but hematinics had IittIe effect. An upper gastrointestinal x-ray in August, 1950, was reported as negative. From this time until hospitalization (six weeks) she Iost 17 pounds. She had noticed exertiona dyspnea and palpitation since the onset of her illness (March, 1949). Through a11 this her appetite remained good and she did not ascribe her weight loss to any decrease in eating. In October, 1949, she had an attack of right upper quadrant abdomina1 pain with nausea, vomiting and jaundice, but no change in the color of her stools. At the time of hospital admission physica examination revealed a thin, pale woman with a normal blood pressure, temperature, pulse and respiration. There was a suggestion of a Ieft upper quadrant mass and a questionably palpable liver. Otherwise the examination was negative. HemogIobin was 9.7 gm. with 8.2 per cent reticulocytes and 5,750 leukocytes with a
normal differential. UrinaIysis was normal. Serum bilirubin, total protein and A/G ratio, cephalin flocculation, thymol turbidity, prothrombin time and bromsuIfaIein excretion were within norma limits. BIood sugar, blood urea nitrogen, sedimentation rate and red cell fragility were normal. Coombs’ test was negative. The stool on three different examinations for occult blood was 4 plus. Proctosigmoidoscopy and barium enema were negative. An upper gastrointestinal x-ray reveaIed a “Iarge intra-IuminaI Iesion at the duodeno-jejunal junction which is almost certainIy due to neopIasm.” There was no obstruction. Laparotomy was performed on October 16, 1950, through an upper left rectus incision. A bulky intraIumina1 mass was felt in the distal duodenum extending beyond the ligament of Treitz. The Iiver contained no nodules. The spleen was slightly enlarged. There were no paIpable lymph nodes. The lesser peritoneal sac was entered through the gastrocolic ligament. The peritoneum Iateral to the duodenum was incised to permit its mobiIization. The duodenum was divided just distal to the entrance of the common duct. The duodenum was separated from the superior mesenteric vessels and the ligament of Treitz was cut. The vessels to the third and fourth portions of the duodenum and the proximal jejunum were clamped, cut and ligated. The jejunum was divided about IO cm. beyond the ligament of Treitz. An end-to-end anastomosis was then made anterior to the superior mesenteric vesseIs. The rent in the mesocolon was cIosed and the abdomen was closed without drainage. The pathologic report was as follows: The specimen consisted of 15.5 cm. of smaI1 bowel containing a fungating lesion 7.5 cm. long. The serosa overIying the Iesion was puckered. Three lymph nodes were present, the largest measuring I cm. in diameter. Microscopic examination revealed a moder-
* From the Mt. Sinai Hospital,
498
Phiiadetphia,
Pa.
American
Journal
of Surgery
Chodoff
et
al.-Carcinoma
of Third
ately malignant adenocarcinoma extending into the muscularis with lymph node metastases. The postoperative course was uneventfu1 and the patient was discharged on the thirteenth day after operation. ImmediateIy after discharge she did fairly well but some backache soon deveIoped and she became bloated after eating. In May, 1931, she again compIained of weakness and anorexia. On June 2, rg3 I, seven and a half months after operation, she expired in her sleep. Autopsy was not obtained.
Portion
of
Duodenum
699
Despite the absence of any gross metastases or extension the lymph nodes removed with the specimen were involved and the survival was reIativeIy short. Obvious extension into the pancreas wouId necessitate pancreaticoduodenectomy for cure and we wonder if our patient would have benefited by such a procedure. In addition to the wider local resection this would permit compIete removal of the lymph nodes and vessels around the superior mesenteric and portal vessels and celiac axis.
COMMENTS
The incidence of primary carcinoma of the duodenum is low. On the basis of autopsy studies Ege? gave it as 0.033 per cent and Howard3 reported it as .047 per cent. Both of these studies found a minority of the Iesions in the infrapapihary portion. In spite of its rarity this Iesion should be diagnosed preoperativeIy. The clinical picture usuaIIy is that of a high intestina1 obstruction, partia1 or compIete. However, in our patient the bowe1 was studied in an attempt to explain a persistent anemia rather than because of any gastrointestinal symptoms. Careful x-ray studies wiI1 revea1 the site of the Iesion. That the diagnosis can be correctIy made was pointed out by and ShaIIow and assoWeber and Kirklin,4 ciates.’ Both of these groups noted a correct diagnosis by x-ray in al1 carcinomas encountered in the third portion of the duodenum.
SUMMARY I. A portion mental 2. It lesion would concept
case of primary carcinoma of the third of the duodenum treated with segresection is reported. is suggested that treatment of this by radica1 pancreaticoduodenectomy be more in keeping with the current of cancer surgery. REFERENCES
SI~ALLO~, T. A., N'AGNEK, F. B., JK. and IZl~~~;~~. A'. B. Primary carcinoma of infrapapillary portion of duodenum. Surq~~, 27: 348-355, 1950. 2. EGER, S. A. Primary malignant disease of tht duodenum. Arch. Surg.. 27: 1o87-I ro8, ,933. 1. HOWARD. J. W. Carcinoma of the duodenum. Am. J: IM. SC., 206: 735-746, 1943. 4. WEBEK, H. M. and KIRKLIN, B. R. Roentgenologic manifestations of tumors of the small intestinw: Am. J. Roentgenol., 47: 243-253, 1~42. 1.
Pennsylvania
C
ARCINOMA of the infrapapillary portion of the duodenum is encountered infrequently. However, it is a condition which can be diagnosed preoperativeIy and which is subject to surgical treatment. Up until rg5o Shallow and associates’ could collect only fifteen cases from the literature in which resection was performed. We have recentIy encountered a patient in whom this lesion was diagnosed preoperatively and in whom a resection and primary end-toend anastomosis was performed. CASE
REPORT
M. T., a forty-one year old white woman, was admitted to Mount Sinai Hospital on September zg, 1950, because of weight loss and easy fatigue. She had been told she was anemic in rg42. In March, 1949, she noticed that she tired easily and was found to have a Iow hemoglobin. She received iron and liver therapy and her condition improved. In May, 1950, there was a recurrence of symptoms but hematinics had IittIe effect. An upper gastrointestinal x-ray in August, 1950, was reported as negative. From this time until hospitalization (six weeks) she Iost 17 pounds. She had noticed exertiona dyspnea and palpitation since the onset of her illness (March, 1949). Through a11 this her appetite remained good and she did not ascribe her weight loss to any decrease in eating. In October, 1949, she had an attack of right upper quadrant abdomina1 pain with nausea, vomiting and jaundice, but no change in the color of her stools. At the time of hospital admission physica examination revealed a thin, pale woman with a normal blood pressure, temperature, pulse and respiration. There was a suggestion of a Ieft upper quadrant mass and a questionably palpable liver. Otherwise the examination was negative. HemogIobin was 9.7 gm. with 8.2 per cent reticulocytes and 5,750 leukocytes with a
normal differential. UrinaIysis was normal. Serum bilirubin, total protein and A/G ratio, cephalin flocculation, thymol turbidity, prothrombin time and bromsuIfaIein excretion were within norma limits. BIood sugar, blood urea nitrogen, sedimentation rate and red cell fragility were normal. Coombs’ test was negative. The stool on three different examinations for occult blood was 4 plus. Proctosigmoidoscopy and barium enema were negative. An upper gastrointestinal x-ray reveaIed a “Iarge intra-IuminaI Iesion at the duodeno-jejunal junction which is almost certainIy due to neopIasm.” There was no obstruction. Laparotomy was performed on October 16, 1950, through an upper left rectus incision. A bulky intraIumina1 mass was felt in the distal duodenum extending beyond the ligament of Treitz. The Iiver contained no nodules. The spleen was slightly enlarged. There were no paIpable lymph nodes. The lesser peritoneal sac was entered through the gastrocolic ligament. The peritoneum Iateral to the duodenum was incised to permit its mobiIization. The duodenum was divided just distal to the entrance of the common duct. The duodenum was separated from the superior mesenteric vessels and the ligament of Treitz was cut. The vessels to the third and fourth portions of the duodenum and the proximal jejunum were clamped, cut and ligated. The jejunum was divided about IO cm. beyond the ligament of Treitz. An end-to-end anastomosis was then made anterior to the superior mesenteric vesseIs. The rent in the mesocolon was cIosed and the abdomen was closed without drainage. The pathologic report was as follows: The specimen consisted of 15.5 cm. of smaI1 bowel containing a fungating lesion 7.5 cm. long. The serosa overIying the Iesion was puckered. Three lymph nodes were present, the largest measuring I cm. in diameter. Microscopic examination revealed a moder-
* From the Mt. Sinai Hospital,
498
Phiiadetphia,
Pa.
American
Journal
of Surgery
Chodoff
et
al.-Carcinoma
of Third
ately malignant adenocarcinoma extending into the muscularis with lymph node metastases. The postoperative course was uneventfu1 and the patient was discharged on the thirteenth day after operation. ImmediateIy after discharge she did fairly well but some backache soon deveIoped and she became bloated after eating. In May, 1931, she again compIained of weakness and anorexia. On June 2, rg3 I, seven and a half months after operation, she expired in her sleep. Autopsy was not obtained.
Portion
of
Duodenum
699
Despite the absence of any gross metastases or extension the lymph nodes removed with the specimen were involved and the survival was reIativeIy short. Obvious extension into the pancreas wouId necessitate pancreaticoduodenectomy for cure and we wonder if our patient would have benefited by such a procedure. In addition to the wider local resection this would permit compIete removal of the lymph nodes and vessels around the superior mesenteric and portal vessels and celiac axis.
COMMENTS
The incidence of primary carcinoma of the duodenum is low. On the basis of autopsy studies Ege? gave it as 0.033 per cent and Howard3 reported it as .047 per cent. Both of these studies found a minority of the Iesions in the infrapapihary portion. In spite of its rarity this Iesion should be diagnosed preoperativeIy. The clinical picture usuaIIy is that of a high intestina1 obstruction, partia1 or compIete. However, in our patient the bowe1 was studied in an attempt to explain a persistent anemia rather than because of any gastrointestinal symptoms. Careful x-ray studies wiI1 revea1 the site of the Iesion. That the diagnosis can be correctIy made was pointed out by and ShaIIow and assoWeber and Kirklin,4 ciates.’ Both of these groups noted a correct diagnosis by x-ray in al1 carcinomas encountered in the third portion of the duodenum.
SUMMARY I. A portion mental 2. It lesion would concept
case of primary carcinoma of the third of the duodenum treated with segresection is reported. is suggested that treatment of this by radica1 pancreaticoduodenectomy be more in keeping with the current of cancer surgery. REFERENCES
SI~ALLO~, T. A., N'AGNEK, F. B., JK. and IZl~~~;~~. A'. B. Primary carcinoma of infrapapillary portion of duodenum. Surq~~, 27: 348-355, 1950. 2. EGER, S. A. Primary malignant disease of tht duodenum. Arch. Surg.. 27: 1o87-I ro8, ,933. 1. HOWARD. J. W. Carcinoma of the duodenum. Am. J: IM. SC., 206: 735-746, 1943. 4. WEBEK, H. M. and KIRKLIN, B. R. Roentgenologic manifestations of tumors of the small intestinw: Am. J. Roentgenol., 47: 243-253, 1~42. 1.