Case Adenocarcinoma at angle of treitz: A report

Report
of two cases with review of literature
Koli Pushpa, Dewoolkar VV, Butale U
Department of General Surgery, K.J. Somaiya Hospital and Research Centre, Everad Nagar, Mumbai,
India.

Correspondence to: Dr. V.V. Dewoolkar, E-mail: [email protected]

Abstract
We report two patients with adenocarcinoma at angle of treitz who presented with upper GI(gastrointestinal) obstruction
and underwent segmental resection of duodeno-jejunal junction. Preoperative investigations failed to reveal the nature of
the lesion suggesting the elusive nature of these lesions, importance of clinical suspicion and decision-making.

Key words: Adenocarcinoma, angle of treitz, duodenojejunal growth

Introduction duodeno-jejunal junction with enlarged mesenteric lymph

nodes, without involvement of adjacent structures.
Primary malignancies of small bowel are rare and present Segmental resection of duodenojejunal (D-J) junction
a unique challenge in terms of preoperative diagnosis, with growth with 1.5 cm of margin and clearance
treatment decisions and postoperative management. of loco regional lymphnodes was done. Postoperative
Adenocarcinoma occurring at ligament of treitz are recovery was uneventful. The histopathology confirmed
extremely rare and difficult to diagnose but have a it as moderately differentiated adenocarcinoma, reaching
better prognosis compared to duodenal adenocarcinoma. the serosa with no lymphovascular invasion. Patient
Segmental resection is the treatment of choice but the refused postoperative chemotherapy and did not come
effect of postoperative chemotherapy is not clear from for regular follow-up.
literature, however it is worth giving.
After one and half years of initial surgery patient got
Case Reports readmitted with features of gastric outlet obstruction
and a palpable epigatric mass. Ultrasound revealed
multiple mesenteric lymph nodes with minimal ascites.
Case 1
On exploration there were multiple lymph nodes at the
A 73-year-old female patient was admitted twice in root of mesentery; the largest was measuring 10 x 8
year 2005 with upper abdominal pain and vomiting cm. The lymph node mass was compressing the pylorus
of three and a half months duration which responded and distal common bile duct causing obstruction. There
to conservative treatment. The patient got readmitted were no bowel lesions and liver metastasis. A palliative
for the third time after a month with copious bilious bypass in the form of anterior gastrojejunostomy,
vomiting and abdominal pain which was suggestive cholecystojejunostomy and jejunojejunostomy was done.
of upper GI obstruction. Patient was evaluated with Patient recovered well and survived for a further period
abdominal ultrasound, upper GI endoscopy and CT of six months.
scan of abdomen. The ultrasound and CT scan were
essentially normal. During the endoscopy the scope was Case 2
passed till 3rd part of duodenum and was normal. After A 40-year-old male patient was admitted with
a brief period of fasting and nasogastric aspiration for complaints of upper abdominal pain, bilious vomiting
three days the patient did not improve. A small bowel and constipation for one and half months. He was
obstruction was suspected and patient was posted for hepatitis B surface antigen positive (HBSAg). On
operation. On exploration there was a 3.5cm growth at upper G I endoscopy there was suspicion of superior

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 Koli et al.: Adenocarcinoma at angle of treitz

mesenteric artery syndrome(SMA syndrome), as the comprises 80% of the length of gastrointestinal tract,
duodenum was dilated till the third part, beyond which yet it counts for only 1% of all GIT malignancies. True
scope could not be negotiated Though ultrasound incidence of adenocarcinomas occurring at ligament
abdomen was normal, CT scan suggested the possibility of treitz is unknown, but duodenal adenocarcinomas
of SMA Syndrome, hence the patient was explored. constitute about 0.3 to 0.4 % of all GIT cancers.

On exploration the duodenum was dilated and there Adenocarcinomas usually present in the 6th and 7th
was a growth at ligament of treitz measuring 4 cm decades. In a study of 129 patients with primary
without involvement of serosa or enlarged lymph nodes small bowel cancers by Tocchi et al, [1] 33% were
[Figure 1]. There was no ascites or liver metastases. adenocarcinomas, 29% were carcinoids and 19% were
Duodenojejunal segmentectomy with 1cm margin and lymphomas. Half of all adenocarcinomas occur in the
duodenojejunal anastomosis was done. Postoperatively duodenum, nearly 20% in jejunum and a little over
the patient recovered well and histopathology 10% in ileum and 14% occur in unspecified sites.[2]
suggested moderately differentiated adenocarcinoma
[Figure 2] which was reaching serosa without perineural/ Among the duodenal carcinomas two third occur in the
lymphovascular invasion. Patient was given chemotherapy periampullary region. Risk factors that are associated
and at six months of follow-up is doing well. with small bowel adenocarcinoma include familial
adenomatous polyposis coli, Gardners and Turcots
Discussion syndrome, Crohns disease, Coeliac disease, Lynch
syndrome, immunosuppression. etc., however, both of
Small bowel cancers are a rare entity. The small bowel our patients did not have any predisposing factors. The
second patient was only HBSAg positive.

The extreme rarity and vagueness of presenting

symptoms makes it hard to diagnose these tumors.[1,2]
The most common presenting complaint is intermittent
pain due to partial intestinal obstruction. 5-10% of the
patients may present with manifestations of hemorrhage
like malena and anemia. Other features include anorexia
and weight loss. The mean duration of symptoms before
presentation is 10 months (range, 0-24 months).[3]

There are no specific methods to diagnose these tumors

in an early stage. Most of the cases require special
investigations for diagnosis. Barium contrast has a
diagnostic accuracy of 83%. [1,2]. Enteroclysis is the
Figure 1: Operative photograph showing growth at angle of treitz investigation of choice for the small bowel intrinsic
after mobilisation pathology. Enteroscopy by the “push” method using the
pediatric colonoscope can yield a biopsy or a “sonde”
enteroscopy can be used to view the lesion. Capsule
endoscopy and double balloon enteroscopy (DBE) are
the newer diagnostic modalities. DBE was described by
Yamamoto et al l in 2001, which helps in diagnosing
the small bowel lesions along with biopsy taking.[4]

Duodenal first and second part tumors are treated by

Whipples’ procedure. For resectable cancers of third and
fourth part of duodenum, segmental resection is the
treatment of choice. Duodenojejunal segmentectomy is
the treatment of choice for angle of treitz tumors with
lymph node clearance, though lymph node positivity
does not preclude resection, [5] and the prognosis of
these tumors is good.[6] In both of our cases segmental
Figure 2: Photomicrograph showing tumor arising from mucosa resection with lymph node clearance in the first case
(adjacent to brunners glands) and infiltrating muscularis propria was done. Large tumor size, transmural invasion and

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 Koli et al.: Adenocarcinoma at angle of treitz

moderate to poor tumor grade were negatively correlated the initial portion of the jejunum should be done to
with survival. Lymph node status did not influence detect their presence so as to reduce the risk of an early
survival, whereas in a multivariate analysis of 101 recurrence.
patients, nodal metastases, positive margins, and stage
were significant prognostic predictors. The three and References
five-year actuarial survival rates of patients with negative
nodes were 73% and 68%, respectively, compared with 1. Tocchi A, Mazzoni G, Puma F, Miccini M, Cassini D, Bettelli E, et al.
Adenocarcinoma the third and fourth portions of the duodenum:
35% and 22% in patients with nodal metastases. [7]
Results of surgical treatment. Arch Surg 2003;138:80-5.
Jejunal and proximal ileal malignancies require resection 2. Howe JR, Karnell LH, Menck HR, Scott-Conner C. Adenocarcinoma
and anastomosis while distal ileal ones require a right of the small bowel: Review of the National Cancer Data Base, 1985-
hemicolectomy. The role of adjuvant chemotherapy 1995. Cancer 1999;86:2693-706.
3. Talamonti MS, Goetz LH, Rao S, Joehl RJ. Primary cancers of the
and radiotherapy in small bowel adenocarcinoma is not small bowel: Analysis of prognostic factors and results of surgical
clearly defined and it has been found in some studies management. Arch Surg 2002;137:564-70.
that adjuvant treatment after complete resection has 4. Yamamoto H, Kita H, Sunada K, Hayashi Y, Sato H, Yano T, et al.
Clinical outcomes of double-balloon endoscopy for the diagnosis and
not been shown to diminish the risk for subsequent treatment of small-intestinal diseases. Clin Gastroenterol Hepatol
recurrence.[3] 2004;2:1010-6.
5. Rose DM, Hochwald SN, Klimstra DS, Brennan MF. Primary duodenal
The overall 5-year survival is 17 to 25%,[2] and median adenocarcinoma: A ten-year experience with 79 patients. J Am Coll
Surg 1996;183:89-96.
survival is 19.7 months,[1] prognosis being worse in 6. Carloni A, Perri S, Gola P, Lotti R, Caterino G, Altilia F, et al. Adeno-
duodenal malignancies. Factors affecting outcome carcinoma of duodenojejunal flexure: A report of 2 clinical cases
are tumor diameter, histological grade and serosal and a review of the literature. Ann Ital Chir 2000;71:133-8.
7. Bakaeen FG, Murr MM, Sarr MG, Thompson GB, Farnell MB, Na-
involvement. Patients should be followed-up closely gorney DM, et al. What prognostic factors are important in duodenal
because the possibility of developing another abdominal adenocarcinoma? Arch Surg 2000;135:635-42.
carcinoma is high. As associated polyps are nearly always
duodenal or jejunal, a preoperative or intraoperative
Source of Support: Nil, Conflict of Interest: None declared.
endoscopy of the upper gastrointestinal tract including

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