Duodenal Carcinoma

Clinical History

A 72 year old female presented to in with an acute episode of dizziness and weakness, accompanied by hematemesis.

Imaging Findings

The patient underwent an urgent upper endoscopy and was found to have a bleeding duodenal ulcer which required cauterization. The ulcer was thought to be due to salicylate use for her known rheumatoid arthritis.
Two months later she developed increasing constitutional symptoms with 20-25 pound weight loss. She also noticed extreme skin itch as well as visible jaundice.
Contrast enhanced CT scan showed an infiltrative periampullary mass (Fig 3a) involving the first and second portions of the duodenum. The mass measures 7.7cm in largest dimension and extends into the lumen of the duodenum (Fig 3b). There was significant mass effect with intra and extrahepatic biliary ductal dilatation as well as pancreatic ductal dilatation (Fig 2). There were several hypoattenuating hepatic lesions consistent with metastases (Fig 1). A repeat endoscopy was performed, which showed 4 lesions worrisome for duodenal ulceration and a periampullary mass. Biopsies were consistent with invasive duodenal adenocarcinoma.
Percutaneous cholangiogram and billiary drain insertion (Fig 4 a,b) was performed with good results.

Discussion

Periampullary cancers arise within 2cm of the major papilla in the duodenum. They are the 3rd most frequent gastrointestinal tumours following gastric and colorectal cancers. These tumours exhibit similar symptoms but different clinical outcomes, according to their origin. That is, the prognoses for ampullary carcinoma and
periampullary duodenal carcinoma are better than those for distal common bile duct carcinoma and pancreatic head carcinoma.
Periampullary tumours include four different types of cancers: ampullary, biliary, pancreatic, and duodenal.
CT scan often demonstrates a mass but is not helpful in differentiating ampullary carcinoma from tumours of the head of the pancreas or periampullary region. If the lesion is smaller than 2cm, pancreatic or bile duct dilation might be the only abnormalities noted on CT scan findings. CT can also reveal tumour involvement of the vasculature and therefore help guide management.
Adenocarcinoma of the duodenum accounts for 45-65% of small-bowel cancers. These tumours may develop de novo in the duodenum or may result from the malignant degeneration of pre-existing adenomatous polyps. Duodenal cancers commonly occur in the ampullary or periampullary regions of the descending duodenum; however, these tumours are occasionally found in other portions of the duodenum, including the duodenal bulb. The most frequent clinical findings are early duodenal cancer include epigastric pain, nausea, vomiting, postprandial bloating, weight loss, and signs of upper gastrointestinal bleeding, such as guaiac-positive stool and iron-deficiency anaemia.
At CT these tumours are soft-tissue-attenuation masses with homogeneous enhancement and have a smoothly margined appearance.
The surgical treatment is pancreaticoduodenal resection (Whipple procedure). The procedure involves en bloc resection of the gastric antrum and duodenum; a segment of the first portion of the jejunum, gallbladder, and distal common bile duct; the head and often the neck of the pancreas; and adjacent regional lymph nodes. Unfortunately, most symptomatic patients with duodenal cancer have advanced lesions at presentation. As a result, these patients have a poor prognosis, with overall 5-year survival rates ranging from 20-40%.

Differential Diagnosis List

Final Diagnosis

Metastatic invasive duodenal adenocarcinoma

URL:	https://www.eurorad.org/case/6637
DOI:	10.1594/EURORAD/CASE.6637
ISSN:	1563-4086