|
1
|
Dang DT, Suresh S, Vance RB, Singla S, Javia S, Watson A, Chathadi KV, Katukuri V, Pompa R, Stidham RW, Zuchelli T, Piraka C. Outcomes of cold snare piecemeal EMR for nonampullary small-bowel adenomas larger than 1 cm: a retrospective study. Gastrointest Endosc 2022; 95:1176-1182. [PMID: 34971667 DOI: 10.1016/j.gie.2021.12.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 12/17/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Nonampullary small-bowel adenomas ≥10 mm are typically resected using cautery-based polypectomy, which is associated with significant adverse events. Studies have demonstrated the safety and efficacy of piecemeal cold snare EMR for removing large colon polyps. Our aim was to assess the safety and efficacy of cold snare EMR for removal of large adenomas in the small bowel. METHODS A retrospective study of patients who underwent lift and piecemeal cold snare EMR of small-bowel adenomas ≥1 cm between January 2014 and March 2019 was conducted at a tertiary care medical center. Polyp characteristics at the time of index and surveillance endoscopy were collected. Primary outcomes were residual or recurrent adenoma (RRA) seen on surveillance endoscopy, polyp eradication rate, and number of endoscopic procedures required for eradication. Adverse events including immediate and delayed bleeding, perforation, stricture, pancreatitis, and postpolypectomy syndrome were assessed. RESULTS Of 43 patients who underwent piecemeal cold snare EMR, 39 had follow-up endoscopy. Polyps ranged in size from 10 to 70 mm (mean, 26.5 mm). RRA was found in 18 patients (46%), with increased polyp size correlating with higher recurrence (P < .001). Polyp eradication was observed in 35 patients (89%), requiring a median of 2 (range, 1-6) endoscopic procedures. Only 1 patient (2.3%) had immediate postprocedural bleeding. No cases of perforation or postpolypectomy syndrome were seen. CONCLUSIONS Piecemeal cold snare EMR may be a feasible, safe, and efficacious technique for small-bowel polyps >10 mm. Prospective, randomized studies are needed to assess how outcomes compare with traditional cautery-based polypectomy.
Collapse
Affiliation(s)
- Duyen T Dang
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Suraj Suresh
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | - R Brooks Vance
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Sumit Singla
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Siddharth Javia
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Andrew Watson
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | | | - Vinay Katukuri
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Robert Pompa
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Ryan W Stidham
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan
| | - Tobias Zuchelli
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Cyrus Piraka
- Division of Gastroenterology, Henry Ford Hospital, Detroit, Michigan, USA
| |
Collapse
|
|
2
|
Massironi S, Rossi RE, Milanetto AC, Andreasi V, Campana D, Nappo G, Partelli S, Gallo C, Scaravaglio M, Zerbi A, Panzuto F, Pasquali C, Falconi M, Invernizzi P. Duodenal Gastric Metaplasia and Duodenal Neuroendocrine Neoplasms: More Than a Simple Coincidence? J Clin Med 2022; 11:2658. [PMID: 35566783 PMCID: PMC9099754 DOI: 10.3390/jcm11092658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/16/2022] [Accepted: 05/06/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Duodenal gastric metaplasia (DGM) is considered a precancerous lesion. No data are available regarding its possible role as a risk factor for duodenal neuroendocrine neoplasms (dNENs). AIMS To assess the prevalence of DGM in a cohort of dNENs. METHODS Subgroup analysis of a retrospective study including dNEN patients who underwent surgical resection between 2000 and 2019 and were observed at eight Italian tertiary referral centers. RESULTS 109 dNEN patients were evaluated. Signs of DGM associated with the presence of dNEN were reported in 14 patients (12.8%). Among these patients, nine (64.4%) had a dNEN of the superior part of the duodenum, one (7.1%) a periampullary lesion, three (21.4%) a dNEN located in the second portion of the duodenum, with a different localization distribution compared to patients without DGM (p = 0.0332). Ten were G1, three G2, and in one patient the Ki67 was not available. In the group with DGM, six patients (35.7%) were classified at stage I, five (28.6%) at stage II, three (21.4%) at stage III, and no one at stage IV. In the group without DGM, 20 patients (31%) were at stage I, 15 (15%) at stage II, 42 (44%) at stage III, and 19 (20%) at stage IV (p = 0.0236). At the end of the study, three patients died because of disease progression. CONCLUSIONS our findings might suggest that DGM could represent a feature associated with the occurrence of dNEN, especially for forms of the superior part of the duodenum, which should be kept in mind in the endoscopic follow up of patients with DGM. Interestingly, dNEN inside DGM showed a more favorable staging, with no patients in stage IV. The actual relationship and the clinical relevance of this possible association require further clarification.
Collapse
Affiliation(s)
- Sara Massironi
- Division of Gastroenterology, San Gerardo Hospital, University of Milano-Bicocca School of Medicine, 20900 Monza, Italy; (C.G.); (M.S.); (P.I.)
| | - Roberta Elisa Rossi
- HBP Surgery, Hepatology and Liver Transplantation Unit, ENETS Center of Excellence, Fondazione IRCCS Istituto Nazionale Tumori (INT, National Cancer Institute), 20133 Milan, Italy
| | - Anna Caterina Milanetto
- Pancreatic and Endocrine Digestive Surgical Unit, Department of Surgery, Oncology and Gastroenterology, Università degli Studi di Padova, 35122 Padua, Italy; (A.C.M.); (C.P.)
| | - Valentina Andreasi
- Pancreatic Surgery Unit, ENETS Center of Excellence, San Raffaele IRCCS, “Vita-Salute” University, 20132 Milan, Italy; (V.A.); (S.P.); (M.F.)
| | - Davide Campana
- ENETS Center of Excellence, Department of Experimental, Diagnostic and Specialty Medicine, Bologna University, St. Orsola-Malpighi University Hospital, 40138 Bologna, Italy;
| | - Gennaro Nappo
- ENETS Center of Excellence, Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Italy; (G.N.); (A.Z.)
| | - Stefano Partelli
- Pancreatic Surgery Unit, ENETS Center of Excellence, San Raffaele IRCCS, “Vita-Salute” University, 20132 Milan, Italy; (V.A.); (S.P.); (M.F.)
| | - Camilla Gallo
- Division of Gastroenterology, San Gerardo Hospital, University of Milano-Bicocca School of Medicine, 20900 Monza, Italy; (C.G.); (M.S.); (P.I.)
| | - Miki Scaravaglio
- Division of Gastroenterology, San Gerardo Hospital, University of Milano-Bicocca School of Medicine, 20900 Monza, Italy; (C.G.); (M.S.); (P.I.)
| | - Alessandro Zerbi
- ENETS Center of Excellence, Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Italy; (G.N.); (A.Z.)
| | - Francesco Panzuto
- Digestive Disease Unit, ENETS Center of Excellence, Sant’Andrea University Hospital, 00189 Rome, Italy;
- Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, 00189 Rome, Italy
| | - Claudio Pasquali
- Pancreatic and Endocrine Digestive Surgical Unit, Department of Surgery, Oncology and Gastroenterology, Università degli Studi di Padova, 35122 Padua, Italy; (A.C.M.); (C.P.)
| | - Massimo Falconi
- Pancreatic Surgery Unit, ENETS Center of Excellence, San Raffaele IRCCS, “Vita-Salute” University, 20132 Milan, Italy; (V.A.); (S.P.); (M.F.)
| | - Pietro Invernizzi
- Division of Gastroenterology, San Gerardo Hospital, University of Milano-Bicocca School of Medicine, 20900 Monza, Italy; (C.G.); (M.S.); (P.I.)
| | | |
Collapse
|
|
3
|
Abstract
CONTEXT.— Duodenal epithelial polyps are reported in 1.5% to 3% of individuals referred for upper endoscopy. Most duodenal epithelial polyps are asymptomatic and nonneoplastic; however, a small subset is neoplastic and may progress to adenocarcinoma. Recent advances in immunohistochemical and molecular techniques have helped further characterize these polyps, shedding light on their origin, classification, and risk of progression to adenocarcinoma. OBJECTIVE.— To provide a comprehensive clinicopathologic review of nonneoplastic and neoplastic duodenal epithelial polyps, with particular emphasis on recent developments in classification schemes and risk stratification based upon immunohistochemical and molecular profiles. DATA SOURCES.— This review is based on peer-reviewed literature and the authors' experiences. CONCLUSIONS.— In this review we provide an update on the clinicopathologic, immunohistochemical, and molecular features of duodenal epithelial polyps and discuss the surveillance recommendations and treatment options available. Particular attention should be placed on recognizing duodenal adenomas with intestinal, gastric, and serrated phenotype, as they have an increased risk of malignant transformation if not completely excised.
Collapse
Affiliation(s)
- Katrina Collins
- From the Department of Pathology & Laboratory Medicine, Hartford Hospital, Hartford, Connecticut
| | - Saverio Ligato
- From the Department of Pathology & Laboratory Medicine, Hartford Hospital, Hartford, Connecticut
| |
Collapse
|
|
4
|
Rajkomar K, Kweon M, Khan I, Frankish P, Rodgers M, Koea JB. Endoscopic assessment and management of sporadic duodenal adenomas: The results of single centre multidisciplinary management. World J Gastrointest Endosc 2017; 9:196-203. [PMID: 28465787 PMCID: PMC5394727 DOI: 10.4253/wjge.v9.i4.196] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Revised: 01/22/2017] [Accepted: 03/02/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To review the role of multidisciplinary management in treating sporadic duodenal adenomas (SDA).
METHODS SDA managed at North Shore Hospital between 2009-2014 were entered into a prospective database. Pathology, endoscopic and surgical management as well as follow up were reviewed.
RESULTS Twenty-eight patients (14 male: Median age 68 years) presented with SDA [18 were classified as non ampullary location (NA), 10 as ampullary location (A)]. All SDA were diagnosed on upper gastrointestinal endoscopy and were imaged with a contrast enhanced CT scan of the chest, abdomen and pelvis. Of the NA adenomas 14 were located in the second part, 2 in the first part and 2 in the third part of the duodenum. Two patients declined treatment, 3 patients underwent surgical resection (2 transduodenal resections and 1 pancreaticoduodenectomy), and 23 patients were treated with endoscopic mucosal resection (EMR). The only complication with endoscopic resection was mild pancreatitis post procedure. Patients were followed with gastroduodenoscopy for a median of 22 mo (range: 2-69 mo). There were 8 recurrences treated with EMR with one patient proceeding to pancreaticodeuodenectomy because of high grade dysplasia in the resected specimen and 2 NA recurrences were managed with surgical resection (distal gastrectomy for a lesion in the first part of the duodenum and a transduodenal resection of a lesion in the third part of the duodenum).
CONCLUSION SDA can be treated endoscopically with minimal morbidity and piecemeal resection results in eradication in nearly three quarters of patients. Recurrent SDA can be treated with endoscopic reresection with surgical resection indicated when the lesions are large (> 4 cm in diameter) or demonstrate severe dysplasia or invasive cancer.
Collapse
|
|
5
|
Lim CH, Cho YS. Nonampullary duodenal adenoma: Current understanding of its diagnosis, pathogenesis, and clinical management. World J Gastroenterol 2016; 22:853-861. [PMID: 26811631 PMCID: PMC4716083 DOI: 10.3748/wjg.v22.i2.853] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 08/10/2015] [Accepted: 10/26/2015] [Indexed: 02/06/2023] Open
Abstract
Nonampullary duodenal adenomas are relatively common in familial adenomatous polyposis (FAP), but nonampullary sporadic duodenal adenomas (SDAs) are rare. Emerging evidence shows that duodenal adenomas, regardless of their anatomic location and whether they are sporadic or FAP-related, share morphologic and molecular features with colorectal adenomas. The available data suggest that duodenal adenomas develop to duodenal adenocarcinomas via similar mechanisms. The optimal approach for management of duodenal adenomas remains to be determined. The techniques for endoscopic resection of duodenal adenoma include snare polypectomy, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and argon plasma coagulation ablation. EMR may facilitate removal of large duodenal polyps. Although several studies have reported cases of successful ESD for duodenal adenomas, the procedure is technically difficult to perform safely because of the anatomical properties of the duodenum. Although current clinical practice recommends endoscopic resection of all large duodenal adenomas in patients with FAP, endoscopic treatment is usually insufficient to guarantee a polyp-free duodenum. Surgery is indicated for FAP patients with severe polyposis or nonampullary SDAs or FAP-related polyps not amenable to endoscopic resection. Further studies are needed to develop newer endoscopic techniques to guide diagnostic and therapeutic decisions for future management of nonampullary duodenal adenomas.
Collapse
|
|
6
|
Shi Z, Dragin N, Miller ML, Stringer KF, Johansson E, Chen J, Uno S, Gonzalez FJ, Rubio CA, Nebert DW. Oral benzo[a]pyrene-induced cancer: two distinct types in different target organs depend on the mouse Cyp1 genotype. Int J Cancer 2010; 127:2334-50. [PMID: 20127859 DOI: 10.1002/ijc.25222] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Benzo[a]pyrene (BaP) is a prototypical polycyclic aromatic hydrocarbon (PAH) found in combustion processes. Cytochrome P450 1A1 and 1B1 enzymes (CYP1A1 and CYP1B1) can both detoxify PAHs and activate them to cancer-causing reactive intermediates. Following high dosage of oral BaP (125 mg/kg/day), ablation of the mouse Cyp1a1 gene causes immunosuppression and death within ∼28 days, whereas Cyp1(+/+) wild-type mice remain healthy for >12 months on this regimen. In this study, male Cyp1(+/+) wild-type, Cyp1a1(-/-) and Cyp1b1(-/-) single-knockout and Cyp1a1/1b1(-/-) double-knockout mice received a lower dose (12.5 mg/kg/day) of oral BaP. Tissues from 16 different organs-including proximal small intestine (PSI), liver and preputial gland duct (PGD)-were evaluated; microarray cDNA expression and >30 mRNA levels were measured. Cyp1a1(-/-) mice revealed markedly increased CYP1B1 mRNA levels in the PSI, and between 8 and 12 weeks developed unique PSI adenomas and adenocarcinomas. Cyp1a1/1b1(-/-) mice showed no PSI tumors but instead developed squamous cell carcinoma of the PGD. Cyp1(+/+) and Cyp1b1(-/-) mice remained healthy with no remarkable abnormalities in any tissue examined. PSI adenocarcinomas exhibited striking upregulation of the Xist gene, suggesting epigenetic silencing of specific genes on the Y-chromosome; the Rab30 oncogene was upregulated; the Nr0b2 tumor suppressor gene was downregulated; paradoxical overexpression of numerous immunoglobulin kappa- and heavy-chain variable genes was found-although the adenocarcinoma showed no immunohistochemical evidence of being lymphatic in origin. This oral BaP mouse paradigm represents an example of "gene-environment interactions" in which the same exposure of carcinogen results in altered target organ and tumor type, as a function of just 1 or 2 globally absent genes.
Collapse
Affiliation(s)
- Zhanquan Shi
- Department of Environmental Health and Center for Environmental Genetics, University of Cincinnati Medical Center, Cincinnati, OH 45267-0056, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
|
7
|
Rubio CA. Stem cells might participate in the cell turnover of duodenal adenomas. INTERNATIONAL JOURNAL OF CLINICAL AND EXPERIMENTAL PATHOLOGY 2008; 2:149-153. [PMID: 19079649 PMCID: PMC2583632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/17/2008] [Accepted: 06/30/2008] [Indexed: 05/27/2023]
Abstract
Eighty-three duodenal adenomas were stained with hematoxylin-eosin (H&E) and with anti-lysozyme immunostain. Mature Paneth cells were those showing coarse brightly red cytoplasmic granules in H&E stain and Paneth cell precursors were those lysozyme-expressing cells that had remained undetected in H&E stain. In the adenomas, the number of mature Paneth cells/high power field varied from 4 to 12 (mean 6.5) in H&E stain, and of lysozyme-expressing cells from 32 to 62 (mean 46.5) (p<0.05). Lysozyme-expressing cells were found haphazardly distributed within the histological profile of the lesion, even in the most superficial cell layer of the dysplastic glands. The latter suggests that if the innate programmed vector of cell migration were valid for duodenal adenomas (from stem cells towards the bottom of the crypts for Paneth cells) the stem cells, normally overlaying Paneth cells, would have been exfoliated into the lumen. Another, less likely option, is that mutated stem cells at the bottom of duodenal adenomas translocate, in an unprecedented manner, the ontogenic signals of migration for Paneth cells. This stochastic molecular option would imply a total reversal of the normal migratory vector for Paneth cells, to a more aberrant, paradoxical migration flow, from stem cells to the villus domain, before exfoliation. Because of the unique migratory direction of the Paneth cells in the crypts of Lieberkühn, the duodenal adenoma emerges as a suitable histo-biological model to monitor the fate of stem cells. It is suggested that stem cells, together with the other recordable mature cells, namely dysplastic enterocytes, Paneth cells and goblet cells, participate in the cell turnover of duodenal adenomas. Further studies are necessary to definitively validate the abovementioned suggested hypothesis.
Collapse
Affiliation(s)
- Carlos A Rubio
- Gastrointestinal and Liver Pathology Research Laboratory, Department of Pathology, Karolinska Institute and University Hospital 17176, Stockholm, Sweden.
| |
Collapse
|
|
8
|
Kim JH, Choi JW, Seo YS, Lee BJ, Yeon JE, Kim JS, Byun KS, Bak YT, Kim I, Park JJ. Inverted cystic tubulovillous adenoma involving Brunner’s glands of duodenum. World J Gastroenterol 2007; 13:3262-4. [PMID: 17589910 PMCID: PMC4436617 DOI: 10.3748/wjg.v13.i23.3262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Benign neoplasia of the duodenum are very rare. Moreover, duodenal tubulovillous adenomas are more uncommon lesions. The microscopic structure of tubulovillous adenoma has frond-like projection of mucosa with branching papillary structure and generally upward growth into the lumen. We describe a 72-year-old man who showed aduodenal tubulovillous adenoma with unusual inverted cystic growth pattern. Interestingly, this tubulovillous adenomatous lesion was interrupted by gastric metaplasia in the deep portion of the cyst and was closely surrounded by Brunner’s glands. Although histogenesis of gastric metaplasia of duodenum is not fully understood, Brunner’s glands has been suggested as a precursor for gastric metaplasia. Therefore, these findings argued that this adenoma arises from Brunner’s glands through gastric metaplasia. This is the first case of inverted cystic tubulovillous adenoma involving Brunner’s glands of duodenum with gastric metaplasia.
Collapse
Affiliation(s)
- Ji Hoon Kim
- Department of Internal Medicine, Guro Hospital, Korea University College of Medicine, 97, Guro-Dong Gil, Guro-Dong, Guro-Ku, Seoul, 152-703, South Korea
| | | | | | | | | | | | | | | | | | | |
Collapse
|