Journal of Surgical Oncology 49:29-34 (1992)

Primary Neoplasms of the Small Bowel FRANCIS SEROUR, MD, GEORGE DONA, MD, SHLOMO BIRKENFELD, MD, MOSHE BALASSIANO, MU, AND MAYER KRISPIN, MD From the Department of Surgery A, Edith Wolfson Medicat Center, Holon, lsrael

Primary neoplasms of the small bowel are unusual and constitute 1-5% of all gastrointestinal tract neoplasms. Preoperative diagnostic difficulties, frequent dissemination at the time of the diagnosis, and poor prognosis are characteristic of this pathology. During a period of 26 years we treated 61 patients with tumors of the small bowel, 44 malignant and 18 benign ( 1 patient had both). The most common symptoms were abdominal pain (62%), weight loss (41%), and gastro-intestinal bleeding (3 1%). More than half of the patients were treated as emergencies and among the remaining, the most useful diagnostic test was the small intestinal barium study. Seventeen patients were operated on for intestinal obstruction, 6 of them due to intussusception of the tumor, while 8 other patients presented with perforation and 7 with massive gastrointestinal bleeding. Leiomyoma was the most frequent benign lesion. Among malignancies lymphoma was encountered in 38.6%, followed by adenocarcinoma (29.6%) and leiomyosarcoma (22.8%). Lymphoma was predominant among Sephardic Jews. Curative procedures were attempted in all but one of the benign cases and in 21 of the malignant cases. At the time of surgery metastases were present in 23 patients. The postoperative mortality was high (20% and 14% in the benign and malignant groups, respectively) most probably due to the high incidence of emergency surgery in a high risk population, The prognosis of the malignant tumors was poor with a 5-year survival of 18%. Their disappointing course seems to be related to late diagnosis because of nonspecific symptoms and difficulty in bringing the tumor to the fore. Hopefully, a greater awareness will lead to an earlier diagnosis and improve the prognosis. ~~

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KEYWORDS:lymphoma, adenocarcinoma, leiomyosarcoma, Sephardic Jews, late diagnosis

INTRODUCTION

MATERIALS AND METHODS

Primary neoplasms of the small bowel (PNSB) are infrequently encountered with reported series of relatively small numbers of cases. Their commonly accepted incidence is from 1 to 5 % of all gastrointestinal tract tumors with a population incidence of 0.4-0.8/100,000 [ 1 1. Prognosis is poor because of frequent dissemination at the time of the diagnosis which is late in most of the cases, probably because of low incidence and difficulty in proving its presence. We present our experience in the diagnosis and treatment of PNSB emphasizing the high number of emergency operations and the predominance of lymphoma in our population. Heightened awareness hopefully will lead to an earlier consideration of PNSB in cases of unexplained abdominal symptoms.

We conducted a retrospective analysis of clinical records of all the patients with histologically proven PNSB treated in our department during the period 1961 to 1986. Patients with carcinoma of the ampulla of Vater, periampullary carcinoma of the duodenum, tumors of the ileocecal region, and Hodgkin’s lymphoma of the small bowel were excluded because of their specific behavior. Tumors incidentally found at autopsy were considered for clinical evaluation but were excluded from treatment and survival results. We found a total of 61 patients, 44 with

0 1992 Wiley-Liss, Inc.

Accepted for publication September 1 I , 1991. Address reprint requests to Francis Serour, MD, Division of Pediatric Surgery, The Edith Wolfson Medical Center, P.O. Box 5 , Holon, 58100, Israel.

30

Serour et al. TABLE I. Type and Location of Malignant Tumors

Lymphoma Adenocarcinoma Leiom yosarcoma Carcinoid Lymphangiosarcoma Total

Total

Duodenum

Jejunum

Ileum

(%I

(%>

(%I

n

(%)

8 1 6 2 2 19 (43)

17 13 10 2 2 44

(38.6) (29.5) (22.7)

-

11 -

11 (25)

9 1 4 -

14 (32)

(4.5) (4.5) (100)

malignant and 18 with benign tumors. One patient had both. Follow-up evaluation was made by reviewing the hospital and clinical files and the autopsy records.

TABLE 11. Correlation Between the Different Categories of the Patients in Israel and the Type of the Intestinal Tumor*

RESULTS Malignant Tumors Population. Forty-four patients (21 males and 23 females) had malignant tumors. Their ages ranged from 3 months to 81 years (mean 53 years), with a 77% incidence of patients over 40. There were 23 Sephardic Jews, 19 Ashkenazi Jews, and 2 Arabs. Two patients had a previous a cancer (breast and thyroid, respectively). Pathologic types and location. Seventeen cases of lymphoma represent the predominant tumor type (38.6%), followed by adenocarcinoma (29.5%), leiomyosarcoma (22.7%), lymphangiosarcoma, and carcinoid tumor (4.5% each). The ileum (19 cases) was the most common site involved (Table I). The duodenum was involved only by adenocarcinoma. On the other hand adenocarcinoma predominated in the duodenum (1 1/13) whereas below it, lymphomas and leiomyosarcomas were equally localized. Carcinoid and lymphangiosarcoma were found only in the terminal ileum. Considering ethnic origin, lymphoma was most frequently found among Sephardic Jews, whereas adenocarcinoma was predominant in Ashkenazi Jews (Table 11). Symptoms and diagnosis. Abdominal pain was the predominant presenting symptom in 30 of the 44 patients (68%) followed by weight loss (55%) and by presence of a palpable abdominal mass (32%). Other symptoms are summarized in Table 111. There were no typical signs of carcinoid syndrome. Two cases of lymphoma were diagnosed at autopsy after a long course of non-specific signs. In 26 cases (60%) there were more than 3 months between the onset of the symptoms and the diagnosis, and in 12 patients (27%), more than 1 year. The preoperative diagnosis of malignant tumor was made by a barium meal in 13 out of 23 examinations performed (57%). The other positive diagnostic investigations were computerized tomography (6 of 9 patients), sonography (4 of 9 patients), and endoscopy (3 of 7 patients). Angiography was useful in one case of bleeding leiomyosarcoma. Among the 21 patients (48%) who

Malignant Lymphoma Adenocarcinoma Leiomyosarcoma Carcinoid Lymphangiosarcoma Benign Leiom yoma Lipoma Aber. pancreas Adenoma Angioma Total

Sephardic Jew

Ashkenazi Jew

Arab

23 13 3 3 2 2 9 3 2

19 3 9 7

2 1 1

8 5 2

I I

1

1

2 1

328

21

3

* Aber. pancreas = aberrant pancreas. aOne patient had both lymphoma and leiomyoma.

needed emergency surgery the most frequent indication was intestinal obstruction (12 cases), three of them because of intussusception due to lymphoma, carcinoid tumor, or lymphangiosarcoma. In about half the patients with lymphoma and leiomyosarcoma and in all of carcinoid and lymphangiosarcoma patients diagnosis was made only by emergency laparotomy (Table IV). Treatment. Twenty-one radical resections were performed, including lymphoma (8/15), leiomyosarcoma (7/ lo), and two cases each of carcinoid and lymphangiosarcoma. In the duodenum only one Whipple’s procedure was done. Palliative or explorative surgery with biopsy only was performed in the remaining 21 operated patients. At surgery macroscopic or microscopic metastases were present in 23 patients (52%). More than 50% of the metastases were found in mesenteric or in retroperitoneal lymph nodes (Table V). There was no intra-operative mortality. In six patients the factors of morbidity were wound infection, leak of anastomosis, gastrointestinal bleeding, pneumonia, disruption of wound, and incisional hernia. Six patients died in the post-operative period (14%), from myocardial infarction (three cases), leakage of the anastomosis, pulmonary emboli, and renal failure. Post-operative chemotherapy only was added to nine patients with lymphoma and to two others with leio-

Primary Neoplasms of the Small Bowel

31

TABLE 111. Predominant Symptoms in Patients With Small Bowel Malignancy (44 Patients) Total

Abdominal pain Weight loss Palpable mass Int. obstruction" Melenal hematemesis Anemia Nausealvomiting Anorexia Peritoneal signs Jaundice Diarrhea Ascites

Lymphoma

Adenocarcinoma

Leiomyosarcoma

Carcinoid

Lymphosarcoma

n

(%)

14 10 4 4

6 9 2 4

7 3

2 2 1 2

1 2

1

5

4 2 7 5

5 4

5 2 1

2

1

(68) (55) (32) (27) (25) (25) (23)

1

3

1 1

1

30 24 14 12 11 11 10 8 6 4 2 2

I

1

1 1

(18) (14)

(9) (5) (5)

aInt. obstruction = intestinal obstruction.

TABLE IV. Indications for Emereencv ODerations* ~

Intestinal obstruction Malignant Lymphoma Adenocarcinoma Leiom yosarcoma Carcinoid Lymphangiosarcoma Benign Leiomyoma Lipoma Ab. pancreas Adenoma Angioma Total

Peritoneal signs

6a 5

12 4 2 2 2 2

1 -

5 -

2 1

3

-

1 17

3

2 1 I44 9/17 3/13 5/10 212 212 11/18 419 314 212 112

1 2 -

-

-

4 3 1 -

8a

I

I

1 -

Total Emergency patients/ Total patients

GI bleeding

111

32/62

* Ab. pancreas = aberrant pancreas. aOne patient had both lymphoma and leiomyoma.

TABLE V. Metastases at Surgery (Macroscopicand Microscopic) in 44 Malignant Cases Retroperitoneum lymph nodes Lymphoma Adenocarcinoma Leiom yosarcoma Carcinoid Lymphangiosarcoma Total

7 3 I 1 1 13

myosarcoma. Radiotherapy was added in two cases of lymphoma, three of leiomyosarcoma, one of adenocarcinoma, and one of carcinoid tumor. Follow-up. Follow-up was available in 36 patients. Six were lost to follow-up during the 1st year including the two patients aged 3 months with lymphangiosarcoma (Table VI). Eighteen patients (9 of them with adenocarcinoma) died within three years of operation, and three cases of leiomyosarcoma died after five years. Twelve patients were alive for one to 10 years. There were two

Liver

Carcinomatosis

1 4 1

1 2 1

-

-

6

4

Total

None

9 9 3

8 4 7

1 1

1 1

23

21

local recurrences that lead to obstruction after six years and in one case of carcinoid tumor and to perforation after three years in one leiomyosarcoma. Benign Tumors

Population. The benign tumors were found in 9 males and 8 females, aged 3 months to 83 years (mean 54 years) (Table 11). Pathological types and location. Locations and histologic types are summed up in Table VII. Leiomyoma

32

Serour et al.

18%. In one patient death was related to a perforated stress ulcer after an operation for a perforation of an Tumor Status No. Survival time (months) aberrant pancreas. Two other elderly patients died from Lymphoma (n = 15) A 9 26,29,35,42,48,52,60,110,112 pulmonary edema after an emergency operation, respecD 6 1,1,2,3,6,8 tively, for bleeding and for intussusception. All the reLF maining patients were followed for a minimum of 1 year. TABLE VI. Survival Rate in 42 Malignant Cases*

Adenocarcinoma (n = 13)

A

D LF A D LF A D LF A D LF

Leiom yosarcoma (n = 10) Carcinoid (n = 2) Lymphangiosarcoma (n = 2)

10 1,1,6,9,10,21,26,30,34,38

3 3 6 1 2

2,3,6 25,29,40 1,1,32,63,69,70 2 36,124

-

2

2,2

* A = alive; D = dead; LF = lost to follow-up.

TABLE VII. TvDe and Location of the Benign Tumors Duodenum (%)

Leiom yoma Lipoma Aberrant pancreas Adenoma Angioma Total

I

Jejunum

(a)

5

2(11)

(a)

n

(9%)

3 4 2

9 4 2 2 1

(50) (22) (11)

1 1

1

5 (28)

Total

Ileum

11 (61)

18

(11)

(6) (100)

was the most common tumor (50%), one of which was located in a Meckel’s diverticulum. The ileum was affected in 61% of the cases. One leiomyoma was found in a case of lymphoma. Symptoms and diagnosis. The most common symptoms were vague abdominal pain and recurrent gastrointestinal bleeding (each 44%). Symptoms are summarized in Table VIII. Emergency operations were indicated in 61% of the cases (five obstructions, four massive gastrointestinal bleedings, and two perforations). One leiomyoma was incidentally discovered during gynecologic surgery and another one during laparotomy for a perforated lymphoma. One case of lipomatosis of the ileum was discovered at autopsy after intestinal obstruction. Aberrant pancreas, angioma, and lipoma were the leading point in the three cases of intussusception. The two rare cases of aberrant pancreas were revealed by intussusception in a 3-month-old boy and by perforation in a 60 year-old man. Angiography was helpful in the diagnosis of two recurrent massive bleedings, whereas of six barium meals performed, only one gave positive results. Treatment. A case of bleeding leiomyoma of the duodenum diagnosed by endoscopy was not operated on. All the other benign tumors were treated either by resection and primary anastomosis or by local excision. There was no postoperative morbidity and the mortality was

DISCUSSION Primary neoplasms of the small bowel are unusual. Malignant tumors represent about 1 % of all gastrointestinal malignancies [ 1,2]. Although several theories were proposed [3-51, no valid explanation for this low incidence was found. The reported male to female ratio is 1.5:1 [2,6,7] and these tumors are most commonly found during the sixth and seventh decades [2,7-91. The majority of our patients were aged between 40 and 60 years, while there was no sex variation. Adenocarcinoma is the most frequent malignant tumor encountered in the literature in an incidence varying from 30 to 50% [27]. Carcinoid tumor ranged from 21 to 35% and lymphoma and leiomyosarcoma approximately 15% each. In our series lymphoma was the most frequent malignancy (38.6%), followed by adenocarcinoma (29.5%), and leiomyosarcoma (22.7%). We have no explanation for the low incidence of carcinoid tumor (4.5%). Our results confirm the predominance of lymphoma (67%) among Sephardic Jews in Israel as reported by Freund et al. [6]. The latter noted that 30% of their patients were children. Except for one case of follicular type all our cases had large cell lymphomas (Hodgkin’s lymphoma was excluded). The majority of these patients (71%) were under 50 years (average age 44 years), and 65% were females. It is well documented that malignant neoplasms occur with increasing frequency progressing down the small bowel, 20% in the duodenum, 30% in the jejunum, and 50% in the ileum [1,8,10,11]. In a review of 29 series Johnson et al. [2] found that carcinoid lesion is the most common tumor in the ileum, accounting for 50% of all malignancies. Furthermore, adenocarcinoma is the most frequent malignant tumor, predominantly located in the duodenum and jejunum (46%). Similar findings were reported by others [ I , 12-14]. The ileum is also affected by leiomyosarcoma [7]. As in the literature, our series shows that ileum was the most frequent location of malignancy (43%). Except in the papillary region the duodenum was involved by adenocarcinoma only, 84.6% of them appearing in this site. Lymphoma and leiomyosarcoma were equally distributed in the jejunum and the ileum. Predisposing factors for the development of the small bowel tumor are controversial. Malignant transformation may occur in benign adenomatous polyps [ 13,161, in hamartomas of Peutz-Jegher’s disease particularly in the duodenum [ 13,151, in Von Recklinghausen’s disease [2,12], and in cases of longstanding Crohn’s disease

Primary Neoplasms of the Small Bowel

33

TABLE VIII. Predominant Symptoms in Patients With Benign Small Bowel Tumors (18 Patients)

Abdominal pain Melena/hematemesis Int. obstructiona Anemia Peritoneal signs None Diarrhea Weight loss

Leiomyoma

Lipoma

Aberrant pancreas

3 5

4 1 3

1 1

2 1 2 1 1

Total Adenoma 1 1 1 1

1

Angioma

n

(%)

8 8 5 3

(44) (44) (28) (17) (11) (11) (6) (6)

2 2 1 1

aInt. obstruction = internal obstruction.

[2,17,18]. Celiac disease seems to be a true risk factor with malignancies occurring in up to 14% of patients [7,19-2 11. Immunosuppression is now recognized as an important etiologic factor for the development of these malignancies. Lowenfels [4] found duodenal cancers during post-mortem examinations of patients treated with steroids for breast cancer. Malignancies and lymphomas of the small bowel in immunosuppressed patients with acquired immunodeficiency syndrome were, respectively, described by Ell et al. [22] and Steinberg et al. [23]. We found no such risk factors among our patients. Tumors of the small bowel are associated with nonspecific symptoms such as vague abdominal pain, anemia, weight loss, signs of incomplete obstruction, and chronic or acute gastrointestinal bleeding. Malignant tumors are diagnosed in a mean time from 6 to 8 months [9] from onset of symptoms. The relative rarity of PNSB and their vague symptomatology diminish the index of suspicion of such a lesion. Thus the delay in diagnosis and the high incidence of diagnosis at operation. In malignant tumors surgical emergency was reported in 25% by Miles et al. [ 101 and in 64% by Brophy and Cahow [ 181. In the present series intestinal obstruction, perforation, and gastrointestinal bleeding lead to the surgical diagnosis in 48% of the malignancies and 61% of the benign tumors (overall 56%). Among the malignant tumors adenocarcinoma had a low incidence of complications and therefore a lower incidence of emergency surgery in contrast to the other types. The most common cause of emergency laparotomy is intestinal obstruction, essentially in carcinoid and sarcoma patients. This seems to be a consequence of the delay of the diagnosis. It was difficult to ascertain the onset of the symptoms from our anamnestic data, but about 50% of the emergency group had previously suffered during a period varying from 3 months to 5 years, and the majority of them underwent some laboratory or clinical investigations. We found a very high percentage of palpable mass in the group of malignant tumors ( 14/44 or 32%) indicating widespread disease as noted by Cicarelli et al. [24]. Five lymphomas appeared as perforation (30%) and 4 as obstruction (24%). Two were found at necropsy of patients hospital-

ized for deterioration, fever, abdominal pain, diarrhea, and anemia. Lymphangiosarcoma is very rare and was revealed as small bowel obstruction in two infants, respectively, aged 3 and 20 months. In one case obstruction was due to intussusception of the tumor. Malignant tumors of the small intestine are often associated with second primary malignancies in an incidence varying from 20 to 30% [ 12,13,15]. This is known for the carcinoid tumor but adenocarcinoma [ 151 and leiomyosarcoma [7] also demonstrated such a tendency. These associated neoplasms may appear in all sites (colorectal and breast being the most frequent), sometimes in a succession of malignancies [ 13,151. We found only two cases of associated neoplasms ( 5 % ) , one breast cancer preceding a lymphoma by a few months, and one cancer of the thyroid preceding an adenocarcinoma of the duodenum by 10 years. The preoperative diagnosis of these tumors remains difficult. The barium meal X-ray study is still the most effective investigation [6,14] with a positive diagnosis rate of 50 to 70% [8,18]. Others now prefer enteroclysis for its higher accuracy [2,25,26]. The barium meal was also the most useful among our diagnostic techniques, positive in 13 out of 23 examinations performed (56%). Endoscopy, sonography , and computerized tomography (CT) have demonstrated limited usefulness in this pathology, although CT was positive in six out of the nine advanced cases that underwent this procedure. Mesenteric angiography may be diagnostic in bleeding vascular tumors like leimyosarcoma [2,7,10] as it was in three of our patients. The surgical treatment of the malignant small bowel tumors should be early and radical. Only an extensive wide resection of the intestine and the adjacent mesentery may be curative [9,14,28]. Unfortunately the frequent dissemination of the disease at the time of surgery does not always permit it. A rate of 30 to 74% of metastatic spread is reported [ 1,9,15, 19,241, and palliative procedures, such as bypass or local resection, have to be substituted. Pancreatoduodenectomy have been performed for duodenal tumors with a high mortality and morbidity [9,28]. For tumors localized to the terminal ileum, cecal

34

Serour et al.

resection or right hemicolectomy have been suggested. The slow growth and the potential positive response to chemotherapy of carcinoid tumors allow a palliative debulking of the tumor mass [9]. For the other tumors chemotherapy and radiotherapy are of little benefit [2,810,281. Our patients also did not benefit significantly from adjuvant treatment although six patients treated for lymphoma had a 3 year disease-free interval. Metastatic spread was found in lymph nodes of the retroperitoneum, liver, omentum, peritoneum, and ovary in 52% (Table V). Operative mortality in malignant tumors varies between 2 to 10% [ 10,181. The higher mortality in our group can be explained by the fact that in 56% of the cases, emergency surgery was performed in a high risk population. Deaths were related to cardiopulmonary problems or to a succession of other post-operative complications. Small bowel malignancies have a poor prognosis with an overall 5 year survival from 19 to 31% [ 1,2,12]. Adenocarcinoma appears to carry the worst prognosis [8,14] particularly in the duodenum [I]. In agreement with these statements we found a low survival in our series of adenocarcinoma (14 cases or 37%), with a 3 year survival rate of 34% (13 cases) and a 5 year survival of 18% (7 cases). Of 13 lymphoma patients 6 have survived from 1 to 4 years after the diagnosis and 3 have survived more than 5 years (23%). Benign tumors are often asymptomatic and therefore not detected [ l ] until the need for emergency surgery which was the case in 61% of our series. Bleeding is the indication for operation in 40% of the cases while 30% of the tumors are incidentally found at surgery [ I]. Leiomyoma is the most frequently encountered benign tumor [6,10] as we also found (50%). Other tumors are lipomas, adenomatous polyps, adenomas, and hemangiomas. In our series there were two rare cases of aberrant pancreas in the ileum, revealed by intussusception in a 3 month old boy (29) and by perforation in a 60 year-old man. Benign tumors are variably distributed along the small intestine most frequently in the duodenum [ I , lo], but in our cases there was a clear predominance in the ileal location (61%).

CONCLUSIONS Small bowel neoplasms are infrequent and have a disappointing course in part due to their late diagnosis. Inclusion of PNSB in the differential diagnosis of patients with unexplained abdominal symptoms and the early utilization of the small intestinal barium study will doubtlessly achieve earlier diagnosis and elective surgical treatment. An improved prognosis will probably result. ACKNOWLEDGMENTS The authors express their appreciation to David L. Chamovitz, M.D., for his contributions to this report.

REFERENCES 1. Norberg KA, Emas S: Primary tumors of the small intestine. Am J

Surg 142569-573. 1981. 2. Johnson AM, Harman PK, Hanks JB: Primary small bowel malignancies. Am Surg 51:31-36, 1985. 3. Wattenberg LW: Carcinogen-detoxifying mechanisms in the gastrointestinal tract. Gastroenterology 5 I :932-935, 1966. 4. Lowenfels AB: Why are small bowel tumors so rare? Lancet 1:24-26, 1973. 5 . Renshaw A, McCrae JS: Why are small bowel tumors so rare? Lancet 1:425, 1973. 6. Freund H, Lavi A, Pfeffermann R , Durst A: Primary neoplasms of the small bowel. Am J Surg 135:757-759, 1978. 7. Chiotasso PJP, Fazio VW: Prognostic factors of 28 leiomyosarcomas of the small intestine. Surg Gynecol Obstet 155:197-202, 1982. 8. Mittal VK, Bodzin J: Primary malignant tumors of the small bowel. Am J Surg 140:396-399, 1980. 9. Zollinger RM, Sternfeld WC, Schreiber H: Primary neoplasms of the small intestine. Am J Surg 151:654-658, 1986. 10. Miles RM, Crdwford D, Duras S: The small bowel tumor problem: an assessment based on a 20-year experience with 116 cases. Ann Surg 189:732-740, 1979. 1 1. Lien G, Mori M, Enjoji M: Primary carcinoma of the small intestine. A clinicopathologic and immunohistochemical study. Cancer 61:31&323, 1988. 12. Awrich AE, Irish CE, Vetto RM, Fletcher WS: A twenty-five year experience with primary malignant tumors of the small intestine. Surg Gynecol Obstet 151:9-14, 1980. 13. Ouriel K, Adan~sJT: Adenocarcinoma of the small intestine. Am J Surg 147:6&7 1, 1984. 14. Koretz MJ, Graham R: Primary adenocarcinoma of the jejunum. Am Surg 55539-542, 1989. 15. Barclay THC, Schapird DV: Malignant tumors of the small intestine. Cancer 51:878-881, 1983. 16. Perzin KH, Bridge MF: Adenomas of the small intestine: a clinicopathologic review of 5 I cases and a study of their relationship to carcinoma. Cancer 48:799-8 19, 198 1. 17. Holter A, Fischer JE: Adenocarcinoma of the small bowel associated with Crohn’s disease. Arch Surg 113:991-993, 1978. 18. Brophy C, Cahow CE: Primary small bowel malignant tumors. Unrecognized until emergent laparotomy. Am Surg 55:408-412, 1989. 19. Holmes GKT, Dunn GI, Cockel R, Brookes VS: Adenocarcinoma of the upper small bowel complicating coeliac disease. Gut 21:1010-1016, 1980. 20. Swinson CM, Slavin G , Coles EC, Booth CC. Coeliac disease and malignancy. Lancet 1:1 11-1 15, 1983. 21. Magnussen PA, Grant JW: Perforation of a jejunal adenocarcinoma complicating coeliac disease. J R Soc Med 79:114-115, 1986. 22. Ell C, Matek W, Gramatzki M, Kaduk B, Demling L: Endoscopic findings in a case of Kaposi’s sarcoma with involvement of the small and large bowel. Endoscopy 17:161-164, 1985. 23. Steinberg JJ, Bridges N , Feiner HD, Valensi Q: Small intestinal lymphoma in three patients with acquired immune deficiency syndrome. Am J Gastroenterol 80:21-26, 1985. 24. Cicarelli 0, Welch JP, Kent GG: Primary malignant tumors of the small bowel. The Hartford Hospital Experience, 1969-1983. Am J Surg 153:350-354, 1987. 25. Ekberg 0, Ekholm S: Radiography in primary tumors of the small bowel. Acta Radio1 [Diagn] (Stockh) 29:79-84, 1980. 26. Maglinte DDT, Hall R, Miller RE, Chernish SM, Rosenak B , Elmore M, Burney BT: Detection of surgical lesions of the small bowel by enteroclysis. Am J Surg 147:225-233, 1984. 27. Williamson RC, Welch CE, Malt RA: Adenocarcinoma and lymphoma of the small intestine. Ann Surg 197:172-178, 1983. 28. Martin RG. Malignant tumors of the small intestine. Surf Clin North Am 66:779-785, 1986. 29. Serour F, Birkenfeld S , Krispin M. Intussusception due to an aberrant pancreas in an infant. Chir Pediatr 2 6 5 - 5 2 , 1985.

Primary neoplasms of the small bowel.

Primary neoplasms of the small bowel are unusual and constitute 1-5% of all gastrointestinal tract neoplasms. Preoperative diagnostic difficulties, fr...
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