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Full Text Background Among the rare types of cancers are malignant neoplasms of the small intestine. It is mainly located in the duodenum and jejuno, and it is rarely located in the ileum. It is frequently located near Vater's ampulla, so it may begin with obstructive jaundice. Therefore, multiple primary tumours refer to neoplasms present in a subject in a simultaneous or consecutive manner, provided they meet the following criteria: 1 each tumour must have a defined malignancy pattern; 2 rule out the possibility of it metastasising from another tumour; 3 each tumour should have a different histology; if both are similar within the same organ, it must be demonstrated that there is no connection between them; 4 each tumour must follow its natural course; 5 they may have independent progressions; and 6 if their diagnosis is simultaneous or if it is made within the first 6 months, they are considered synchronous; if their diagnosis is consecutive, they are considered metachronous. Multifocality is defined as the presence of two or more tumour foci in the same area, located less than 5cm from the primary focus, while multicentricity is the presence of two or more tumour foci in different sites, located more than 5cm from the primary focus.
Other promising studies include the Doppler ultrasound with intravenous contrast material, which reveals the lesion blood supply, distribution and structure. This considerably improves the diagnosis and visibility of lesions and also confirms the diagnosis in patients who have previously undergone conventional radiological studies which revealed apparently normal results.
The double-balloon enteroscopy allows for the assessment of the small intestine through an antegrade and retrograde exam, which results in visibility of the entire intestine. In stage III cancers, if the lesion is located near the ileocecal valve, a laparoscopically assisted right hemicolectomy is recommended, with full resection of the tumour through a lymphadenectomy, so as to avoid recurrence or metastases.
This objective has an impact on the prognosis, but not all patients will have a considerable life expectancy. Nevertheless, in advanced-stage patients, with inoperable metastases or adenocarcinoma, these techniques improve life expectancy.
There is not much experience with adenocarcinomas. Chemotherapy treatments are used with other tumours, such as colon cancers, such as 5-fluorouracil combined with leucovorin, irinotecan and oxaliplatin, as well as organoplatin agents, tyrosine kinase inhibitors imatinib mesylate or multikinase inhibitors sunitinib. However, it may be used as a palliative treatment for pain or obstructive symptoms.
It has also been observed that it offers benefits for the control of chronic blood loss related to the tumour. Clinical case A year-old male patient with two symptoms of intestinal subocclusion and non-quantified weight loss 3 months before his admission.
When admitted to the Surgery Department, he presented one-week progression abdominal pain in the form of intense colics, and vomiting with food content, who denied having obstipation but did confirm the presence of constipation.
After conducting a physical examination, the following findings were obtained: thin, non-icteric, regularly hydrated patient. Neck with positive jugular ingurgitation. Distended abdomen, with generalised tympanism, pain on superficial and deep palpation, without decompression pain, hydro-aerial noises, without megalia. Carcinoembrionary antigen 4.
The simple abdominal X-ray showed an image of intestinal occlusion with distended small intestinal loops and hydro-aerial levels, with air in the rectum ampulla Fig. Figure 1. Simple abdominal X-ray showing intestinal distension without hydro-aerial levels and distal air in the rectum.
The patient was diagnosed with paraneoplastic syndrome with symptoms of intestinal occlusion. The colon X-ray through an enema was reported as normal.
The abdominal ultrasound showed a normal liver, without presence of metastasis, with considerable intestinal distension and no indication of the cause of the intestinal obstruction. Medical care was provided during 48 hours, without any improvement in the intestinal subocclusion syndromes.
Therefore, the first surgical team decided to perform an exploratory laparotomy.
Upon examining the small intestine, three annular stenoses were found in the terminal ileum Fig. After the collection of these findings, the following procedures were performed: an en-block intestinal resection of the three stenoses, termino-terminal anastomosis of the intestine at 20cm from the ileocecal valve, and placement of two Penrose-type drains. In the macroscopic cut of one of the stenoses, tissue with fish-meat characteristics was observed in the mesenteric border Fig.
One week after the surgical intervention, there was biliary output due to the Penrose drain, so a new exploratory laparotomy was performed by our surgical team.
In this case, the anastomosis microscopic dehiscence was located, with presence of localised peritonitis. Thus, the anastomosis was resected, the terminal ileum was closed with Hartmann's pouch, and an ileostomy was performed.
Figure 2. Annular stenosis in the ileum, at 70cm from the ileocecal valve. Macroscopic cut of annular adenocarcinoma tumour in the ileum and ulceration.
The histopathological study revealed the following: moderately differentiated adenocarcinoma of the small intestine, ulcerated, multifocal, peritumoural adipose tissue infiltration, with tumour-free surgical limits, 22 peritumoural lymph nodes with sinusoidal hyperplasia and two with tumoural activity.
Thus, the patient was diagnosed with adenocarcinoma of the small intestine, with presence of omental metastasis Fig. During the following 10 days, the patient was treated with oxygen therapy, antibiotics therapy, parenteral fluids and parenteral nutrition. He was discharged 17 days after his admission and continued with ambulatory treatment in the Medical Oncology Department using 5-fluorouracil and cisplatin.
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