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Successful treatment of primary duodenal carcinoma with bilateral adrenal metastases with docetaxel–cisplatin–5-fluorouracil regimen
A 45-year-old man was admitted to our hospital with epigastric pain, asthenia, emesis and loss of weight. Physical examination was otherwise normal. Endoscopy showed duodenal mass in the third part of the duodenum. Endoscopic biopsy specimens of the lesion revealed duodenal adenocarcinoma. Thorax and abdominal computed tomography (CT) scans were normal. A Billroth's II gastroduodenectomy was carried out. At surgery, pancreas invasion by the tumor was observed. Pathologic examination of the resected specimen revealed a middifferentiated adenocarcinoma spreading over the pancreas. Three months after the surgery, the patient had severe asthenia, orthostatic hypotension and emesis. The patient was diagnosed with adrenal insufficiency with a typical pigmentation of skin. He received treatment for adrenal insufficiency. Abdominal CT scan showed newly onset bilateral adrenal metastases. The patient was treated with docetaxel, cisplatin, 5-fluorouracil (TCF) chemotherapy regimen. After six cycles of TCF regimen, response evaluation showed complete resolution of metastases in both adrenals.Malignant neoplasms of the small bowel are among the rarest types of cancer [1]. These tumors most commonly involve the ampullary or periampullary regions of the descending duodenum. Metastatic lesions of duodenal adenocarcinoma are often seen in regional lymph nodes, liver and lungs [2]. There is no reported case of duodenal carcinoma with isolated bilateral adrenal metastases in the literature. Early detection of duodenum carcinoma is an extremely rare condition. The most frequent clinical findings of early duodenal cancer include epigastric pain, nausea, vomiting, weight loss and signs of upper gastrointestinal bleeding. Unfortunately, most symptomatic patients with duodenal cancer have advanced lesions at presentation because of delayed diagnosis [3].
Because of the rarity of duodenum adenocarcinoma, the role of chemotherapy in this disease remains undefined. Most centers have only limited experience treating these patients [4, 5]. It has been shown that chemotherapy for patients with inoperable or metastatic small bowel adenocarcinomas (SBA) resulted in an improved overall survival when compared with no chemotherapy [3, 6]. The Eastern Cooperative Oncology Group conducted prospective study of chemotherapy for SBA. In this study, 39 patients with metastatic or advanced SBA received 5-fluorouracil (5-FU), doxorubicin and mitomycin C and demonstrated 18% response rate and a median survival of 8 months [6]. A retrospective study reported a 21% response rate for 20 patients with advanced SBA who were treated with a combination of 5-FU and a platinum agent [7]. In a recent large retrospective study from the MD Anderson Tumor Registry, from 1978 to 2005, 80 patients with small bowel adenocarcinoma received chemotherapy regimen with or without 5-FU and platinum agent and it was observed that 5-FU and a platinum agent improved response rate and progression-free survival significantly when compared with other chemotherapy combinations. The response rate was 41% and progression-free survival was 8.7 months [8]. One large randomized phase III study showed clinical benefit with TCF compared with cisplatin and fluorouracil in advanced gastric or gastroesophageal cancer adenocarcinoma [9]. The benefit observed from the addition of a docetaxel chemotherapy agent to cisplatin and fluorouracil in gastric adenocarcinoma suggested a possible role for this kind of chemotherapy in the treatment of SBA and therefore we used TCF regimen in our patient.
In conclusion, the choice of chemotherapy in recurrent SBA is not standard. The infrequency of SBA has made it difficult to do randomized study. However, the combination of 5-FU and a platinum ± docetaxel maybe recommended for the treatment of patients with metastatic SBA.
1 Faculty of Medicine, Hacettepe University, Ankara
2 Department of Medical Oncology, Hacettepe University Institute of Oncology, Ankara, Turkey
* (E-mail: altundag66{at}yahoo.com)
references
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