Intralymphatic Tumor in Duodenal Biopsies: Clinicopathologic Features
Stuti Shroff, Melissa W Taggart, Susan C Abraham, Asif Rashid. MD Anderson Cancer Center, Houston, TX
Background: Duodenal biopsies are occasionally taken for suspected metastases or identification of nearby tumors (e.g., pancreatic, ampullary). Rarely, metastatic tumor cells are identified only in lymphatic spaces of the biopsy. The clinicopathologic features of this unusual phenomenon have not been described.
Design: We searched the computerized pathology database at our institution from 1992-2012 for duodenal biopsies containing distant or loco-regional metastases. Cases in which neoplastic cells were only present in lymphovascular spaces were selected and the histologic slides were reviewed. Clinical data (gender, age, symptoms, and history of malignancy) and endoscopic appearance of the duodenum were collected from electronic medical records.
Results: Thirty-three patients (18 M:15 F) ranging from 26-75 (mean 60) years had neoplastic cells exclusively in duodenal lymphovascular spaces. Endoscopy reports were available for review in all but 3 patients (91%). Endoscopy was performed on 13 patients (43%) to evaluate gastrointestinal symptoms (nausea, vomiting, abdominal pain, early satiety, new onset reflux and/or bleeding/melena). In the other 17 patients (57%), endoscopy was prompted by clinical and/or radiologic suspicion of a duodenal mass. Endoscopic appearance of the duodenum was variable and included mass (9), nodularity (6), ulcer (6), stricture (5), "thickening" of duodenum or thickened duodenal folds (4), edema (2), erythema (2), and mucosal friability (1). The primary tumors were all carcinomas with the exception of one (3%) metastatic melanoma. Eleven patients (33%) had loco-regional primary sites (pancreas-8, extrahepatic bile ducts-2, duodenum-1), 19 (58%) had metastases from distant primary sites (colorectum-4, kidney-3, lung-2, ovary-2, breast-2, skin-2, uterus-1, bladder-1, gastroesophageal junction-1 and small intestine-1), and in 3 patients (9%) the primary site remained unknown. In 10 patients (30%), the duodenal biopsy provided the first diagnosis of malignancy.
Conclusions: Exclusive involvement of lymphovascular spaces by metastatic tumors in the duodenum is a rare finding, with only 33 cases identified over a 20 year period at a busy cancer center. This phenomenon occurs almost exclusively in carcinoma, rarely in melanoma and never in sarcoma. In nearly one third of such cases, the duodenal biopsy served as the initial diagnostic material for identification and classification of malignancy. When a neoplastic process is suspected endoscopically but the low power appearance of the duodenal biopsy is unremarkable, close attention should be directed lymphovascular spaces for evidence of microscopic disease.
Tuesday, March 5, 2013 1:00 PM
Poster Session IV # 108, Tuesday Afternoon