Author: Rodrigo Arrangoiz MS, MD, FACS, FSSO

• Randomized Clinical Trials for DCIS
  • Irene L. Wapnir, James J. Dignam, Bernard Fisher, Eleftherios P. Mamounas, Stewart J. Anderson, Thomas B. Julian, Stephanie R. Land, Richard G. Margolese, Sandra M. Swain, Joseph P. Costantino, Norman Wolmark
• Background:
  • Ipsilateral breast tumor recurrence (IBTR):
    • Is the most common failure event after lumpectomy for ductal carcinoma in situ (DCIS)
  • Wapnir and colleagues evaluated invasive IBTR (I-IBTR) and its influence on survival:
    • Among participants in two National Surgical Adjuvant Breast and Bowel Project (NSABP) randomized trials for DCIS:
      • NSABP B-17
      • NSABP B-24
• Methods:
  • In the NSABP B-17 trial:
    • Accrual period:
      • October 1, 1985, to December 31, 1990
  • Patients with localized DCIS were randomly assigned to:
    • The lumpectomy only (LO, n = 403) group or
    • To the lumpectomy followed by radiotherapy (LRT, n = 410) group
  • In the NSABP B-24 trial:
    • Double-blinded, placebo-controlled trial
    • Accrual period:
      • May 9, 1991, to April 13, 1994
    • All accrued patients were randomly assigned to:
      • LRT+ placebo, (n=900) or
      • LRT + tamoxifen (LRT + TAM, n = 899)
  • Endpoints included:
    • I-IBTR
    • DCIS-IBTR
    • Contralateral breast cancers (CBC)
    • Over-all and breast cancer–specific survival
    • Survival after I-IBTR
  • Median follow-up was:
    • 207 months for the B-17 trial:
      • N = 813 patients
    • 163 months for the B-24 trial:
      • N = 1799 patients
• Results:
  • Of 490 IBTR events:
    • 263 (53.7%) were invasive
  • Radiation reduced I-IBTR by:
    • 52% in the LRT group compared with LO:
      • NSABP B-17:
        • Hazard ratio [HR] of risk of I-IBTR:
          • 0.48, 95% confidence interval [CI] = 0.33 to 0.69, P < .001
      • NSAPB B-24:
        • LRT + TAM reduced I-IBTR:
          • By 32% compared with LRT + placebo:
            • HR of risk of I-IBTR:
              • 0.68, 95% CI = 0.49 to 0.95, P = .025)
  • The 15-year cumulative incidence of I-IBTR was:
    • 19.4% for LO
    • 8.9% for LRT (B-17)
    • 10.0% for LRT + placebo (B-24)
    • 8.5% for LRT + TAM
  • The 15-year cumulative incidence of all contralateral breast cancers was:
    • 10.3% for LO
    • 10.2% for LRT (B-17)
    • 10.8% for LRT + placebo (B-24)
    • 7.3% for LRT + TAM
  • I-IBTR:
    • Was associated with increased mortality risk:
      • HR of death = 1.75, 95% CI = 1.45 to 2.96, P < .001
    • Whereas recurrence of DCIS was not
    • Twenty-two of 39 deaths after I-IBTR were attributed to breast cancer
  • Among all patients (with or without I-IBTR), the 15-year cumulative incidence of breast cancer death was:
    • 3.1% for LO
    • 4.7% for LRT (B-17)
    • 2.7% for LRT + placebo (B-24)
    • 2.3% for LRT + TAM

#Arrangoiz #BreastSurgeon #CancerSurgeon #BreastCancer #Teacher #Surgeon

👉The nasopharynx is a difficult area to access surgically due to:

• Its central location
• Its surrounding facial skeleton and skull base
• Presence of great vessels and lower cranial nerves

👉The ideal surgical approach to the nasopharynx should:

• Provide adequate exposure to the nasopharynx:
  • For tumor resection
• The great vessels:
  • Must be safely controlled
• Lower cranial nerves:
  • Should be spared

👉The surgical approach chosen is dependent on:

• Extent of primary tumor (size / T stage)
• Surgical expertise
• Facilities available

👉Classification of the surgical approaches to the nasopharynx:

• Anterior approach
• Inferior approach
• Lateral approach

👉Anterior approaches to the nasopharynx:

• Lateral rhinotomy
• Transnasal transmaxillary approach
• Midfacial degloving
• Lefort I osteotomy
• Maxillary swing approach

👉Lateral rhinotomy:

• This approach exposes the:
  • Nasal cavity and choana well
• It can be used alone or in combination with other surgical approaches:
  • To enhance exposure of the nasopharynx
• This approach is useful in resection of:
  • Anteriorly placed tumors

👉Transnasal transmaxillary approach:

• In this approach a lateral rhinotomy is combined with:
  • A medial / subtotal maxillectomy
• This approach exposes the:
  • Nasopharynx
  • Ipsilateral spheno-ethmoidal complex
  • Pterygopalatine fossa
  • Medial end of infratemporal fossa

👉Midfacial degloving approach:

• This is a bilateral transnasal, transmaxillary approach
• The advantage of this procedure is that it is performed:
  • Via sublabial incision:
    • Thereby avoiding facial scar
• In this approach the:
  • Infraorbital nerves on both sides:
    • Are safeguarded
  • Midface is degloved subperiosteally:
    • Up to the level of root of the nose
  • A bilateral medial maxillectomy is performed to improve exposure
  • The pterygopalatine fossa and the medial end of infratemporal fossa is ideally exposed

👉Lefort I osteotomy:

• In this approach through a sublabial incision:
  • A transverse maxillary osteotomy is performed through both maxillary sinuses:
    • Allowing the whole hard palate and both inferior maxillae to be down fractured
• Access to the central skull base and nasopharynx is ensured without any visible facial scars

👉Maxillary swing approach:

• This is one of the common approaches to the nasopharynx
• It exposes the nasopharynx and surrounding areas:
  • From the anterolateral aspect
• Through a Weber Ferguson incision:
  • The maxilla is separated from its bony attachments and swung laterally intact with the masseter muscle and cheek flap
• Access to the opposite side can be established by removing the posterior portion of nasal septum
• After tumor resection:
  • The maxilla is swung back and fixed to facial skeleton

👉Inferior approaches:

• Transpalatal approach:
  • The nasopharynx can be accessed by raising a palatal mucoperiosteal flap off the hard palate:
    • Separating the soft palate from its bony portion
  • The posterior edge of bony hard palate is removed as much as it is necessary:
    • To access the nasopharynx
  • Greater palatine neurovascular bundle:
    • Must be mobilized bilaterally to prevent flap necrosis

• Mandibular swing approach:
  • This is actually a combination of:
    • Transcervical, transmandibular, transpalatal approach:
      • Via Frazier incision
  • Soft tissues including parotid gland are elevated from the mandible
  • The mid portion of the ascending ramus of the mandible including the coronoid process:
    • Is cut and removed to facilitate exposure and to prevent post operative trismus
  • The lateral and medial pterygoid muscles are divided to enter the nasopharynx
  • Tracheostomy is a must to secure the airway
  • Dead space after tumor removal needs to be repaired

👉Lateral approach:

• This approach is via the infratemporal fossa:
  • This approach is limited by:
    • The facial nerve and carotid sheath
  • It is used when the tumor extends laterally to involve the parapharyngeal space

#Arrangoiz #HeadandNeckSurgeon #CancerSurgeon #SurgicalOncologist #HeadandNeckCancer

• The differential diagnosis of a small bowel mass:
  • Is extensive
• Focal small bowel wall thickening can be present in:
  • Bowel ischemia
  • Inflammation:
    • Inflammatory bowel disease
  • Infection
  • Radiation enteritis
  • In addition to small bowel neoplasms
• Many of these conditions can be confirmed or excluded by:
  • The history and physical examination
  • Imaging characteristics
  • Further studies:
    • Endoscopy
• True small bowel masses can:
  • Be either malignant or benign:
    • Malignant lesions include:
      • Adenocarcinoma (36.9% of the cases)
      • Carcinoid tumor (37.4% of the cases)
      • Gastrointestinal stromal tumor (8.4% of the cases)
      • Lymphoma (17.3% of the cases)
      • Metastatic disease

• The most common benign small bowel masses include:
  • Adenomas
  • Leiomyomas
  • Lipomas
• More rare benign small bowel masses include:
  • Fibromas
  • Desmoids
  • Hemangiomas
  • Hamartomas
  • Schwannomas
• Patients who present with:
  • Obstruction, bleeding, or perforation from a small bowel mass:
    • Typically require exploration and resection:
      • Regardless of the etiology of the mass:
        • Unless they are medically unfit for surgery
• Patients who are asymptomatic or present with mild symptoms from a small bowel mass:
  • Should be worked up further with:
    • Tumor markers
    • Endoscopic evaluation:
      • For biopsy and tattoo if the lesion is endoscopically accessible:
        • If the lesion is not endoscopically accessible:
          • Then surgical resection:
            • May be necessary for definitive diagnosis and treatment

Laboratory Test (Tumor Markers)

• Carcinoembryonic antigen (CEA):
  • Is not sensitive or specific:
    • For small bowel adenocarcinoma:
      • But is elevated in 30% to 44% of those with:
        • Advanced local or metastatic disease
• CA 19-9:
  • Is also elevated in 30 % to 40% of those with:
    • Advanced local or metastatic disease
• These markers (CEA and CA 19-9) are best used:
  • To raise suspicion:
    • In patients being worked up for small bowel adenocarcinoma
  • For surveillance:
    • In those in whom it is elevated before treatment
  • Given the high false negative rate:
    • They should not be used to rule out adenocarcinoma

Imaging Work-Up

• Imaging is critical to differentiate a malignant etiology of nonspecific gastrointestinal symptoms from other causes:
  • Nausea
  • Vomiting
  • Obstipation
  • Bleeding
• Upper Gastrointestinal Series / Small Bowel Follow-through:
  • An upper gastrointestinal series with small bowel follow-through has a relatively low sensitivity in the detection of small bowel tumors (< 60%):
    • It is most commonly obtained in patients with a small bowel obstruction:
      • To help ascertain the presence and location of a complete small bowel obstruction and may reveal:
        • Intussusception
        • Mucosal defect
        • Tumor / mass:
          • Which should prompt further (cross-sectional) imaging
• Computed Tomography Scan:
  • CT is useful to identify:
    • Small bowel masses
    • Nodal disease
    • Distant metastases
    • Alternative etiologies of abdominal symptoms
  • Its sensitivity in detection of primary small bowel adenocarcinomas is:
    • Approximately 80%
  • CT appearance of small bowel adenocarcinoma includes:
    • Demonstration of a discrete mass
    • Focal mural thickening
    • Small bowel obstruction
    • Intussusception without a clear associated mass

• PET can be useful to:
  • Identify occult metastatic disease
  • Increase the suspicion of malignancy:
    • In nonspecific small bowel abnormalities on CT
• Enterography:
  • Advanced cross-sectional imaging techniques, including:
    • CT and magnetic resonance enterography:
      • Can be more accurate than other imaging to confirm or exclude small bowel cancers:
        • However, they are not universally available and have not been well studied in this population
• Endoscopy:
  • Endoscopic diagnosis of small bowel adenocarcinoma:
    • Is often definitive:
      • But is limited by the location of the tumor:
        • Which must reside in an endoscopically accessible location
    • Because adenocarcinomas are mucosal tumors:
      • They can often be visualized endoscopically:
        • Assuming they can be reached
    • Endoscopy also allows biopsy to be performed and can tattoo a lesion that may not be visible externally during bowel resection
    • Standard upper endoscopy is most useful if the suspected small bowel tumor is in the:
      • Duodenum or proximal jejunum.
• Enteroscopy:
  • Enteroscopy refers to upper endoscopy beyond the range of standard endoscopy:
    • Into the proximal jejunum
  • Techniques employed to advance the endoscope include:
    • Push
    • Balloon
    • Intraoperative assistance
  • Advantages over standard endoscopy include:
    • Increased range:
      • 50 cm to 150 cm distal to the ligament of Treitz
        • Occasionally:
          • The entire small bowel can be visualized using:
            • Anterograde and retrograde (transanal) approaches
  • Disadvantages include:
    • Technical difficulty with a requisite learning curve
    • iIncreased rates of:
      • Pancreatitis
      • Perforation:
        • Over standard endoscopy
• Wireless video capsule endoscopy:
  • Wireless video capsule endoscopy is typically used to:
    • Identify the source of occult gastrointestinal bleeding:
      • But is infrequently used to visualize small bowel masses
    • It has a high false negative rate (19%):
      • In identifying small bowel masses:
        • As well as a 2% false positive rate
  • Wireless capsule endoscopy:
    • Also has no biopsy capability
    • Can become lodged in nearly obstructing or obstructed segments of bowel

#Arrangoiz #Surgeon #CancerSurgeon #SurgicalOncologist #Teacher #SmallBowelCancer

• Many patients with small bowel adenocarcinoma present with abdominal pain:
  • But they may also present with:
    • Obstruction
    • Bleeding
    • Weight loss
    • Perforation
    • Jaundice:
      • Duodenal adenocarcinomas
• Due to the rarity of the disease, variable symptoms, lack of physical findings, and diagnostic difficulty:
  • Delays in definitive diagnosis are common
• Small bowel adenocarcinomas:
  • Are most common in the duodenum:
    • Followed by the jejunum:
      • And are least common in the ileum

• Due to the difficulties in diagnosis and absence of reliable screening:
  • Greater than 50% of patients with small bowel adenocarcinoma:
    • Present at stage III to IV
• Those with metastatic disease:
  • Most commonly metastasize to:
    • The liver and peritoneum

#Arrangoiz #CancerSurgeon #SurgicalOncologist #Teacher #SmallBowelCancer

👉The role of neck dissection after chemoradiotherapy for oropharyngeal cancer with advanced nodal disease.

👉Clayman GL1, Johnson CJ 2nd, Morrison W, Ginsberg L, Lippman SM. Arch Otolaryngol Head Neck Surg. 2001;127(2):135-139. doi:10.1001/archotol.127.2.135

👉Objective:

1. To analyze and compare the effectiveness of sequential platinum-based chemotherapy and radiotherapy with and without selective neck dissection in patients with N2a and greater stage node-positive squamous cell carcinoma of the oropharynx.

👉Design

1. Nonrandomized controlled trial.

👉Setting

1. Tertiary referral center.

👉Patients:

1. Sixty-six patients with squamous cell carcinoma of the oropharynx staged N2a or greater.

👉Interventions:

1. Platinum-based induction chemotherapy followed by definitive radiation therapy and selective neck dissections 6 to 10 weeks following the completion of radiation therapy in patients with radiographic evidence suggesting residual neck disease.

👉Main Outcome Measures

1. Locoregional recurrence and disease-free survival.

👉Results

• Of the 66 patients:
  • 24 (36%) had complete responses:
    • In the primary local tumor (oropharynx) and regional disease (neck nodes):
      • As assessed clinically and radiographically.
    • These patients had lower rates of locoregional recurrence than did patients showing no or partial responses:
      • But the differences were not significant (P>.05).
• Of 18 patients undergoing neck dissection:
  • 10 (56%) had pathological evidence of residual tumor.
• Patients showing a complete response of regional and neck disease:
  • Had significantly improved disease-specific and overall survival (P = .01 for both) compared with patients showing no or partial responses of their neck disease.
• Patients with no or partial responses who underwent neck dissections:
  • Had significantly improved overall survival compared with similar patients who did not undergo neck dissections (P = .002).

👉Conclusions

• Even in patients with bulky nodal disease:
  • A complete response in the neck to sequential chemotherapy and radiotherapy may indicate that neck surgery is not necessary for good locoregional control and improved disease-free survival.
• Neck dissection is recommended for patients with no or partial radiographic responses.

#Arrangoiz #HeadandNeckSurgeon #CancerSurgeon #SurgicalOncologist #Teacher #Surgeon #HeadandNeckCancer

👉Total Thyroidectomy Versus Lobectomy in Small Nodules Suspicious for Papillary Thyroid Cancer: Cost-Effectiveness Analysis. Al-Qurayshi Z, Farag M, Shama MA, Ibraheem K, Randolph GW, Kandil E. Laryngoscope. 2020 Apr 2. PMID: 32239764 https://www.ncbi.nlm.nih.gov/pubmed/32239764

👉Postoperative Hypoparathyroidism After Total Thyroidectomy in Children. Zobel MJ, Long R, Gosnell J, Sosa JA, Padilla BE. J Surg Res. 2020 Mar 29;252:63-68. PMID: 32234570 https://www.ncbi.nlm.nih.gov/pubmed/32234570

👉Radiomics signature for prediction of lateral lymph node metastasis in conventional papillary thyroid carcinoma. Park VY, Han K, Kim HJ, Lee E, Youk JH, Kim EK, Moon HJ, Yoon JH, Kwak JY. PLoS One. 2020 Jan 15;15(1):e0227315. PMID: 31940386 https://www.ncbi.nlm.nih.gov/pubmed/31940386
American Thyroid Association American Association of Clinical Endocrinologists Endocrine Society ThyCa, Inc. Graves’ Disease and Thyroid Foundation

#Arrangoiz #ThyroidSurgeon #ThyroidExpert #HeadandNeckSurgeon #ThyroidCancer

👉J Natl Cancer Inst. 1999 Dec 15;91(24):2081-6. Randomized trial of radiation therapy versus concomitant chemotherapy and radiation therapy for advanced-stage oropharynx carcinoma.

👉Calais G1, Alfonsi M, Bardet E, Sire C, Germain T, Bergerot P, Rhein B, Tortochaux J, Oudinot P, Bertrand P. Abstract

👉BACKGROUND

• The Calais et al group designed a randomized clinical trial to test whether the addition of three cycles of chemotherapy during standard radiation therapy would improve disease-free survival in patients with stages III and IV (i.e., advanced oropharynx carcinoma).

👉METHODS

• A total of 226 patients have been entered in a phase III multicenter, randomized trial comparing radiotherapy alone (arm A) with radiotherapy with concomitant chemotherapy (arm B).
• Radiotherapy was identical in the two arms, delivering, with conventional fractionation, 70 Gy in 35 fractions.
• In arm B, patients received during the period of radiotherapy three cycles of a 4-day regimen containing carboplatin (70 mg/m(2) per day) and 5-fluorouracil (600 mg/m(2) per day) by continuous infusion.
• The two arms were equally balanced with regard to age, gender, stage, performance status, histology, and primary tumor site.

👉RESULTS

• Radiotherapy compliance was similar in the two arms with respect to total dose, treatment duration, and treatment interruption.
• The rate of grades 3 and 4 mucositis was statistically significantly higher in arm B (71%; 95% confidence interval [CI] = 54%-85%) than in arm A (39%; 95% CI = 29%-56%).
• Skin toxicity was not different between the two arms.
• Hematologic toxicity was higher in arm B as measured by neutrophil count and hemoglobin level.
• Three-year overall actuarial survival and disease-free survival rates were, respectively,:
  • 51% (95% CI = 39%-68%) versus 31% (95% CI = 18%-49%) and 42% (95% CI = 30%-57%) versus 20% (95% CI = 10%-33%):
    • For patients treated with combined modality versus radiation therapy alone (P =.02 and.04, respectively).
• The locoregional control rate:
  • Was improved in arm B (66%; 95% CI = 51%-78%) versus arm A (42%; 95% CI = 31%-56%).

👉CONCLUSION

• The statistically significant improvement in overall survival that was obtained supports the use of concomitant chemotherapy as an adjunct to radiotherapy in the management of carcinoma of the oropharynx.

#Arrangoiz #HeadandNeckSurgeon #CancerSurgeon #SurgicalOncologist #OralCavityCancer #PhryngealCancer #Teacher #Surgeon

• Figure 1 A and B: Nomenclature system for parathyroid location.

  • A type A gland is a “normal” superior gland in proximity to the posterior surface of the thyroid parenchyma:

    • It may be compressed within the capsule of the thyroid.

  • A type B gland is a superior parathyroid gland that has fallen posteriorly into the tracheoesophageal groove:

    • There is minimal or no contact between the gland and the posterior surface of the thyroid tissue.

  • A type C gland is a superior gland that has fallen posteriorly into the tracheoesophageal groove and lies at the level of or below the inferior pole of the thyroid.

  • The type D gland lies in the mid region of the posterior surface of the thyroid parenchyma, near the junction of the RLN and the inferior thyroid artery:

    • The type D gland may be either a superior or inferior gland, depending on its exact relationship to the nerve, which generally cannot be determined on imaging.

  • The type E gland is an inferior gland in close proximity to the inferior pole of the thyroid parenchyma anterior to the trachea.

  • The type F gland is an inferior gland that has descended into the thyrothymic ligament or superior thymus:

    • It may appear to be “ectopic” or within the mediastinum.

  • A type G gland is a rare intrathyroidal parathyroid gland.

• Reference:

  • Rodgers SE, Hunter GJ, Hamberg LM, et al. Improved preoperative planning for directed parathyroidectomy with 4-dimensional computed tomography. Surgery 2006;140(6):932–940.)

Rodrigo Arrangoiz MS, MD, FACS cirujano de tumores de cabeza y cuello / cirugia endocrina miembro de Sociedad Quirúrgica S.C. experto en el manejo delhiperparatiroidismo primario.

Entrenamiento:

• Cirugia general y gastrointestinal:

• Michigan State University:

• 2004 al 2010

• Cirugia oncológica / tumores de cabeza y cuello / cirugia endocrina:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Maestria en ciencias (Clinical research for healthprofessionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Cirugia de tumores de cabeza y cuello / cirugiaendocrina

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

http://www.sociedadquirurgica.com

http://www.hiperparatiroidismo.info

http://www.cirugiatiroides.com

#Arrangoiz

#CirugiadeTumoresdeCabezayCuello

#CirugiaEndocrina

#CirugiaOncologica

#HeadandNeckSurgery

#EndocrineSurgery

#SurgicalOncology

#Hiperparatiroidismo

👉Small bowel carcinoids are staged per the American Joint Committee on Cancer (AJCC) Staging Manual (8th Ed.)

• In addition to AJCC TNM staging, the World Health Organization classification:
  • Divides neuroendocrine tumors into two broad subgroups:
    • Based on grade:
      • Which is determined by:
        • Differentiation
        • Mitotic rate
        • Ki-67 index
• Well-differentiated tumors include:
  • Low-grade tumors:
    • < 2 mitoses/10 HPF
    • < 3% Ki-67 index
  • Intermediate-grade tumors:
    • 2 to 20 mitoses/10 HPF
    • 3% to 20% Ki-67 index
• Poorly differentiated neuroendocrine tumors:
  • High-grade tumors:
    • > 20 mitoses/10 HPF
    • > 20% Ki-67 index
      • Resembling small or large cell lung cancer

• The risk of metastases is high with small bowel carcinoids:
  • 41% present with nodal metastases
  • 16% with distant metastases
• The risk of metastasis is dependent on:
  • Primary tumor size:
    • But can still occur with tumors less than 1 cm in size

#Arrangoiz #CancerSurgeon #SurgicalOncologist #Surgeon #SmallBowelTumors #Carcinoids

• Small bowel tumors are relatively rare:
  • Comprising only:
    • 5% of all gastrointestinal malignancies
• Despite the small intestine being:
  • 75% to 80% of the total length of the gastrointestinal tract:
    • Small bowel adenocarcinomas are less common:
      • Than colorectal adenocarcinomas
        • This may be due:
          • To the more dilute and liquid small bowel contents
          • More rapid transit
          • Decreased bacterial load (compared to the colon):
            • Although the precise reasons for this low rate of malignancy are unknown
• Estimated new cases and deaths from small intestine cancer in the United States in 2020:
  • New cases:
    • 11,110
  • Deaths:
    • 1,700
• Adenocarcinoma (36.9%), lymphoma (17.3%), sarcoma (8.4%), and carcinoid tumors (37.4%):
  • Account for the majority of small intestine malignancies:
    • Which, as a whole:
      • Account for only 4% of all gastrointestinal malignancies
• Small bowel adenocarcinomas:
  • Comprise approximately 37% of all small bowel malignancies:
    • And are the second most common small bowel cancer:
      • Slightly less common than small bowel carcinoid tumors (37.4%):
        • 9.3 per million new cases of small bowel carcinoid tumor annually in the United States
• There are an estimated:
  • 7.3 per million new cases of small bowel adenocarcinoma annually in the United States
• Small bowel adenocarcinomas:
  • Arise in men slightly more often than in women:
    • 53% versus 47%
  • The median age at diagnosis:
    • Is 67 years old

• Small bowel adenocarcinomas:
  • Are thought to arise from adenomas:
    • But the details of this process are less well understood:
      • Than the natural history and biology of colorectal adenoma to adenocarcinoma development
  • There are several known risk factors for small bowel adenocarcinoma, including:
    • Familial syndromes:
      • Lynch syndrome
      • Familial adenomatous polyposis [FAP]
      • Peutz-Jeghers syndrome
    • Chronic inflammation:
      • Crohn disease
      • Celiac disease
    • Previous colorectal adenocarcinoma.

#Arrangoiz #SurgicalOncologist #CancerSurgeon #CancerExpert #SmallBowelTumors