What is the management of jejunal adenocarcinoma?

Management of Jejunal Adenocarcinoma

Surgical resection of the jejunum with regional lymphadenectomy is the primary treatment for localized jejunal adenocarcinoma, and this should be performed with careful examination of the entire bowel for synchronous lesions. 1

Surgical Management

Primary Surgical Approach

• Segmental bowel resection with regional lymphadenectomy is the definitive treatment for patients presenting with jejunal adenocarcinoma 1
• During surgery, perform a thorough examination of the entire bowel, as multiple synchronous lesions may be present in up to one-third of cases 1
• Assess the proximity to or involvement of the superior mesenteric artery and superior mesenteric vein during the operation 1
• If future treatment with somatostatin analogues (octreotide or lanreotide) is anticipated, consider prophylactic cholecystectomy due to the association between long-term treatment and development of biliary symptoms and gallstones 1

Extent of Resection

• Curative segmental bowel resection is performed in approximately 65% of patients, while 35% require palliative procedures including resection or bypass 2
• The goal is R0 resection (complete removal with negative margins) whenever feasible 2

Staging and Prognosis

Stage-Specific Outcomes

• Tumor stage is the most significant prognostic factor affecting survival 2
• Median survival by stage: 72 months for stage I-II, 30 months for stage III, and 9 months for stage IV disease 2
• Most patients (51%) present with stage IV disease at diagnosis, with only 1% presenting at stage I 2
• Disease recurrence occurs in 66% of patients who undergo curative resection 2

Negative Prognostic Indicators

• Tumor recurrence, advanced stage, and weight loss at presentation are significant negative prognostic factors in multivariate analysis 2

Systemic Therapy

Advanced Disease (Stage IV)

• For stage IV disease, FOLFOX (folinic acid, fluorouracil, and oxaliplatin) with bevacizumab represents a viable multimodal approach that can achieve surprising outcomes even in advanced presentations 3
• In select cases with initially unresectable stage IV disease, systemic chemotherapy may achieve sufficient response to allow conversion surgery with R0 resection 3
• Adjuvant chemotherapy should be initiated early in the postoperative period (as early as POD 10-11) for patients achieving R0 resection 4

Adjuvant and Palliative Chemotherapy

• Approximately 40% of patients receive postoperative chemotherapy, radiation therapy, or combination treatment 2
• For patients with resectable metastases (such as solitary liver or lung metastases), aggressive multimodal therapy including metastasectomy may be considered 3, 4

Diagnostic Considerations

Clinical Presentation

• Jejunal adenocarcinoma typically presents with vague symptoms including abdominal pain, discomfort, weight loss, nausea, vomiting, and signs of small bowel obstruction 5
• Early recognition requires a high index of suspicion due to nonspecific presentation 2
• Mean age at presentation is 63 years 2

Preoperative Diagnosis

• Double-balloon enteroscopy (DBE) can facilitate preoperative diagnosis and tissue confirmation, increasing patient acceptance of surgery and surgical planning confidence 6
• CT imaging may reveal dilated small bowel loops and obstructing masses 5
• In resource-limited settings, exploratory laparotomy serves as both diagnostic and therapeutic modality 5

Common Pitfalls and Caveats

• Do not mistake jejunal adenocarcinoma for neuroendocrine tumors (NETs), which have different management algorithms and prognosis 1
• Failure to examine the entire bowel during surgery may miss synchronous lesions present in a significant proportion of patients 1
• Late presentation with advanced disease (stage III-IV in 76% of cases) limits curative options, emphasizing the need for early suspicion in patients with persistent gastrointestinal symptoms 2
• Despite curative resection, two-thirds of patients experience tumor recurrence, necessitating close surveillance 2
• In patients achieving R0 resection after neoadjuvant or conversion therapy, continue systemic chemotherapy from the early postoperative period to maximize outcomes 4