Title: Investigations on the significance of the adenoma-carcinoma sequence in the small bowel
Abstract: CancerVolume 66, Issue 4 p. 702-715 Immunology and PathologyFree Access Investigations on the significance of the adenoma-carcinoma sequence in the small bowel F. Sellner MD, Corresponding Author F. Sellner MD Department of Surgery, Kaiser-Franz-Josef Spital, Vienna, AustriaDepartment of Surgery, Kaiser-Franz-Josef Spital, Kundratstrasse 3, A-1100 Vienna, Austria===Search for more papers by this author F. Sellner MD, Corresponding Author F. Sellner MD Department of Surgery, Kaiser-Franz-Josef Spital, Vienna, AustriaDepartment of Surgery, Kaiser-Franz-Josef Spital, Kundratstrasse 3, A-1100 Vienna, Austria===Search for more papers by this author First published: 15 August 1990 https://doi.org/10.1002/1097-0142(19900815)66:4<702::AID-CNCR2820660419>3.0.CO;2-ZCitations: 144AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Abstract In view of the rarity of small-bowel epithelial neoplasms as compared with the case for the large bowel, evidence for an adenoma-carcinoma sequence in the small bowel was studied based on a search for data in the medical literature for the years 1927 through 1986. Sufficiently defined data were found for comparison of 185 benign adenomas, 76 adenoma-with-carcinomas, and 1333 carcinomas in patients without familial polyposis disease and for 63, five, and 30, respectively, in patients with disease. For patients without polyposis, it was found that (1) 29.8% of all small-bowel adenomas (33.6% if those at Vater's ampulla are excluded) showed malignancy; (2) the mean and median ages were lower for benign adenoma than for adenoma-with-carcinoma and carcinoma, although the ratios by sex were the same; (3) there is a nearly identical spatial distribution of the three types of epithelial neoplasms within the small bowel; and (4) both the frequency of finding adenomatous residues existing in continuity with carcinoma and the life history of the adenoma-carcinoma sequence are similar in the small bowel as in the large. In comparing these results with those from patients with familial polyposis disease, it was particularly noted that (1) the only difference was that adenomas in familial polyposis occurred earlier and multiply, and (2) the spatial distributions of adenomas and carcinomas for both cases were closely similar. It is therefore postulated that the adenoma-carcinoma sequence is as significant in the small bowel as in the large. A hypothesis regarding the relationship of epithelial neoplasms in people with and without familial polyposis disease is suggested. References 1 Perzin K, Bridge M. Adenoma of the small intestine. A clinicopathological review of 51 cases and a study of their relationship to carcinoma. Cancer 1981; 48: 799– 819. 2 Golden R. Non-malignant tumors of the duodenum. Report of two cases. AJR 1928; 20: 405– 413. 3 Müller L. Über einen Fall von seitlicher Duodenalinvagination durch Duodenalpolypen mit gleichzeitigen iso- und antiperistaltischen Invaginationen des Dünndarmes. Langenbecks Arch Klin Chir 1929; 154: 493– 498. 4 Balfour D, Henderson E. Benign tumors of the duodenum. Ann Surg 1929; 70: 30– 35. 5 Archibald E. Discussion of an article by Bazin: Benign neoplasm of the common bile duct. Ann Surg 1930; 92: 658– 662. 6 Bookmann N. Papilloma of the duodenum. Ann Surg 1930; 91: 626– 629. 7 Christopher E. Adenoma of the ampulla of Vater. Surg Gynecol Obstet 1933; 56: 202– 204. 8 Landivar A. Papilloma de la ampulla de Vater: Operation-curacion. Bol Soc Chir B Air 1934; 18: 880– 886. 9 Mallory T. Papilloma of the ampulla of Vater. Case records of the Massachusetts General Hospital. N Engl J Med 1936; 214: 786– 789. 10 Grasmik T. Successful extirpation of tumor of Vater's papilla. Vestrik Khir 1937; 49: 227. 11 Mallet-Guy M. Resection d'un tumeur de l'ampoulle de Vater coexsistant avec des calculs multiples du choledoque. Bol Asoc Med Puerto Rico 1939; 36: 247– 248. 12 Horseley J. Resection of the duodenum for tumor of the ampulla of Vater. Ann Surg 1941; 113: 802– 809. 13 Grove L, Blackstone E. Benign papilloma of the ampulla of Vater. Am J Surg 1944; 64: 141– 143. 14 Hoffman B, Grayzel D. Benign tumors of the duodenum. Am J Surg 1945; 70: 394– 400. 15 Del Valle D, Sanchez-Zinny J. Adenoma de la ampulla de Vater. Arch Argent d'Enferm d'Ap Digest 1946; 21: 105– 116. 16 Baker K, Caldwell D. Lesions of the ampulla of Vater. Surgery 1947; 21: 523– 531. 17 Basora-Defillo J, Lugo I. Icterus of the newborn with report of a case of congenital tumor of the ampulla of Vater. Bol Asoc Med PR 1949; 41: 118. 18 Macumber H, Stoll R, Helwig F. Papillary adenoma of the duodenum producing obstruction. Gastroenterology 1949; 13: 468– 470. 19 Bauss A. Zur Kasuistik gutartiger Zwölffingerdarmtumoren. Chirurg 1950; 9: 558– 559. 20 Wheelock M, Atkinson A, Tucker J. Adenomatous papilloma of the ampulla of Vater. Gastroenterology 1950; 14: 425– 427. 21 Smith H, Blakemoore W. Benign polyps of the ampulla of Vater. Radiology 1951; 56: 571– 574. 22 Noon C. Adenoma of the duodenum. Br J Surg 1952; 39: 87. 23 Girard M, Traisse H, Maroin P. Syndrome choledochien par tumeur de l'ampoulle de Vater. Arch Mal App Dig Nutr 1953; 42: 245– 248. 24 Hunter W, Wilson W. Adenomatous polyps of the small intestine. Br J Surg 1953; 40: 524– 525. 25 Kirsteins A, Govostis M, Prohaska J. Benign tumors of the ampulla of Vater. Arch Surg 1953; 67: 706– 714. 26 Van Weel M. Importance of pancreaticoduodenectomy in treatment of tumours in the region of the head of the pancreas and Vater's papilla. Arch Chir Neerl 1953; 5: 31– 36. 27 Van der Zwaag. Benign tumours of the bile ducts. Arch Chir Neerl 1956; 8: 102– 106. 28 Fenoglio C, Kaye G, Lane N. Distribution of human colonic lymphatics in normal, hyperplastic and adenomatous tissue. Gastroenterology 1973; 64: 51– 66. 29 Brombart M, Henry C, Delcourt R. Sur quelques cas de tumeurs benignes de l'ampoulle de Vater. Acta Gastroenterol Beig 1958; 21: 230– 239. 30 Terasse J, Jaquement L, Jabouzit A. Tumeurs benignes de l'ampoulle de Vater. Arch Mal App Dig Nutr 1958; 47: 986– 988. 31 Darling C, Welch C. Tumors of the small intestine. N Engl J Med 1959; 260: 397– 408. 32 Leger L, Gaultier M, Gayo N. Ampulloma Vaterienne. J Chir (Paris) 1959; 78: 563– 571. 33 Lucarelli G. I cosidetti tumori benigni dell'ampolla di Vater. Minerva Chir 1959; 14: 729– 732. 34 Rock J, Fisher E. Papillary adenoma of the ampulla of Vater. Arch Chir 1959; 79: 175– 177. 35 Alrich M, Blank R, Fomon J. Primary tumours of the small intestine. Am J Surg 1960; 100: 33– 38. 36 Barber K, ReMine W, Harrison E, Priestley J. Benign neoplasms of extrahepatic bile ducts including papilla of Vater. Arch Surg 1960; 81: 479– 484. 37 Andersen M, Gregor W. Papilloma of the ampulla of Vater. Am J Surg 1961; 102: 865– 870. 38 Catell R, Braasch J, Kahn F. Polypoid epithelial tumors of the bile ducts. N Engl J Med 1962; 266: 57– 61. 39 Dowdy G, Oild W, Shelton E, Wladron G. Benign tumors of the extrahepatic bile ducts. Arch Surg 1962; 85: 503– 507. 40 Greenwald E, Parker J, Schultz S, Reed E. Benign papillary adenoma of the ampullary region of the duodenum with intussusception. Gastroenterology 1962; 43: 344– 350. 41 Moersch R, Woolner L, Clagett T. Villous adenoma of the duodenum. Surgery 1962; 51: 574– 577. 42 Boyer C, Helfrich A. Adenoma of the duodenal bulb. AJR 1963; 90: 753– 755. 43 Goldstein H, Daviglus G. Benign adenomatous polyps of the ampulla of Vater with partial obstruction. Ann Surg 1964; 160: 844– 866. 44 Knudson R, Rosser R, Lynch R. Melena due to adenoma of the ampulla of Vater. Am J Surg 1964; 108: 889– 891. 45 Schmutzer K, Holleran W, Regan J. Tumors of the small bowel. Am J Surg 1964; 108: 270– 276. 46 Andersen A, Iversen O, Østberg J. Primary tumours of the duodenum. Acta Chir Scand [Suppl] 1965; 343: 28– 35. 47 Malmed L, Levin B. Villous adenoma of the duodenum. AJR 1965; 94: 362– 365. 48 Oh C, Jemerin E. Benign adenomatous polyps in the papilla of Vater. Surgery 1965; 57: 495– 501. 49 Meltzer D, Ostrum B, Isard H. Villous tumors of the stomach and duodenum. Radiology 1966; 78: 511– 513. 50 Peracchia A, Colla L. L'ostruzione biliare da polipi benigni della papilla di Vater. Ann Ital Chir 1966; 42: 644– 656. 51 Serrano J, McPeak C. Primary neoplasms of the duodenum. Surgery 1966; 59: 199– 202. 52 Piffaretti P, Tatti V, Molo C. Adénome villeux du duodenum: A propos d'un cas personnel. Radiol Clin Biol 1967; 36: 357– 364. 53 Bremer E, Battailie W, Bulle P. Villous tumors of the upper gastrointestinal tract. AJR 1968; 50: 135– 143. 54 Deucher F, Villiger KJ. Zwei maligne degenerierte Duodenalpapillome: 10 und 14 Jahres-Heilung nach Duodenopankreatektomie. Schweiz Med Wochenschr 1968; 98: 1822– 1825. 55 Griffen W, Schaefer J, Schindler S, Hyde C, Bryant L. Ampullary obstruction by benign duodenal polyp. Arch Surg 1968; 97: 444– 449. 56 James E, Melvin J. Villous adenoma of the jejunum. Am J Dig Dis 1969; 10: 265– 268. 57 Johansen A, Larsen E. Adenomas of the small intestine. Acta Pathol Microbiol Immunol Scand A 1969; 75: 247– 256. 58 Keeley A, Gottlieb L. Villous adenoma of the small bowel, an unusual lesion. Gastroenterology 1969; 57: 185– 190. 59 Makkar J, Song K, Cogbill C. Villous adenoma of the duodenum: Report of a case with massive hemorrhage. Am Surg 1969; 35: 656– 659. 60 Stassa G, Klingensmith W. Primary tumors of the duodenal bulb. AJR 1969; 107: 105– 110. 61 Blessing M, Timm W. Papillomatosis der Ampulla Vateri. Zentralbl Allg Pathol 1971; 114: 227– 232. 62 Hillemand P, Roux M, Müller JM, Bernard HJ, Delavierre P. Les tumeurs villeuses du jejuno-ileon. J Chir (Paris) 1971; 102: 176– 184. 63 Liguori G, Tenze L. Tumori benigni della papilla di Vater. Acta Chir Ital 1971; 27: 157– 175. 64 Dayal Y, Bass A, Kraft A, Glotzer D, Goldman H. Villous adenoma of the duodenum. Am J Surg 1972; 124: 394– 398. 65 Ring E, Ferrucci J, Eaton B, Clements J. Villous adenomas of the duodenum. Radiology 1972; 104: 45– 48. 66 Saibil E, Guttman F, Palayew M. Villous adenoma of the duodenum. A case report and review of the literature. J Can Assoc Radiol 1972; 23: 257– 258. 67 Shah S, Elibol T, Aquiline J. Villous adenoma of the duodenum and multiple duodenal polyps. Gastrointest Endosc 1972; 18: 179– 180. 68 Taenzer V, Wöllgens P. Der Duodenaltumor als kausalgenetisches und diagnostisches Problem. Dtsch Med Wochenschr 1972; 97: 1413– 1415. 69 Barbier J, Breuil J, Blavon-Duchesne N, Babin P, Beauchant J. Tumeur villeuse du duodénum. Arch Mal App Dig Nutr 1973; 62: 323– 329. 70 Steinberg L, Shieber W. Villous adenomas of the small intestine. Surgery 1972; 71: 423– 428. 71 Haubrich W, Johnson R, Foroozan P. Endoscopic removal of a duodenal adenoma. Gastrointest Endosc 1973; 19: 201. 72 Jones T, Clegg J. Villous adenoma in a blind duodenal loop. Postgrad Med J 1973; 49: 657– 660. 73 Mir-Madjlessi S, Farmer R, Hawk W. Villous tumors of the duodenum and jejunum. Am J Dig Dis 1973; 18: 467– 476. 74 Palmisano P, Guzzo F. Benign villous tumors of the duodenum. J Fla Med Assoc 1973; 59: 35– 36. 75 Dwyer W, O'Brian R, Maio T. Villous adenomas and malignant villous tumors of the duodenum. Conn Med 1975; 39: 286– 290. 76 Kutin N, Ranson J, Gouge T, Localio A. Villous tumors of the duodenum. Ann Surg 1975; 181: 164– 168. 77 Poilleux J, Lichtenstein H, Lelouch G, Hivet M. Les tumeurs benignes de la region Vaterienne. Med Chir Dig 1975; 4: 25– 30. 78 Wald A, Milligan F. The role of fiberoptic endoscopy in the diagnosis and treatment of duodenal neoplasms. Am J Dig Dis 1975; 20: 499– 505. 79 Shabot M, Asch M, Moore T, State D. Benign obstructing papilloma of the ampulla of Vater in infancy. Surgery 1975; 78: 560– 563. 80 Haffejee A, Angorn I, Baker L. Villous tumour of the duodenum. S Afr Med J 1976; 50: 1900– 1901. 81 Brandstätter G, Kratochvil P, Wiédner F, Köle W. Polypöses T1-Carcinom des Duodenum. Chirurg 1976; 48: 675– 677. 82 Ohmori K, Kinoshita H, Shiraha Y, Satake K. Pancreatic duct obstruction by a benign polypoid adenoma of the papilla Vateri. Am J Surg 1976; 132: 662– 663. 83 Schulten M, Oyasu R, Beal J. Villous adenoma of the duodenum. Am J Surg 1976; 132: 90– 96. 84 Uppaputhangkule V, Maas L, Gelzayd E. Endoscopic diagnosis of villous adenoma of the duodenum. Gastrointest Endosc 1976; 22: 97– 98. 85 Weber M, Berchtold R. Rezidivierender, gutartiger papillärer Tumor im Bereich den Papilla Vateri. Helv Chir Acta 1976; 43: 561– 563. 86 Arnaud J, Miclo S, Doffoel M, Adloff M. Tumeur villeuse du duodénum. J Chir (Paris) 1977; 114: 461– 470. 87 Dupas J, Marti R, Capron J, Delamarre J. Villous adenoma of the duodenum. Endoscopy 1977; 9: 245– 247. 88 Cornet A, Debesse B, Barbier JP, Carnot F, Martignon C. Adenomes du duodénum. Acta Gastroenterol Belg 1977; 40: 27– 30. 89 Seifert E, Urakami Y, Elster K. Duodenoscopic guided biopsy of the biliary and pancreatic duct. Endoscopy 1977; 9: 154– 161. 90 Spira I, Wolff W. Villous tumors of the duodenum. Am J Gastroenterol 1977; 67: 63– 68. 91 Archie J, Murray H. Benign polypoid adenoma of the ampulla of Vater. Arch Surg 1978; 113: 180– 181. 92 Cooperman M, Clausen K, Hecht C, Lucas J, Keith L. Villous adenomas of the duodenum. Gastroenterology 1978; 74: 1295– 1297. 93 Freeny P, Vimont T. Villous tumours of the stomach and small bowel. Arch Surg 1978; 113: 255– 259. 94 Hessler P, Braunstein E. Adenocarcinoma of the duodenum arising in a villous adenoma. Gastrointest Radiol 1978; 2: 355– 357. 95 Shead G, Mathan M. Villoglandular adenoma of the duodenum. Aust NZ J Surg 1978; 48: 193– 195. 96 Sobol S, Cooperman A. Villous adenoma of the ampulla of Vater: An unusual cause of biliary colic and obstructive jaundice. Gastroenterology 1978; 75: 107– 109. 97 Lukes P, Nilson A, Rolny P, Gamklou R. Premalignant lesions of the papilla of Vater and the common bile duct. Acta Chir Scand 1979; 145: 545– 548. 98 Reinhardt K. Cholangiographischer Befund bei einem "Ampulloma Vateri." Radiologe 1979; 19: 405– 411. 99 Rousseau B, Martel JG. Tumeur villeuse du duodenum. Un Med Can 1979; 108: 823– 825. 100 Taxier M, Sivak M, Cooperman A. Villous adenoma of the ampulla of Vater. Gastrointest Endosc 1979; 25: 155– 156. 101 Alwmark A, Andersson A, Lasson A. Primary carcinoma of the duodenum. Ann Surg 1980; 191: 13– 18. 102 Choctaw W, Burbige E, McCandless C. Duodenal villous adenoma. Am Surg 1980; 46: 640– 643. 103 Hasleton P, Shah S, Buckley C, Tweedle D. Ampullary carcinoma associated with multiple duodenal villous adenomas. Am J Gastroenterol 1980; 73: 418– 422. 104 Kalmar J, Merritt C. Villous adenoma of the duodenum with intussusception. South Med J 1980; 73: 651– 653. 105 Murao T, Toda K, Tomiyama Y. Papillary adenoma of the duodenum: Report of a case and review of the literature in Japan. Acta Med Okayama 1980; 34: 197– 201. 106 Benediksdottir K, Lundell L, Thulin A. Premalignant lesions of the periampullary region. Report of two cases. Ann Chir Gynaecol 1981; 70: 86– 89. 107 Everett G, Shirazi S, Mitros F. Villous tumors of the duodenum. Am J Gastroenterol 1981; 75: 376– 379. 108 Herbsman H, Wetstein L, Rosen L. Tumors of the small intestine. Curr Probl Surg 1981; 17: 127– 182. 109 Komorowski R, Cohen E. Villous tumörs of the duodenum. Cancer 1981; 47: 1377– 1386. 110 Kozuka S, Tsubone M, Yamaguchi A, Hachisuka K. Adenomatous residue in cancerous papilla of Vater. Gut 1981; 22: 1031– 1034. 111 Reddy R, Schuman B, Priest R. Duodenal polyps: Diagnosis and management. J Clin Gastroenterol 1981; 3: 139– 145. 112 Reiter J, Kaufmann W, Saeger HD. Primäre Duodenaltumoren. Chirurg 1981; 52: 457– 461. 113 White S, Nazarian N, McEwen Smith A. Periampullary adenoma causing pancreatitis. Br Med J 1981; 283: 527. 114 Börner CH, Eichfuss P, Schreiber HW. Diagnostik und Therapie gutartiger Tumoren den Papilla Vateri. Akt Chir 1982; 17: 305– 315. 115 Nakao N, Siegel J, Stenger R, Gelb A. Tumors of the ampulla of Vater. Early diagnosis by intraampullary biopsy during endoscopic cannulation. Gastroenterology 1982; 83: 459– 464. 116 Reynolds R, Lloyd D, Sweeny J, Stamm B, Slinger R. Villous adenoma of the duodenum presenting as acute pancreatitis. J Clin Gastroenterol 1982; 4: 533– 536. 117 Batra S, Schuman B, Reddy R. The endoscopic variety of duodenal villous adenoma—an experience with ten cases. Endoscopy 1983; 15: 89– 92. 118 Bar-Meir S, Hallak A, Baratz M. Endoscopic removal of a giant duodenal polyp. Endoscopy 1983; 15: 29– 30. 119 Delikaris P, Knudsen F, Hjorth L, Balslew I. Tubulovillous adenoma of the papilla of Vater: A case with malignant changes, managed with local resection. Mt Sinai J Med (NY) 1983; 50: 81– 84. 120 Kniemeyer HW, Meyer W, Borchard F, Kaschner A, Wolff G. Benigne epitheliale Neoplasien der Papilla Vateri. Z Gastroenterol 1983; 21: 330– 341. 121 Siegel J, Yatto R. Endoscopic evaluation and therapy of periampullary adenoma. Am J Gastroenterol 1983; 78: 225– 226. 122 Sellner F, Jelinek R, Machacek E. Zur diagnostischen und therapeutischen Problematik der Adenome der Papilla Vateri. Akt Chir 1984; 19: 211– 214. 123 Blackman E. Diagnosis of duodenal and ampullary epithelial neoplasms by endoscopic biopsy: A clinicopathological and immunohistochemical study. Hum Pathol 1985; 16: 901– 910. 124 Haglund U, Fork F, Genell S, Rehnberg O. Villous adenomas in the duodenum. Br J Surg 1985; 72: 26– 27. 125 Heimann T, Cohen L, Bolnik K, Szporn A. Villous polyposis of the ileum. Am J Gastroenterol 1985; 80: 983– 985. 126 Lipper S, Graves G. Villous adenocarcinoma arising in the bypassed duodenum 18 years after a Billroth II subtotal gastrectomy. Report of a case and review of the literature. Am J Gastroenterol 1985; 60: 174– 176. 127 Rosenberg J, Welch J, Pyrtek L, Walker M, Trowbridge P. Benign villous adenomas of the ampulla of Vater. Cancer 1986; 58: 1563– 1568. 128 Ryan D, Schapiro R, Warshaw A. Villous tumors of the duodenum. Ann Surg 1986; 203: 301– 306. 129 Schafmayer A, Schlemminger R, Kunze E, Peiper HJ. Koexistenz eines ausgedehnten tubulo-villösen Adenoms des Duodenums und eines Carcinoms der Papilla Vateri. Chirurg 1986; 57: 634– 637. 130 Weiss J, Semerdjian G. Recurrent villous adenoma of the duodenum. Gastroenterology 1986; 90: 440– 442. 131 Sellner F, Machacek E. Ein maligen degeneriertes, villöses Adenom des distalen Ileum. Akt Chir 1989; 24: 40– 43. 132 Barclay T, Kent H. Primary cancer of the duodenum. Gastroenterology 1956; 30: 432– 438. 133 Brenner R, Brown C. Primary carcinoma of the duodenum. Gastroenterology 1956; 29: 189– 199. 134 Southam J. Primary malignant tumours of the jejunum and ileum. Br J Surg 1963; 50: 393– 399. 135 Moody F, Thorbjarnson E. Carcinoma of the ampulla of Vater. Am J Surg 1964; 107: 572– 579. 136 Good A. Tumors of the small intestine. Am J Surg 1964; 89: 685– 693. 137 Brookes V, Waterhouse J, Powell D. Malignant lesions of the small intestine. Br J Surg 1968; 55: 405– 416. 138 Eckart A. Das primäre Carcinom des freien Dünndarmabschnittes. Chirurg 1968; 39: 22– 26. 139 Hentschel M, Körtge P, Schondorf KW. Primäres, infrapapilläres Duodenalkarzinom. Dtsch Med Wochenschr 1968; 93: 1433– 1436. 140 Kreel L, Mackintosh C. Carcinoma of the duodenum. Gut 1968; 9: 222– 226. 141 Cleator I. Carcinoma of the third part of the duodenum. Br J Surg 1970; 57: 934– 937. 142 Ponka J, Uthappa N. Carcinoma of the ampulla of Vater. Am J Surg 1971; 121: 263– 270. 143 Cortese A, Cornell G. Carcinoma of the duodenum. Cancer 1972; 29: 1010– 1015. 144 Kenefick J. Carcinoma of the duodenum. Br J Surg 1972; 59: 50– 55. 145 Mouchet A, Marquand J, Garcin J, Guivarch M, Accary D. Les tumeurs malignes de l'ampoulle de Vater. Ann Chir 1973; 27: 819– 824. 146 Poilleux J, Lichtenstein H, Lelouch G, Hivet M. Les tumeurs malignes de la region Vaterienne. Resúltats–Indication. Ann Chir 1973; 27: 815– 818. 147 Safaie-Shirazi S, Tike W, Condon R. Periampullary carcinoma. J Surg Oncol 1973; 5: 71– 75. 148 Sakker S, Ware C. Carcinoma of the duodenum: Comparison of surgery, radiotherapy and chemotherapy. Br J Surg 1973; 60: 867– 872. 149 Moss W, McCart M, Juler G, Miller D. Primary adenocarcinoma of the duodenum. Arch Surg 1974; 108: 805– 807. 150 Bridge M, Perzin K. Primary adenocarcinoma of the jejunum and ileum. Cancer 1975; 36: 1876– 1887. 151 Makipour H, Cooperman A, Danzi J, Farmer R. Carcinoma of the ampulla of Vater. Ann Surg 1975; 183: 341– 344. 152 Spohn K, Fux H, Tewes G, Hahn K. Das Pankreaskarzinom—Palliative Operationen. Langenbecks Arch Chir 1975; 339: 267– 273. 153 Middendorp U. Klinische Aspekte des Verschlußikterus. Aktuelle Probleme in der Chirurgie: 22 Bd. Bern Stuttgart Wien: Hans Huber, 1976. 154 Akwari O, van Héerden, J, Adson, M, Baggenstoss, A. Pancreatoduodenectomy for cancer of the papilla of Vater. Arch Surg 1977; 112: 451– 456. 155 Anderson A, Bergdahl L, van der Linden, W. Malignant tumors of the extrahepatic bile ducts. Surgery 1977; 81: 198– 202. 156 Brandstätter G, Kratochvil P, Wiedner F, Köle W. Polypöses T1-Carcinom des Duodenum. Chirurg 1977; 48: 675– 677. 157 Coutsoftides T, MacDonald J, Shibata H. Carcinoma of the pancreas and the periampullary region. Ann Surg 1977; 186: 730– 733. 158 Sato T, Saitoh Y, Natu S, Matsuno S. Follow-up studies of radical resection for pancreaticoduodenal cancer. Ann Surg 1977; 186: 581– 588. 159 Spira I, Ghazi A, Wolff W. Primary adenocarcinoma of the duodenum. Cancer 1977; 39: 1721– 1726. 160 Otto H, Soehendra N, Gebbers JO, Werner B, Eichen R. Das Duodenalcarcinom. Chirurg 1978; 49: 368– 373. 161 Schlippert W, Lucke D, Anuras S, Christensen J. Carcinoma of the papilla of Vater. Am J Surg 135: 763– 770. 162 Arthaud B, Guinee V. Jejunal and ileal adenocarcinoma. Am J Gastroenterol 1979; 72: 638– 647. 163 Forrest J, Longmire W. Carcinoma of the pancreas and peri ampullary region. Ann Surg 1979; 189: 129– 138. 164 Kerremans R, Lerut J, Penninckx F. Primary malignant duodenal tumors. Ann Surg 1979; 190: 179– 182. 165 Rückert R, Kümmerle F. Das Papillencarcinom. Chirurg 1979; 52: 423– 428. 166 Nix G. Early carcinoma of the ampulla and papilla of Vater. Clin Radiol 1980; 31: 95– 100. 167 Berg M, Jilhewar A, Chowdhury L, Smamy S. Jejunal adenocarcinoma presenting with hematemesis. Am J Gastroenterol 1981; 76: 276– 279. 168 Hölscher AH. Megaduodenum durch stenosierendes Duodenalcarcinom. Chirurg 1981; 52: 786– 788. 169 Adler S, Lyon D, Sullivan P. Adenocarcinoma of the small bowel. Am J Gastroenterol 1982; 77: 326– 330. 170 Cohen J, Kuchta N, Geller N, Shires T, Dineen P. Pancreaticoduodenectomy. Ann Surg 1982; 195: 608– 612. 171 Eggert A, Teichmann W. Die Pancreaticogastrostomie beim Papillenkarzinom. Chirurg 1982; 53: 382– 386. 172 Schippers E, Langer S, Flosdorff W, Hilber U. Das primäre Dünndarmmalignom. Chirurg 1982; 53: 364– 369. 173 Walsh A, Eckhauser F, Cronenwett J, Turcotte J, Lindenauer S. Adenocarcinoma of the ampulla of Vater. Ann Surg 1982; 195: 152– 157. 174 Ouriel K, Adams J. Adenocarcinoma of the small intestine. Ann J Surg 1984; 147: 66– 71. 175 Clemens M, Meyer J, Sulkowski U, Saase W, Bünte H. Perioperatives Staging und Münsteraner TNM-Klassifikation beim Papillen und Pankreaskarzinom. Langenbecks Arch Chir 1985; 365: 168– 178. 176 Knox R, Kingston R. Carcinoma of the ampulla of Vater. Br J Surg 1986; 73: 72– 73. 177 Yamaguchi K, Enjoji M. Carcinoma of the ampulla of Vater. A clinicopathological study and pathologic staging of 109 cases of carcinoma and 5 cases of adenoma. Cancer 1987; 59: 506– 515. 178 Taggart D, Imrie C. A new pattern of histological predominance and distribution of malignant diseases of the small intestine. Surg Gynecol Obstet 1987; 165: 515– 518. 179 Allen J, Seamans J. Duodenal polyps associated with multiple polyposis of the colon. Gastroenterology 1955; 28: 856– 861. 180 Chiat H, Ross S, Janelli D, Mandel P. Familial polyposis of the colon with subsequent development of a duodenal polyp. Dis Colon Rectum 1962; 5: 444– 445. 181 Heald R. Gardner's syndrome in association with two tumours in the ileum. Proc R Soc Med 1967; 60: 38– 39. 182 Martel A, Bonanno C. Multiple polyposis of the gastrointestinal tract with osteoma and soft tissue tumors. Am J Dig Dis 1968; 13: 588– 591. 183 Coli R, Moore J, La Marche P, DeLuce, F, Thayer, W. Gardner's syndrome. A revisit to a previously described family. Ann J Dig Dis 1970; 15: 551– 555. 184 Hoffmann D, Goligher J. Polyposis of the stomach and small intestine in association with familial polyposis coli. Br J Surg 1971; 58: 126– 128. 185 Stalport J, Letáwe P. Syndrome de Gardner associe á une dégénérescence maligne d'un polype de sphincter d'Oddi. Acta Gastroenterol Belg 1971; 34: 644– 651. 186 Melmed R, Bouchier I. Duodenal involvement in Gardner's syndrome. Gut 1972; 13: 524– 527. 187 Schnur P, David E, Brown P, Beahrs O, ReMine W, Harrison E. Adenocarcinoma of the duodenum and the Gardner syndrome. JAMA 1973; 223: 1229– 1232. 188 Capron JP, Descombes P, Dupas JL, Delamarre J, Lorriaux A. Le polypose gastrique dans le syndrome de Gardner. Arch Mal App Dig Nutr 1975; 64: 391– 398. 189 Grosberg S. Gardner's syndrome and villous adenoma of the jejunum. Am Surg 1975; 41: 177– 179. 190 Schulman A. Gastric and small bowel polyps in Gardner's syndrome and familial polyposis coli. J Ass Can Radiol 1976; 27: 206– 209. 191 Ushio K, Sasagawa M, Doi H et al. Lesions associated with familial polyposis coli: Studies of lesions of the stomach, duodenum, bones and teeth. Gastrointest Radiol 1976; 1: 76– 80. 192 Yao T, Iida M, Ohsato K, Watanabe H, Omae T. Duodenal lesions in familial polyposis of the colon. Gastroenterology 1977; 73: 1086– 1092. 193 Moore E, Potts D. Villous tumors of the duodenum. Oklahoma State Med J 1977; 70: 481– 488. 194 Keshkegian A, Enterline H. Gardner's syndrome with duodenal adenomas, gastric adenomyoma and thyroid papillary-follicular adenocarcinoma. Dis Colon Rectum 1978; 21: 255– 260. 195 Hamilton S, Bussey HJR, Mendelsohn, G et al. Ileal adenomas after colectomy in nine patients