eMedicine Specialties > Oncology > Carcinomas of the Gastrointestinal Tract

Malignant Neoplasms of the Small Intestine: Differential Diagnoses & Workup

Author: N Joseph Espat, MD, MS, FACS, Professor and Chief of Surgical Oncology, Vice-Chairman of Department of Surgery, Roger Williams Medical Center
Coauthor(s): Ponnandai S Somasundar, MD, FACS, Assistant Professor of Surgery, Boston University; Surgical Oncologist, Roger Williams Medical Center; Director of Oncology, Kent County Hospital; Piero Marco Fisichella, MD, Assistant Professor of Surgery, Stritch School of Medicine, Loyola University; Director, Esophageal Motility Center, Loyola University Medical Center
Contributor Information and Disclosures

Updated: Apr 30, 2008

Differential Diagnoses

Ampullary Carcinoma
Gastritis, Chronic
Benign Neoplasm of the Small Intestine
Intestinal Leiomyosarcoma
Bile Duct Tumors
Intestinal Polypoid Adenomas
Colon Cancer, Adenocarcinoma
Intestinal Pseudo-obstruction: Surgical Perspective
Crohn Disease
Irritable Bowel Syndrome
Duodenal Ulcers
Pancreatic Cancer
Gastric Cancer

Other Problems to Be Considered

Intestinal leiomyoma

Workup

Laboratory Studies

  • CBC count may show mild anemia related to chronic blood loss.
  • Liver function tests may reveal hyperbilirubinemia, which may be related to biliary obstruction from periampullary tumors.16 Elevated transaminase levels also may be found in the presence of liver metastases.
  • Carcinoembryonic antigen levels may be elevated.

Imaging Studies

  • Plain abdominal x-ray films may reveal partial or complete small-bowel obstruction.
  • Upper GI series with small-bowel followthrough show abnormalities in 53-83% of patients with small-bowel cancer.
  • Small bowel enteroclysis studies are done with double contrast barium enema, which has a sensitivity of 95%. However, it is difficult to perform as it requires a long tube to be inserted in the small bowel to instill air and contrast.
  • Abdominal CT scan may elucidate the site and extent of local disease and the presence of liver metastases.

Other Tests

In those rare cases of bleeding due to a small bowel tumor, the diagnostic approach is the same for all cases of lower GI bleeding. In case of negative upper and lower endoscopy, tagged red blood cell scan and angiography can be helpful in localizing the disease process. A newer test is called the capsule endoscopy, which has a better sensitivity and specificity is being performed for occult GI bleeding.

Procedures

  • Upper GI endoscopy with small-bowel enteroscopy (push enteroscopy) may identify and allow biopsy of lesions in the duodenum and jejunum. Push enteroscopy is difficult to perform. The endoscopes are long and difficult to manipulate. The procedure takes a long time to perform.
  • Colonoscopy with retrograde ileoscopy may be useful in identifying ileal tumors.
  • Capsule endoscopy: This test is done with a pill with dimensions of 11 × 26 mm in size and weighs 4 g. The pill has a small video camera, batteries, and a radiofrequency transmitter. The batteries last 8 hours. The pill takes about 50,000 pictures as it passes the GI system. The pictures are captured in a device like a Walkman, which is strapped to the waist. It was FDA approved for small bowel use in 2001. Cobrin et al reported that 9% of cases of occult GI bleeding were caused by small bowel tumors.17

Histologic Findings

  • Adenocarcinomas (40%) - Grade I (well differentiated, 0-42%), grade II (moderately differentiated, 24-45%), grade III (poorly differentiated, 34-42%)
  • Sarcomas/GISTs (15%) - High-grade lesions (>5 mitoses per 10 high-power fields, infiltration of overlying mucosa by the tumor). Immunohistochemical staining is an important marker for GIST. Miettinen et al reported that GISTs arising at different anatomic sites display different percent of immunohistochemical staining. Their review of 292 patients revealed that there was equal positivity for both CD34 and smooth muscle actin. However, in cases of GISTs arising from stomach, colon, and rectum, 100% of them were positive for CD34 and none for smooth muscle actin. Only 50% of the small bowel GISTs were positive for CD34. Miettinen et al also reported that c-kit protein (CD117 or c-kit) is expressed in 85-100% of the GIST tumors.5  C-Kit is a transmembrane protein receptor with a tyrosine kinase domain intracellularly. Only those patients who are c-kit-positive respond to imatinib mesylate.
  • Carcinoids (30%)
  • Lymphomas (15%)

Staging

This is according to the American Joint Committee on Cancer staging system.

  • Primary tumor (T)
    • TX: Primary tumor cannot be assessed.
    • T0: No evidence of primary tumor is present.
    • Tis: Carcinoma in situ is present.
    • T1: Tumor invades the lamina propria or submucosa.
    • T2: Tumor invades the muscularis propria.
    • T3: Tumor invades through the muscularis propria into subserosa or into nonperitonealized perimuscular tissue (mesentery or retroperitoneum), with extension of less than 2 cm.
    • T4: Tumor penetrates the visceral peritoneum or directly invades other organs or structures.
  • Regional lymph nodes (N)
    • NX: Regional lymph nodes cannot be assessed.
    • N0: No regional lymph node metastasis is present.
    • N1: Regional lymph node metastasis has occurred.
  • Distant metastases (M)
    • MX: Presence of distant metastasis cannot be assessed.
    • M0: No distant metastasis is present.
    • M1: Distant metastasis has occurred.
  • Stage grouping
    • Stage 0 - Tis, N0, M0
    • Stage I - T1-2, N0, M0
    • Stage II - T3-4, N0, M0
    • Stage III - Any T, N1, M0
    • Stage IV - Any T, any N, M1

The staging for the duodenal polyps found in familial adenomatous polyposis is that of Spigelman.18

More on Malignant Neoplasms of the Small Intestine

Overview: Malignant Neoplasms of the Small Intestine
Differential Diagnoses & Workup: Malignant Neoplasms of the Small Intestine
Treatment & Medication: Malignant Neoplasms of the Small Intestine
Follow-up: Malignant Neoplasms of the Small Intestine
References
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Further Reading

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Keywords

small bowel cancer, small-bowel cancer, small bowel neoplasm, small-bowel neoplasm, small bowel malignancy, small-bowel malignancy, small bowel tumor, small-bowel tumor, small bowel mass, small-bowel mass, small intestine malignancy, small intestine tumor, small intestine cancer, gastrointestinal malignancy, gastrointestinal tumor, gastrointestinal cancer, GI cancer, GI malignancy, GI tumor, gastrointestinal mass, GI mass, gastrointestinal neoplasm, GI neoplasm, small bowel adenocarcinoma, small-bowel adenocarcinoma, adenocarcinoma, GI adenocarcinoma, small intestine adenocarcinoma, GI adenocarcinoma, familial adenomatous polyposis, FAP, gastrointestinal stromal tumor, GIST

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Contributor Information and Disclosures

Author

N Joseph Espat, MD, MS, FACS, Professor and Chief of Surgical Oncology, Vice-Chairman of Department of Surgery, Roger Williams Medical Center
N Joseph Espat, MD, MS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American College of Surgeons, American Hepato-Pancreato-Biliary Association, American Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Clinical Oncology, Association for Academic Surgery, Central Surgical Association, Chicago Medical Society, International Hepato-Pancreato-Biliary Association, Pancreas Club, Sigma Xi, Society for Leukocyte Biology, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Surgical Oncology, Society of University Surgeons, Southeastern Surgical Congress, Southern Medical Association, and Surgical Infection Society
Disclosure: Nothing to disclose.

Coauthor(s)

Ponnandai S Somasundar, MD, FACS, Assistant Professor of Surgery, Boston University; Surgical Oncologist, Roger Williams Medical Center; Director of Oncology, Kent County Hospital
Ponnandai S Somasundar, MD, FACS is a member of the following medical societies: American College of Surgeons, American Hepato-Pancreato-Biliary Association, Association for Academic Surgery, Association of Surgeons of India, and Society of Surgical Oncology
Disclosure: Nothing to disclose.

Piero Marco Fisichella, MD, Assistant Professor of Surgery, Stritch School of Medicine, Loyola University; Director, Esophageal Motility Center, Loyola University Medical Center
Piero Marco Fisichella, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, Society for Surgery of the Alimentary Tract, and Society of American Gastrointestinal and Endoscopic Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Lodovico Balducci, MD, Professor of Oncology and Medicine, University of South Florida College of Medicine; Division Chief, Senior Adult Oncology Program, H Lee Moffitt Cancer Center and Research Institute
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Benjamin Movsas, MD, Vice-Chairman, Department of Radiation Oncology, Fox Chase Cancer Center
Benjamin Movsas, MD is a member of the following medical societies: American College of Radiology, American Radium Society, American Society for Therapeutic Radiology and Oncology, and American Society of Clinical Oncology
Disclosure: Nothing to disclose.

CME Editor

Rajalaxmi McKenna, MD, FACP, Consulting Staff, Department of Medicine, Southwest Medical Consultants, SC, Good Samaritan Hospital, Advocate Health Systems
Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis
Disclosure: Nothing to disclose.

Chief Editor

Jules E Harris, MD, Visiting Professor of Medicine, Division of Hematology/Medical Oncology, Department of Internal Medicine, University of Arizona College of Medicine at Tucson; Consulting Staff, Arizona Cancer Center
Jules E Harris, MD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Association of Immunologists, American Society of Clinical Oncology, American Society of Hematology, and Central Society for Clinical Research
Disclosure: GlobeImmune Salary Consulting; Amplimed Consulting fee Consulting

 
 
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