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Malignant Neoplasms of the Small Intestine Workup

  • Author: Ponnandai S Somasundar, MD, MPH, FACS; Chief Editor: N Joseph Espat, MD, MS, FACS  more...
 
Updated: Dec 31, 2015
 

Laboratory Studies

See the list below:

  • 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.[20] Elevated transaminase levels also may be found in the presence of liver metastases.
  • Carcinoembryonic antigen levels may be elevated.
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Imaging Studies

See the list below:

  • 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.
  • Cross-sectional imaging can, in manyh casesk, detect small bowel malignancies that are usually inaccessible to conventional endoscopy. Modern multidetector computed tomographies permit accurate diagnosis, complete pretreatment staging, and follow-up of these lesions.[21]
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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.[22]

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Procedures

See the list below:

  • 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.[23]
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Histologic Findings

See the list below:

  • 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%)
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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.[24]

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Contributor Information and Disclosures
Author

Ponnandai S Somasundar, MD, MPH, FACS Assistant Chief of Surgical Oncology, Assistant Professor of Surgery, Boston University School of Medicine; Hepatopancreatobiliary/Surgical Oncologist, Roger Williams Medical Center

Ponnandai S Somasundar, MD, MPH, FACS is a member of the following medical societies: American College of Surgeons, Association for Academic Surgery, Society of Surgical Oncology, Americas Hepato-Pancreato-Biliary Association, Association of Surgeons of India

Disclosure: Nothing to disclose.

Coauthor(s)

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, Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

N Joseph Espat, MD, MS, FACS Harold J Wanebo Professor of Surgery, Assistant Dean of Clinical Affairs, Boston University School of Medicine; Chairman, Department of Surgery, Director, Adele R Decof Cancer Center, 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 Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Clinical Oncology, Americas Hepato-Pancreato-Biliary Association, 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, Surgical Infection Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Benjamin Movsas, MD 

Benjamin Movsas, MD is a member of the following medical societies: American College of Radiology, American Radium Society, American Society for Radiation Oncology

Disclosure: Nothing to disclose.

Chief Editor

N Joseph Espat, MD, MS, FACS Harold J Wanebo Professor of Surgery, Assistant Dean of Clinical Affairs, Boston University School of Medicine; Chairman, Department of Surgery, Director, Adele R Decof Cancer Center, 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 Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Clinical Oncology, Americas Hepato-Pancreato-Biliary Association, 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, Surgical Infection Society

Disclosure: Nothing to disclose.

Additional Contributors

Lodovico Balducci, MD Professor, Oncology Fellowship Director, Department of Internal Medicine, Division of Adult Oncology, H Lee Moffitt Cancer Center and Research Institute, University of South Florida Morsani College of Medicine

Lodovico Balducci, MD is a member of the following medical societies: American Association for the Advancement of Science, American Association for Cancer Research, American College of Physicians, American Geriatrics Society, American Society of Hematology, New York Academy of Sciences, American Society of Clinical Oncology, Southern Society for Clinical Investigation, International Society for Experimental Hematology, American Federation for Clinical Research, American Society of Breast Disease

Disclosure: Nothing to disclose.

Acknowledgements

Medscape Reference extends its thanks to Alfred I Neugut, MD, PhD , Head, Cancer Prevention and Control, Herbert Irving Comprehensive Cancer Center; Professor, Department of Medicine and Public Health, Columbia University College of Physicians and Surgeons and Allen C Chen, MD, MS, Assistant Professor, Department of Medicine, Division of Medical Oncology, New York University School of Medicine for previous versions of this article.

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