Malignant Neoplasms of the Small Intestine Treatment & Management

Updated: Sep 26, 2019
  • Author: Ponnandai S Somasundar, MD, MPH, FACS; Chief Editor: N Joseph Espat, MD, MS, FACS  more...
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Treatment

Approach Considerations

The mainstay of treatment for adenocarcinoma and leiomyosarcoma is radical surgical resection. If the lesion is unresectable, surgical bypass of obstruction and palliative radiation therapy are treatment options. [1]  A Japanese study by Nakanoko et al reported that patients with unresectable stage IV who received chemotherapy achieved survival durations of over 11 months. In contrast, overall survival without chemotherapy was 3.3 months. [22]  

However, no standard effective chemotherapy exists for patients with recurrent metastatic adenocarcinoma or leiomyosarcoma of the small intestine. These patients should be considered candidates for clinical trials evaluating the use of new anticancer drugs or biologicals in phase I and phase II trials. For locally recurrent disease, options include surgery, palliative radiation therapy, palliative chemotherapy and clinical trials evaluating ways of improving local control, such as the use of radiation therapy with radiosensitizers with or without systemic chemotherapy. [1]

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Medical Care

Chemotherapy

Although surgical resection remains the primary component of treatment, distant recurrence is frequent after surgical resection, and this suggests a role for adjuvant systemic therapy. Chemotherapy is associated with improved long‐term survival and increasing retrospective evidence supports the use of adjuvant chemotherapy, particularly in patients with regional lymph node involvement. [23]

Chemotherapy drugs that may be used in the treatment of SBA include:

  • Capecitabine
  • 5-fluorouracil (5-FU) [24, 25, 26]
  • Oxaliplatin
  • Irinotecan

Drug combinations that have been used in advanced small intestine cancer include:

  • Capecitabine and oxaliplatin (called CAPOX) [27]
  • CAPOX and bevacizumab [28]
  • 5-FU and leucovorin with oxaliplatin (FOLFOX) [29]
  • 5-FU and leucovorin with irinotecan (FOLFIRI) [27]

Radiation Therapy

Although no survival benefit is achieved with adjuvant radiotherapy after surgery for small-bowel adenocarcinoma or sarcoma, [30] radiotherapy is used as a palliative procedure for pain relief or obstructive symptoms in patients with advanced disease. Also, radiotherapy may be of benefit for controlling chronic tumor-related blood loss.

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Surgical Care

Surgical resection provides the only hope of cure for patients with small-bowel adenocarcinomas and sarcomas. This is possible in approximately two thirds of patients with adenocarcinoma. The remaining have unresectable disease as a result of extensive local disease or metastases to regional lymph nodes, the liver, or the peritoneum.

Patients with lesions in the proximal duodenum, including those in the periampullary region, should undergo pancreaticoduodenectomy, which now has an operative mortality rate of less than 5%. Several studies have shown that patients who undergo resection have an improved 5-year survival rate of 40-60%.

Surgery is indicated for palliation in patients with symptomatic advanced disease, such as intestinal obstruction. Ileal tumors are more likely to develop intestinal obstruction than jejunal tumors. Emergency surgery for these patients relieves the obstruction but precludes a complete and negative margin resection.

Tumors in the distal duodenum, jejunum, or ileum should be resected with wide margins; tumors close to the ileocecal valve may require a right hemicolectomy.  Lymph node metastasis is rare, and therefore an extensive lymph node dissection is not recommended. Resection appears to prolong survival, but recurrence with widely metastatic disease is typical.

Biliary obstruction may result from compression of the extrahepatic common bile duct by a periampullary or proximal duodenal tumor. Biliary stenting via endoscopic retrograde cholangiopancreatography or transhepatic biliary drainage may be performed if feasible.

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Consultations

 A gastroenterologist may assist in diagnosis through upper GI endoscopy and colonoscopy.

 

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Complications

Partial or complete small-bowel obstruction may occur because of an obstructing intraluminal tumor. This may be treated either conservatively (ie, nasogastric tube decompression and parenteral nutrition) or with surgery (ie, small-bowel resection or bypass).

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Long-Term Monitoring

Patients who have undergone surgical resection for localized disease should have a follow-up visit in the outpatient setting every 3 months to assess for symptoms or signs suggestive of recurrent disease. CBC count and liver function test results may be checked periodically to identify anemia related to blood loss or abnormal liver enzymes related to hepatic metastases or biliary obstruction, respectively.

Abdominal CT scan images should be obtained every 6 months to identify subclinical recurrent disease early, which may be amenable to repeat surgical resection.

Patients with small-bowel adenocarcinoma should also undergo colorectal cancer screening (ie, colonoscopy) because of the high risk of secondary malignancies.

Patients with advanced metastatic disease may be treated with chemotherapy in an outpatient setting. They should also be observed for hematologic and other toxicity related to chemotherapy.

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