Small intestine cancer diagnostic study of choice

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Qurrat-ul-ain Abid, M.D.[2]

Overview

The diagnosis of a small intestine cancer is often made late as the symptoms are nonspecific (abdominal pain, weight loss, nausea and vomiting, occult GI tract bleeding). Early diagnosis requires a high index of suspicion. Histopathological analysis by tissue sample through biopsy of the lesion is the gold standard.

Diagnostic Study of Choice

Gold Standard

  • Biopsy is the gold standard test for the diagnosis of small intestine cancer.
  • Endoscopy and imaging tests may locate the mass, however, the only way to confirm the diagnosis is to do a biopsy and histopathological analysis.
  • There are numerous ways to take biopsy of small intestine:
    • Endoscopic biopsy: Endoscopy may be used to biopsy the lesions of proximal duodenum to the ligament of Treitz or in the terminal ileum. Push enteroscopes may reach the proximal jejunum, but not distal jejunum and ileum.[1]
    • Laproscopic biopsy: It is useful for the diagnosis of malignancy when the laboratory workup is negative and for obtaining an adequate tissue samples of intestinal lesions.
    • Exploratory laparotomy: This may be done if the tumor cannot be reached with an endoscope.It is the most sensitive diagnostic study and is needed to biopsy a tumor in the intestine.[2]
Diagnostic results
  • Biopsy samples are used to study histopathlogy of the lesions to confirm the diagnosis.
  • Summary of histology of different intestinal cancers is described in the table below:[3]
Histology Typical appearance
Adenocarcinoma
Carcinoid
Lymphoma
GIST
Metastases
Sequence of Diagnostic Studies
Flowchart showing sequence of diagnostic studies
 
 
 
Complete blood count,
serum electrolytes,
carcinoembryonic antigen,
Liver function tests,
and tumor markers
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fluoroscopy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CT and CT enteroclysis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
MRI and MRI enetroclysis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Endoscopic biopsy and capsule enteroscopic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Laproscopic biopsy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgical biopsy
 
 
 

UGIS/SBFT:

  • Fluoroscopy is the most commonly used tests to examine the small bowel.[4]
  • Barium swallow and Barium enema are used to visualize the lesion of intestine, however, they are not sensitive at detecting small intestinal cancer until very advanced stage.
  • Upper GI shows features of mucosal distortion, obliteration and narrowing. Delayed images may show hold up of barium at the site of the lesion.

CT and CT enteroclysis (CTE):

  • CT and CTE are modern diagnostic tools used primarily for the detection and localization of small intestinal cancers.[5]

MR enteroclysis (MRE):

Endoscopy and capsule enteroscopy:

Staging

The American Joint Committee on Cancer (AJCC) has designated staging by TNM classification to define small intestine cancer[8]:

Primary Tumor (T):

TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1a Tumor invades lamina propria
T1b Tumor invades submucosa
T2 Tumor invades muscularis propria
T3 Tumor invades through the muscularis propria into the subserosa or into the non-peritonealized perimuscular tissue (mesentery or retroperitoneum) with extension ≤2 cm
T4 Tumor perforates the visceral peritoneum or directly invades other organs or structures (includes other loops of small intestine, mesentery, or retroperitoneum >2 cm, and abdominal wall by way of serosa; for duodenum only, invasion of pancreas or bile duct)

Regional Lymph Nodes (N)

Nx Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in 1–3 regional lymph nodes
N2 Metastases in ≥4 regional lymph nodes

Distant Metastasis (M)

M0 No distant metastasis
M1 Distant metastasis

AJCC Stage Groupings

Stage T N M
0 Tis N0 M0
I T1 N0 M0
II T2 N0 M0
IIA T3 N0 M0
IIB T4 N0 M0
IIIA Any T N1 M0
IIIB Any T N2 M0
IV Any T Any N M1

References

  1. 1.0 1.1 Cheung DY, Choi MG (September 2011). "Current advance in small bowel tumors". Clin Endosc. 44 (1): 13–21. doi:10.5946/ce.2011.44.1.13. PMC 3363052. PMID 22741107.
  2. Dabaja BS, Suki D, Pro B, Bonnen M, Ajani J (August 2004). "Adenocarcinoma of the small bowel: presentation, prognostic factors, and outcome of 217 patients". Cancer. 101 (3): 518–26. doi:10.1002/cncr.20404. PMID 15274064.
  3. Anzidei M, Napoli A, Zini C, Kirchin MA, Catalano C, Passariello R (August 2011). "Malignant tumours of the small intestine: a review of histopathology, multidetector CT and MRI aspects". Br J Radiol. 84 (1004): 677–90. doi:10.1259/bjr/20673379. PMC 3473441. PMID 21586504.
  4. Ekberg O, Ekholm S (1980). "Radiography in primary tumors of the small bowel". Acta Radiol Diagn (Stockh). 21 (1): 79–84. PMID 7376936.
  5. Maglinte DD, Bender GN, Heitkamp DE, Lappas JC, Kelvin FM (March 2003). "Multidetector-row helical CT enteroclysis". Radiol. Clin. North Am. 41 (2): 249–62. PMID 12659337.
  6. Van Weyenberg SJ, Meijerink MR, Jacobs MA, Van der Peet DL, Van Kuijk C, Mulder CJ, Van Waesberghe JH (March 2010). "MR enteroclysis in the diagnosis of small-bowel neoplasms". Radiology. 254 (3): 765–73. doi:10.1148/radiol.09090828. PMID 20177091.
  7. Talamonti MS, Goetz LH, Rao S, Joehl RJ (May 2002). "Primary cancers of the small bowel: analysis of prognostic factors and results of surgical management". Arch Surg. 137 (5): 564–70, discussion 570–1. PMID 11982470.
  8. "Stage Information for Small Intestine Cancer".

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