Small intestine cancer diagnostic study of choice
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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
- 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.
- 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.
- 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:
Sequence of Diagnostic Studies
- Patients with symptoms of small bowel cancer should undergo a complete history, physical examination, and screening for fecal occult blood.
- Laboratory work-up should include:
- Fluoroscopy is the most commonly used tests to examine the small bowel.
- 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.
- These are extremely useful modalities to visualize the small intestine pathologies.
- Tumor Markers: the role of tumor markers in the diagnosis of cancer is unclear they are mostly used for the follow up surveillance post treatment.
- The majority of small intestine adenocarcinomas are positive for CEA. other markers that can come positive are: urinary 5-hydroxyindoleacetic acid (5-HIAA), serum chromogranin A (CGA) and serum 5-hydroxytryptamine (5-HT, serotonin)
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|
AJCC Stage Groupings
|IV||Any T||Any N||M1|
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