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{{Small intestine cancer}}
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== Overview ==
== Overview ==
The diagnosis of a [[small intestine]] cancer is often made late as the symptoms are nonspecific ([[Abdominal pain, constipation and GI bleeding|abdominal pain,]] weight loss, nausea and vomiting, occult [[Gastrointestinal tract|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 ==
== Diagnostic Study of Choice ==


=== Study of choice ===
=== Gold Standard ===
[Name of the investigation] is the gold standard test for the diagnosis of [disease name].
*[[Biopsy]] is the [[Gold standard (test)|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.<ref name="pmid22741107">{{cite journal |vauthors=Cheung DY, Choi MG |title=Current advance in small bowel tumors |journal=Clin Endosc |volume=44 |issue=1 |pages=13–21 |date=September 2011 |pmid=22741107 |pmc=3363052 |doi=10.5946/ce.2011.44.1.13 |url=}}</ref>
**'''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.
**'''[[Laparotomy|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.<ref name="pmid15274064">{{cite journal |vauthors=Dabaja BS, Suki D, Pro B, Bonnen M, Ajani J |title=Adenocarcinoma of the small bowel: presentation, prognostic factors, and outcome of 217 patients |journal=Cancer |volume=101 |issue=3 |pages=518–26 |date=August 2004 |pmid=15274064 |doi=10.1002/cncr.20404 |url=}}</ref>


OR
===== Diagnostic results =====
 
The following result of [gold standard test] is confirmatory of [disease name]:
* [Result 1]
* [Result 2]
 
OR
 
[Name of the investigation] must be performed when:
* The patient presents with [symptom/sign 1], [symptom/sign 2], and [symptom/sign 3].
* A [name of test] is positive for [sign 1], [sign 2], and [sign 3] in the patient.
 
OR
 
[Name of the investigation] is the gold standard test for the diagnosis of [disease name].
 
OR
 
The diagnostic study of choice for [disease name] is [name of the investigation].
 
OR
 
There is no single diagnostic study of choice for the diagnosis of [disease name].
 
OR
 
There is no single diagnostic study of choice for the diagnosis of [disease name], but [disease name] can be diagnosed based on [name of the investigation 1] and [name of the investigation 2].
 
OR
 
[Disease name] is primarily diagnosed based on the clinical presentation.
 
OR


Investigations:
*[[Biopsy]] samples are used to study histopathlogy of the lesions to confirm the diagnosis.
* Among the patients who present with clinical signs of [disease name], the [investigation name] is the most specific test for the diagnosis.
*Summary of histology of different intestinal cancers is described in the table below:<ref name="pmid21586504">{{cite journal |vauthors=Anzidei M, Napoli A, Zini C, Kirchin MA, Catalano C, Passariello R |title=Malignant tumours of the small intestine: a review of histopathology, multidetector CT and MRI aspects |journal=Br J Radiol |volume=84 |issue=1004 |pages=677–90 |date=August 2011 |pmid=21586504 |pmc=3473441 |doi=10.1259/bjr/20673379 |url=}}</ref>
* Among the patients who present with clinical signs of [disease name], the [investigation name] is the most sensitive test for diagnosis.
* Among the patients who present with clinical signs of [disease name], the [investigation name] is the most efficient test for diagnosis.


==== The comparison of various diagnostic studies for [disease name] ====
{|
{|
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Histology
! style="background: #4479BA; color: #FFFFFF; text-align: center;" | Test
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Typical appearance
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Sensitivity
|-
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Specificity
| style="background:#DCDCDC;" align="left" + |'''Adenocarcinoma'''
| style="background:#F5F5F5;" + |
* Polypoid lesions
* Complete [[bowel obstruction]]
* Heterogenous enhancement
|-
| style="background:#DCDCDC;" align="left" + |'''Carcinoid'''
| style="background:#F5F5F5;" + |
* Single or multiple [[Barium swallow|filling defects]]
* [[Desmoplasia|Desmoplastic reaction]] of the [[mesentery]]
* Hypervascularity in the lesions
|-
| style="background:#DCDCDC;" align="left" + |'''Lymphoma'''
| style="background:#F5F5F5;" + |
* Segmental wall thickening with [[ulceration]] and [[necrosis]]
* [[Lymphadenopathy|Lymphadenopathies]]
* Dilatation of bowel loops
|-
|-
! style="background: #696969; color: #FFFFFF; text-align: center;" |Test 1
| style="background:#DCDCDC;" align="left" + |'''GIST'''
| style="background: #DCDCDC; padding: 5px; text-align: center;" |...%
| style="background:#F5F5F5;" + |
| style="background: #DCDCDC; padding: 5px; text-align: center;" |...%
* Large mass with homogeneous enhancement
* [[Necrosis]] and [[ulceration]]
* Located in [[ileum]]
|-
|-
! style="background: #696969; color: #FFFFFF; text-align: center;" |Test 2
| style="background:#DCDCDC;" align="left" + |'''Metastases'''
| style="background: #DCDCDC; padding: 5px; text-align: center;" |...%
| style="background:#F5F5F5;" + |
| style="background: #DCDCDC; padding: 5px; text-align: center;" |...%
* [[Nodules]] in [[Submucosa|submucosal layers]] and in [[mesentery]] and surrounding organs
|}
|}
<small> [Name of test with higher sensitivity and specificity] is the preferred investigation based on the sensitivity and specificity</small>
===== Diagnostic results =====
The following finding(s) on performing [investigation name] is(are) confirmatory for [disease name]:
* [Finding 1]
* [Finding 2]


===== Sequence of Diagnostic Studies =====
===== Sequence of Diagnostic Studies =====
The [name of investigation] must be performed when:
* The patient presented with symptoms/signs 1, 2, and 3 as the first step of diagnosis.
* A positive [test] is detected in the patient, to confirm the diagnosis.


OR
{| align="right"
|+'''Flowchart showing sequence of diagnostic studies'''
|
{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= [[Complete blood count]],<br>[[serum electrolytes]],<br>[[carcinoembryonic antigen]],<br>[[Liver function tests]],<br>and tumor markers}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= Fluoroscopy}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= CT and CT enteroclysis}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= MRI and MRI enetroclysis}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= Endoscopic biopsy and capsule enteroscopic}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= Laproscopic biopsy}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= Surgical biopsy}}
{{Family tree/end}}
|}


The various investigations must be performed in the following order:
*Patients with symptoms of [[Small intestine cancer|small bowel cancer]] should undergo a complete history, physical examination, and screening for fecal [[occult blood]].
* [Initial investigation]
*Laboratory work-up should include:
* [2nd investigation]
**[[Complete blood count]] (CBC)
**Measurement of [[Electrolyte disturbance|serum electrolytes]]
**[[Carcinoembryonic antigen]] ([[CEA]])
**[[Liver function tests]] ([[Liver function tests|LFT]]).


=== Name of Diagnostic Criteria ===
'''[[UGIS/SBFT]]:'''
* [[Fluoroscopy]] is the most commonly used tests to examine the [[Small intestine|small bowel]].<ref name="pmid7376936">{{cite journal |vauthors=Ekberg O, Ekholm S |title=Radiography in primary tumors of the small bowel |journal=Acta Radiol Diagn (Stockh) |volume=21 |issue=1 |pages=79–84 |date=1980 |pmid=7376936 |doi= |url=}}</ref>
*[[Barium swallow]] and [[Barium enema]] are used to visualize the lesion of intestine, however, they are not sensitive at detecting [[Small intestine|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):'''
*[[Computed tomography|CT]] and CTE are modern diagnostic tools used primarily for the detection and localization of [[Small intestine|small intestinal]] cancers.<ref name="pmid12659337">{{cite journal |vauthors=Maglinte DD, Bender GN, Heitkamp DE, Lappas JC, Kelvin FM |title=Multidetector-row helical CT enteroclysis |journal=Radiol. Clin. North Am. |volume=41 |issue=2 |pages=249–62 |date=March 2003 |pmid=12659337 |doi= |url=}}</ref>
'''[[MR enteroclysis (MRE)]]:'''
*MRE is extensively used for the visualization of [[Small intestine|small intestinal]] cancer.<ref name="pmid20177091">{{cite journal |vauthors=Van Weyenberg SJ, Meijerink MR, Jacobs MA, Van der Peet DL, Van Kuijk C, Mulder CJ, Van Waesberghe JH |title=MR enteroclysis in the diagnosis of small-bowel neoplasms |journal=Radiology |volume=254 |issue=3 |pages=765–73 |date=March 2010 |pmid=20177091 |doi=10.1148/radiol.09090828 |url=}}</ref>
'''[[Endoscopy and capsule enteroscopy]]:'''
*These are extremely useful modalities to visualize the [[small intestine]] pathologies.<ref name="pmid22741107">{{cite journal |vauthors=Cheung DY, Choi MG |title=Current advance in small bowel tumors |journal=Clin Endosc |volume=44 |issue=1 |pages=13–21 |date=September 2011 |pmid=22741107 |pmc=3363052 |doi=10.5946/ce.2011.44.1.13 |url=}}</ref>
*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.<ref name="pmid11982470">{{cite journal |vauthors=Talamonti MS, Goetz LH, Rao S, Joehl RJ |title=Primary cancers of the small bowel: analysis of prognostic factors and results of surgical management |journal=Arch Surg |volume=137 |issue=5 |pages=564–70; discussion 570–1 |date=May 2002 |pmid=11982470 |doi= |url=}}</ref>
*The majority of [[small intestine]] [[adenocarcinoma]]<nowiki/>s are positive for [[CEA]]. other markers that can come positive are: urinary [[5-Hydroxyindoleacetic acid|5-hydroxyindoleacetic acid]] (5-HIAA), serum chromogranin A (CGA) and serum 5-hydroxytryptamine ([[5-HT]], [[serotonin]])


'''It is recommended that you include the criteria in a table. Make sure you always cite the source of the content and whether the table has been adapted from another source.'''
==Staging==


[Disease name] is primarily diagnosed based on clinical presentation. There are no established criteria for the diagnosis of [disease name].
The [[American Joint Committee on Cancer|American Joint Committee]] on Cancer (AJCC) has designated staging by [[TNM classification]] to define [[small intestine cancer]]<ref>{{Cite web | title =Stage Information for Small Intestine Cancer | url =http://www.cancer.gov/types/small-intestine/hp/small-intestine-treatment-pdq#section/_10 }}</ref>:


OR
===Primary Tumor (T):===


There is no single diagnostic study of choice for [disease name], though [disease name] may be diagnosed based on [name of criteria] established by [...].
*
{| class="wikitable"
|+
|-
| style="background:#DCDCDC;" align="left" + |'''TX'''
| style="background:#F5F5F5;" + |'''<small>Primary tumor cannot be assessed</small>'''
|-
| style="background:#DCDCDC;" align="left" + |'''T0'''
| style="background:#F5F5F5;" + |<small>'''No evidence of primary tumor'''</small>
|-
| style="background:#DCDCDC;" align="left" + |'''Tis'''
| style="background:#F5F5F5;" + |'''<small>Carcinoma in situ</small>'''
|-
| style="background:#DCDCDC;" align="left" + |'''T1a'''
| style="background:#F5F5F5;" + |'''<small>Tumor invades lamina propria</small>'''
|-
| style="background:#DCDCDC;" align="left" + |'''T1b'''
| style="background:#F5F5F5;" + |'''<small>Tumor invades submucosa</small>'''
|-
| style="background:#DCDCDC;" align="left" + |'''T2'''
| style="background:#F5F5F5;" + |'''<small>Tumor invades muscularis propria</small>'''
|-
| style="background:#DCDCDC;" align="left" + |'''T3'''
| style="background:#F5F5F5;" + |'''<small>Tumor invades through the muscularis propria into the subserosa or into the non-peritonealized perimuscular tissue (mesentery or retroperitoneum) with extension ≤2 cm</small>'''
|-
| style="background:#DCDCDC;" align="left" + |'''T4'''
| style="background:#F5F5F5;" + |'''<small>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)</small>'''
|}


OR
===Regional Lymph Nodes (N)===
{| class="wikitable"
|+
| style="background:#DCDCDC;" align="left" + |'''Nx'''
| style="background:#F5F5F5;" + |'''<small>Regional lymph nodes cannot be assessed</small>'''
|-
| style="background:#DCDCDC;" align="left" + |'''N0'''
| style="background:#F5F5F5;" + |'''<small>No regional lymph node metastasis</small>'''
|-
| style="background:#DCDCDC;" align="left" + |'''N1'''
| style="background:#F5F5F5;" + |'''<small>Metastasis in 1–3 regional lymph nodes</small>'''
|-
| style="background:#DCDCDC;" align="left" + |'''N2'''
| style="background:#F5F5F5;" + |'''<small>Metastases in ≥4 regional lymph nodes</small>'''
|}


The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
===Distant Metastasis (M)===
{| class="wikitable"
|+
| style="background:#DCDCDC;" align="left" + |'''M0'''
| style="background:#F5F5F5;" + |'''<small>No distant metastasis</small>'''
|-
| style="background:#DCDCDC;" align="left" + |'''M1'''
| style="background:#F5F5F5;" + |'''<small>Distant metastasis</small>'''
|}


OR
===AJCC Stage Groupings===
{| class="wikitable"
|+
! colspan="1" style="background:#4479BA; color: #FFFFFF; +" |'''Stage'''
! colspan="1" style="background:#4479BA; color: #FFFFFF; +" |'''T'''
! colspan="1" style="background:#4479BA; color: #FFFFFF; +" |'''N'''
! colspan="1" style="background:#4479BA; color: #FFFFFF; +" |'''M'''
|-
| style="background:#DCDCDC;" align="left" + | '''0'''||Tis||N0||M0
|-
| style="background:#DCDCDC;" align="left" + | '''I'''||T1||N0||M0
|-
| style="background:#DCDCDC;" align="left" + |'''II'''||T2||N0
|M0
|-
| style="background:#DCDCDC;" align="left" + | '''IIA'''||T3||N0||M0
|-
| style="background:#DCDCDC;" align="left" + | '''IIB'''||T4||N0||M0
|-
| style="background:#DCDCDC;" align="left" + | '''IIIA'''||Any T||N1||M0
|-
| style="background:#DCDCDC;" align="left" + | '''IIIB'''||Any T||N2||M0
|-
| style="background:#DCDCDC;" align="left" + |'''IV'''||Any T||Any N||M1
|}


The diagnosis of [disease name] is based on the [criteria name] criteria, which includes [criterion 1], [criterion 2], and [criterion 3].
==References==
 
{{reflist|2}}
OR
 
[Disease name] may be diagnosed at any time if one or more of the following criteria are met:
* Criteria 1
* Criteria 2
* Criteria 3
 
OR
 
'''IF there are clear, established diagnostic criteria'''
 
The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
 
OR


The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
OR
The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].
OR
'''IF there are no established diagnostic criteria'''
There are no established criteria for the diagnosis of [disease name].
==References==
{{Reflist|2}}
{{WH}}
{{WH}}
{{WS}}
{{WS}}
[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Oncology]]
[[Category:Medicine]]
[[Category:Gastroenterology]]
[[Category:Surgery]]

Latest revision as of 16:18, 16 January 2019

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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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