Small intestine cancer diagnostic study of choice: Difference between revisions
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| style="background:#F5F5F5;" + | | | style="background:#F5F5F5;" + | | ||
* Polypoid lesions | * Polypoid lesions | ||
* Complete bowel obstruction | * Complete [[bowel obstruction]] | ||
* Heterogenous enhancement | * Heterogenous enhancement | ||
|- | |- | ||
| style="background:#DCDCDC;" align="left" + |'''Carcinoid''' | | style="background:#DCDCDC;" align="left" + |'''Carcinoid''' | ||
| style="background:#F5F5F5;" + | | | style="background:#F5F5F5;" + | | ||
* Single or multiple filling defects | * Single or multiple [[Barium swallow|filling defects]] | ||
* Desmoplastic reaction of the mesentery | * [[Desmoplasia|Desmoplastic reaction]] of the [[mesentery]] | ||
* Hypervascularity in the lesions | * Hypervascularity in the lesions | ||
|- | |- | ||
| style="background:#DCDCDC;" align="left" + |'''Lymphoma''' | | style="background:#DCDCDC;" align="left" + |'''Lymphoma''' | ||
| style="background:#F5F5F5;" + | | | style="background:#F5F5F5;" + | | ||
* Segmental wall thickening with ulceration and necrosis | * Segmental wall thickening with [[ulceration]] and [[necrosis]] | ||
* | * [[Lymphadenopathy|Lymphadenopathies]] | ||
* Dilatation of bowel loops | * Dilatation of bowel loops | ||
|- | |- | ||
| Line 45: | Line 45: | ||
| style="background:#F5F5F5;" + | | | style="background:#F5F5F5;" + | | ||
* Large mass with homogeneous enhancement | * Large mass with homogeneous enhancement | ||
* Necrosis and ulceration | * [[Necrosis]] and [[ulceration]] | ||
* Located in ileum | * Located in [[ileum]] | ||
|- | |- | ||
| style="background:#DCDCDC;" align="left" + |'''Metastases''' | | style="background:#DCDCDC;" align="left" + |'''Metastases''' | ||
| style="background:#F5F5F5;" + | | | style="background:#F5F5F5;" + | | ||
* Nodules in submucosal layers and in | * [[Nodules]] in [[Submucosa|submucosal layers]] and in [[mesentery]] and surrounding organs | ||
|} | |} | ||
===== Sequence of Diagnostic Studies ===== | ===== Sequence of Diagnostic Studies ===== | ||
{| 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}} | |||
|} | |||
*Patients with symptoms of [[Small intestine cancer|small bowel cancer]] should undergo a complete history, physical examination, and screening for fecal [[occult blood]]. | *Patients with symptoms of [[Small intestine cancer|small bowel cancer]] should undergo a complete history, physical examination, and screening for fecal [[occult blood]]. | ||
*Laboratory work-up should include: | *Laboratory work-up should include: | ||
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**[[Carcinoembryonic antigen]] ([[CEA]]) | **[[Carcinoembryonic antigen]] ([[CEA]]) | ||
**[[Liver function tests]] ([[Liver function tests|LFT]]). | **[[Liver function tests]] ([[Liver function tests|LFT]]). | ||
'''[[UGIS/SBFT]]:''' | '''[[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. | *[[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 | *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 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> | *[[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> | ||
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*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]]) | *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]]) | ||
==Staging== | |||
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>: | 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>: | ||
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 |
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| Carcinoid |
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| Lymphoma |
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| GIST |
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| Metastases |
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Sequence of Diagnostic Studies
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- 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:
- Complete blood count (CBC)
- Measurement of serum electrolytes
- Carcinoembryonic antigen (CEA)
- Liver function tests (LFT).
- 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]
- MRE is extensively used for the visualization of small intestinal cancer.[6]
Endoscopy and capsule enteroscopy:
- These are extremely useful modalities to visualize the small intestine pathologies.[1]
- 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.[7]
- 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)
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
- ↑ 1.0 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.
- ↑ 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.
- ↑ 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.
- ↑ Ekberg O, Ekholm S (1980). "Radiography in primary tumors of the small bowel". Acta Radiol Diagn (Stockh). 21 (1): 79–84. PMID 7376936.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ "Stage Information for Small Intestine Cancer".