Source: Cancer Resource Room

What is Small Bowel Cancer (Small Intestine)?
Any cancer that starts in the small bowel (small intestine) is called small bowel cancer. Cancers are formed by abnormal cells that grow and divide without control. These cancer cells replace normal cells and form a tumor or lump. As a tumor gets bigger, it can grow into nearby tissues and organs. Cancer cells can spread to other parts of the body through the blood or lymph vessels. Most small bowel cancers start in the cells that line the inside of the intestine. Tumor cells grow there, invade through the layers of the small bowel, and spread to lymph nodes and other tissues. Small bowel cancer is an uncommon cancer, with about 2100 new cases a year in the United States.

What is the small intestine and what does it do?

The small intestine links the stomach to the large intestine (colon).

It is divided into three parts:

• duodenum—part closest to the stomach
• jejunum—middle part
• ileum—part closest to the colon

The small intestine is separated from the stomach by a circle of muscle called the pylorus. The pylorus controls the flow of food and fluid from the stomach into the small intestine. In the duodenum, food is processed and broken down into particles that can be absorbed for nutrition. The jejunum completes the chemical digestion of food and absorbs a lot of nutrients. The ileum absorbs nutrients and water. There is another circle of muscle where the ileum joins the large intestine. It is called the ileocecal valve and controls the flow of fluid from the small to the large bowel.

There are four layers of tissue that make up the small intestine:

• inside lining (mucosa)
• support tissue for lining (submucosa)
• muscle (muscularis)
• outside covering layer (serosa)

Small bowel cancer usually starts in the lining layer. It grows larger and deeper through the other layers, spreading to nearby tissues and lymph nodes. The intestines can keep working even though a cancer has started in one part of it. This means a small bowel cancer can get quite large or deep before it is diagnosed.

Is there only one type of small bowel cancer?
Not all small bowel cancers are the same. The most common are called adenocarcinomas (gland-forming cancers). They mostly occur in the duodenum. Two types of cancers that are found in the ileum are called carcinoid tumors and lymphoma. A fourth type of small bowel cancer is called sarcoma and occurs throughout the small intestine.

What are the symptoms of small bowel cancer?
Symptoms of small bowel cancer are caused by the tumor taking up space inside the intestine and disturbing its normal functions. A tumor can cause a blockage or obstruction so the digesting food cannot pass by easily. The cancer tissue can also bleed into the intestine. Some symptoms are caused by cancer cells invading the layers of the small bowel or spreading to other tissues nearby. Small bowel cancer usually grows for some time before it causes any symptoms. And the symptoms can be similar to some common problems, such as irritable bowel syndrome and peptic ulcer disease. What makes symptoms from cancer different are:

1. having a variety of symptoms for several weeks,
2. having the same symptoms for several weeks, and (3) older age (more than 50 years old). When symptoms occur they include:
   • abdominal discomfort or pain
   • weight loss (without dieting)
   • weakness or tiredness (due to anemia—a low blood count)
   • nausea and vomiting
   • bloody or black, sticky bowel movements
   • lump in the abdomen
   • jaundice (yellow skin color)
   • loss of appetite

These symptoms often have other causes and should be checked by a doctor.

How is small bowel cancer diagnosed?
A patient’s medical history and physical exam are the first steps in making a diagnosis of any disease. The medical history includes many details of a person’s health. In particular, the history will focus on the digestive tract—changes in eating habits, changes in bowel movements, abdominal pain or bloating, and how food affects any of the symptoms. In the case of small bowel cancer the patient’s history may also include information about other diseases such as Crohn’s disease, adult celiac disease, familial polyps of the digestive tract, Peutz-Jeghers syndrome, or previous GI operations.

The physical exam will focus on areas of discomfort in the abdomen, the presence of a mass (a lump) in the abdomen, an enlarged liver, fluid or swelling in the abdomen, any skin color change (yellow jaundice), or enlarged lymph nodes. The stool must be checked for blood.

After the history and physical exam, some diagnostic tests may be ordered. Blood tests and a chest x-ray check a patient’s general health. Blood tests that may be done include:

• Blood count - to check for anemia
• Liver enzymes- for possible spread to the liver or blockage of the bile duct
• CEA - marker protein that may increase

Special tests that are useful in diagnosing small bowel cancer are:

1. Upper GI with Small Bowel Follow-Through (barium contrast study)—an x-ray test in which the patient swallows a liquid containing barium. The barium, a white liquid, goes down the esophagus to the stomach and on into the small intestine. It lines the inside layer of all these structures. X-rays are then taken of the abdomen. The x-rays can show small changes in the smooth inner surface of the small bowel. This study is done in the radiology department of a hospital. The test is painless, but the barium liquid is unpleasant to drink. Barium can cause constipation and makes a person’s bowel movements white or light-colored for a few days.
2. CT scan—x-rays made in thin cross-sections of the small intestine and surrounding tissues. This set of x-rays can show a tumor in the small bowel, as well as its spread to nearby tissues and lymph nodes.
3. Endoscopy—a flexible tube with a tiny camera in it is passed down the patient’s throat, down the esophagus, through the stomach and into the duodenum. The camera transmits pictures of the inside of these structures to a TV screen. If an abnormal spot of tissue is “seen” with the camera, a small clipper inside the end of the tube takes a sample of the tissue for diagnosis. This sample is called a biopsy. Of the entire small bowel, only the duodenum can be viewed by endoscopy. Many biopsy samples can be taken during an endoscopy. The procedure is done using sedation (a strong relaxing medication) given through an IV. After the endoscopy, the patient feels sleepy from the medication, may have a mild sore throat from the tube, but is fine after the medicine wears off. It will take several days to get the results from the biopsy.
4. Colonoscopy—similar to endoscopy, this test uses a thin, flexible tube with a camera in it to look at the inside of the colon (large intestine) and the end of the small intestine, the ileum. In preparation for the test, the patient drinks only liquids the day before, including a fluid that helps clean out the bowel. The procedure is done using sedation for relaxation. The colonscope is passed through the anus and rectum into the colon and up through the large intestine into the end of the small bowel. The procedure is done using sedation for relaxation. It is not a painful procedure and does not require anesthesia.

These tests are useful in about 50% of patients with small bowel cancer. Many patients are operated on even though the test results are questionable. This is because the history, symptoms, and physical exam all suggest a diagnosis of small bowel cancer.

What is a biopsy? What does it mean to the patient?
A biopsy is a small piece of tissue or group of cells used to diagnose a disease. The tissue is taken from a spot suspected of being abnormal. Then the biopsy tissue is looked at under a microscope by a pathologist. The diagnosis is based on the appearance of the tissue and cells. The biopsy result helps plan the patient’s treatment.

What if the biopsy shows small bowel cancer?
If the biopsy shows cancer, the next step is to find out how much disease there is. In particular, you need to know:

• how widespread is the disease in the small bowel
• how many layers has it spread through
• has it spread beyond the small bowel into the lymph nodes, into nearby tissues, or to distant lymph nodes and other organs

What tests are used to find the spread of small bowel cancer?

• CT scans—these are x-rays that show cross-section pictures of the body. CT images let the radiologist see the stomach and other organs in many ways, going across, as well as up and down the body. An abdominal CT scan shows the stomach, lymph nodes, liver, gallbladder and bile ducts, pancreas, small and large intestines, kidneys, major blood vessels, and part of the spine. The patient may need to drink a contrast solution to help outline the digestive organs. An IV is used to give the patient contrast “dye” that travels through the blood. Contrast dye in the blood makes a person feel very warm for a brief time, and causes a sensation of needing to pee urgently. Both feelings pass quickly. CT scans are not painful, but do require lying on a table for about 30 minutes.
• Laparoscopy—this procedure lets the surgeon look inside the abdomen with a laparoscope, a thin tube with a small camera in the end. The laparoscope is inserted through a small abdominal incision. It transmits pictures from inside the abdomen to a TV monitor so the surgeon can see what tissues look normal and which do not. This helps plan the patient’s surgery and other treatments. Laparoscopy is done in the operating room with the patient under general anesthesia.
  The information about the patient, including the medical history, physical exam, blood tests, x-rays, special scans, and procedures, are used to describe the patient’s stage of disease and plan the best treatment for that disease.

What is the stage of a cancer? How is it determined?
The stage of a cancer describes how much cancer there is, what tissue it has invaded, and whether or not it spread to lymph nodes and other parts of the body. The higher the stage, the more complicated the disease. The stage is a combination of the size or extent of tumor growth, the number of lymph nodes involved, and the spread to other sites (metastases).

These are the stages for adenocarcinoma of the small bowel:

• Stage 0: cancer cells are only in the lining layer (in the mucosa) and have not invaded the outer layers or lymph nodes. May be called, “carcinoma in situ.”
• Stage I: cancer has invaded from the lining layer into the submucosa or as far as the muscle layer. Cancer has not grown into any lymph nodes.
• Stage II: cancer has invaded the muscle layer, serosa, and into nearby tissue, but has not spread to lymph nodes.
• Stage III: cancer has grown through all layers of the intestine, into nearby tissues, and to lymph nodes. Cancer has not traveled to distant nodes or organs.
• Stage IV: cancer has spread to other parts of the body (liver, lungs, bones, brain).

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