Small Bowel Cancer

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What is Small Bowel Cancer ?

Small bowel cancer starts when cells in the lining of the small bowel (also called the small intestine) change and grow uncontrollably, forming a mass called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous, meaning it can spread to other parts of the body). These changes can take a long time to develop. Both genetic and environmental factors can cause such changes, although the specific causes of small bowel cancer are generally not well understood.

About the small bowel

The small bowel is part of the digestive system, and its function is to break down food and nutrients to be absorbed into the body. It links the stomach to the large intestine (colon). The small bowel is divided into three parts: the duodenum, the part closest to the stomach; the jejunum, the middle portion; and the ileum, the bottom section, which connects to the large intestine, or colon. The small bowel is approximately 15 feet long, folds many times to fit inside the abdomen, and makes up three-quarters of the digestive system.

Types of small bowel cancer

There are five main types of small bowel cancer:

Adenocarcinoma. Adenocarcinoma is the most common type of small bowel cancer, usually occurring in the duodenum or jejunum. Adenocarcinoma begins in the gland cells of the small bowel.

Sarcoma. Small bowel sarcoma is generally a leiomyosarcoma (a tumor that arises in the muscle tissue that makes up part of the intestine) and most often occurs in the ileum. 

Gastrointestinal stromal tumor (GIST). GIST is an uncommon tumor that is believed to start in cells found in the walls of the gastrointestinal (GI) tract, called interstitial cells of Cajal (ICC). GIST belongs to a group of cancers called soft tissue sarcomas. 

Carcinoid tumor. Carcinoid tumors are classified as neuroendocrine tumors (tumors that originate in the hormone-producing cells of various organs) and generally occur in the ileum.

Lymphoma. Lymphoma is a cancer of the lymph system, which is part of the body’s immune system. Lymphoma that occurs in the small bowel usually occurs in the jejunum or ileum and is most commonly non-Hodgkin lymphoma. 

Risk Factors

A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and talking about them with your doctor can help you make more informed lifestyle and health care choices.

The following factors may raise a person’s risk of small bowel cancer:

Diet. Eating high-fat foods may raise the risk of small bowel cancer. Regularly consuming smoked or cured foods may also increase a person’s risk.

Crohn’s disease. Crohn’s disease is a chronic inflammation of the gastrointestinal tract. People with Crohn’s disease have a higher risk of colorectal and small bowel cancers.

Celiac disease. Celiac disease is a digestive disease that interferes with the absorption of nutrients from food in the small bowel. The body’s immune system responds to a protein called gluten—which is found in wheat, rye, barley, and oats—and can damage the lining of the small bowel.

Familial adenomatous polyposis (FAP). FAP is an inherited condition characterized by hundreds or thousands of colon polyps (small growths). The polyps are usually benign (noncancerous), but there is nearly a 100% chance that the polyps will develop into cancer if left untreated. Individuals with FAP are also at risk for other types of cancer, including stomach cancer, duodenal cancer, thyroid cancer, pancreatic cancer, and hepatoblastoma (liver cancer seen mainly in early childhood).

Symptoms and Signs

People with small bowel cancer may experience the following symptoms or signs. Sometimes, people with small bowel cancer do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. If you are concerned about a symptom or sign on this list, please talk with your doctor.

Blood in the stool (feces)

Dark/black stools

Diarrhea

A lump in the abdomen

Pain or cramps in the abdomen

Unexplained weight loss

Episodes of abdominal pain that may be accompanied by severe nausea or vomiting

Your doctor will ask you questions about the symptoms you are experiencing to help find out the cause of the problem, called a diagnosis. This may include how long you’ve been experiencing the symptom(s) and how often.

If cancer is diagnosed, relieving symptoms and side effects remains an important part of cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms.

Diagnosis

Doctors use many tests to diagnose cancer and find out if it has metastasized (spread). Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:

Age and medical condition

Type of cancer suspected

Severity of symptoms

Previous test results

In addition to a physical examination, the following tests may be used to diagnose small bowel cancer:

Blood tests. A blood sample may be tested for liver disease, which can be caused by small bowel cancer. Blood may also be tested for high levels of certain proteins, which can indicate that a cancer is aggressive or has spread to other parts of the body. A test of the number of red blood cells in the blood can indicate whether the cancer is causing any bleeding.

Fecal occult blood test. This test detects occult (hidden) blood in the stool, which can be caused by small bowel cancer. A small amount of stool is placed on a plastic slide or special paper and tested in the doctor's office or a laboratory.

X-ray. An x-ray is way to create a picture of the structures inside of the body using a small amount of radiation. It can help the doctor find a tumor. For small bowel cancer, x-rays may be taken of the entire gastrointestinal system, including the esophagus, stomach, small bowel, large intestine, and rectum. Sometimes, the person will drink a substance called barium, which outlines the esophagus, stomach, and small bowel on the x-ray and helps the doctor see tumors or other abnormal areas. This is called an upper gastrointestinal series with small bowel follow-through (UGI SBFT). To get a better picture of the lower gastrointestinal tract, a barium enema may be performed. In this procedure, barium is placed into the rectum and coats the rectum and large intestine. Abdominal x-rays may also show the location of a tumor.

Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. The sample removed from the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease).

Endoscopy. A test called an endoscopy allows the doctor to see the inside much of the gastrointestinal system. The person may be sedated while the doctor inserts a thin, lighted, flexible tube called an endoscope through the mouth, down the esophagus, and into the stomach and small bowel. If abnormal areas are found, the doctor can remove a sample of tissue and check it for evidence of cancer. Sometimes, the small bowel cannot be seen entirely using this traditional method of endoscopy, so the doctor may instead recommend videocapsule endoscopy (VCE). In this method, the patient swallows a small (pill-sized) capsule that contains a tiny camera and light. Pictures are collected from the capsule as it travels through the patient’s gastrointestinal system. The capsule exits the body during the patient’s next bowel movement.

Colonoscopy. A colonoscopy is similar to the traditional endoscopy described above, except that the endoscope enters the body through the anus and rectum into the colon and lower part of the small bowel.

Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a contrast medium (a special dye) is injected into a patient’s vein to provide better detail. A CT scan can check for the spread of cancer to the lungs, liver, and other organs.

Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body. This substance is absorbed mainly by organs and tissues that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body.

Laparotomy. In this procedure, a surgical incision is made in the abdomen to check for disease. Sometimes, tissue samples are taken and, often, surgery is performed at the same time to remove the tumor.

After these diagnostic tests are done, your doctor will review all of the results with you. If the diagnosis is cancer, these results also help the doctor describe the cancer; this is called staging.

Stages and Grades

Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer’s stage, so staging may not be complete until all the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis (chance of recovery). There are different stage descriptions for different types of cancers.

One tool that doctors use to describe the stage is the TNM system. This system judges three factors: the tumor itself, the lymph nodes around the tumor, and if the tumor has spread to the rest of the body. The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero) and stages I through IV (one through four). The stage provides a common way of describing the cancer so doctors can work together to plan the best treatments.

TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:

How large is the primary tumor, and where is it located? (Tumor, T)

Has the tumor spread to the lymph nodes? (Node, N)

Has the cancer metastasized to other parts of the body? (Metastasis, M)

Tumor. Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the location of the small bowel tumor. Some stages are also divided into smaller groups that help describe the tumor even in more detail. This helps the doctor develop the best treatment plan for each patient. Specific tumor stage information is listed below.

TX: The primary tumor cannot be evaluated.

T0: There is no evidence of a primary tumor.

Tis: This refers to carcinoma (cancer) in situ. Cancer in situ is very early cancer in which cancer cells are found only in one small area and have not spread.

T1a: There is a tumor in the lamina propria (the innermost layer of the small bowel).

T1b: There is a tumor in the submucosa (the next deepest layer of the small bowel).

T2: The tumor is in the muscularis propria (the third layer of the small bowel).

T3: The tumor has grown through the muscularis propria and into the subserosa (a thin layer of connective tissue beneath the outer layer of some parts of the large intestine) or into tissues surrounding the small bowel.

T4: The tumor has invaded other organs or has grown through the lining of the abdominal cavity (the space between the abdomen and the spine that holds several organs) called the visceral peritoneum.

Node. The “N” in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. Lymph nodes near the small bowel are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes.

NX: The regional lymph nodes cannot be evaluated.

N0 (N plus zero): There is no regional lymph node metastasis.

N1: Cancer has spread to one to three regional lymph nodes.

N2: Cancer has spread to four or more lymph nodes.

Distant metastasis. The “M” in the TNM system indicates whether the cancer has spread to other parts of the body.

MX: Distant metastasis cannot be evaluated.

M0: The disease has not metastasized.

M1: There is distant metastasis, meaning the cancer has spread to other parts of the body beyond the small bowel.

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classifications.

Stage 0: This refers to cancer in situ. The cancer is found in only one place and has not spread (Tis, N0, M0).

Stage I: The cancer has grown through the inner layers of the small bowel. It has not spread into nearby tissue or lymph nodes (T1 or T2, N0, M0).

Stage IIA: The cancer has spread through the wall of the small bowel, and it may have spread to nearby tissue. It has not spread to the nearby lymph nodes (T3, N0, M0).

Stage IIB: The cancer has invaded nearby structures outside of the small bowel, but it has not spread to the nearby lymph nodes (T4, N0, M0).

Stage IIIA: The cancer has spread to one to three regional lymph nodes. It may or may not have grown through the inner lining or into the muscle layers of the small bowel, but it has not spread to other parts of the body (any T, N1, M0).

Stage IIIB: The cancer has spread to four or more regional lymph nodes. It may or may not have grown through the inner lining or into the muscle layers of the small bowel, but it has not spread to other parts of the body (any T, N2, M0).

Stage IV: The cancer has spread to other parts of the body, such as the liver or lungs (any T, any N, M1).

Recurrent: Recurrent cancer is cancer that comes back after treatment. The disease may return in the colon, rectum, or another part of the body. If there is a recurrence, the cancer may need to be staged again (called re-staging) using the system above.

Grading

In addition to determining the stage of the disease using the TNM system, doctors also determine the histologic grade, which indicateshow closely the cancer cells resemble normal tissue under a microscope. In general, the lower the grade, the better the prognosis. A tumor's grade is described using the letter “G” and a number.

GX: The tumor grade cannot be identified.

G1: The cells look more like normal tissue cells (well differentiated).

G2: The cells are somewhat different (moderately differentiated).

G3: The cells look very unlike normal cells (poorly differentiated).

G4: The cells barely resemble normal cells (undifferentiated).

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