Small Bowel Cancer: Staging and Treatment
What is staging for cancer?
Staging is the process of learning how much cancer is in your body and where it is. Tests like barium X-ray, biopsy, endoscopy, CT, MRI, and PET scan may be done to help stage your cancer. Your providers need to know about your cancer and your health so that they can plan the best treatment for you.
Staging looks at the size of the tumor and where it is, and if it has spread to other organs. The staging system for small bowel cancer (also called small intestine cancer) is called the “TNM system,” as described by the American Joint Committee on Cancer. It has three parts:
- T-describes the size/location/extent of the "primary" tumor in the small bowel/small intestine.
- N-describes if the cancer has spread to the lymph nodes.
- M-describes if the cancer has spread to other organs (called metastases).
How is small bowel cancer staged?
Staging for small bowel cancer is based on:
- The size of your tumor on imaging tests and what is found after surgery.
- Any evidence of spread to other organs (metastasis).
- Surgery to test if your lymph nodes have cancer cells.
The staging system is very complex. Below is a summary. Talk to your provider about the stage of your cancer.
- Tis, N0, M0: The cancer is only in the epithelium (the top layer of cells of the mucosa). It has not grown into the deeper tissue layers. It has not spread to nearby lymph nodes or distant parts of the body.
- T1/T2, N0, M0: The cancer has grown into deeper layers (the lamina propria or the submucosa) OR it has grown through the submucosa into the muscularis propria. The cancer has not spread to nearby lymph nodes or to distant parts of the body.
- IIA (T3, N0, M0): The cancer has grown through the muscularis propria and into the subserosa. It has not started to grow into any nearby organs. The cancer has not spread to nearby lymph nodes or to distant parts of the body.
- IIB (T4, N0, M0): The cancer has grown through the outer layer of tissue covering the intestine (the serosa or visceral peritoneum) or into nearby organs. The cancer has not spread to nearby lymph nodes or to distant parts of the body.
- IIIA (Any T, N1, M0): The cancer might have grown into any layers of the wall of the small intestine. It has spread to 1 or 2 nearby lymph nodes but not to distant parts of the body.
- IIIB (Any T, N2, M0): The cancer might have grown into any layers of the wall of the small intestine. It has spread to 3 or more nearby lymph nodes but not to distant parts of the body.
- Any T, Any N, M1: The cancer might have grown into any layers of the wall of the small intestine. It might or might not have spread to nearby lymph nodes. It has spread to distant lymph nodes or organs such as the liver or the peritoneum (the inner lining of the belly).
How is small bowel cancer treated?
Treatment for small bowel cancer depends on many things, like your cancer stage, age, overall health, and testing results. Your treatment may include some or all of the following:
- Targeted Therapy.
- Radiation Therapy.
- Clinical Trials.
Surgery is the main treatment option for small bowel cancer. The goal of surgery is to:
- Remove as much of the tumor as possible from the small bowel and nearby areas.
- If the cancer has spread (metastasized) to other areas and cannot be fully removed, surgery can be done to help with any symptoms or problems the tumor may be causing (like blocking the bowel). This is called palliative surgery, discussed below.
The type of surgery you have will depend on your overall health and the size and location of your tumor. Examples of surgery for small bowel cancer are:
- Segmental Resection: As much of the tumor and some healthy tissue is removed (resected). The two cut ends of the bowel are reattached. This surgery can be done with a long incision (surgical cut) or laparoscopically (through small holes).
- Whipple Surgery (also called pancreaticoduodenectomy): The duodenum (first part of the small bowel), gallbladder, part of the common bile duct, some of the pancreas, part of the stomach, and some lymph nodes are removed. This is a complex procedure, so it is important to have this surgery at a cancer center that has experience with it.
- Palliative Surgery: If your tumor is not able to be removed with surgery, or if the cancer has spread too far, surgery can be done to help relieve symptoms of the cancer. Palliative surgery can be used to help with a blocked intestine, pain, nausea, and problems with swallowing. There are a few different options for palliative surgery, so be sure to talk with your care team about options.
Chemotherapy is the use of anti-cancer medications to kill cancer cells. Chemo may be given as part of your treatment for small bowel cancer:
- If your cancer has metastasized (spread) to other parts of your body.
- After surgery to remove as much of the tumor as possible (called adjuvant therapy). This is done to try to stop the cancer from coming back in the future (called recurrence).
- As an intraperitoneal infusion. The chemotherapy is given right into your belly after surgery if the cancer has spread there. Intraperitoneal means “inside your peritoneum.” Your peritoneum is the inner lining of your belly.
Some of the chemotherapy medications used to treat small bowel cancer are capecitabine, oxaliplatin, fluorouracil, and irintotecan. Leucovorin can be used with fluorouracil to help it work better. These medications are often used in combination.
Interferon is a type of medication called a targeted therapy and may be used to treat small bowel cancer. Interferon is used for some types of small bowel cancers, often carcinoids. This medication works by helping the body's immune system fight the cancer.
For gastrointestinal stromal tumors (GIST) of the small bowel, there is a large role for targeted therapy medications, such as imatinib, sunitinib and regorafenib.
Radiation treatment is the use of high-energy x-rays to kill cancer cells. It may be used after surgery if there is tumor left behind or if there are close surgical margins (the cancer cells were close to the edge of the tissue removed). Radiation is given to help get rid of any leftover cancer cells. It may also be used to help palliate (relieve) symptoms from advanced disease, such as blood loss or pain from the tumor. This kind of radiation is called palliative radiation. Radiation therapy for bowel cancer is often given by external beam radiation.
You may be offered a clinical trial as part of your treatment plan. To find out more about current clinical trials, visit the OncoLink Clinical Trials Matching Services.
Making Treatment Decisions
Your care team will make sure you are included in choosing your treatment plan. This can be overwhelming as you may be given a few options to choose from. It feels like an emergency, but you can take a few weeks to meet with different providers and think about your options and what is best for you. This is a personal decision. Friends and family can help you talk through the options and the pros and cons of each, but they cannot make the decision for you. You need to be comfortable with your decision – this will help you move on to the next steps. If you ever have any questions or concerns, be sure to call your team.
You can learn more about small bowel cancer at OncoLink.org.
SEER Stat Fact Sheets. Small Intestine Cancer.
American Cancer Society. Small Intestine Cancer.
American Cancer Society. (2018). Small Intestine Cancer (Adenocarcinoma). Retrieved from https://www.cancer.org/cancer/small-intestine-cancer/detection-diagnosis-staging/staging.html
Aparicio, T., Zaanan, A., Svrcek, M., Laurent-Puig, P., Carrere, N., Manfredi, S., ... & Afchain, P. (2014). Small bowel adenocarcinoma: epidemiology, risk factors, diagnosis and treatment. Digestive and Liver Disease, 46(2), 97-104.
Kim, K, Chie, J., … Im, S.A.(2012). Role of adjuvant chemoradiotherapy for duodenal cancer: a single center experience. American Journal of Clinical Oncology, 35, 533-536.
Maisonneuve, P., Marshall, B. C., Knapp, E. A., & Lowenfels, A. B. (2012). Cancer risk in cystic fibrosis: a 20-year nationwide study from the United States. Journal of the National Cancer Institute, djs481.
Overman, M. J., Kopetz, S., Wen, S., Hoff, P. M., Fogelman, D., Morris, J., ... & Wolff, R. A. (2008). Chemotherapy with 5?fluorouracil and a platinum compound improves outcomes in metastatic small bowel adenocarcinoma. Cancer, 113(8), 2038-2045.
Smoot, R. L., & Que, F. G. (2015). Evidence of Surgical Management of Duodenal Cancer. Pancreatic Cancer, Cystic Neoplasms and Endocrine Tumors, 194-196.
Youn, J. C., Nahm, J. H., & Kang, S. M. (2013). Duodenal cancer after cardiac transplantation. Heart, 99(17), 1304-1304.