Treatment of small bowel neoplasms pictures electricity pylons

The treatment of the various types of neoplasms that arise in the small bowel will be reviewed here. The epidemiology, clinical manifestations, diagnosis, and staging of small bowel tumors are discussed separately. (See "Epidemiology, clinical features, and types of small bowel neoplasms" and "Diagnosis and staging of small bowel neoplasms".)

Surgery — Localized adenocarcinomas of the small bowel are best managed with wide segmental surgical resection. Resection of the primary and investing mesentery achieves surgical clearance of both the primary and the regional nodes at risk for metastases, and provides important staging information that impacts decisions regarding the need for adjuvant therapy (see below). However, resection of adequate mesentery may be limited by the proximity of the nodes or tumor to the superior mesenteric artery.

Pancreaticoduodenectomy is required for tumors involving the first and second portions of the duodenum. Some surgeons promote pancreaticoduodenectomy rather than wide local excision as a superior operation for all duodenal adenocarcinomas because of its more radical clearance of the tumor bed and regional lymph nodes [ 1,2]. However, this is not necessary for the following reasons:

●Unlike pancreatic cancers, which diffusely infiltrate into the surrounding soft tissues, the extension of duodenal adenocarcinomas into adjacent tissues is usually a more localized process, and tumor-free resection margins may be obtained without resection of adjacent organs and soft tissues. Because a negative margin is critical to a curative procedure, the margin status of the resected specimen must be confirmed on frozen-section and subsequent permanent histologic sections [ 1,3,4].

• Howe JR, Karnell LH, Menck HR, Scott-Conner C. The American College of Surgeons Commission on Cancer and the American Cancer Society. Adenocarcinoma of the small bowel: review of the National Cancer Data Base, 1985-1995. Cancer 1999; 86:2693.

• Ecker BL, McMillan MT, Datta J, et al. Adjuvant chemotherapy versus chemoradiotherapy in the management of patients with surgically resected duodenal adenocarcinoma: A propensity score-matched analysis of a nationwide clinical oncology database. Cancer 2017; 123:967.

• Nakayama N, Horimatsu T, Takagi S, et al. A phase II study of 5-FU/l-LV/oxaliplatin (mFOLFOX6) in patients with metastatic or unresectable small bowel adenocarcinoma (abstract). J Clin Oncol 32: 5s, 2014 (suppl; abstr 3646). Abstract available online at http://meetinglibrary.asco.org/content/130721-144 (Accessed on June 17, 2014).

• Enzinger PC, Zhu A, Blaszkowsky L, et al. Phase I dose finding and pharmacologic study of cisplatin (P), irinotecan (C), and either capecitabine (X) or infusional 5-FU (F) in patients with advanced gastrointestinal malignancies (abstract). Data presented at the 2005 ASCO Gastrointestinal Cancers Symposium, Miami, FL, January 27-29, 2005.

• Zaanan A, Gauthier M, Malka D, et al. Second-line chemotherapy with fluorouracil, leucovorin, and irinotecan (FOLFIRI regimen) in patients with advanced small bowel adenocarcinoma after failure of first-line platinum-based chemotherapy: a multicenter AGEO study. Cancer 2011; 117:1422.

• Gulhati P, Raghav K, Shroff RT, et al. Bevacizumab combined with capecitabine and oxaliplatin in patients with advanced adenocarcinoma of the small bowel or ampulla of vater: A single-center, open-label, phase 2 study. Cancer 2017; 123:1011.

• Nikou GC, Lygidakis NJ, Toubanakis C, et al. Current diagnosis and treatment of gastrointestinal carcinoids in a series of 101 patients: the significance of serum chromogranin-A, somatostatin receptor scintigraphy and somatostatin analogues. Hepatogastroenterology 2005; 52:731.