1. Small Bowel Tumors Keith D. Lillemoe M.D. Dept. of Surgery
Indiana University
School of Medicine

2. Small Bowel Tumors Epidemiology
Exceedingly rare - < 5500 new cases,1200 deaths/year
Explanations
lack of bacteria
rapid transit
role of pancreatic and mucosal enzymes
secretory Ig A / intramural lymphoid tissue

3. Predisposing Conditions
Small Bowel Tumors
Predisposing Conditions
Adenocarcinoma
HNPCC
Familial Adenomatous Polyposis
Crohn’s Disease
Lymphoma
Celiac Disease
Crohn’s Disease
Immunologic Dysfunction

4. Small Bowel Tumors Pathology - Benign Adenomas (20 – 30%)
simple tubular adenomas
villous adenomas
Brunner’s gland adenomas
Leiomyomas (30 – 40%)
Lipomas (15 – 20%)
Hemangiomas (<10%)
Hamartomas (<5%)

5. Small Bowel Tumors Pathology - Malignant Distribution (%)
Type of Tumor Duodenum Jejunum Ileum % of Total
Adenocarcinoma
Carcinoid Tumor
Lymphoma
Gastrointestinal
Stromal Tumors

6. Small Bowel Tumors Clinical Presentation Benign Malignant Symptom %
Pain
Obstruction
Bleeding
Asymptomatic <50
Malignant
Symptom %
Weight Loss
Abdominal Pain
Obstruction
Abdominal Mass
Perforation
Bleeding
Jaundice

7. Small Bowel Tumors Diagnosis Radiology Endoscopy Plain films Upper
Contrast Studies CT
Laparotomy/Laparoscopy
Endoscopy
Upper
Lower
Enteroscopy
Capsule endoscopy

8. Small Bowel Tumors Management – Benign Neoplasms Adenomas:
Duodenum : Endoscopic polypectomy
Transduodenal excision
Duodenectomy
Jejunum/Ileum : Local excision

9. Small Bowel Tumors Management – Benign Tumors
Hamartomas – Limited resection of responsible lesion (s)
Hemangiomas – Resection
Electrocautery

10. Small Bowel Tumors Management - Adenocarcinoma
Duodenum – Pancreaticoduodenectomy
5 year – survival : %
Jejunum-ileum – En bloc resection of bowel/mesentery
5 year survival : overall %
node  15%
node Θ 50-70%
? role for adjuvant therapy

11. Small Bowel Tumors Gastrointestinal Stomal Tumors
formerly leiomyoma / leiomyosarcoma
arise from mesenchymal tissue
interstital (cell of Cajal)
grow extrinsically, often to large size
present with palpable mass, hemorrhage
associated with mutation of C-kit

12. Small Bowel Tumors Management – Gastrointestinal Stromal Tumors
Limited surgical resection
Imatnib Mesylate
(gleevac)
5 year survival %

13. Small Bowel Tumors Lymphomas
vague symptoms – fatigue, malaise, weight loss, pain
perforation, obstruction – 25%
palpable mass – 33%

14. Small Bowel Tumors Lympoma – Pathology/Staging
Non-Hodgkin’s, B-cell
Usually intermediate/high grade with large cell features
Ann Arbor classification
IE – Tumor continued to SI without lymph nodes
IIE – Regional lymph node involvement
IIIE – Nonresectable lymph nodes
IVE – Spread to nonlymphatic organs

15. Small Bowel Tumors Management - Lymphoma
I-E / II-E – Limited resection, ?CTX
5-year survival : 60%
III-E / IV-E – Limited resection + CTX / Radiation
5-year survival : rare

16. Small Bowel Tumors Carcinoid Tumors arise from enterochromatin cells
often present late with nodal/hepatic metastasis
obstruction due to desmoplastic reaction of
mesentery
carcinoid syndrome

17. Small Bowel Tumors Management – Carcinoid Tumors
segmental resection with en bloc mesenteric resection
aggressive treatment of metastatic disease
treatment of carcinoid syndrome : octreotide
5 year survival : localized 100%
regional 65%
distant %

18. Small Bowel Tumors Metastatic Neoplasms
direct extension, carcinomatosis
Hematogenous metastasis
(melanoma, hypernephroma, breast, lung)