Small Bowel Adenocarcinoma Clinical Practice Guidelines (2019)

National Comprehensive Cancer Network

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

October 07, 2019

The guidelines on small bowel adenocarcinoma (SBA) were released on September 1, 2019, by the National Comprehensive Cancer Network.[1]

Workup

Patients with SBA require a complete staging workup, including the following:

  • Biopsy (if appropriate)

  • Pathologic tissue review

  • Imaging studies

  • Complete blood count

  • Chemistry profile

  • Carbohydrate antigen 19-9

  • Carcinoembryonic antigen

  • Studies for celiac disease or inflammatory bowel disease (depending on tumor location and patient history)

  • DNA mismatch repair (MMR) or microsatellite instability (MSI) testing

Imaging studies may include the following:

  • Esophagogastroduodenoscopy with endoscopic ultrasound is recommended when a duodenal malignancy is suspected.

  • Double balloon endoscopy may be of particular benefit for patients with small bowel strictures.

  • CT or MRI may be used to evaluate the extent of local tumor invasion and to assess for distant metastases; CT or MR enterography or enteroclysis may be used when conventional CT or MRI with contrast have failed to show a tumor.

  • PET/CT is not routinely indicated, but may be considered when CT or MR results are equivocal.

Treatment of Stage I–III Small Bowel Adenocarcinoma

Primary treatment for local (stage I–III) SBA consists of surgical resection with en bloc removal of at least 8 regional lymph nodes.

The type of resection used to treat localized SBA depends on the location of the primary tumor, as follows:

  • Segmental resection of the small bowel is often the mainstay of treatment.

  • Duodenal tumors may require either pancreaticoduodenectomy (Whipple procedure) or segmental duodenal resection.  Experienced surgeons may consider minimally invasive procedures (eg, laparoscopic surgery) for pancreaticoduodenectomy.

  • For tumors of the jejunum or ileum, segmentectomy is the preferred method of resection.

Participation in a clinical trial is preferred for all patients with SBA who are considering adjuvant therapy, as the optimal approach is unknown.

Observation is recommended after surgical treatment of all stage I SBA tumors and stage II tumors that have high MSI (MSI-H) or deficient MMR (dMMR).

Observation or 6 months of adjuvant treatment with fluorouracil/leucovorin (5-FU/LV) or capecitabine is recommended for T3, N0, M0 (stage IIA) tumors that are microsatellite stable (MSS) or MMR proficient (pMMR) and have no high-risk features.

Observation or 6 months of adjuvant treatment with 5-FU/LV/oxaliplatin (FOLFOX), capecitabine plus oxaliplatin (CAPEOX), 5-FU/LV, or capecitabine is recommended for stage II tumors that are MSS or pMMR and have high-risk features (eg, T4 stage, close or positive surgical margins, few lymph nodes examined)

Six months of adjuvant treatment with FOLFOX, CAPEOX, 5-FU/LV, or capecitabine is recommended for any locally advanced SBA with positive lymph nodes (stage III).

Chemoradiation with capecitabine or infusional 5-FU is another option for stage III duodenal cancer that is margin-positive after resection.

Patients with locally unresectable or medically inoperable SBA may undergo neoadjuvant therapy, with routine monitoring for conversion to resectable disease. In cases where conversion to resectable disease is not feasible, palliative chemotherapy may be considered.

Treatment of Distant Metastatic (Stage IV) Small Bowel Adenocarcinoma

Recommended first-line chemotherapy regimens are FOLFOX, CAPEOX, or FOLFOXIRI (infusional 5-FU, LV, oxaliplatin, irinotecan), any of which may be combined with bevacizumab. Patients who are not appropriate candidates for intensive therapy may receive these regimens with the more toxic components excluded (ie, 5-FU/LV or capecitabine with or without bevacizumab).

Second-line therapy for tumors that are dMMR or MSI-H is checkpoint inhibitor therapy with programmed death 1 (PD-1) inhibitors, alone or in combination with a cytotoxic T-lymphocyte antigen 4 (CTLA-4) inhibitor.

FOLFIRI or taxane-based chemotherapies are second-line options for tumors that are pMMR/MSS or are refractory to checkpoint inhibitor therapies.

Larotrectinib is an option in subsequent lines of therapy for metastatic SBA with neurotrophic tyrosine receptor kinase (NTRK) gene fusion and no satisfactory alternative treatments.

Treatment with trifluridine-tipiracil or regorafenib is not recommended.

Certain patients with SBA and limited metastasis to visceral organs may be candidates for metastasectomy.

For resectable peritoneal carcinomatosis, surgical cytoreduction may be considered. With unresectable peritoneal metastases, treatment is palliative and primarily consists of systemic therapy.

Posttreatment Surveillance

Due to the lack of data regarding optimal surveillance following curative-intent treatment of SBA, an approach similar to that for colorectal cancer is recommended. This includes regular history and physical examination; carcinoembryonic antigen and/or carbohydrate antigen 19-9 measurement; and CT of the chest, abdomen, and pelvis.

Patients with Crohn disease or familial syndromes (eg, Lynch syndrome, familial adenomatous polyposis, Peutz-Jeghers syndrome) may require more intensive surveillance (eg, with endoscopy/enteroscopy).

For more information, see Malignant Neoplasms of the Small Intestine. For more Clinical Practice Guidelines, please go to Guidelines

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