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Small bowel adenocarcinoma

Key sources
The following summarized guidelines for the evaluation and management of small bowel adenocarcinoma are prepared by our editorial team based on guidelines from the European Society of Gastrointestinal Endoscopy (ESGE 2023), the Society for Immunotherapy of Cancer (SITC 2023), the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS/JGCA 2022), the American Society for Gastrointestinal Endoscopy (ASGE 2021), and the French Society of Oncological Radiotherapy (SFRO/GERCOR/UNICANCER/SFCD/SNFGE/FFCD/SFED 2018).


1.Classification and risk stratification

Risk factors: recognize that there are no known risk factors for non-ampullary duodenal cancer other than familial adenomatous polyposis of the colon.
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2.Diagnostic investigations

Initial evaluation
Include the following in the pretreatment evaluation:
physical examination
CT of the chest, abdomen and pelvis for tumor localization and extension
upper and lower gastrointestinal endoscopy of lesions associated with a predisposing disease
Obtain ultrasound for duodenal sites to determine the possibility of tumor resection in the absence of metastasis.

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  • Imaging for staging

  • Genetic testing

3.Diagnostic procedures

Small bowel endoscopy
Consider performing device-assisted enteroscopy in preference to small bowel capsule endoscopy if imaging has already demonstrated a suspected small bowel tumor.
Perform device-assisted enteroscopy and/or obtain cross-sectional imaging, depending on local availability and expertise, to confirm the diagnosis of a subepithelial mass detected by small bowel capsule endoscopy.

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  • Video capsule endoscopy

  • Biopsy

4.Medical management

Systemic therapy: as per SITC 2023 guidelines, offer pembrolizumab monotherapy in patients with previously treated, advanced high MSI/MMR-deficient small bowel adenocarcinoma. Offer dostarlimab monotherapy for MMR-deficient tumors only.
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5.Therapeutic procedures

Endoscopic stenting: as per ESGE 2023 guidelines, consider performing enteroscopic placement of self-expanding metal stents as an alternative option to surgery for the palliation of malignant small bowel strictures.

6.Surgical interventions

Surgical resection, indications, JSHBPS/JGCA: consider performing additional surgery after endoscopic treatment in cases of submucosal carcinoma and vascular invasion.

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  • Surgical resection (technical considerations)

  • Gastrojejunostomy

7.Follow-up and surveillance

Clinical and imaging surveillance: as per JGCA 2022 guidelines, consider obtaining careful follow-up with various imaging tests after surgical treatment of duodenal cancer in order to detect distant metastasis and local recurrence.

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  • Endoscopic surveillance