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Cancers of the small intestine are rare and often found late because the small bowel is hard to see and symptoms are vague. Surgery cures early disease, chemotherapy borrowed from bowel cancer helps after surgery and in advanced disease, and a large minority of tumours have a repair defect that makes them respond well to immunotherapy.
Small bowel adenocarcinoma (SBA) is the epithelial cancer of the duodenum, jejunum and ileum; the small intestine also gives rise to neuroendocrine tumours (the most common small bowel malignancy in some registries), gastrointestinal stromal tumours and lymphoma, each covered on their own pages. Risk factors for SBA are inflammatory and hereditary: Crohn's disease (ileal tumours), coeliac disease (jejunal tumours, often MSI-high), Lynch syndrome, familial adenomatous polyposis (duodenal and periampullary tumours) and Peutz-Jeghers syndrome. Molecularly, SBA sits between colorectal and gastric cancer: KRAS and TP53 mutations are common, APC mutation is less common than in colon cancer, and mismatch-repair deficiency is found in a larger share than in colorectal cancer, with a further subset carrying HER2 amplification or ERBB2 mutations.
Segmental resection with regional lymphadenectomy (pancreatoduodenectomy for duodenal tumours) is the curative treatment. Adjuvant chemotherapy has been extrapolated from colorectal cancer; the international BALLAD trial (NCT02502370) is the first randomised test of adjuvant fluoropyrimidine with or without oxaliplatin versus observation in stage I to III disease. For advanced disease, CAPOX or FOLFOX is first line; pembrolizumab is the first-line choice for MSI-high or mismatch-repair-deficient tumours, where response rates are high and durable. The NCCN small bowel adenocarcinoma guideline (2019 onwards) and the ASCO 2024 guideline now give the disease its own recommendations rather than a footnote in the colon guideline.
Open questions include the BALLAD result, second-line therapy beyond taxanes and irinotecan, HER2-directed therapy, and better ways to image the small bowel in high-risk patients (capsule endoscopy, MR enterography).
The small intestine is three quarters of the gut's length but hosts only a few percent of gastrointestinal cancers; adenocarcinoma, neuroendocrine tumours, lymphoma and GIST each make up a share (SEER).
Right-sided tumours behave differently from left-sided and rectal ones; the colon drains along its mesenteric vessels, the rectum into the mesorectum and pelvic side wall.
Same organ: Colon cancer (adenocarcinoma of the colon), Micropapillary adenocarcinoma of the colon and rectum, Adenoma-like adenocarcinoma of the colon and rectum, Lynch syndrome-associated colorectal cancer, Familial adenomatous polyposis-associated colorectal cancer, Mucinous adenocarcinoma of the colon and rectum, Signet ring cell carcinoma of the colon and rectum, Medullary carcinoma of the colon, Serrated adenocarcinoma of the colon and rectum, Peritoneal mesothelioma, Colorectal cancer, Rectal cancer, Mismatch-repair deficient (MSI-high) colorectal cancer, BRAF V600E-mutant colorectal cancer, HER2-amplified colorectal cancer, KRAS G12C-mutant colorectal cancer, Early-onset colorectal cancer (under 50), Anal cancer (squamous cell carcinoma), Appendiceal cancer and pseudomyxoma peritonei, Small intestinal neuroendocrine tumours, Anal high-grade squamous intraepithelial lesions (precursor), Localised anal squamous cell carcinoma (stage I to III), Metastatic and recurrent anal squamous cell carcinoma, Low-grade appendiceal mucinous neoplasm and pseudomyxoma peritonei, Appendiceal adenocarcinoma (mucinous and non-mucinous, including signet ring cell), Goblet cell adenocarcinoma of the appendix, Localised small bowel adenocarcinoma (stage I to III, resected), Advanced and metastatic small bowel adenocarcinoma
Nothing recorded yet.
Nothing recorded yet.
Also on OnCo: Symptoms and red flags · Early detection roadmap.
Segmental resection with en bloc lymphadenectomy; pancreatoduodenectomy for duodenal tumours not amenable to segmental resection.
Fluoropyrimidine with oxaliplatin (CAPOX or FOLFOX) for six months, extrapolated from colon cancer; BALLAD is the randomised test.
Pembrolizumab first line (tumour-agnostic approval; ZEBRA and KEYNOTE-158 cohorts).
CAPOX or FOLFOX first line; taxane- or irinotecan-based second line; HER2-directed therapy in trials; clinical trial enrolment encouraged.
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Query for this cancer: (TITLE:"Small intestine cancer" OR ABSTRACT:"Small intestine cancer" OR TITLE:"small bowel adenocarcinoma" OR ABSTRACT:"small bowel adenocarcinoma" OR TITLE:"Small bowel adenocarcinoma" OR ABSTRACT:"Small bowel adenocarcinoma" OR TITLE:"Duodenal cancer" OR ABSTRACT:"Duodenal cancer" OR TITLE:"Jejunal and ileal cancer" OR ABSTRACT:"Jejunal and ileal cancer" OR TITLE:"SBA" OR ABSTRACT:"SBA") AND (treatment OR therapy OR trial OR survival OR diagnosis). Results are unfiltered search hits about Small intestine cancer (small bowel adenocarcinoma), not a curated reading list.
Hamburger's case report.
Registry analyses show the distinct site distribution and association with Crohn's, coeliac and FAP.
Schrock and colleagues (JAMA Oncol 2017) later show SBA is genomically distinct from colorectal and gastric cancer, with frequent dMMR and ERBB2 alterations.
First randomised trial in resected small bowel adenocarcinoma (NCT02502370).
Small bowel adenocarcinoma is one of the eligible tumours.
The targets of this cancer's medicines and the ones linked to it directly.
Cases by country, the UK and NHS pathway and other country lenses, the expert centres with trials on record, and the centres named on this cancer's subtypes.
One section per setting: the options named, what each is for, the trials behind them, the recorded trade-offs and the questions to ask.
Bleeding that does not stop by itself, bleeding from more than one site, or new bruising in several places or one large area.
Persistent headache with extreme tiredness, nausea, dizziness on standing or low blood pressure. Vomiting, severe weakness or collapse is adrenal crisis.
No pharmacokinetic interactions expected (antibody). See the irAE guide for toxicity management.
The bowel cancer regimens share low blood counts, tiredness, sickness and a sore mouth. Oxaliplatin adds cold-triggered tingling, irinotecan adds early and late diarrhoea, capecitabine adds hand-foot syndrome and needs a DPD test first, and cetuximab or panitumumab add an acne-like rash and low magnesium. The rule for all of them: ring the 24-hour number rather than wait.
Eyebrows and eyelashes usually fall later than scalp hair and come back later, and their absence is felt more than people expect, because they frame the face and keep dust and sweat out of the eyes.
Taxane and anthracycline chemotherapy for triple-negative breast cancer causes hair loss in most people, usually starting after the first or second cycle and almost always growing back; scalp cooling kept more than half the hair in about half of women in a randomised trial and is offered in many UK units.
See all on the product pages:CAPOX (capecitabine, oxaliplatin)FOLFIRI (5-FU, leucovorin, irinotecan)FOLFOX (5-FU, leucovorin, oxaliplatin)Paclitaxel / nab-paclitaxelPembrolizumab·Printable cards in the navigator
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Everything in development, the medicines held by this cancer's subtypes, the open problems and what is being done about them, the roadmaps, and what changed on this record.
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