Auto Text: “Insert Small Bowel Tumor”

The most common histologic types of malignant tumors of the small intestine are Adenocarcinoma (45%), Carcinoid (29%), Lymphoma (16%), Sarcoma (10%). Certain subtypes have a predilection for specific regions. Adenocarcinoma is the most common malignancy affecting the proximal small intestine, while carcinoid is the most common tumor in the ileum. Sarcoma and lymphoma develop throughout the small intestine, but are most prevalent in the distal small bowel.

Triage

1. Identify (if possible) the portions of bowel resected
2. Palpate for tumor and ink the serosa adjacent to tumor
3. Ink the entire mesenteric margin (cauterized, roughened surface)
4. Open longitudinally along the anti-mesenteric border, unless this would mean cutting through the tumor
5. Take the following measurements:
   • length of the intestinal segment
   • circumference at the proximal and distal resection margins
   • narrowest circumference at the tumor site
   • maximal tumor size in three dimensions
   • distance of the tumor from the 1.) mesenteric margin, 2.) nearest tubular margin
6. Photograph
7. Pin out on wax and fix in formalin overnight

Gross

1. Obtain the following sections:
2. Margins:
   1. Mesenteric margin: representative shaved section in the area closest to the tumor, submitted en face
   2. Nearest Margin: If the tumor is within 2.0 cm of the nearest margin: ink the margin a different color, remove the proximal 2 cm of margin (with lesion and margin), section perpendicularly to the margin, and submit entirely (or showing closest approach to margin). If there is remaining margin grossly >2.0 cm from lesion, a representative section can be submitted en face. (see diagram)
   3. Farthest Margin: If the tumor is > 2.0 cm from one or both margins: submit either a) circumferential margin (if small diameter), b) a representative en face section, or c) a representative perpendicular section. (see diagram)
   4. Serially section tumor and measure depth of invasion into wall and distance from inked serosa
   5. Photograph cut surface at deepest point of invasion
   6. Take at least three sections of the tumor, to include the maximal depth of invasion and representative section of uninvolved small bowel
   7. Section any additional lesions
   8. Submit as many lymph nodes as you can find