Esophageal/gastric Cancer

Question 1

Esophageal Cancer

general

types

Answer 1

♂>♀
↑ risk with age; 6th and 7th decade of life

Types:
Squamous cell carcinoma (SCC)
Most common type worldwide
Blacks/Asians > Whites

Adenocarcinoma
Most common type in the United States
Accounts for 2/3 of esophageal carcinoma cases
Increasing incidence
Whites > Blacks

Metastatic cancer
Constitutes 3% of esophageal cancer
Melanoma and breast cancer are the most likely to metastasize

Question 2

esophageal cancer

S/Sx

Answer 2

Asymptomatic in the early stage
Dysphagia
Occurs when constriction of the esophageal lumen is < 13 mm
Progressive problem: solid food → semisolid food → liquids and/or saliva
Odynophagia
Weight loss
Present in almost all cases despite good appetite
Chest pain
Pressure or burning pain that radiates to the back
GI bleeding
Vocal cord paralysis and hoarseness
Compression of the recurrent laryngeal nerve
Dyspnea
Malignant pleural effusions or pulmonary metastasis

Question 3

Squamous Cell Carcinoma of the Esophagus

General
Early vs advanced lesion

Answer 3

Most common malignant tumor in the proximal 2/3 of the esophagus

Early lesion: friable tissue, erythema, and erosions
Advanced lesion: infiltrating or ulcerated mass, may be circumferential

Question 4

Squamous Cell Carcinoma of the Esophagus

RF

Answer 4

Risk factors:
Alcohol
Tobacco use (in any form)
HPV infection

Question 5

Adenocarcinoma of the Esophagus

general

Answer 5

Most common malignant tumor in the distal 1/3 of the esophagus
Most often arises from Barrett esophagus – a condition brought on by chronic gastrointestinal reflux disease and reflux esophagitis
Early lesion: mucosal irregularities, ulcer, or nodule
Advanced lesion: ulcerated or exophytic mass with obstruction

Question 6

Adenocarcinoma of the Esophagus

RF

Answer 6

Tobacco use (in any form)
GERD
Obesity (central fat distribution)

Question 7

Esophageal cancer

Question 8

esophageal cancer

Dx

Answer 8

Endoscopy with brush cytology and biopsy
Identified cancer

CT of the chest and abdomen
Determine the extent of tumor spread

Endoscopic ultrasound (EUS) of the esophagus
Determine the depth of the tumor in the esophageal wall and regional lymph node involvement

Basic blood tests: CBC with differential, electrolytes, and liver function

Question 9

Esophageal cancer

Tx

Answer 9

Treatment depends on tumor staging, size, and location

TNM classification
Staging is 0-IV

Surgical resection, often combined with chemotherapy and radiation

Immunotherapy plus chemotherapy for advanced cancers

Question 10

Locoregional esophageal cancer staging

Answer 10

Locoregional esophageal cancer staging:
The cancer is seen as the lesion penetrating the esophageal wall
Staging from T1 (mucosa and submucosa) to advanced disease, involving adjacent structures in T4 and the lymph nodes (N)

Question 11

Esophageal cancer

Prognosis

Answer 11

Depends on the stage of the tumor
Overall survival is poor due to patients presenting with advanced disease
Cancer restricted to the mucosa → 80% survival rate
Cancer with submucosal involvement → < 50% survival rate
Cancer with extension to the muscularis → ~20% survival rate
5-year survival: < 5%

Question 12

Esophageal cancer

Prevention

Answer 12

Making healthy choices is the best prevention

Question 13

Question 14

Gastric metaplasia

general

Answer 14

Precancerous change characterized by histologic change from normal gastric cardia, fundic, and antral mucosa to epithelium that resembles the small intestine

Occurs due to chronic irritation and inflammation of the stomach lining caused by various factors such as gastric acid, bile salts, H. pylori infection, smoking, alcohol, and environmental contaminants

Increased risk of dysplasia → stomach cancer

Question 15

What would be 1st on your differential?

Answer 15

GERD

Question 16

Gastric Cancer/ Stomach Cancer

general

Answer 16

♂ > ♀
Increases with age
>75% of patients are >50 years of age
Incidence has declined in the United States in recent decades
Extremely high incidence in Eastern Asia (Japan, China), Eastern Europe,and South America

Question 17

gastric cancer`

types

Answer 17

Gastric adenocarcinoma – columnar glandular epithelium
Accounts for 85% of gastric cancers
Gastric lymphomas - lymphocytes
Leiomyosarcoma – smooth muscle cells
Carcinoid tumor – G cells

Question 18

gastric cancer

RF

Answer 18

Helicobacter pylori infection
Autoimmune atrophic gastritis (pernicious anemia gastritis)
Smoking
Alcohol
Obesity
Family history of gastric cancer
Mutation of the cadherin 1 gene (CDH1) – autosomal dominant trait

Dietary factors
Association between the consumption of processed meat and stomach cancer (nitrates)

Question 19

Question 20

Adenocarcinoma gastric cancer

Intestinal

Answer 20

Intestinal
Most common type
Caused by H. pylori (bacterium causes damage to epithelial cells = chronic gastritis)
Cells change to resemble intestinal epithelium rather than stomach epithelium (metaplasia)

Question 21

adenocarcinoma gastric cancer

Diffuse

Answer 21

Diffuse
Most aggressive type
Related to the genetic mutation in the CDH-1 gene (tumor suppressor gene) that codes for a membrane adhesion molecule called E-cadherin
E-cadherin is not working properly, cells detach and starts dividing uncontrollably

Question 22

Gastric adenocarcinoma

Question 23

gastric cancer

S/Sx

initial / later

Answer 23

Asymptomatic is the early stages when the cancer is most treatable

Initial symptoms are nonspecific
Dyspepsia
Nausea

Later symptoms
Early satiety
Dysphagia – esophagogastric and cardiac tumors
Vomiting
Weight loss
Hematemesis or melena

Question 24

gastric cancer

Metastatic disease

Answer 24

Metastasis to the liver, peritoneum, lungs, and bones
Occasionally are the first symptoms
Jaundice, ascites, or fractures

Question 25

Gastric cancer

Dx imaging

Answer 25

Endoscopy with biopsy and brush cytology
Positive biopsy
CT scan of the chest, abdomen, and pelvis
Determine the extent of tumor spread (metastatic disease)

Negative CT scan
Endoscopic ultrasound
Determine tumor depth and regional lymph node involvement

Question 26

Gastric cancer

Dx labs

Answer 26

CBC, CMP, CA 19-9 (carbohydrate antigen 19-9), and CEA (carcinoembryonic) level before and after surgical treatment

Question 27

Gastric cancer

staging

Answer 27

TMN staging
Staging 0-4

Question 28

gastric cancer

prognosis

Answer 28

Prognosis depends on the stage and location of the tumor

Most patients present with advanced disease

Overall survival is poor
5-years: < 5-15%

Tumor in the mucosa or submucosa
5-year survival up to 80%

Question 29

gastric cacner

Tx monitoring

Answer 29

Determined by the tumor staging

Curative surgical resection
Performed for patients with disease limited to the stomach and regional lymph nodes
Removal of most or all of the stomach (gastrectomy) and adjacent lymph nodes

Adjuvant chemotherapy or chemotherapy and radiation

Monitor CEA levels
Rise signifies recurrence

Question 30

Answer 30

Distal gastrectomy with Bilroth II reconstruction, performed for cancers of the lower stomach

Question 31

Answer 31

Subtotal gastrectomy with Roux-en-Y reconstruction, performed for cancers of the upper or middle stomach

Question 32

Post-gastrectomy Complications

Answer 32

Small intestinal bacterial overgrowth (SIBO)
Bacterial growth in the small intestine increases

Dumping syndrome
Rapid gastric emptying due to bypass of the pyloric sphincter

Gastric stasis
Slow gastric transit due to vagal denervation and small stomach remnant

Reducedironabsorption → anemia
Reduced B12absorption(nointrinsic factor) → B12deficiency
Reducedcalciumabsorption → osteoporosis