Esophageal, gastric, pancreatic cancers

Question 1

The highest rates of esophageal cancer are in

Answer 1

East Asia, East Africa

Primarily squamous cell carcinoma in this area

Question 2

Over the last several decades there has been a shift from mostly _____ esophageal cancer to mostly ______ esophageal cancer in the US

Answer 2

squamous cell carcinoma—-> adenocarcinoma

Question 3

List risk factors for squamous cell esophageal cancer

Answer 3

Male gender
age
African American
smoking
lye
pickled foods

Question 4

Explain the field cancerization effect

Answer 4

Higher rates of squamous cell carcinoma when tobacco and alcohol are used together

Question 5

Explain risk factors for esophageal adenocarcinoma

Answer 5

Arises from Barrett’s esophagus, associated with GERD and obesity

Question 6

______ has been shown to be a risk factor for esophageal adenocarcinoma independent of Barrett’s esophagus

Answer 6

obesity

Question 7

Describe the approach to a patient with Barrett’s esophagus to prevent cancer

Answer 7

Acid suppression
weight loss
frequent follow up

Question 8

What are presenting symptoms of esophageal cancer?

Answer 8

dysphagia
weight loss
bleeding, melenic stools

Question 9

Describe the diagnostic workup of esophageal cancer

Answer 9

Endoscope exam with dilation of strictures, biopsy
endoscopic ultrasound
CT/PET to look for metastasis

Question 10

Describe the management of localized esophageal cancer

Answer 10

1. neoadjuvant chemotherapy and radiation
2. surgery- esophagectomy with gastric pull up
   - patients can never lie flat again
   - will experience weight loss, early satiety

Question 11

Describe management of metastatic esophageal cancer

Answer 11

chemotherapy prolongs life (from 4 to 10 months)

palliative radiotherapy for persistent dysphagia- improves symptoms but not survival

Question 12

Most gastric cancers are ______ (histologic type)

Answer 12

adenocarcinoma

Question 13

In what geographic area is the prevalence of gastric cancer greatest?

Answer 13

East Asia

Question 14

What factors are associated with the lower incidence of gastric cancer in the US?

Answer 14

Changes in dietary habits, recognition and treatment of H. Pylori, and better food preparation/preservation

Question 15

What are risk factors for gastric cancer

Answer 15

H pylori
Diet high in nitrates, salt
inadequately preserved foods

Question 16

Describe the two types of gastric cancer

Answer 16

Intestinal: More mass-like, intraluminal, prone to bleeding; Higher association with H.pylori

Diffuse: Often submucosal; Presenting complaint of early satiety; More often presenting in late stage; Thought to be more aggressive

Question 17

_______ arises from a mutation in CDH1 which inactivates e-cadherin

Answer 17

hereditary diffuse gastric cancer

Question 18

Describe the presentation of gastric cancer

Answer 18

Long asymptomatic period

nausea, bloating, unexplained weight loss, early satiety

Question 19

_______ is the gold standard for diagnosis of gastric cancer

Answer 19

upper endoscopy (EGD) with tissue biopsy

Question 20

Staging is critical in gastric cancer, because it frequently presents with ______ early in its course

Answer 20

metastasis

CT/PET analysis

Question 21

Describe management of localized gastric cancer

Answer 21

• surgery: partial gastrectomy or total gastrectomy including D1 or D2 node harvest
• neo-adjuvant chemotherapy then post-op adjuvant chemotherapy or radiation

Question 22

Describe the management of metastatic gastric cancer

Answer 22

palliative chemotherapy

mOS measured in months

Question 23

Describe the benefits of pre-operative chemotherapy

Answer 23

• provides some degree of tumor shrinkage

- test of time for metastases to develop to avoid futile surgery

Question 24

List chemotherapeutic agents used in metastatic gastric or esophageal cancers

Answer 24

5-FU, taxanes, platinums, irinotecan

targeted therapy: Her-2, ramucirumab (anti-VEGF)

Question 25

List risk factors for pancreatic cancer

Answer 25

smoking | obesity and diabetes (but pancreatic cancer often presents with new onset glucose intolerance)

Question 26

List familial syndromes associated with pancreatic cancer

Answer 26

(HNPCC and FAP, BRCA2, cystic fibrosis, familial atypical mole-melanoma syndrome

Question 27

List presenting signs and symptoms of pancreatic cancer

Answer 27

``` jaundice epigastric pain radiating to the back new onset diabetes weight loss, nausea, vomiting palpable gallbladder acholic (clay colored) stool cola colored urine ```

Question 28

Describe the diagnostic work up of pancreatic cancer

Answer 28

ERCP (Endoscopic Retrograde CholangioPancreatography) is used for diagnosis and can also directly sample epithelium Endoscopic ultrasound: assesses local lymph nodes and tissue invasion

Question 29

The most common pancreatic cancer is ________

Answer 29

adenocarcinoma

Question 30

In order to be considered resectable, the tumor must not invade or abut the _________. If it does, then a margin negative resection (so-called R0 resection) cannot be performed

Answer 30

mesenteric arterial supply

Question 31

85% of patients with pancreatic cancer present with ______ disease

Answer 31

advanced, non-resectable cancers due to local invasion or metastatic disease

Question 32

What are the components of a Whipple procedure?

Answer 32

Pancreaticoduodenectomy Gastrojejunostomy Pancreaticojejunostomy Choledochojejuonstomy resection of the head of the pancreas, connecting the stomach to the jejunum, connecting the bile ducts to the small intestine, and reapproximating any remaining pancreatic tissue to the small intestine

Question 33

Pre-operative radiotherapy may be helpful in ______-resectable pancreatic cancers

Answer 33

borderline

Question 34

Neoadjuvant therapy in pancreatic cancer is used to:

Answer 34

- make operation easier and improve chances of R0 resection | - avoid potentially futile surgeries

Question 35

What are chemotherapy options for metastatic pancreatic cancer?

Answer 35

- gemcitabine, with possible improvement when gemcitabine + abraxane - FOLFIRINOX: 5-FU, oxaliplatin, irinotecan

Question 36

Patients with any GI cancer are at increased risk of thrombotic complications including ___________

Answer 36

pulmonary embolism and DVT

Question 37

What is Trousseau's syndrome

Answer 37

Migratory thrombophlebitis which can progress to DVT/PE