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Flashcards in GI neoplasms Deck (77):
1

Esophageal Tumors
1. Benign?
2. Malignant?

1. Benign
Leiomyoma

2. Malignant
Esophageal carcinoma

2

Esophageal carcinomas
Squamous cell carcinoma
1. More prevalent where?
2. Risk factors? 5

1. More prevalent worldwide
2. Risk factors:
-long-standing esophagitis,
-achalasia,
-smoking,
-alcohol,
-diet

3

Esophageal carcinomas
Adenocarcinoma
1. More common where?
2. Occurs in what disease?
3. What part of the esophagus?

Adenocarcinoma
1. More common in USA
2. Occurs in Barrett’s esophagus
3. More in distal 1/3

4

Cancer of the Esophagus
Symptoms?
7

1. Progressive dysphagia
2. Odynophagia
3. Regurgitation
4. Heartburn
5. Anorexia
6. Vomiting
7. Weight loss

5

Diagnosis of esophageal cancer?
4

1. UGI/barium swallow
2. Endoscopic ultrasound
3. EGD…tissue is the issue
4. CT for staging and r/o mets

6

Treatment for esophageal cancer?
3

1. Chemo (preop and post-op protocols)
2. Radiation (post-op)
3. Surgery (best cure)

Combined Modality Treatment leads to the best outcome

7

Benign stomach tumors?
1. Polyps?
2. Tumors? 2

1. Polyps
-Hyperplastic

2. Tumors
-Leiomyomas (smooth muscle)
-Lipomas

8

Malignant stomach cancers
1. Tumors? 4

1. Carcinoma (epithelial cell origin)
2. Lymphoma (lymphatic system)
3. Sarcoma (connective tissue tumor)
4. Carcinoid (serotonin secreting)

9

Gastric Polyps: Neoplastic polyps?
1. Types? 2
2. Macroscopic appearance more often where?
3. What do they look like? 4
4. Treatment?

1.
-Tubular
-Villous (often larger …> 2cm and malignant)
2. More often in antrum
3.
-Pedunculated with malignant potential
-Solitary,
-large
-ulcerated

4. Treatment
-Endoscopic removal if no malignancy identified… the periodic surveillance

10

Gastric Leiomyoma: Pathology?
1. Arise from where?
2. What is it difficult to distinguish from?
3. More benign or malignant?
4. Differentiatied how?
5. What do they look like?

1. Arise from smooth muscle of the GI tract
2. Difficult to distinguish from
Gastrointestinal stromal tumor
3 75% benign
4Differentiation only on mitotic index
5. Large protruding lesions with central ulcer

11

1. Gastric Leiomyoma
usually present how?

2. Treatment?

1. Usually presents with bleeding if at all

2. Treatment is local excision with 2 – 3cm margin

12

Adenocarcinoma of the Stomach
1. What bug is associated with this and why?

2. Also related to what? 4

1. HP associated due to chronic atrophic gastritis

2. Also related to
-Low dietary intake vegetables and fruit
-High dietary intake of starches
-More common in males ( 3 : 1 )
-Increased incidence with pernicious anemia and blood group A

13

Adenocarcinoma of the Stomach
Histological typing? 4

1. Ulcerated carcinoma (25%)

2. Polipoid carcinoma (25%)

3. Superficial spreading carcinomas (15%)

4. Linitis plastica (aka Brinton’s disease or leather bottle stomach) (10%)

14

1. Ulcerated carcinoma (25%) looks like what?
-Usually through what layers of the stomach?

2. Polipoid carcinoma (25%) look likw what?
-Metastasis?

3. Superficial spreading carcinomas (15%) are confined to where?
-Prognosis?

4. Linitis plastica (aka Brinton’s disease or leather bottle stomach) (10%) involves what layers of the stomach and what is the prognosis?
-what kind of appearance on XRAY?

1. Deep penetrated ulcer with shallow edges
-Usually through all layers of the stomach

2. Intraluminal tumors, large in size
-Late metastasis

3. Confinement to mucosa and sub-mucosa
-Metastasis 30% at time of diagnosis (Best prognosis)


4. involves all layers of stomach
(poor prognosis)
-“leather-bottle” appearance on X-ray



15

1. Adenocarcinoma of the Stomach
signs and symptoms? 3

2. At late stages? 3

1.
-Vague discomfort difficult to distinguish from dyspepsia
-Anorexia
-Pronounced weight loss

2. At late stage
-Epigastric mass
-Hematemesis usually coffee ground
-Metastasis...Virchow’s node (L supraclavicular)

16

What kind of anorexia is specific to adenocarcinoma?

Meat aversion

17

Spread of Gastric Carcinoma

4

1. Local infiltration (through wall of stomach to peritoneum, pancreas etc)
2. Lymphatic – local and regional lymph nodes
3. Blood – liver, lungs
4. Transcoelomic (across peritoneal cavity).

18

Transcoelomic (across peritoneal cavity) often involves what?

1. Often involves ovaries (esp. signet ring cancer) – Krukenberg tumour (ovarian tumor that metastasized from a primary site…colon or stomach

19

Diagnosis of Gastric Cancer
5

1. Anemia in 40%
2. Elevated CEA in 65%
3. UGI
4. Endoscopy…..tissue is the issue
5. CT scans for metastatic work up

20

Adenocarcinoma of the Stomach
1. Whats the only cure?
2. Prognosis? 2
3. What offers little benefot for treatment?

1. Surgical resection only cure
2.
-Prognosis overall…. 12% 5 year survival
-90% for stage I disease
3. Radiation and chemo offer little benefit

21

Adenocarcinoma of the Stomach
1. What often makes surgery futile?
2. Palliation controversial for what? 2

1. Late presentation makes surgery often futile

2.
-Hemorrhage
-Gastric outlet obstruction

22

Less Common Gastric Neoplasms
3

1. Lymphoma
2. Gastrointestinal stromal tumour (GIST)
3. Neuroendocrine (carcinoid) tumours

23

Gastric Lymphoma
1. Whats the lymphoma called?
2. treatment?

1. (MALT…mucosa associated lymphoid tissue)

2. Treatment….sensitive to radiation

24

1. Gastrointestinal Stromal Tumors (GIST)?
2. most common site?

1. Mesenchymal neoplasms

2. Stomach most common site

25

Neuroendocrine Tumors
1. What are the tumors of resident neuroendocrine cells in gastric glands?

carcinoids

26

Gastric Sarcoma
Includes a variety of tumors such as? 3

1. Leiomyosarcoma
2. Leiomyoblastoma
3. GIST

27

Pathophysiology of Pancreatic Cancer
1. Arises from where?
2. Tumor usually discovered when?
3. Describe its progression?
4. Whats the most common site for it on the pancreas?

1. Usually arises from epithelial cells of the pancreatic ducts

2. Tumor typcially discovered in late stages so has spread throughout pancreas

3. Rapid growing with spread to surrounding tissue

4. Most common site is head of pancreas

28

Signs and Symptoms of pancreatic cancer
10

1. Vague, dull, abdominal pain
2. “Painless jaundice”
3. Weigh loss, weakness
4. Anorexia, nausea, vomiting
5. Glucose intolerance
6. Flatulence
7. GI bleeding
8. Ascites
9. Leg/calf pain
10. Jaundice (if head of pancreas involved)
-Clay colored stools
-Dark urine

29

Diagnostics of pancreatic cancer?4

1. No specific blood tests to diagnose
2. Elevated amylase, lipase, alkaline phosphatase, bilirubin, CEA (carcinoembryonic antigen) C19-9
3. CT, Ultrasonography
4. ERCP – most definitive diagnostic test

30

Clinical Management of pancreatic cancer?
5

1. Goal is to prevent spread of tumor
2. Chemotherapy or radiation
3. Pain control (opioids)
4. Distal resection
5. Whipple procedure

31

1. What is the whipple procedure?
2. Used for what only?

1. Radical pancreaticoduodenectomy
-Excision or all or part of the pancreas together with the duodenum and usually the distal stomach


2. Used for cancer of the pancreas head only

32

1. What is Zollinger-Ellison Syndrome?
2. What is hypergastrinemia and what does it lead to?

1. “Islet cell” tumor of the pancreas [or of the duodenum] →Gastrinoma
2. Hypergastrinemia (excess levels of serum gastrin) →
Gastric acid hypersecretion

33

Zollinger-Ellison Syndrome:
1. Gastric acid hypersecretion leads to what? 3

1. Consequences of acid hypersecretion:
2. PUD, GERD [ with or without complications]
3. Diarrhea, malabsorption*******

34

Symptoms in patients with the Zollinger-Ellison syndrome: Presentation from most common to least common?
5

1. Pain and diarrhea 50-60%
2. Pain without diarrhea 25%
3. Diarrhea without pain 20%
4. Heartburn ± dysphagia 30%
5. Multiple Endocrine Neoplasia-1 features 20-25%

35

Diagnosis of ZE Syndrome

2

Begins with clinical suspicion

Fasting serum gastrin measurement
-high sensitivity (> 95%)
-poor specificity, even at high levels

36

1. Management of ZE syndrome?
2. Prognosis?
3. Tumor search is used for what and what do we use?
4. Tumor search and possible resection for cure is only prudent for patients who are what?

1. Acid control (PPIs) takes precedence over tumor search
2. Prognosis is excellent in patients w/o metastatic disease
3. Tumor search is designed to find tumor and to stage its/their extent…CT Scan
4. surgical candidates

37

1. What is the most common form of liver cancer and it comes from the main type of liver cell, the hepatocyte?

2. Cholangiocarcinoma starts where and is carried where?

1. Hepatocellular carcinoma

2. starts in the small bile ducts that carry bile to the gallbladder.

38

Liver Cancer…..causes?
4

1. Chronic infection with hepatitis B (HBV) and hepatitis C (HCV)

2. Cirrhosis (scar tissues in liver) due to alcohol, hepatitis

3. Tobacco use.

4. Aflatoxins from a fungus that can contaminate peanuts, wheat, soybeans, groundnuts, corn, and rice.

39

Can cancer of the liver be prevented?
1. Hep B is found where?
2. It can be transmitted through what?

1. Hepatitis B transmission:
Hepatitis B is found in body fluids including blood, saliva, semen, mucus, vaginal fluid, and breast milk.
2. It can be transmitted through sexual activity, sharing injecting equipment, toothbrushes, or razors.
It can be transmitted from mother to child at birth.

40

WAYS TO REDUCE HEPATITIS B TRANSMISSION:?
4

1. Wash hands after touching blood or body fluids.
2. Avoid sharing personal hygiene items that may come into contact with body fluids.
3. Cover all cuts and open sores with bandage.
4. Practice safe sex.

41

Preventing liver cancer
2

1. Hepatitis B vaccination
For all children.
For adults at high risk.
2. Avoid alcohol abuse.

42

1. Hep C is generally transmitted how?

2. Different ways?
5

1. Hepatitis C is transmitted by blood to blood contact only.
2.
-Transmission can occur through sharing of needles, unsterile tattooing, body piercing.
-Sharing razor blades and toothbrushes.
-Certain sexual activities.
-Mother to baby.
-No vaccine

43

Symptoms of liver carcinoma
4

1. Loss of appetite and weight
2. Jaundice
3. Swelling of the abdomen
4. Pain in the abdomen.

44

Liver Cancer….diagnosis
Labs?
3

1. LFTs
2. AFP (alpha fetoprotein) blood test (tumor marker to help detect and diagnose cancers of the liver, testicles and ovaries.)
3. Blood tests for Hepatitis B and C.

45

Imaging and procedures for Liver Cancer?
5

1. Ultrasound of the liver.
2. CT scan or MRI scan of liver.
3. Biopsy
4. Angiogram of the liver.
5. Laparoscopy.

46

Liver Cancer Staging:
Describe stages I-IV?

Stage I – Single small tumor less than 2 cm.

Stage II – Single large tumor or many small tumors confined to one lobe of the liver.

Stage III – Many large tumors confined to one lobe of the liver or cancer spread to lymph nodes

Stage IV – Cancer spread to both lobes of the liver.

47

Liver Cancer Treatment: Surgery
4

SURGERY:
-Curative intent in Stages I, II
-Liver wedge resection
-Liver lobectomy
-Liver transplantation

48

Liver Cancer Treatment: Chemotherapy
1. Drugs are given how? 2

1. Drugs given by hepatic artery infusion.
2. Drugs given by chemo embolization.

49

Liver Cancer….survival rates
1. Survival rates at 5 years?
-Early localized?
-All stages combined?

Early localized cancer – 30-40%
All stages combined – 10%

50

Small Bowel Cancers (RARE)
Name the top 4 types in order of prevelance?

1. 30-50% are adenocarcinomas***

2. 25-30% are carcinoids

3. 15-20% are lymphomas

4. 10-20% are gastrointestinal stromal tumors

51

Risk Factors for Small Bowel Adenocarcinoma
8

1. Pre-existing adenoma, either single or multiple
2. Crohn’s
3. Celiac disease
4. IgA deficiency
5. Alcohol abuse
6. Neurofibromatosis
7. Urinary diversion procedures
8. Red meat

52

Clinical Presentation of Small Bowel CA
6

1. Abdominal pain
2. Nausea and vomiting
3. Bleeding/Anemia
4. Weight loss
5. Gastric outlet obstruction
6. Diarrhea

53

Diagnosis of Small Bowel Malignancies
4

1. UGI/SBFT
2. Single contrast flouroscopy
-Mass
-Mucosal defect

3. CT scan as well
4. Capsule endosocopy

54

Prognosis and treatment
of small bowel CA

Pretty good with surgery

55

Colorectal Cancer screenning
1. The vast amjority of colorectal cancers arise from where?

2. The polyps grow from small to larger polyps ultimately accumulating what?

3. Current thought is that this progression probably takes at least how long in most people?

1. adenomatous polyps.

2. accumulating increasing dysplastic characteristics.
--Dysplasia means neoplastic (tumor like) changes.

3. 10 years in most people.

56

Adenoma Carcinoma Sequence
1. Some cancers unfortunately also arise from flat adenomas (i.e. they are not polypoid).
The two main types of colorectal polyps are either what two things?

2. What is required for diagnosis?

3. Two-thirds of polyps are what?

1. adenomas or hyperplastic polyps. These lesions cannot be distinguished reliably on gross appearance;

2. biopsy is required for diagnosis.

3. adenomas

57

Adenoma Carcinoma Sequence
1. The ______ the polyp, the more likely is progression to cancer.

2. Hyperplastic polyps account for most of the remaining polyps and are mainly ______. They are generally thought not to progress to cancer, although some may.

1. larger

2. distal

58

Why is this important?
1. If you remove the polyps when they are smaller, they cannot do what?
2. Colonoscopy drastically decreases the risk of colorectal cancer (well over ___%).

1. grow into cancer.

2. 90

59

Screening tests for colon cancer?

1. Fecal occult blood tests (FOBT & FIT).
2. Flexible sigmoidoscopy.
3. Colonoscopy.

60

Flexible sigmoidoscpoy
1. This test involves which part of the colon?
2. This has largely been replaced by what?

1. This test involves inspecting only the last third of the colon.
2. This has largely been replaced by complete colonoscopy.

61

Why colonoscopy has become the screening test of choice
4

1. It looks at the entire colon.
2. If a polyp is found, it can be removed through the scope and sent to pathology to determine the type of polyp and to rule out cancer.
3. Other abnormalities of the colon can be identified.
4. When polyps are removed, they cannot grow into cancer.

62

1. Describe colon cancer histology?
2. Usually begins as a what?

1. A disease in which normal cells in the lining of the colon or rectum begin to change, grow without control, and no longer die

2. noncancerous polyp

63

Risk Factors
for Colorectal Cancer
7

1. Polyps (a noncancerous or precancerous growth associated with aging)
2. Age
3. Inflammatory bowel disease (IBD)
4. Diet high in saturated fats, such as red meat
5. Personal or family history of cancer
6. Obesity
7. Smoking

64

1. Hereditary Colorectal Cancer Syndromes: HNPCC aka?
2. The risk of colorectal cancer in families with HNPCC is _______, which is several times the risk of the general population
3. People with HNPCC are diagnosed with colorectal cancer at an average age of ___?

1. Lynch syndrome
2. 70% to 90%
3. 45

65

Hereditary Colorectal Cancer Syndromes: FAP
1. People with FAP typically develop how many colon polyps (small growths)?
2. the polyps are initially what, but there is nearly a 100% chance that the polyps will develop into cancer if left untreated

3. Colorectal cancer usually occurs by age __ in people with FAP

1. hundreds to thousands

2. benign (noncancerous)

3. 40

66

Symptoms
of colon cancer?
3

1. A change in bowel habits: diarrhea, constipation, or a feeling that the bowel does not empty completely

2. Bright red or dark blood in the stool

3. Abdominal discomfort

67

How is Colorectal Cancer Evaluated?
1. Diagnosis is confirmed with?
2. Stage of disease is confirmed by what? 4

1. a biopsy

2.
-pathologists and imaging tests,
-(CT) scans….nodes and liver, lung involvement
-Endoscopic ultrasound and
-magnetic resonance imaging (MRI) may also be used to stage rectal cancer

68

Cancer Treatment:
-Foundation of curative therapy?

Surgery:
-The tumor, along with the adjacent healthy colon or rectum and lymph nodes, is typically removed to offer the best chance for cure

May also use chemo and or radiation

69

New Therapies: Antiangiogenesis Therapy
1. How is this done?
2. Given along side what?

1. “Starves” the tumor by disrupting its blood supply

2. This therapy is given along with chemotherapy

Bevacizumab (Avastin) was approved by the U.S. Food and Drug Administration (FDA) in 2004 for the treatment of stage IV colorectal cancer

70

Staging is described by the TNM system describe this?

the size (the depth of penetration of the Tumor into the wall of the bowel),

whether cancer has spread to nearby lymph Nodes, and

whether the cancer has Metastasized

71

Stage I Colorectal Cancer
Describe stage I?

Treatment?

The cancer has grown through the mucosa and invaded the muscularis (muscular coat)

Treatment is surgery to remove the tumor and some surrounding lymph nodes

72

Stage II Colorectal Cancer
Describe?

Treatment?

The cancer has grown beyond the muscularis of the colon or rectum but has not spread to the lymph nodes

Stage II colon cancer is treated with surgery and, in some cases, chemotherapy after surgery

73

Describe Stage III ?


Treatment?

The cancer has spread to the regional lymph nodes (lymph nodes near the colon and rectum)

Stage III colon cancer is treated with surgery and chemotherapy

74

Describe stage IV and treatment?

The cancer has spread outside of the colon or rectum to other areas of the body


Stage IV cancer is treated with chemotherapy. Surgery to remove the colon or rectal tumor may or may not be done

75

Follow-Up Care
for colon cancer?
3

1. Serial carcinoembryonic antigen (CEA) measurements are recommended
2. Colonoscopy one year after resection of colorectal cancer
3. Surveillance colonoscopy every three to five years to identify new polyps and/or cancers

76

Colon vs. Rectal

5

1. Rectal better prognosis
2. Rx not beneficial for colon
3. DRE/Hemoccult
4. CEA
5. Surgery

77

Anal Cancer
1. Most common kind?
2. Symtpoms? 2
3. Risk associations? 2
4. Treatment? 3
5. Survival?

1. SCC
2.
-Bowel changes
-Bleeding

3.
-HPV association (major cause)
-smokers/HIV

4. Treatment….often effective/cured
--Surgery, Radiation, Chemo

5. Survival….better than CRC
5 year 65.7% overall...for localized dz with early dx 80%