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Flashcards in GI neoplasms Deck (73):
1

benign and malignant tumors of the esophagus?

- benign: leiomyoma
- malignant: esophageal carcinoma

2

Esophageal carcinomas?

- SCC: more prevalent worldwide, RFs: long standing esophagitis, achalasia, smoking, ETOH, diet
- adenocarcinoma: more common in USA, occurs in barrett's esophagus, more in distal 1/3

3

Mortality rate, prevalence of esophageal cancer?

- high mortality rate
- relatively rare - 1% of malignancies
- increased prevalence in N China, India, and Iran
- higher incidence in men
- 50-80 yrs old
- bad actor and presents late

4

Sx of esophageal cancer?

- progressive dysphagia
- odynophagia
- regurgitation
- heartburn
- anorexia
- vomiting
- wt loss

5

Dx imaging of esophageal cancer?

- UGI/barium swallow
- endoscopic US
- EGD: tissue is the issue
* GOLD standard
- CT for staging and r/o mets

6

Why is an EUS used along with an endoscopy in dx esophageal cancer?

- because EUS shows how extensive the tumor is, endoscopy can't show that

7

Tx of esophageal cancer?

- chemo (Preop and post-op protocols)
- radiation (post-op)
- surgery (best cure)
- combined modality tx leads to best outcome

8

What is the hypothesis for why stomach cancer rates are declining?

- popularization of refrigerators marks a pivotal pt for the decline. They have improved storage of food, thereby reducing salt-based preservation and preventing bacterial and fungal contamination. Fridges also allowed for fresh food and veggies to be more readily available, which may be a valuable source of antioxidants impt for cancer prevention
- recognition of role of H. pylori
- high mortality unless disease is detected early
- highest rate in Republican of Korea b/c of salted and pickled foods

9

Benign sources of stomach cancer?

- polyps: hyperplastic
- tumors: leiomyomas (smooth muscle)
- lipomas

10

Malignant sources of stomach cancer?

- carcinoma (epithelial)
- lymphoma (Lymphatic)
- sarcoma (CT)
- carcinoid (serotonin secreting)

11

Gastric polyps - types and macroscopic appearance? Tx?

- types:
tubular
villous (often larger, greater than 2 cm and malignant)

- macroscopic appearance:
more often in antrum
pedunculated with malignant potential
solitary, large and ulcerated

-tx:
endoscopic removal if no malignancy ID - periodic surveillance

12

How common are gastric leiomyomas? Pathology? Tx?

- incidence is 16% at autopsy
- pathology:
arise from smooth muscle of GI tract - difficult to distinguish from GI stromal tumor
- 75% benign: diff only on mitotic index
- large protruding lesions with central ulcer
- usually presents with bleeding if at all
- tx: local excision with 2-3 cm margin

13

Adenocarcinoma of the stomach RFs?

- declining incidence in western world
- HP assoc due to chronic atrophic gastritis

also related to:
- low dietary intake of veggies and fruit
- high dietary intake of starches
- more common in males (3:1)
- increased incidence with pernicious anemia and blood group A

14

Histological typing of adenocarcinoma of the stomach?

- ulcerated carcinoma (25%): deep penetrate ulcer with shallow edges, usually through all layers of the stomach
- polipoid carcinoma (25%): intraluminal tumors, large in size, late mets
- superficial spreading carcinomas (15%): confinement to mucosa and sub-mucosa, mets 30% at time of dx, best prognosis
- linitis plastica (aka Brinton's disease or leather bottle stomach) - 10%
involves all layers of the stomach, poor prognosis, "leather bottle" appearance on xray

15

Signs and sxs of adenocarcinoma of the stomach?

- vague discomfort difficult to distinguish from dyspepsia
- anorexia: meat aversion, pronounced wt loss
- at late stage:
epigastric mass
hematemesis usually coffee ground
- mets: Virchow's node (L supraclavicular)

16

How do gastric carcinomas spread?

- local infiltartion (through wall of stomach to peritoneum, pancreas)
- lymphatic: local and regional lymph nodes
- blood: liver and lungs
- transcoelomic (across peritoneal cavity): often involves ovaries (esp signet ring cancer) - krukenberg tumor (ovarian tumor that met from primary site - colon or stomach)

17

Dx of gastric cancer?

- anemia in 40%
- elevated CEA in 65% (not specific)
- UGI
- endoscopy: tissue is the issue
- CT scans for met work up

18

Tx of adenocarcinoma of the stomach?

- surgical resection is the only cure:
late presentation makes surgery often futile
palliation controversial for:
hemorrhage
gastric outlet obstruction
- prognosis overall: 12% 5 yr survival:
90% for stage 1 disease
radiation and chemo offer little benefit

19

Less common gastric neoplasms?

- lymphoma
- gastrointestinal stromal tumor (GIST)
- neuroendocrine (carcinoid) tumors

20

How common are gastric lymphomas? Types? Tx?

- 5% of primary gastric neoplasms
- 2 diff types of lymphoma (MALT: mucosa assoc lymphoid tissue)
- tx: sensitive to radiation

21

Most common site for GIST?

- mesenchymal neoplasms
- stomach is the most common site

22

Neurodendocrine tumors of the stomach?

- carcinoids are tumors of resident neuroendocrine cells in the gastric glands

23

Gasric sacroma - how common, diff types?

- 1-3% of gastric malignancies
- wide variety of tumors:
leiomyosarcoma
leomyoblastoma
GIST

24

Mortality of pancreatic cancer, incidence of it?

- one of leading causes of cancer mortality
- 28000 new cases/year
- incidence increases with age
- rarely b/f 50, usually 60-70
- slightly more in men
- less than 20% live longer than 1 yr

25

Etiology of pancreatic cancer?

- exact cause is unknown
- smokers at high risk
- high fat, high protein, high alcohol diets
- may be genetic

26

PP of pancreatic cancer?

- usually arises from epithelial cells of pancreatic ducts
- tumor typically discovered in late stages so has spread throughout pancreas
- rapid growing with spread to surrounding tissue
- most common site is head of pancreas

27

Signs and sxs of pancreatic cancer?

- vague, dull, abdominal pain
- painless jaundice
- weight loss, weakness
- anorexia, N/V
- glucose intolerance
- flatulence
- GI bleeding
- ascites
- leg/calf pain
- jaundice (if head of pancreas involved)
clay colored stools
dark urine

28

Dx pancreatic cancer?

- no specific blood tests to dx
- elevated amylase, lipase, AP, bili, CEA C19-9
- CT, US
- ERCP - most definitive dx test

29

Clinical management of pancreatic cancer?

- goal is to prevent spread of tumor
- chemo or radiation
- pain control (opioids)
- distal resection
- whipple procedure

30

What is the whipple procedure?

- radical pancreaticoduodenectomy
- used for cancer of the pancreas head only: excision of all or part of the pancreas together with the duodenum and usually distal stomach

31

What is ZES?

- islet cell tumor of pancreas (or duodenum) - gastronome
- hypergastrinemia: secreting excess levels of serum gastrin - consequences of acid hyper secretion - leads to PUD, GERD (w/ or w/o complications), hallmarks: chronic diarrhea, and malabsorption

32

Epidemiology of ZES?

- any age group (mean age: 43)
- male: female 3:2
- occurs in approx 0.1-1% of all pts with duodenal ulcers

33

Sxs in pts with ZES?

- pain and diarrhea (50-60%)
- pain w/o diarrhea (25%)
- diarrhea w/o pain ( 20%)
- heartburn +/- dysphagia (30%)
- MEN-1 features: 20-25%

34

Dx ZES?

- begins with clinical suspicion
- fasting serum gastrin measurement:
high sensitivity: greater than 95%
poor specificity, even at high levels

35

Management of ZES?

- acid control (PPI) takes precedence over tumor search
- prognosis is excellent in pts w/o met disease
- tumor search is designed to find tumor and to stage its/their extent - CT
- tumor search and possible resection for cure is only prudent for pts who are surgical candidates

36

Other types of pancreatic cancers?

- insulinoma
- glucagonoma: very rare

37

Cancer of the liver: most common? Other type?

- HCC is most common form and it comes form main type of liver cell, hepatocyte
- about 3 out of 4 primary liver cancers are HCC
- cholangiocarcinoma starts in small bile ducts that carry bile to the gallbladder
- about 1 or 2 out of 10 cases of liver cance rare cholangiocarcinomas

38

Incidence of liver cancer?

- 35,660 new cases of liver cancer and bile duct cancer in US in 2015
- 24, 550 est deaths in 2016
- it is 2x as common in men as in women
- 14th most common cancer in the US

39

Causes of liver cancer?

- chronic infection with HBV and HCV
- cirrhosis (scar tissue in liver) due to alcohol, hepatitis
- tobacco
- aflatoxins from fungus that can contaminate peanuts, wheat, soybeans, groundnuts, corn and rice

40

How can HBV transmission be prevented? How is it spread?

- Prevent HBV transmission: found in body fluids - blood, saliva, semen, mucus, vaginal fluid, and breast milk, sharing injecting equip, toothbrushes or razors
- it can be transmitted from mother to child at birth
- wash hands after touching blood or bodily fluids
- avoid sharing personal hygiene items that may come into contact with body fluids
- cover all cuts and open sores with bandage
- practice safe sex

- HBV vaccination - for all kids and high risk adults
- avoid alcohol use

41

How is HCV spread?

- by blood to blood contact only
- transmission can occur through sharing needles, unsterile tattooing, body piercings, sharing razor blades and toothbrushes
- certain sexual activities- - mother to baby
- no vaccine

42

Sxs of liver carcinoma?

- loss of appetite and wt
- jaundice
- swelling of the abdomen
- pain in the abdomen

43

Dx liver cancer - labs and imaging

- LFTs: will be elevated
- AFP (alpha fetoprotein) blood test (tumor marker to help detect and dx cancers of the liver, testicles and ovaries)
- blood tests for Hep B and C
- bx
- US
- CT or MRI of liver
- angiogram of liver
- laparoscopy

44

Staging of liver cancer?

- stage 1: single small tumor less than 2 cm
- stage 2: single large tumor or many small tumors confined to one lobe of the liver
- stage 3: many large tumors confined to one lobe of the liver or cancer spread to lymph nodes
- stage 4: cancer spread to both lobes of the liver

45

Tx of liver cancer?

- surgery:
curative intent in stages I, II
- liver wedge resection
- liver lobectomy
- liver tranplantation

- chemo: drugs given by hepatic artery infusion, drugs given by chemo embolization

46

Survival rates of liver cancer?

- at 5 yrs:
early localized cancer: 30-40%
all stages combined: 10%

47

How common are small bowel cancers? How big is the small intestine? Incidence?

- SI accounts for approximately 75% of length of GI tract and more than 90% of mucosal surface
- fewer than 2% of GI malignancies arise in SI
- incidence: 1/100,000
- est to be less than 5000 cases per year dx in US

48

Types of small bowel malignancies?

- 30-50% are adenocarcinomas
- 25-30% are carcinoids
- 15-20% are lymphomas
- 10-20% are gi stromal tumors

49

RFs for small bowel adenocarcinoma?

- pre-existing adenoma, either single or multiple
- crohns
- celiac disease
- IgA deficiency
- alcohol abuse
- neurofibromatosis
- urinary diversion procedures
- red meat

50

Clinical presentation of small bowel CA?

- abdominal pain
- N/V
- bleeding/anemia
- wt loss
- gastric outlet obstruction
- diarrhea

51

Dx small bowel malignancies?

- UGI/SBFT
- single contrast fluoroscopy: mass, mucosal defect
- CT scan
- capsule endoscopy

52

Prognosis and tx of small bowel CA?

- pretty good with surgery!!

53

How common is colorectal cancer?

- common in both sexes
- can be lethal
- 3rd most common cancer and 3rd leading cause of cancer death in both sexes. Up to 1/3 of pts ultimately succumb to this disease
- prognosis improves the earlier the cancer is dx
- commonly a preventable disease - get a colonoscopy

54

Incidence of CRC?

- infrequent b/f age 40
- incidence rises progressively after age 40 to 3.7/1000 per year by age 80
- lifetime incidence for pts at avg risk is 5%
- 90% of all cases occur after age 50

55

Screening for CRC?

- purpose of screening - find cancer at earlier stage to improve survival
- once colonoscopy became readily available, it ultimately became screening method of choice
- colonoscopy drastically decreases the risk of colorectal cancer (over 90%)

56

Adenoma-carcinoma sequence of progression?

- DNA alteration - going to have normal epithelium - but will lead to adenoma and then to late adenoma and then to early cancer and late cancer
- vast majority of colorectal cancers arise from adenomatous polyps
- polyps grow from small to larger polyps ultimately accum. increasing dysplastic characteristics
- current thought is that progression probably takes at least 10 yrs in most people
- prevalence of adenomas is about 25% by age 50 and 50% by age 70

57

Polyps that are harder to ID that can cause cancer? Two main types of colorectal polyps?

- some cancers arise from flat adenomas (not polypoid)
- 2 main types of colorectal polyps are either adenomas or hyperplastic polyps, these lesions can't be distinguished reliably on gross appearance, bx is required for dx
- 2/3 of polyps are adenomas
- larger the polyp, the more likely is progression to cancer - impt because if you remove the polyps when they are smaller they can't grow into cancer
- hyperplastic polyps account for most of remaining polyps and are mainly distal. They are generally thought not to progress to cancer, although some may

58

What are other screening tests for CRC?

- FOBT and FIT: stool on a card to detect blood, helped to id those pts with large polyps and cancers
- flex sigmoidoscopy: involves inspecting only last 1/3 of colon, largely has been replaced by complete colonoscopy
- COLONOSCOPY

59

Why has the colonoscopy become the screening test of choice?

- looks at the entire colon
- if a polpy is found, it can be removed through the scope and sent to pathology to determine the type of polyps and to rule out cancer
- other abnormalities of teh colon can be ID'd
- when polyps are removed they cant grow into cancer

60

RFs for CRC?

- polpys (Noncancerous or precancerous growth assoc with aging)
- age
- IBD
- diet high in saturated fats such as red meat
- personal or family hx of cancer
- obesity
- smoking

61

What is HNPCC?

- heriditary non-polypossi colorectal cancer, sometimes called lynch syndrome, accounts for approx 5-10% of all colorectal cancer cases
- risk of colorectal cancer in families with HNPCC is 70-90%
- people with HNPCC are dx with CRC at avg age of 45

62

What is FAP?

- familial adenomatous polpyosis accounts for 1% of colorectal cancer cases
- people with FAP typically develop 100s to 1000s of colon polyps, polyps are initially benign but there is nearly a 100% chance that the polyp will develop into cancer if left untx
- colorectal cancer usually occurs by age 40 in people with FAP

63

Sxs of CRC?

- change in bowel habits: diarrhea, constipation, or a feeling that the bowel does not empty completely
- bright red or dark blood in the stool
- abdominal discomfort

64

How is CRC evaluated?

- dx is confirmed by bx
- stage of disease is confirmed by pathologist and imaging tests, CT - nodes, liver and lung involvement
- endoscopic US and MRI may also be used to stage rectal cancer

65

Tx of CRC cancer?

- surgery: foundation of curative surgery, tumor along with adjacent healthy colon or rectum and lymph nodes, is typically removed to offer the best chance for cure
- chemo: typical meds include fluorouracil (5-FU), oxaliplatin (eloxatin), irinotecan (camptosar), and capecitbaine (xeloda)
- radiation: used to tx rectal cancer, eitehr before or after surgery, diff methods of delivery, external beam (outside the body)
- antiangiogenesis: starves tumor by disrupting its blood supply, therapy is given along with chemo, Avastin was approved in 2004 for tx of stage IV colorectal cancer

66

Staging TNM system?

- T: the size (depth of penetration of tumor into the wall of bowel)
- N: if cancer has spread to nearby lymph nodes
- M: if cancer has metastasized

67

What is stage I colorectal cancer?

- cancer has grown through mucosa and invaded muscularis (muscular coat)
- tx is surgery to remove tumor and surrounding lymph nodes

68

Stage II colorectal cancer?

- cancer has grown beyond muscularis of the colon or rectum but hasn't spread to lymph nodes
- stage II is tx with surgery and in some cases - chemo after surgery

69

Stage III CRC?

- cancer has spread to regional lymph nodes (near colon and rectum)
- stage III colon cancer is tx with surgery and chemo

70

Stage IV CRC?

- cancer has spread outside of colon or rectum to other areas of the body
- stage IV cancer is tx with chemo. Surgery to remove the colon or rectal tumor may or may not be done

71

F/U care for CRC?

- serial CEA measurements are recommended
- colonoscopy one yr after resection of CRC
- surveillance colonoscopy q 3-5 yrs to ID new polyps and/or cancers

72

Rectal cancer?

- better prognosis than colon
- rx not beneficial for rectal cancer (problems with incontinence)
- DRE/hemoccult
- CEA
- surgery

73

How is anal cancer diff than colon or rectal cancer?

- SCC
- risk slightly higher in women
- 2016: est 8000 more cases
- bowel changes
- bleeding
- HPV assoc (major cause) - smokers/HIV
- 10% mets
- tx: often effective/cured: surgery, radiation, chemo
- survival: better than CRC, 5 yr 65.7% overall, for localized disease with early dx: 80%