GI neoplasms part 2: esophageal, gastric and biliary-mcgowan

Question 1

who is more likely to get esophageal cancer

Answer 1

Men>Women (4:1) - new cases and deaths

Question 2

what is included in esophageal cancer

Answer 2

gastroesophageal junction (GEJ) and 5cm into the stomach

Question 3

what is the most common esophageal cancer

Answer 3

adenocarcinoma = most secondary to Barretts

Question 4

where in the world in SCC the more prevalent esophageal cancer

Answer 4

asia and sub-saharan africa

Question 5

what is the later findings of esophageal cancers (presentation)

Answer 5

dysphagia (progressive over weeks to months)
weight loss
+/- odynophagia, heart burn, dyspepsia, bleeding, coughing, pneumonia, chest/mediastinal/back pain, hoarseness, lymphadenopathy

Question 6

what is the test of choice for esophageal cancer

Answer 6

EDG with biopsy - establishes diagnosis

Question 7

what tests are completed after diagnosis of esophageal cancer is confirmed

Answer 7

CBC to check for anemia
LFTs to check AST, ALT and alk phos
CT of check, abdomen, pelvis - look for regional spread
PET CT for distal spread
Endoscopic US - assess depth of tumor and nodes
+/- FNA of any possibly involved nodes

Question 8

what is the treatment for localized esophageal cancer

Answer 8

endoscopic resection or esophagectomy

Question 9

what is the treatment of localized esophageal cancer with lymph nodes involved

Answer 9

chemo and/or radiation, then esophagectomy + lymphnodeectomy

Question 10

what is the treatment for distant spread esophageal cancer

Answer 10

palliative tx with chemo and or radiation
esophageal stending
local brachytherapy
jujunostomy or gastrostomy tube for nutrition

Question 11

what are the prevention methods for esophageal ccancer

Answer 11

no routine screening
monitor/follow up for Barretts esophagus
encourage lifestyle modifications
NSAIDs may be protective
Anti-acid medications may be protective

Question 12

what are risk factors for gastric cancer

Answer 12

H/pylori infection/gastritis strongest overall risk factor
pernicious anemia, hx partial gastric resection, smoking, high nitrate/salt diets, low vitamin C diet, hereditary tumor syndromes

Question 13

what is the most common type of gastric cancer

Answer 13

adenocarcinoma
proximal - secondary to metaplasia
distal - secondary to H. pylori infection

Question 14

what is intestival gastric cancer

Answer 14

more common
metaplasia of glandular structures
H. pyloria - atrophic gastritis - metaplasia - dysplasia - CA

Question 15

what is diffuse gastric cancer

Answer 15

poorly differentiated, less glandular
less related to h.pylori, mor ehereditary

Question 16

what are the different morphologies of gastric cancer

Answer 16

fungating
poylpoid
ulcerating
diffusely spreading
superficial spreading

Question 17

what is the later symptoms of gastric CA

Answer 17

dyspepsia
early satiety
epigastric pain
anorexia
weight loss
+/- signs of UGI bleeding, post prandial vomiting, dysphagia

Question 18

what is virchow node

Answer 18

palpable left supraclavicular lymph node

Question 19

what is sister mary joseph nodule

Answer 19

umbilical nodule

Question 20

what is the test of choice for gastric cancer

Answer 20

EGD with biopsy
-age 55+ with new epigastric symptoms, persistent dyspepsia, often with barium swallow

Question 21

what further tests are completed once gastric cancer is confirmed

Answer 21

EUS for depth and spread, CT C/A/P, PET for distal mets

Question 22

what is the treatment of localized gastric CA

Answer 22

laparoscopic or open gastrectomy (either total or subtotal) + lymphadenectomy
need vit B12 supplemental after gastrectomy
preop chemo and/or radiation improves survival

Question 23

what is the treatment of advanced (non-locally resectable) gastric cancer disease

Answer 23

palliative treatment

Question 24

what is cholangiocarcinoma

Answer 24

carcinoma of the gallbladder itself or the bile duct

Question 25

what are risk factors for GB cancer

Answer 25

cholelithiasis salmonella typhii infection gallbladder polyps calcification of the gallbladder (porcelain gallbladder) genetics (K-ras and P52 mutations)

Question 26

what are risk factors for cholangiocarcinoma

Answer 26

bile duct adenomas ulcerativ colitis primary sclerosing cholangitis biliary cirrhosis DM hyperthyroidism chronic pancreatitis ETOH - heavy consumption smoking HIV/HCV NAFLD/cirrhosis obesity helmith infection of bile ducts (SE Asia)

Question 27

what can reduce the risk of all types of bile duct cancer

Answer 27

ASA and statin

Question 28

what can reduce the risk of intra-hepatic cholangiocarcinoma

Answer 28

metformin

Question 29

what is the presentation of biliary A

Answer 29

progressive jaundice signaling obstruction RUQ abdominal pain anorexia and weight loss +/- fever and chills, hematemesis or melena, pruritis and skin excoriations

Question 30

what is seen on PE with biliary CA

Answer 30

jaundice (in severe dz) palpable gallbladder Hepatomegaly (tender) +/- ascites

Question 31

what is the Courvoisier sign

Answer 31

palpable nontender GB + obstructive jaundice *suggests malignancy

Question 32

what is the laboratory workup of biliary CA

Answer 32

elevated conjugated (indirect) bilirubin +/- elevated alk phos and cholesterol AST normal to mildly elevated Elevated CA19-9 (tumor marker)

Question 33

what is the test of choice for biliary CA

Answer 33

MRI with magnetic resonance cholangiopancreatography (MRCP)

Question 34

what is the benefit of MRCP

Answer 34

visualization of entire biliary tree defines extent of involvement elucidates any vascular involvement

Question 35

what is the treatment of biliary CA

Answer 35

mainstay = surgery -young and fit: cholecystectomy if sx not an option - palliative tx