02-02-23 - Gastrointestinal tumours (upper tract)

Question 1

Learning outcomes

Answer 1

• Describe common tumours of oesophagus
• Describe common tumours of stomach

Question 2

What are the 2 types of benign tumours of the oesophagus?

What are the 2 types of malignant tumours of the oesophagus?

What are the 2 types of benign tumours of the stomach?

What are the 4 types of malignant tumours of the stomach?

Answer 2

• 2 types of benign tumours of the oesophagus (account for 5% of oesophagus tumours)
  1) Mesenchymal Tumours
  2) Squamous papillomas
• 2 types of malignant tumours of the oesophagus:
  1) Squamous Cell Carcinoma
  2) Adenocarcinoma
• 2 types of benign tumours of the stomach:
  1) Polyps (Non-neoplastic or Adenomas)
  2) Mesenchymal
• 4 types of malignant tumours of the stomach:
  1) Carcinoma
  2) Lymphoma
  3) Carcinoid
  4) Mesenchymal

Question 3

What are 8 benign tumours of the oesophagus?

How are they often found?

Answer 3

• 8 benign tumours of the oesophagus:
  1) Leiomyomas (most common) – tumour of smooth muscle cells
  2) Fibromas – tumour of fibrous tissue
  3) Lipomas – tumour of fat tissue
  4) Haemangiomas
  5) Neurofibromas
  6) Lymphangiomas
  7) Mucosal polyps
  8) Squamous papillomas
• They are often found accidentally through endoscopy/gastroscopy

Question 4

What are the 2 main types of Malignant Tumours of the Oesophagus?

What are 4 rare types of malignant tumours of the oesophagus?

Answer 4

• 2 main types of Malignant Tumours of the Oesophagus:
  1) Squamous Cell Carcinoma (90% of all)
  2) Adenocarcinoma
• 4 rare types of malignant tumours of the oesophagus:
  1) Carcinoid tumour
  2) Malignant melanoma
  3) Lymphoma
  4) Sarcoma

Question 5

What groups does squamous cell carcinoma affect the most?

What country in the world is most affected?

Answer 5

• Squamous cell carcinoma is more common in those > 50
• It is more prevalent in men than women (ranges from 2:1 to 20:1) - 5 per 100 000 population in males and 1 per 100 000 in females (Average in Europe)
• Most common place in the world for occurrence is Iran
• Can be common in places that drink hot tea, as hot trauma is a risk factor

Question 6

What are 3 dietary risk factors for squamous cell carcinoma?

What are 2 lifestyle risk factors for squamous cell carcinoma?

What are 2 oesophageal condition risk factors for squamous cell carcinoma?

What else are risk factors for squamous cell carcinoma?

Answer 6

• 3 dietary risk factors for squamous cell carcinoma:
  1) Deficiency of vitamins (A, C, riboflavin, thiamine, pyridoxine)
  2) Fungal contamination of foodstuffs (e.g dried mets)
  3) High content of nitrites/nitrosamines
• 2 lifestyle risk factors for squamous cell carcinoma:
  1) Burning-hot beverages or food
  2) Alcohol and tobacco
• 2 oesophageal condition risk factors for squamous cell carcinoma:
  1) Long-standing oesophagitis
  2) Achalasia – difficult swallowing/drinking
• Genetic Predisposition can also be a risk factor for squamous cell carcinoma

Question 7

What % of squamous cell carcinoma occurs in the upper, lower, and middle thirds of the oesophagus?

How does squamous cell carcinoma present in endoscopy/gastroscopy?

What 3 patterns can squamous cell carcinoma present in?

What % makes up each type?

Answer 7

• % of squamous cell carcinoma occurs in the upper, lower, and middle thirds of the oesophagus:
  1) 20% in the upper third
  2) 50% in the middle third, and
  3) 30% in the lower third of the oesophagus
• Squamous cell carcinoma presents as small, gray-white, plaque-like thickenings that become tumorous masses in gastroscopy/endoscopy
• 3 patterns can squamous cell carcinoma present in (morphology):

1) Protruded polypoid exophytic (60%)
* Quick symptoms

2) Flat, diffuse, infiltrative (15%)
* Difficult to spot

3) Excavated, ulcerated, (25%)
 

Question 8

How can the morphology of squamous cell carcinoma be identified?

Answer 8

• The morphology of squamous cell carcinomas can be identified using a barium swallow x-ray

Question 9

What are the 3 histological features of squamous cell carcinoma?

What is degree of atypica? How is it classified?

Answer 9

• 3 histological features of squamous cell carcinoma:

1) Pleomorphism
* Different size/shape of cell nuclei

2) Hyperchromatism
* Invading darker cells

3) Mitotic figures
* Nuclei can be darker because cells are active and multiplying faster

• Degree of atypica is a measure of how much cancerous cells imitate their normal counterparts
• Dysplasia is disorganized growth
• Degree of atypica can be measured through their grade of dysplasia
• Cells can have a low grade of dysplasia and be relatively similar to their normal counterparts or a high grade of dysplasia and be very abnormal

Question 10

What are 5 clinical features of squamous cell carcinoma?

What is the prognosis of squamous cell carcinoma?

Answer 10

• 5 clinical features of squamous cell carcinoma:

1) Dysphagia

2) Extreme weight loss (cachexia)

3) Haemorrhage and sepsis

4) Cancerous tracheoesophageal fistula

5) Metastases (lymph nodes):
* Cervical
* Mediastinal
* Paratracheal
* Tracheobronchial
* Gastric and celiac

• The prognosis of squamous cell carcinoma is a 5% overall five-year survival

Question 11

What part of the oesophagus does adenocarcinoma affect?

What age does it affect?

What can adenocarcinomas arise from?

What are risk factors for adenocarcinomas?

Answer 11

• Adenocarcinoma affects the lower third of the oesophagus
• Start to appear at 40 years old, with a median age of 60
• Adenocarcinomas can arise from the Barrett mucosa (Makes up 10% of cases of adenocarcinomas)
• Barrett’s oesophagus is Intestinal metaplasia caused by gastric reflux
• Metaplastic columnar epithelium that predisposes to cancer development replaces the stratified squamous epithelium
• Risk factors for adenocarcinomas are tobacco and obesity

Question 12

What are 2 morphological features of adenocarcinomas?

Describe the histology of adenocarcinomas

Answer 12

• 2 morphological features of adenocarcinomas:
  1) Flat or raised patches or nodular masses
  2) May be infiltrative or deeply ulcerative
• A feature of the histology of adenocarcinomas is mucin-producing glandular tumours

Question 13

Describe TNM staging of oesophageal cancers

Answer 13

• TNM staging of oesophageal cancers
• Related to invasion and how deep cells have gone through the oesophagus:
• T is carcinoma in situ
• T1 invasion of submucosa
• T2 invasion of muscularis propria
• T3 invasion of adventitia
• T4 invasion of adjacent structures
• N0 no node spread
• N1 regional node metastases
• M0 no distant spread
• M1 distant metastases

Question 14

What are 7 clinical features of adenocarcinomas?

What is the prognosis of adenocarcinomas?

Answer 14

• 7 clinical features of adenocarcinomas:
  1) Dysphagia
  2) Progressive weight loss
  3) Bleeding
  4) Chest pain
  5) Vomiting
  6) Heartburn
  7) Regurgitation
• Prognosis of adenocarcinomas - 20% overall five-year survival

Question 15

What are 2 types of benign tumours of the stomach?

How can polyps affect the emptying of the stomach?

What can adenomas develop into?

Answer 15

• 2 types of benign tumours of the stomach:

1) Polyps:
* Nodule or mass that projects above the level of the surrounding mucosa, usually in the antrum

• Non neoplastic polyps (90%)
• Most are small and sessile (without a stalk)
• Hyperplastic surface epithelium
• Cystically dilated glandular tissue
• Neoplastic polyps – adenomas (5-10%)
• Contains proliferative dysplastic epithelium
• Malignant potential
• Sessile (without a stalk) or pedunculated (stalked).

2) Leiomyomas and Schwannomas – rare

• Polyps can affect the emptying of the stomach by affecting the pyloric sphincter
• Adenomas (non-cancerous tumours) can become cancerous
   

Question 16

What % of malignant tumours are gastric carcinomas?

How common is it in the world?

Answer 16

• 90% to 95% of malignant tumours of the stomach are gastric carcinomas/adenocarcinomas
• It is the second most common tumour in the world, with it being most common in Japan

Question 17

What are 4 environmental factors associated with gastric carcinoma?

What are 4 genetic factors associated with gastric carcinoma?

What are 3 host conditions associated with gastric carcinoma?

Answer 17

• 4 environmental factors associated with gastric carcinoma:
  1) Infection by H. pylori
  2) Diet
  3) Low socioeconomic status
  4) Cigarette smoking
• 4 genetic factors associated with gastric carcinoma:
  1) Slightly increased risk with blood group A
  2) Family history
  3) Hereditary nonpolyposis colon cancer syndrome
  4) Familial gastric carcinoma syndrome
• 3 host conditions associated with gastric carcinoma:
  1) Chronic gastritis
  2) Gastric adenomas
  3) Barrett oesophagus

Question 18

What parts of the stomach can be affected by gastric carcinomas?

What 3 things are gastric carcinomas classified on the basis of?

Answer 18

• Parts of the stomach can be affected by gastric carcinomas:
  1) Pylorus and antrum - 50% to 60%
  2) Cardia - 25%
  3) Body and fundus – 5 to 25%
• 3 things are gastric carcinomas classified on the basis of:

1) Depth of invasion
* Early and Advanced

2) Macroscopic growth pattern

3) Histological subtype

Question 19

What are the 3 stages in the macroscopic growth patterns of gastric carcinomas?

Answer 19

• 3 stages in the macroscopic growth patterns of gastric carcinomas:
  1) Exophytic
  2) Flat or depressed / Linitis plastica
  3) Excavated

Question 20

Morphology of exophytic gastric carcinoma

Answer 20

Question 21

Describe the morphological features of an excavated gastric carcinoma

Answer 21

• Morphological features of an excavated gastric carcinoma:
• Ill-defined, central ulcer surrounded by irregular, heaped-up borders

Question 22

Describe the 3 morphological features of Linitis plastica, “(leather bottle) gastric carcinomas

Answer 22

• 3 morphological features of Linitis plastica, “(leather bottle) gastric carcinoma:
  1) Diffuse infiltrative gastric carcinoma
  2) Mucosal erosion
  3) Markedly thickened gastric wall

Question 23

Describe the barium meal x-ray of gastric carcinomas

Answer 23

• The barium meal x-ray of gastric carcinomas looks as if part of the stomach has been eaten away

Question 24

What are the 3 types in the Adenocarcinoma Lauren histopathological Classification?

Describe each type

Answer 24

• 3 types in the Adenocarcinoma Lauren histopathological Classification:

1) Intestinal type
* Composed of neoplastic intestinal glands resembling those of colonic adenocarcinoma
* Cells often contain apical mucin vacuoles, and abundant mucin may be present in gland lumens

2) Diffuse type
* Composed of gastric-type mucous cells, which generally do not form glands, but rather permeate the mucosa and wall as scattered individual cells or small clusters in an “infiltrative” growth pattern
* Mucin formation expands the malignant cells and pushes the nucleus to the periphery, creating a “signet ring”

3) Mixed type

Question 25

What do all gastric carcinomas eventually do?

What 4 places can gastric carcinomas spread to?

Answer 25

• All gastric carcinomas eventually penetrate the wall and spread to regional and more distant lymph nodes.
• 4 places can gastric carcinomas spread to:

1) Supraclavicular (Virchow) node
2) Local invasion of gastric carcinoma into the duodenum, pancreas, and retroperitoneum
3) Metastases to the liver and lungs are common
4) Metastases to the ovaries called Krukenberg tumour

Question 26

What is the TNM staging for gastric cancer?

Answer 26

• TNM staging for gastric cancer:
• T is - carcinoma in situ (intraepithelial)
• T0 - no evidence of primary tumour
• T1 - invades lamina propria or submucosa
• T2 - invades muscularis propria or subserosa (not visceral peritoneum)
• T3 - penetrates visceral peritoneum but not adjacent structures
• T4 - invades adjacent structures (spleen, colon etc)
• N0 - no LN (lymph node) metastasis
• N1 - 1-6 lymph nodes
• N2 - 7-15 lymph nodes
• N3 - more than 15 lymph nodes
• M0 - no distant metastasis
• M1 - distant metastasis, in portal LN, mesenteric, retroperitoneal or more distant

Question 27

What are 9 clinical features of gastric carcinomas?

What is the prognosis of early and advanced gastric cancer?

Answer 27

• 9 clinical features of gastric carcinomas:
  1) Asymptomatic until late
  2) Weight loss
  3) Abdominal pain
  4) Anorexia
  5) Vomiting
  6) Altered bowel habits
  7) Dysphagia
  8) Anaemic symptoms
  9) Haemorrhage
• Prognosis – 5-year survival:
• Early gastric cancer is 90% to 95%
• Advanced gastric cancer < 15%

Question 28

What % of stomach cancer is gastric lymphoma?

What tissues do these affect?

What are >80% of cases associated with?

What is the prognosis?

Answer 28

• 5% of all gastric malignancies are gastric lymphoma
• B-cell lymphomas affect the mucosa-associated lymphoid tissue (MALT lymphomas).
• > 80% of cases are associated with chronic gastritis and H. pylori infection
• Prognosis - 50% five-year survival (as lymphomas are very sensitive to chemo)

Question 29

Which layer of tissue do gastric lymphomas typically occur?

Describe the histology of gastric lymphoma. Is this easy to diagnose?

Answer 29

• Gastric lymphomas commonly occurs in the mucosa or superficial submucosa
• Histology of gastric lymphoma - Lymphocytic infiltrate of the lamina propria surrounds gastric glands massively infiltrated with atypical lymphocytes and undergoing destruction
• This forms the “lymphoid epithelioid” lesion, where 1 or 2 normal epithelial cells are surrounded by malignant T cells
• This looks very uniform when looking down the microscope and is easy to diagnose