109 : Upper GI tract Cancers Flashcards
T or F: In esophageal cancers worldwide, adenocarcinoma is the more common cell type.
False
Squamous cell carcinoma
Some etiologic factors associated with SCCA of esophagus
- Excess alcohol consumption (whiskey > wine, beer)
- Cigarette smoking
- Ingested carcinogens
- Mucosal damage from physical agents (extremely hot tea long-term exposure, Lye ingestion, radiation-induced strictures)
- Esophageal web with glossitis and iron deficiency (Plummer-Vinson or Paterson-Kelly syndrome)
- Hyperkeratosis and pitting of the palms and soles
Some etiologic factors associated with ADENOCARCINOMA of esophagus
- Chronic GERD
- Obesity
- Barrett’s esophagus
- Male sex
- Cigarette smoking
Part of the esophagus where adenocarcinoma arises?
Distal third of esophagus
From squamous epithelium –> columnar mucosa
T or F: Adenocarcinoma of esophagus behave clinically like gastric adenocarcinomas, hence they are associated with Helicobacter pylori infections.
False
NOT associated with H. pylori
Percentage of cancer in each part of the esophagus
Upper third : 5%
Middle third: 20%
Lower third: 75%
Incidence of adenoCA in esophagus is increasing in the US more than SCCA
T or F: SCCA and adenoCA of esophagus can be distinguished radiographically or endoscopically
False
CANNOT be distinguished
Percentage of esophageal circumference infiltrated with cancer when difficulty of swallowing begin to appear?
> 60%
By the time symptoms appear, disease is already very advanced
Esophageal CA most commonly spreads to what adjacent organs?
- Adjacent and supraclavicular lymph nodes
- Liver
- Lungs
- Pleura
- Bone
Procedure that should be performed in ALL patients SUSPECTED of having an esophageal abnormality to visualize and identify the tumor, and also to obtain histopathologic confirmation of diagnosis
Esophagoscopy
a. Endoscopic inspection of larynx, trachea, and bronchi should also be carried out
b. Endoscopic examination of fundus of stomach is imperative as well
Imagings used to determine extent of tumor spread to the mediastinum and para-aortic lymph nodes
CT scan of chest and abdomen
Endoscopic ultrasound
Imaging that provides useful assessment of the presence of distant metastatic disease with accurate information regarding spread to mediastinal lymph nodes, helpful in defining radiation therapy fields
Positron emission tomography (PET) scan
Prognosis for patients with esophageal carcinoma
Poor
5-year survival after diagnosis is 10%
Goal of treatment for esophageal CA
Symptom control
Surgical resection in esophageal cancer
Feasible only in 45% of cases
Associated with frequent residual tumors
Increased post-op mortality due to many complications
T or F: Chemotherapy with radiation therapy produces better survival outcome than radiotherapy alone
True
Patient presented with esophageal CA, however the tumor is unresectable. What major issues in the management should you be concerned or need to prioritize?
- Dysphagia (endoscopic dilatation, radiation therapy)
- Malnutrition (gastrostomy or jejunostomy)
- Tracheoesophageal fistulas (stenting)
T or F: Gastric cancer is associated among lower socioeconomic class and intake of dietary carcinogens
True
Frequencly of the different stomach cancers
Adenocarcinoma: 85%
Lymphomas, MALT: <15%
Leiomyosarcoma, GIST : 1-3%
2 types of gastric adenocarcinoma
- Diffuse type
2. Intestinal type
Type of gastric adenoCA common in younger patients, develops througgout the stomach, causing linitis plastica or “leather bottle” appearance, and carries poorer prognosis
Diffuse type
Cell cohesion is absent, and individual cells infiltrate and thicken the stomach wall without forming a discrete mass
Type of adenoCA which are frequently ulcerative, more common in the ANTRUM and LESSER curvature of stomach, often initiated by H. pylori infection
Intestinal type
Part of the stomach where most gastric CA originate
Proximal third of stomach (40%)
30% distal stomach
20% midportion
10% entire stomach
Factor in the causation of gastric carcinoma due to long-term ingestion of high concentrations of nitrates in dried, smoked, and salted foods
Nitrate-converting bacteria
T or F: Increased gastric acidity is an endogenous factor that favors the growth of nitrate-converting bacteria in stomach
False
Decreased gastric acidity
Others: prior antrectomy, atrophic gastritis and/or pernicious anemia
T or F: Infection with H. pylori increases risk of gastric cancer by sixfold.
True
A germline mutation in this gene, inherited in autosomal dominant pattern, normally codes for a cell adhesion protein, results in high incidence of occult diffuse-type gastric cancers in young asymptomatic carriers
E-cadherin gene (CDH1)
T or F: A palpable abdominal mass may be an early sign caused by diffuse type of gastric cancer
False
There may be no early physical signs
Palpable mass indicates long-standing growth and predicts regional extension
How do gastric CA metastasize?
- Direct extension
- Lymphatics
- Hematogenous
Gastric CA that metastasize to the ovary
Krukenberg’s tumor
Gastric CA that metastasize to the periumbilical region
“Sister Mary Joseph node”
Gastric CA that metastasize to the peritoneal cul-de-sac
Blumer’s shelf palpable on rectal or vaginal examination
Most common site for hematogenous spread of tumor in Gastric CA
Liver
Pertinent history that should mandate a search for an occult blood in the stool
- Iron-deficiency anemia in MEN
2. Occult blood in stool in both sexes
UNUSUAL clinical features associated with gastric adenocarcinomas
- Migratory thrombophlebitis
- Microangiopathic hemolytic anemia
- Diffuse seborrheic keratoses (Leser-Trelat sign)
- Acanthosis nigricans
Treatment for Gastric Adenocarcinoma
Complete surgical removal of tumor WITH resection of adjacent lymph nodes
Treatment of choice for DISTAL carcinomas of gastric adenocarcinoma
Subtotal gastrectomy
Treatment of choice for PROXIMAL carcinomas of gastric adenocarcinoma
Total or near-total gastrectomy
T or F: 5-year survival of gastric adenoCa patients who underwent complete resection is higher for proximal tumors when compared to distal tumors.
False
Higher survival in DISTAL tumors (20%) vs proximal (<10%)
In gastric CA, best form of palliation and enhance probability of benefit from subsequent therapy
Reduction of tumor bulk
T or F: Gastric adenocarcinoma is a highly radiosensitive tumor.
False
Relatively radioRESISTANT
Requires external-beam irradiation that exceed tolerance of surrounding structures
Major function: palliation of PAIN only
Based on clinical setting, this chemodrug for gastric adenoCA functions as radiosensitizer that increases survival of patients in combination with radiation therapy compared to radiotherapy alone
5-fluorouracil (5-FU)
Drug combination for advanced gastric adenocarcinoma that gives partial response in 30-50% of cases
Cisplatin + Epirubicin or Docetaxel with
5-FU infusion OR Capecitabine OR Irinotecan
Which therapy reduces recurrence rate and increases survival in gastric CA?
A. adjuvant chemotherapy alone + complete resection of gastric cancer
B. Combination chemotherapy before and after surgery (perioperative treatment)
C. Postoperative chemotherapy with radiation therapy
B and C
Organ which is the most frequent extranodal site for lymphoma
Stomach
Characteristics of gastric lymphoma
- Difficult to distinguish clinically from gastric adenoCA
- Detected during sixth decade of life
- Presents with epigastric pain, early satiety, and generalized fatigue
- Characterized by ulcerations with a ragged, thickened mucosal pattern seen on contrast radiographs of endoscopic appearance
T or F: H. pylori increases risk for gastric lymphoma in general and in mucosa-associated lymphoid tissue (MALT) lymphomas
True
T or F: Antibiotic treatment to eradicate H. pylori infection can regress gastric MALT lymphomas.
True
> 75% of gastric MALT lymphomas regress after treatment
Should be considered before surgery, radiation or chemotherapy
But still needs to undergo periodic endoscopic surveillance
Highly effective chemotherapy regimen for gastric lymphoma
CHOP protocol (cyclophosphamide + doxorubicin + vincristine + prednisone) PLUS rituximab
Part of the stomach frequently involved in leiomyosarcomas and GISTs
Anterior and posterior wall of the gastric fundus
T or F: Leiomyosarcoma and GISTs rarely invade adjacent viscera and characteristically do not metastasize to lymph nodes
True
Adjacent organs where leiomyosarcoma and GIST can spread
- Liver
2. Lungs
Treatment of choice for gastric (nonlymphoid) sarcoma
Surgical resection
Combination chemotherapy : for metastatic disease
All gastric sarcoma tumors should be analyzed for what mutation?
c-kit receptor
GISTs are unresponsive to conventional chemotherapy. However, this selective inhibitor of c-kit tyrosine kinase are given to patients with GIST because it can prolong their survival in 50% of cases
Imatinib mesylate (Gleevec) 400-800mg PO daily
Situations where small-bowel tumors should be considered
- Recurrent, unexplained episodes of crampy abdominal pain
- Intermittent bouts of intestinal obstruction, especially in the absence of inflammatory bowel disease (IBD) or prior abdominal surgery
- Intussusception in the adult
- Evidence of chronic intestinal bleeding in the presence of negative conventional and endoscopic examination
Diagnostics for small-bowel tumors
- Small-bowel barium study / infusing barium thru NGT placed into duodenum (enteroclysis)
- Capsule endoscopic procedures
Benign tumors of the small-bowel is more often seen in the proximal or distal part?
Distal small intestine
Most common benign tumors of small-bowel
- Adenomas
- Leiomyomas
- Lipomas
- Angiomas
Benign tumor of the small-bowel that represent hypertrophy or hyperplasia of submucosal duodenal glands secreting a highly viscous alkaline mucus
Brunner’s gland adenomas
Benign tumor of the small-bowel that are occasionally located outside the pancreas
Islet cell adenomas
Are papillary villous adenomas benign or malignant tumors?
Benign
T or F: Hamartomas (juvenile polyps) in Peutz-Jeghers syndrome have low potential for malignant degeneration
True
Benign tumors of the small intestine that occur in greatest frequency in the distal ileum and ileocecal valve that is radiolucent on imaging, usually intramural and asymptomatic.
Lipomas
T or F: Multiple intestinal telangiectasias occur in nonhereditary form confined to the GI tract or as part of the hereditary Osler-Rendu-Weber syndrome. These are commonly benign lesions.
True
Best procedure to evaluate angiomas especially during bleeding
Angiography
Small-bowel malignancies are rare, however, what type of patients do they commonly occur?
- Long-standing regional enteritis
- Celiac sprue
- AIDS
Most frequently occurring small-bowel malignancies
- Ampullary carcinomas ( fr biliary or pancreatic ducts)
- Adenocarcinomas
- Lymphomas
- Carcinoid tumors
- Leiomyosarcomas
Most common primary cancers of the small bowel accounting for 50% of malignant tumors
Adenocarcinomas
Sites where most of the adenocarcinoma of small bowel frequently occur
Distal duodenum
Proximal jejunum
Diagnosis for adenocarcinoma of small-bowel
Endoscopy
Biopsy under direct vision
Treatment of choice for adenocarcinomas of small-bowel
Surgical resection with suggested postoperative adjuvant chemotherapy
Type of intestinal lymphoma requiring histologic confirmation where palpable adenopathy and hepatosplenomegaly are absent and no evidence of lymphoma is seen on imaging studies
PRIMARY intestinal lymphoma
> non-Hodgkin’s lymphomas (T cell origin)
Type of intestinal lymphoma consisting of involvement of intestine by a lymphoid malignancy extending from involved retroperitoneal or mesenteric lymph nodes
SECONDARY intestinal lymphoma
Most frequent site of occurrence of intestinal lymphoma
Ileum (most frequent) - highest amt of lymphoid cells
Jejunum
Duodenum (least frequent)
Risk of small-bowel lymphoma is increased in these conditions
- Prior history of malabsorptive conditions (celiac sprue)
- Regional enteritis
- Depressed immune function (congenital immunodeficiency syndromes, prior organ transplantation, autoimmune disorders, AIDS)
Imaging findings where small-bowel lymphoma can be suspected
- Infiltration and thickening of mucosal folds
- Mucosal nodules
- Areas of irregular ulceration
- Stasis of contrast material
Confirmation of small-bowel lymphoma
Surgical exploration and resection of invovled segments
Initial treatment modality for small-bowel lymphoma
Resection of tumor
A B-cell tumor, which is a unique form of small-bowel lymphoma diffusely involving the entire intestine; presentation includes chronic diarrhea and steatorrhea associated with vomiting and abdominal cramps
Immunoproliferative small intestine disease (IPSID) OR
Mediterranean lymphoma OR
Alpha heavy chain disease
Curious feature of this disease is presence of blood and intestinal secretions of an abnormal IgA that contains a shortened alpha heavy chain devoid of light chains
IPSID
Treatment for IPSID
Combination of antibiotics (Tetracycline) and chemotherapy
Tumors that arise from argentaffin cells of the crypts of Lieberkuhn and are found from the distal duodenum to the ascending colon
Carcinoid tumors
