278. GI Cancer

Question 1

Esophageal Cancer

• epi - what types are more common, where?
• pathophys
• RFs
• Sx/CP
• Dx
• Tx

Answer 1

Epi: Epithelial origin most common (Squamous cell carcinoma in upper 2/3rds esophagus, Adenocarcinoma in lower 1/3rd)

RF:

1. Barrett’s esophagus (obese, older white males, frequent GER) - intestinal metaplasia
2. Tobacco
3. Mediastinal Radiotx
   - Alcohol, diet low in fruits and veggies (squamous only)

PPhys: LN invasion occurs EARLY and QUICKLY (lymphatics are located within lamina propria)

Sx: dysphagia, abd pain, bloating, weight loss, hemoptysis/melena sometimes

Dx: Endoscopy - MAINSTAY, EUS (eval tumor extent), CT Chest/abd/pelvis (eval distant mets), PET for occult mets

Tx:

1. Chemo (+ Her2, PDL1 testing!)
2. Radiation
3. Surg

Question 2

Gastric Cancer

• RFs (universal - 3, and enviro)
• sx/CP
• dx
• tx

Answer 2

RF: 1. increasing age

2. male
3. deprivation
   enviro: H. Pylori, tobacco, diet, alcohol, BMI, some genetics

sx/CP: same as esophageal: dysphagia, abd pain, bloating, belching, weight loss, hemoptysis/melena sometimes

Dx: endoscopy, EUS, CT chest/abd/pelvis, PET for occult mets
AND Dx Laparascopy - if peritoneal fluid positive = METS DISEASE = NON CURATIVE

Tx:

1. Chemo (+ Her2, PDL1 testing)
2. Radiation
3. Surgery

Question 3

Pancreatic Cancer

• epi
• RF
• sx/CP (3 sx, 3 types tumor)
• Dx
• Tx

Answer 3

Epi: 4th leading cause of cancer death and ON THE RISE

RF: hereditary, DM, chronic/recurrent pancreatitis, smoking, pancreatic cysts, metabolic syndrome, obesity

Sx: WEIGHT LOSS, PAIN, JAUNDICE (N/V)
CP: 1. Acinar cell tumor (secrete digestive enzymes, trypsinogen, pancreatitis - <1%), 2. Islet cell neuroendocrine tumor (ins, DM, <5%, MEN syndrome)
3. Columnar cell adenocarcinoma (CFTR mLc, CF, 90% most common)

Dx: Endoscopy (ERCP), CT chest/abd/pelvis (distant dz), Ca19-9/CEA in blood (TUMOR MARKERS)

Tx: TNM is IRRELEVANT

• resectable: local = surgery, chemo (adjuvant)
• borderline: locally advanced = chemo (neoadjuvant), surgery
• unresectable: metastatic = chemo (palliative) - most pts metastatic at presentation

Question 4

Liver Cancer

• RF
• dx
• tx

Answer 4

RF: HBV, HCV (successful tx reduces HCC risk), NAFLD/NASH (most prevalent RF in western world), Obesity (increases NAFLD), inherited disease (hemachromatosis, A1AT) = anything causing cirrhosis or long term inflammation (HCC can occur in noncirrhotic livers too though)

Dx: AFP (elevated tumor marker), MRI (washout images), biopsy (not needed for definitive dx)

Tx:
Curative: Resection (if small, local), Transplant (large or multiple)
Liver-Directed: chemoembolization (inject tumor with chemo) or radioembolization (radiation beads into tumor)
Systemic: TKIs, Immunotx, Combotx (chemo)

Question 5

Gallbladder Cancer

• RF
• CP (4sx, 3 types)
• dx
• tx

Answer 5

RF: Primary Sclerosing Cholangitis (chronic inflammation), infection with flukes (rare in US), inflammatory state

CP: Jaundice, Abd Pain, Pruritis, Weight loss (similar to pancreatic cancer)

1. Intra (5-10%)
2. Extra (20%)
3. Hilar (60-70%) - bifurcation of biliary system

Dx: ERCP (Endoscopy), EUS, CT Chest/Abd/Pelvis, MRCP (depends on presentation)

tx: Surgery if possible (localized, or consolidate with radiation)
- systemic tx (chemo with gemcitabine, cisplatin) - no specific targeted tx