Colorectal, Esophageal and Gastric Cancer Flashcards
Esophageal Cancer
Etiology
Risk Factors
adenocarcinomas: more common in the US
squamous cell carcinoma is the majority of cases worldwide
Risk Factors for …
Adenocarcinoma
- 60% have evidence of barrets esophagus
- long-standing GERD
- tobacco use
- obesity
- MSR I, ASCCI & CTHRCI gene mutations
Squamous Cell Carcinoma
- alcohol & tobacco use (highest risk factors)
- dietary factors
- alkaline/lye ingestions
- tylosis palmaris and plantaris (chrom. 17 deletion)
Barrett’s Esophagus
etiology
risk factors
patho: where does this occur within the esophagus & Diagnosis
long-standing GERD: exposure to the stomach acid leads to change from normal squamous epithelium to gastric columnar cells
- increased risk for the developement of esophageal cancer by 30-60%
Risk Factors for Barrett’s
- chronic GERD
- hiatial hernia
- age > 50
- male, white
- obese
- smoker
- cancer of esophagus in family 1st degree relative
- some assocation with h pylori (low)
Diagnosis
- normally: there is a Z line: where the cells go from columnar to squamous of the esophagus: Z line is at the GEJ
- if columnar epithelium is > 1 cm of the distal esophagus AND biposy shows metaplasia = barretts
low grade dysplais: 1% increased risk
high grade dysplasia: 5% increased risk
if concurrent esophagitis: need to repeat the EGD in 3 months to recheck for barretts or adenocarcinomas
Screening Recommendations for Esophageal Cancer in those with Barrett’s
Treatments for Barrett’s (if not PPI)
screenign every 3 years if thye have nondysplasia Barrett’s
- if they have dysplsaia: more frequently
the earlier you catch teh adenocarcinoma, the better the outcome!
Barretts Treatment
- can do radiofrequency ablation: still need to screen for dysplasia (can comeback)
esophageal cancer
Symptoms
Symptoms
1. progressive dysphagia: (most common symptom)
- started with solids initially: now liquids too
- this is unfortunaltey a late manifestation of the disease
- Odynophagia/globus sensation (food is stuck feeling)
- anoerexia/weight loss
- worsening refulx
- nauseas
- GI bleed: an upper Gi bleed from the tumor itself (hematemeisis, melana)
oropharyngeal function is usually in tact
Esophageal Cancer
Work up
Histology and locations
Diagnosis
Work-up
Esophagogastrodudenoscopy (EGD) with ultrasound
- with a bioposy of the tumor
- US helps reveal the primary tumors size and if there is lymph node involvement
if need to elvaulated for mets…
- CT chest/abd/pelvis with IV contrast
- PET/CT can be used
Histology/Location of the Cancer
Squamous Cell Carcinoma
- will see squamous dysplasia
- loactsion: majority in the middle 1/3 of esophagus
Adenocarcinoma
- will see barrett’s first, or incomplete intestinal metaplasia on biopsy
- location: distal 1/3 of the esophagus MC at the GE junction
Classification of GEJ Tumors
Type 1: center of lesion 1-5 cm proximal to GE junction (esophageal cancer)
Type 2: 1 cm proximal to and 2 cm distal to teh GE junction (iffy zone)
Type 3: 2-5 cm distal to the GE junction (shows its really stomach cancer)
Esophageal Cancer: Staging
the basics
Staging: gives idea baout how far the cancer has spread from its original location; higher sprea = poor prognosis
in situ = cells are abnormal, high RISK for being cancerous
metastatic: cancer cells have spread from orgin to elsewhere
staging is done using the TNM system
T= Tumor
N = regional lymph nodes
M = metastisis
(ex. T2N1M0 is a TNM that gives you a “stage”)
the Stage guides treatment decisions and re-staging can occur through treatment
Esophageal Cancer: Treatment
general principles
- surgical resecetion when
- systemic therapy options (meds)
Generally for cancer, early finding = early treatmetn can be curative
Early = neoadjuvant chemo + surgical resection + post-op radiation
Advanced Stages: palliative treatment
- chemothearpy to slow the spread and imrpove symptoms
Surgical Ressection
1. if early stage (Tis or Tia): endoscopic surgery can be done
2. locoregional (stage 2-3 ot T4b): tradional surgery
- pt. recives pre-op chemo carboplatin/taxol + radiation
- transhiatal esophagectomy (connect stomach to upper part of esophagus and remove distal esophagus)
Systemic Thearpy: for Stage IV
1. first-line: platinum-based thearpy + fluropyrimidine backbone
- example: DCT (docetaxel, cisplatin, 5-FU)
- Ramucircumab + -taxel
- Immunotherapy with anti- PDL-I (if they have CA which expressed PDL-I) –> nivlumab + pembrolizumab
Complications of Esophageal Cancer
Liver Mets
Peritoneal Mets
- worsening dysphagia: can get worse while doing treatment, then gets better
- can require a G or J tube for short term combat if needed - metastatic disease: lymph, liver, lung, bone, adrenal glands and brain
Liver Metastitsis (normal function: mets effect)
- toxin removal : hepatic encephalopathy
- bilirubin: jaundice
- proteins: third-spacing, risk of bleeding and increased infection risk
- platelets: chronic thrombycytopenia
- glycogen storage: imparied glucose regulation
Peritoneal Metatstisis (poor prognosis)
peritoneum: lining of abdominal wall and cavitiy; mesintery: attaches the viseral organs to the peritoneum
- ascites
- pain
- abd. distension
- bowel obstruction: SBO
- not able to get G or J tube because too risky of surgery
survival is better if caught early
avoid red meats, tobacco, alcohol, treat the GERD, use statins to avoid esophageal cancer
Gastric Cancer
types
risk factors
Types
- gastric adenocarcinoma (most common)
- gastrointestinal stromal tumors (nerve cell)
- carcinoid tumors (secreting things it should not be)
- lymphoma
more commonly found at the GE junction: proximal stomach
Risk Factors
- H pylori infection
- tobacco, alcohol
- obestiy
- GERD
- EBV
- radiation
- pernicious anemia
- exposures (coal/rubber)
- poor diet with cured/smoked foods, salts, low vit. c/a
Genetic Risk Factors
- 15% are familial in origin
- Lynch Syndrome
- Diffuse heredity Gastric Cancer (A-dom.) (gasterectomy at 40 to prevent CA)
others..
- li-fraumei
- polyposis (familial)
- juvenile polyposis
- peutz-jeghers syndrome
Gastric Cancer
Symptoms
Diagnositc Workup
Staging
unfortunately; usually diagnosed late
- weight loss/anorexia
- stomach pain
- early satiety
- GI bleed (upper GI)
- ascites (later in disease when they present with this)
Diagnostic
- EGD with US & biopsy
- CT w/ IV contrast if needed to assess spread
- PET if needed
Staging
- TNM system: assessing the spread of disease based on histology, pathology and spread
biopsy
- polypoid: looks like a mushroom
- Fungating: necortic; eating the middle
- Ulcerated: infilterative
- Flat: younger pts, but high grade signet ring sign
Histology Lauren Histological Classification
1. Intestinal Type: columnar, gland-forming cells with irregular margins and ulcerations
2. Diffuse Type: Signet ring cells, with linitis plastica: rubber think wall (worse)
lots of pathological testing to determine the genetics which underlie the cancer cells to figure out how best to treat it
Gastric Cancer
Treatment
Stages I-III: locoregional disease
- subtotal gasterctomy preferred: part of stomach is removed
- may include neoadjuvant or adjuvcant chemotherapy
neoadjuvt: FLOT or FOLFOX or epirubicin/cicplatin/5-FU
adjuvcant: leucovorin + radiation OR cisplatin + radiation OR capecitabine + oxaliplatin
Stage IV (advanced)
- first line treatment: anti-PDL-I (pembrolizumab or nivolumab) if its PDL-I expressing
- seond line: platium based + fluropyrimidine backbone
- third line: VEGFR-2 monoclonal antibody (ramucirumab + paclitaxel)
Gastric Cancer
Complications and Prevention
Complications (cancer or teh treatment)
- occult GI bleeding (diffiuclt to treat)
- early satiety + N/V/reflux
- metastatic disease: to the liver, peritoneum and lungs
Prevention
- screen for h pylori!!!
- screenig for gastric cancer in high risk groups
High Risk
- gastric adenoma
- pernicious anemia
- gastric intestinal metaplasia
- familial polyposis
- lynch syndrome
- jeuvinile polyposis
- peutz-jeghers
earlier you catch it, the better off the pt. is
Colon Cancer
Etiology
Risk Factors
polyp type and size
3rd most common death in women, 2nd in men
Risk Factors
- high red meat diet
- alcohol use
- DM
- metabolic syndrome
- longstanding IBD : 25 years (more likely with pan-colitis)
- streptococcus bovis bacteremia
- familial polyposis
- lynch syndrome & heridiatray non-polyposis
asprin/NSAIDS can and may be protective
Etiology: begins as a polyp (various types)
Sessile polyps: flat
villous adenoma: pedunculated
tubulovillous adenoma: pedunculated
tubular adenoma: pedunculated
assessed by their shape, size, type of polyp, number and location
Size
- < 1.5 cm = low risk
- 1.5-2.5 = intermediate risk
- > 2.5 = high risk
Colon Cancer
Symptoms
Work-Up and Diagnosis
Symptoms
- Bleeding: (importatnt early symptom)
- a change in bowel habits (anythin that theyve noticed is different –> weeks/months)
- fecal urgency
- imcomplete bowel emptying
- pain (late symptom)
Location & Symptoms
- right colon: microcytic anemia
- Left colon: abdominal cramping, obstruction or performation
- rectosigmoid: hematochezia, tenesmus, stool pattern change
Diagnosis
- biopsy via colonoscopy = most sensitive and specific (over a sigmoidoscpy - doesnt got the whole colon)
- barium enema: apple core lesions
- CT with IV contrast + oral contrast for staging
- Carcinoembryonic antigen (CEA) = tumor marker to monitor treatment (NOT used to dx.)
Staging
- TNM system used here as well
Colon Cancer
Treatment
Resectable Disease
- colectomy with regional lymph node dissection
can do adjuvant therapy if…
1. T4 tumor
2. poor histology
3. lymphovascualr invasion
4. bowel obstruction
5. interdeterminate margins on colectomy
adjuvcant therapy: = 5-FU/leucorvorin, capecitabine, FOLFOX or CAPEOX
Metastatic Disease
- if liver mets only: can rescent the liver mets! good survival
- systemic therapy = 5-FU/leucorvorin, capecitabine, FOLFOX or CAPEOX
- progressive disease: MMR or MSI tumors = pembrolizumab or nivolumab (PDL-I) or ipilimumab +nivolumab
