Esophageal and Gastric Cancer - Eidelman Flashcards
Risk factors for esophageal cancer
Smoking
Alcohol
Vitamin and trace mineral deficiency
Achalasia- a disease that causes motility problems
and stasis
Tylosis – severe keratosis (genetic skin disorder, 100% incidence)
Lye ingestion (also strictures)
Thermal injury (Mate)
Viral infection
Areas of China, Afghanistan and Iran (Cancer belt)
Higher in black men in US
Squamous cell cancer: mutations in cyclin D1 gene
Adenocarcinoma: inactivation of p16 gene, p53 mutations.
Barrett’s esophagus (adenocarcinoma)
Symptoms of esophageal cancer
Asymptomatic at early stage. Some present with heartburn, atypical chest pain or dyspepsia. Occult blood in stool or IDA (from bleeding lesions), mild dysphagia, odynophagia or foreign body sensation depending on sensitivity.
Advanced: Dysphagia of solids then progressing to liquids complaints of lumional occlusion only when luminal diameter <13mm (<50%). Weight loss and anorexia, esophageal obstruction and can aspirate.
If extends:
Hoarseness from layngeal nerve invasion.
Coughing from mediastinal invasion-fistula invading airways. Also would cause retrosternal or back pain and abscess formation. Hiccups with mediastinal or diaphragmatic involvement.
Diagnosis of Esophageal Cancer
- Gastroscopy with biopsy/brush (esp if stricture too tight)
- Barium swallow (70% diagnostic accuracy if double-contrast)
- Esophageal ultrasound (to see progression)
Staging:
N: lymph nodes
M: distand metastasis
T1-T4: depth of esophageal invasion
Prognosis and treatment according to staging of esophageal cancer: 5 year survival
Stage I (T1, N0, M0) is 60%
Stage II (T2-3 with N0 or T1-2 N1) is 31%
Curative until IIA: presurgical (neoadjuvant) and postsurgical (adjuvant) chemo and radiation. Surgery is esophagectomy.
Can treat localized disease endoscopically. Saline/snare, photodynamic therapy, etc.
Most present in a late stage with low cure rate:
Stage III (T3, N1, M0 or any T4) is 20%
Chemo to reduce symptoms, surgery if good candidate
Stage IV (M1) is 4%
Palliative symptom control
General prognosis is <5% for 5 year survival.
For squamous cell: radiation (no response to chemo).
Stent with covering for fistula and for palliative methods.
Look for estrogen receptors and treat with Herceptin
Distal surgery: leave only fundus and cardia, enastemose proximal stomach with jejunum.
Proximal surgery: total or near total gastrectomy from EG junction.
Epidemiology of Gastric Cancer
Higher incidence, Survival rate
Developing > industrialized nations
Rare < age 40
Peaks in the seventh decade
Rate in men > women
Risk factors-
lower socioeconomic classes
dietary carcinogens
Blood group A (less mucous secretion)
Incidence and mortality of the distal stomach has decreased in the past 60 years, proximal stomach and esophagogastric junction has increased. Duodenal ulcers are NOT associated with gastric cancer.
Gastric ulcers and adenomatous polyps can be linked only if ulcerated or already neoplastic.
If incomplete resection, 5y survival not good (20% distal and <10% proximal). Recurrences for at least 8 years after surgery.
Total 5y survival rate: 23%, 60% if early diagnosis.
Intestinal vs Diffuse type gastric adenocarcinoma
Intestinal type:
Polyp-like tumors. All normal except for an early localized tumor in the antrum. End result of an inflammatory process: chronic gastritis –> atrophic gastritis –> intestinal metaplasia –> dysplasia
More common among elderly.
Diffuse type:
Spread everywhere
Clinical features, symptoms, and signs of gastric cancer
Superficial and surgically curable, no symptoms
Upper abdominal discomfort
Postprandial fullness
Severe, steady pain
Anorexia
Nausea (present in any superficial change of the mucosa)
Vomiting (alarm sign)
Dysphagia (if in cardia)
There are no early physical signs
Weight loss
Palpable abdominal mass
Iron-deficiency anemia because of bleeding or poor absorption
Atrophic gastritis or pernicious anemia-B12 deficiency from no intrinsic factor
Migratory thrombophlebitis, microangiopathic hemolytic anemia, and acanthosis nigricans is black gastric folds
Role of H. pylori in Gastric cancer
Causes chronic gastritis –> hypochlorydria –> chronic atrophic gastritis with intestinal metaplasia (can be gastrin proliferative factor) –> incomlete metaplasia –> severe dysplasia –> gastric cancer
Overall incidence of gastric cancer diminishing with eradication of H. pylori.
HOWEVER:
H. pylori has a protective effect in the proximal stomach and esophagus from achlorhydria and atrophic gastritis. Does NOT cause reflux. Gastric acid production (restored with H. pylori eradication) induces reflux in predisposed patients–> contribute to distal esophagus and cardia cancers. Incidence of proximal gastric cancers rising compared to distal.
Early Gastric cancer
Adenocarcinoma limited to the gastric mucosa and submucosa (doesn’t reach muscularis mucosa)
Regional lymph nodes involved or not
Favorable prognosis
Survival rates of 85 to > 90 percent five years after resection (of complete tumor)
Survival was similar for EGC and benign gastric ulcer
May be a different disease than others. Or an earlier stage of disease with long latent period. Higher survival in Japan.
Diffuse type Gastric cancer
More prevalent among women and in individuals under the age of 50
Characterized by the development of linitis plastica
Associated with an unfavorable prognosis because the diagnosis is often delayed until the disease is quite advanced
Like a nonexpandable leather water bottle.
Cells invade through gastric wall, not just mucosa (may appear normal). Barium swallow won’t show protrusion or tumor growth.
Cause may have to do with loss of acidity, genetic factor.
Seen in CT scan.
Signet ring cells seen.
Spread of gastric cancer
Direct extension through the gastric wall to the perigastric tissues
Adherence to adjacent organs
Structures adjacent to the stomach include the spleen, transverse colon, liver, diaphragm, pancreas, abdominal wall, adrenal gland, kidney, small intestine, and retroperitoneum
Via lymphatics or by seeding of peritoneal surfaces
Metastases to intraabdominal and supraclavicular lymph nodes
Hematogenous spread of tumor- mostly to the liver
Malignant ascites
Peritoneal cul-de-sac metastases- (Blumer’s shelf palpable on rectal or vaginal examination)
Krukenberg: metastasis from tumor to ovary
Sister Mary Joseph nodes (umbilical tumor)
Imaging and diagnosis of gastric cancer
Double-contrast radiographic examination
The stomach should be distended (give soda with gas to drink with barium)
Decreased distensibility may be the only indication of a diffuse infiltrative carcinoma
Distinguishing benign from malignant ulcers is difficult
The anatomic location of an ulcer is not an indication of the presence or absence of a cancer
Don’t forget to look up into the fundus during endoscopy
Hereditary (Familial) Gastric Cancer
Families in which several members under the age of 40 have had the diffuse type of gastric cancer.
The criteria for diagnosis are
Two or more cases of diffuse gastric cancer in first- or second-degree relatives
At least one diagnosed before the age of 50 years
OR three or more pathologically documented cases of diffuse gastric cancer in first- or second-degree relatives of any age.
Look for the gene and may discuss preventative gastrotomy. Treat H. pylori regardless of symptoms.
