Esophageal/gastric Cancer Flashcards
Esophageal Cancer
general
types
♂>♀
↑ risk with age; 6th and 7th decade of life
Types:
Squamous cell carcinoma (SCC)
Most common type worldwide
Blacks/Asians > Whites
Adenocarcinoma
Most common type in the United States
Accounts for 2/3 of esophageal carcinoma cases
Increasing incidence
Whites > Blacks
Metastatic cancer
Constitutes 3% of esophageal cancer
Melanoma and breast cancer are the most likely to metastasize
esophageal cancer
S/Sx
Asymptomatic in the early stage
Dysphagia
Occurs when constriction of the esophageal lumen is < 13 mm
Progressive problem: solid food → semisolid food → liquids and/or saliva
Odynophagia
Weight loss
Present in almost all cases despite good appetite
Chest pain
Pressure or burning pain that radiates to the back
GI bleeding
Vocal cord paralysis and hoarseness
Compression of the recurrent laryngeal nerve
Dyspnea
Malignant pleural effusions or pulmonary metastasis
Squamous Cell Carcinoma of the Esophagus
General
Early vs advanced lesion
Most common malignant tumor in the proximal 2/3 of the esophagus
Early lesion: friable tissue, erythema, and erosions
Advanced lesion: infiltrating or ulcerated mass, may be circumferential
Squamous Cell Carcinoma of the Esophagus
RF
Risk factors:
Alcohol
Tobacco use (in any form)
HPV infection
Adenocarcinoma of the Esophagus
general
Most common malignant tumor in the distal 1/3 of the esophagus
Most often arises from Barrett esophagus – a condition brought on by chronic gastrointestinal reflux disease and reflux esophagitis
Early lesion: mucosal irregularities, ulcer, or nodule
Advanced lesion: ulcerated or exophytic mass with obstruction
Adenocarcinoma of the Esophagus
RF
Tobacco use (in any form)
GERD
Obesity (central fat distribution)
Esophageal cancer
esophageal cancer
Dx
Endoscopy with brush cytology and biopsy
Identified cancer
CT of the chest and abdomen
Determine the extent of tumor spread
Endoscopic ultrasound (EUS) of the esophagus
Determine the depth of the tumor in the esophageal wall and regional lymph node involvement
Basic blood tests: CBC with differential, electrolytes, and liver function
Esophageal cancer
Tx
Treatment depends on tumor staging, size, and location
TNM classification
Staging is 0-IV
Surgical resection, often combined with chemotherapy and radiation
Immunotherapy plus chemotherapy for advanced cancers
Locoregional esophageal cancer staging
Locoregional esophageal cancer staging:
The cancer is seen as the lesion penetrating the esophageal wall
Staging from T1 (mucosa and submucosa) to advanced disease, involving adjacent structures in T4 and the lymph nodes (N)
Esophageal cancer
Prognosis
Depends on the stage of the tumor
Overall survival is poor due to patients presenting with advanced disease
Cancer restricted to the mucosa → 80% survival rate
Cancer with submucosal involvement → < 50% survival rate
Cancer with extension to the muscularis → ~20% survival rate
5-year survival: < 5%
Esophageal cancer
Prevention
Making healthy choices is the best prevention
Gastric metaplasia
general
Precancerous change characterized by histologic change from normal gastric cardia, fundic, and antral mucosa to epithelium that resembles the small intestine
Occurs due to chronic irritation and inflammation of the stomach lining caused by various factors such as gastric acid, bile salts, H. pylori infection, smoking, alcohol, and environmental contaminants
Increased risk of dysplasia → stomach cancer
What would be 1st on your differential?
GERD
Gastric Cancer/ Stomach Cancer
general
♂ > ♀
Increases with age
>75% of patients are >50 years of age
Incidence has declined in the United States in recent decades
Extremely high incidence in Eastern Asia (Japan, China), Eastern Europe,and South America
gastric cancer`
types
Gastric adenocarcinoma – columnar glandular epithelium
Accounts for 85% of gastric cancers
Gastric lymphomas - lymphocytes
Leiomyosarcoma – smooth muscle cells
Carcinoid tumor – G cells
gastric cancer
RF
Helicobacter pylori infection
Autoimmune atrophic gastritis (pernicious anemia gastritis)
Smoking
Alcohol
Obesity
Family history of gastric cancer
Mutation of the cadherin 1 gene (CDH1) – autosomal dominant trait
Dietary factors
Association between the consumption of processed meat and stomach cancer (nitrates)
Adenocarcinoma gastric cancer
Intestinal
Intestinal
Most common type
Caused by H. pylori (bacterium causes damage to epithelial cells = chronic gastritis)
Cells change to resemble intestinal epithelium rather than stomach epithelium (metaplasia)
adenocarcinoma gastric cancer
Diffuse
Diffuse
Most aggressive type
Related to the genetic mutation in the CDH-1 gene (tumor suppressor gene) that codes for a membrane adhesion molecule called E-cadherin
E-cadherin is not working properly, cells detach and starts dividing uncontrollably
Gastric adenocarcinoma
gastric cancer
S/Sx
initial / later
Asymptomatic is the early stages when the cancer is most treatable
Initial symptoms are nonspecific
Dyspepsia
Nausea
Later symptoms
Early satiety
Dysphagia – esophagogastric and cardiac tumors
Vomiting
Weight loss
Hematemesis or melena
gastric cancer
Metastatic disease
Metastasis to the liver, peritoneum, lungs, and bones
Occasionally are the first symptoms
Jaundice, ascites, or fractures
Gastric cancer
Dx imaging
Endoscopy with biopsy and brush cytology
Positive biopsy
CT scan of the chest, abdomen, and pelvis
Determine the extent of tumor spread (metastatic disease)
Negative CT scan
Endoscopic ultrasound
Determine tumor depth and regional lymph node involvement
Gastric cancer
Dx labs
CBC, CMP, CA 19-9 (carbohydrate antigen 19-9), and CEA (carcinoembryonic) level before and after surgical treatment
Gastric cancer
staging
TMN staging
Staging 0-4
gastric cancer
prognosis
Prognosis depends on the stage and location of the tumor
Most patients present with advanced disease
Overall survival is poor
5-years: < 5-15%
Tumor in the mucosa or submucosa
5-year survival up to 80%
gastric cacner
Tx monitoring
Determined by the tumor staging
Curative surgical resection
Performed for patients with disease limited to the stomach and regional lymph nodes
Removal of most or all of the stomach (gastrectomy) and adjacent lymph nodes
Adjuvant chemotherapy or chemotherapy and radiation
Monitor CEA levels
Rise signifies recurrence
Distal gastrectomy with Bilroth II reconstruction, performed for cancers of the lower stomach
Subtotal gastrectomy with Roux-en-Y reconstruction, performed for cancers of the upper or middle stomach
Post-gastrectomy Complications
Small intestinal bacterial overgrowth (SIBO)
Bacterial growth in the small intestine increases
Dumping syndrome
Rapid gastric emptying due to bypass of the pyloric sphincter
Gastric stasis
Slow gastric transit due to vagal denervation and small stomach remnant
Reducedironabsorption → anemia
Reduced B12absorption(nointrinsic factor) → B12deficiency
Reducedcalciumabsorption → osteoporosis
