Esophageal, gastric, pancreatic cancers Flashcards
The highest rates of esophageal cancer are in
East Asia, East Africa
Primarily squamous cell carcinoma in this area
Over the last several decades there has been a shift from mostly _____ esophageal cancer to mostly ______ esophageal cancer in the US
squamous cell carcinoma—-> adenocarcinoma
List risk factors for squamous cell esophageal cancer
Male gender age African American smoking lye pickled foods
Explain the field cancerization effect
Higher rates of squamous cell carcinoma when tobacco and alcohol are used together
Explain risk factors for esophageal adenocarcinoma
Arises from Barrett’s esophagus, associated with GERD and obesity
______ has been shown to be a risk factor for esophageal adenocarcinoma independent of Barrett’s esophagus
obesity
Describe the approach to a patient with Barrett’s esophagus to prevent cancer
Acid suppression
weight loss
frequent follow up
What are presenting symptoms of esophageal cancer?
dysphagia
weight loss
bleeding, melenic stools
Describe the diagnostic workup of esophageal cancer
Endoscope exam with dilation of strictures, biopsy
endoscopic ultrasound
CT/PET to look for metastasis
Describe the management of localized esophageal cancer
- neoadjuvant chemotherapy and radiation
- surgery- esophagectomy with gastric pull up
- patients can never lie flat again
- will experience weight loss, early satiety
Describe management of metastatic esophageal cancer
chemotherapy prolongs life (from 4 to 10 months)
palliative radiotherapy for persistent dysphagia- improves symptoms but not survival
Most gastric cancers are ______ (histologic type)
adenocarcinoma
In what geographic area is the prevalence of gastric cancer greatest?
East Asia
What factors are associated with the lower incidence of gastric cancer in the US?
Changes in dietary habits, recognition and treatment of H. Pylori, and better food preparation/preservation
What are risk factors for gastric cancer
H pylori
Diet high in nitrates, salt
inadequately preserved foods
Describe the two types of gastric cancer
Intestinal: More mass-like, intraluminal, prone to bleeding; Higher association with H.pylori
Diffuse: Often submucosal; Presenting complaint of early satiety; More often presenting in late stage; Thought to be more aggressive
_______ arises from a mutation in CDH1 which inactivates e-cadherin
hereditary diffuse gastric cancer
Describe the presentation of gastric cancer
Long asymptomatic period
nausea, bloating, unexplained weight loss, early satiety
_______ is the gold standard for diagnosis of gastric cancer
upper endoscopy (EGD) with tissue biopsy
Staging is critical in gastric cancer, because it frequently presents with ______ early in its course
metastasis
CT/PET analysis
Describe management of localized gastric cancer
- surgery: partial gastrectomy or total gastrectomy including D1 or D2 node harvest
- neo-adjuvant chemotherapy then post-op adjuvant chemotherapy or radiation
Describe the management of metastatic gastric cancer
palliative chemotherapy
mOS measured in months
Describe the benefits of pre-operative chemotherapy
- provides some degree of tumor shrinkage
- test of time for metastases to develop to avoid futile surgery
List chemotherapeutic agents used in metastatic gastric or esophageal cancers
5-FU, taxanes, platinums, irinotecan
targeted therapy: Her-2, ramucirumab (anti-VEGF)
List risk factors for pancreatic cancer
smoking
obesity and diabetes (but pancreatic cancer often presents with new onset glucose intolerance)
List familial syndromes associated with pancreatic cancer
(HNPCC and FAP, BRCA2, cystic fibrosis, familial atypical mole-melanoma syndrome
List presenting signs and symptoms of pancreatic cancer
jaundice epigastric pain radiating to the back new onset diabetes weight loss, nausea, vomiting palpable gallbladder acholic (clay colored) stool cola colored urine
Describe the diagnostic work up of pancreatic cancer
ERCP (Endoscopic Retrograde CholangioPancreatography) is used for diagnosis and can also directly sample epithelium
Endoscopic ultrasound: assesses local lymph nodes and tissue invasion
The most common pancreatic cancer is ________
adenocarcinoma
In order to be considered resectable, the tumor must not invade or abut the _________. If it does, then a margin negative resection (so-called R0 resection) cannot be performed
mesenteric arterial supply
85% of patients with pancreatic cancer present with ______ disease
advanced, non-resectable cancers due to local invasion or metastatic disease
What are the components of a Whipple procedure?
Pancreaticoduodenectomy
Gastrojejunostomy
Pancreaticojejunostomy
Choledochojejuonstomy
resection of the head of the pancreas, connecting the stomach to the jejunum, connecting the bile ducts to the small intestine, and reapproximating any remaining pancreatic tissue to the small intestine
Pre-operative radiotherapy may be helpful in ______-resectable pancreatic cancers
borderline
Neoadjuvant therapy in pancreatic cancer is used to:
- make operation easier and improve chances of R0 resection
- avoid potentially futile surgeries
What are chemotherapy options for metastatic pancreatic cancer?
- gemcitabine, with possible improvement when gemcitabine + abraxane
- FOLFIRINOX: 5-FU, oxaliplatin, irinotecan
Patients with any GI cancer are at increased risk of thrombotic complications including ___________
pulmonary embolism and DVT
What is Trousseau’s syndrome
Migratory thrombophlebitis which can progress to DVT/PE
