GI Neoplasia I

Question 1

50+ yo patient with dysphagia

Answer 1

THINK CANCER!!!!

Question 2

A patient presents with fatigue, trouble swallowing solids but not liquids, and white patches in his mouth. What other findings should you check for?

Answer 2

Achlohydria, glossitis, koilonychia, microcytic hypochromic anemia

(Plummer Vinson syndrome; due to iron deficiency, causes anemia, esophageal webs, leukoplakia in mouth and esophagus, glossitis, spoon nails, achlorhydria)

Question 3

A hair dresser who works from home is with a client when her young daughter begins screaming and grabbing her throat. She has massive hematemesis. She is taken to the ER and successfully treated. What complication may develop many years later from this episode?

Answer 3

Squamous cell carcinoma of the esophagus

(Hairdresser with kid = think lye ingestion)

Question 4

What is the major risk factor for the pathology associated with this finding?

Answer 4

GERD/intestinal metaplasia/Barrett’s esophagus

(Sister Mary Joseph nodule = intestinal type gastric carcinoma)

Question 5

Dx?

Answer 5

Tylosis with esophageal CA

(Hereditary condition causing palmoplantar keratoderma around age 10 and esophageal cancer around age 20)

Question 6

A patient with this radiographic finding is at increased risk for which esophageal cancer?

Answer 6

Squamous

(Pancreatic calcifications = alcoholic)

Question 7

Usual location of esophageal adenocarcinoma vs. squamous carcinoma

Answer 7

Adeno - GEJ

Squamous - mid-esophagus

Question 8

A 65 year old male presents with dysphagia and weight loss. Biopsy of a mass in the esophagus taken during endoscopy is below. Dx? Main risk factor?

Answer 8

Esophageal squamous cell carcinoma

Smoking, EtOH

(Notice the lack of glands = not adenocarcinoma)

Question 9

Black, tarry stool is indicative of:

Answer 9

Upper GI bleed (proximal to duodenojejunal junction)

(Acid causes breakdown of hemoglobin into hematin, which makes stool black)

Question 10

A 70 yo male patient presents with weight loss, abdominal pain, hematemesis, and hiccups. Explain the hiccups.

Answer 10

This patient probably has gastric cancer that invaded the diaphragm, causing hiccups

Question 11

Treatment?

Answer 11

Remove if >1 cm otherwise watch

Question 12

A 65 yo male patient with a history of GERD presents with weight loss and early satiety. Endoscopy reveals no mass and manometry is normal. Barium x ray is below. Biopsy would show:

Answer 12

Signet ring cells

(Linitis plastica = leather water bottle; thickened stomach wall = early satiety; diffuse type adenocarcinoma = intestinal metaplasia is precursor so hx of GERD common; no mass lesion)

Question 13

This patient is at increased risk for which esophageal cancer?

Answer 13

Adenocarcinoma

(Scleroderma = can’t clear acid)

Question 14

How does atrophic gastritis predispose to gastric cancer?

Answer 14

No acid –> bacterial overgrowth –> bacterial enzymes –> formation of nitrite –> formation of N-nitroso compounds

Question 15

What would this lesion look like histologically? What is it associated with?

Answer 15

Cystic spaces in gastric epithelium

PPI use and FAP

(Fundic gland polyp)

Question 16

How does chronic inflammation lead to gastric and esophageal cancers?

Answer 16

Chronic inflammation –> cell death –> accelerated repair –> mistakes in repair –> metaplasia or dysplasia –> neoplasia

(Can go through metaplasia or straight to dysplasia then neoplasia but HAS TO GO THROUGH DYSPLASIA)

Question 17

This patient is at increased risk for which esophageal cancer?

Answer 17

Adenocarcinoma

(Truncal obesity = increased abdominal pressure = reflux)

Question 18

Dx?

Answer 18

Esophageal cancer

(Asymmetric mass on barium x ray)

Question 19

Why is esophageal cancer so deadly?

Answer 19

Late presentation + spreads easily because esophagus has no serosa

Question 20

A 68 yo female presents with weight loss, epigastric pain, adnexal pain, and ascites. Bimanual exam reveals bilateral palpable ovaries. Biopsy of the primary tumor reveals:

Answer 20

Signet ring cells from diffuse type gastric adenocarcinoma

(Kruckenburg tumor; ovarian tumors causing the ascities)

Question 21

In which country does diet play a role in gastric cancer? How?

Answer 21

Japan

Smoked fish = lots of dietary nitrate –> converted to nitrite –> formation of N-nitroso compounds

Question 22

Polyp in body of stomach? Antrum? Anywhere?

Answer 22

Body - fundic gland polyp

Antrum - adenomatous polyp

All over - hyperplastic (but caused by H. pylori and atrophic gastritis, which are in antrum; also caused by chronic inflammation so can be anywhere)

Question 23

p53 mutations are an early component of:

Answer 23

Esophageal adenocarcinoma and squamous carcinoma

Question 24

This lesion is associated with ___ and treatment includes ___.

Answer 24

Atrophic gastritis

Removal

(Adenomatous polyp = pedunculated; may also be sessile; must be removed because of pre-malignant potential)

Question 25

Why can gastric cancer cause early satiety? What else should be on your differential?

Answer 25

Invasion causes decreased compliance, leading to early satiety

Gastroparesis, which also causes early satiety

Question 26

Biopsy of the pathology associated with this finding would reveal:

Answer 26

Gastric adenocarcinoma with lots of glands infiltrating mucosa

Question 27

Describe the progression of esophageal squamous cell carcinoma

Answer 27

Esophagitis with loss of p53 –> low-grade dysplasia –> high-grade dysplasia –> invasive carcinoma

(Like cervical carcinoma)

Question 28

List the 4 molecular changes associated with esophageal adenocarcinoma

Answer 28

1. Loss of p53
2. Loss or silencing of p16/INK4 cyclin-dependent kinase inhibitor
3. Mutation of Rb
4. Amplification of cERB-B2 (HER2), cyclin-D, and cyclin-E

Question 29

What two skin conditions are associated with gastric adenocarcinoma?

Answer 29

Leser-Trelate sign (multiple seborrheic keratoses) and acanthosis nigricans