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GI neoplasms Flashcards

1
Q

benign and malignant tumors of the esophagus?

A
  • benign: leiomyoma

- malignant: esophageal carcinoma

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2
Q

Esophageal carcinomas?

A
  • SCC: more prevalent worldwide, RFs: long standing esophagitis, achalasia, smoking, ETOH, diet
  • adenocarcinoma: more common in USA, occurs in barrett’s esophagus, more in distal 1/3
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3
Q

Mortality rate, prevalence of esophageal cancer?

A
  • high mortality rate
  • relatively rare - 1% of malignancies
  • increased prevalence in N China, India, and Iran
  • higher incidence in men
  • 50-80 yrs old
  • bad actor and presents late
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4
Q

Sx of esophageal cancer?

A
  • progressive dysphagia
  • odynophagia
  • regurgitation
  • heartburn
  • anorexia
  • vomiting
  • wt loss
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5
Q

Dx imaging of esophageal cancer?

A
  • UGI/barium swallow
  • endoscopic US
  • EGD: tissue is the issue
  • GOLD standard
  • CT for staging and r/o mets
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6
Q

Why is an EUS used along with an endoscopy in dx esophageal cancer?

A
  • because EUS shows how extensive the tumor is, endoscopy can’t show that
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7
Q

Tx of esophageal cancer?

A
  • chemo (Preop and post-op protocols)
  • radiation (post-op)
  • surgery (best cure)
  • combined modality tx leads to best outcome
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8
Q

What is the hypothesis for why stomach cancer rates are declining?

A
  • popularization of refrigerators marks a pivotal pt for the decline. They have improved storage of food, thereby reducing salt-based preservation and preventing bacterial and fungal contamination. Fridges also allowed for fresh food and veggies to be more readily available, which may be a valuable source of antioxidants impt for cancer prevention
  • recognition of role of H. pylori
  • high mortality unless disease is detected early
  • highest rate in Republican of Korea b/c of salted and pickled foods
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9
Q

Benign sources of stomach cancer?

A
  • polyps: hyperplastic
  • tumors: leiomyomas (smooth muscle)
  • lipomas
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10
Q

Malignant sources of stomach cancer?

A
  • carcinoma (epithelial)
  • lymphoma (Lymphatic)
  • sarcoma (CT)
  • carcinoid (serotonin secreting)
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11
Q

Gastric polyps - types and macroscopic appearance? Tx?

A
  • types:
    tubular
    villous (often larger, greater than 2 cm and malignant)
  • macroscopic appearance:
    more often in antrum
    pedunculated with malignant potential
    solitary, large and ulcerated

-tx:
endoscopic removal if no malignancy ID - periodic surveillance

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12
Q

How common are gastric leiomyomas? Pathology? Tx?

A
  • incidence is 16% at autopsy
  • pathology:
    arise from smooth muscle of GI tract - difficult to distinguish from GI stromal tumor
  • 75% benign: diff only on mitotic index
  • large protruding lesions with central ulcer
  • usually presents with bleeding if at all
  • tx: local excision with 2-3 cm margin
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13
Q

Adenocarcinoma of the stomach RFs?

A
  • declining incidence in western world
  • HP assoc due to chronic atrophic gastritis

also related to:

  • low dietary intake of veggies and fruit
  • high dietary intake of starches
  • more common in males (3:1)
  • increased incidence with pernicious anemia and blood group A
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14
Q

Histological typing of adenocarcinoma of the stomach?

A
  • ulcerated carcinoma (25%): deep penetrate ulcer with shallow edges, usually through all layers of the stomach
  • polipoid carcinoma (25%): intraluminal tumors, large in size, late mets
  • superficial spreading carcinomas (15%): confinement to mucosa and sub-mucosa, mets 30% at time of dx, best prognosis
  • linitis plastica (aka Brinton’s disease or leather bottle stomach) - 10%
    involves all layers of the stomach, poor prognosis, “leather bottle” appearance on xray
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15
Q

Signs and sxs of adenocarcinoma of the stomach?

A
  • vague discomfort difficult to distinguish from dyspepsia
  • anorexia: meat aversion, pronounced wt loss
  • at late stage:
    epigastric mass
    hematemesis usually coffee ground
  • mets: Virchow’s node (L supraclavicular)
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16
Q

How do gastric carcinomas spread?

A
  • local infiltartion (through wall of stomach to peritoneum, pancreas)
  • lymphatic: local and regional lymph nodes
  • blood: liver and lungs
  • transcoelomic (across peritoneal cavity): often involves ovaries (esp signet ring cancer) - krukenberg tumor (ovarian tumor that met from primary site - colon or stomach)
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17
Q

Dx of gastric cancer?

A
  • anemia in 40%
  • elevated CEA in 65% (not specific)
  • UGI
  • endoscopy: tissue is the issue
  • CT scans for met work up
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18
Q

Tx of adenocarcinoma of the stomach?

A 
- surgical resection is the only cure:
late presentation makes surgery often futile
palliation controversial for:
hemorrhage
gastric outlet obstruction
- prognosis overall: 12% 5 yr survival: 
90% for stage 1 disease
radiation and chemo offer little benefit
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19
Q

Less common gastric neoplasms?

A
  • lymphoma
  • gastrointestinal stromal tumor (GIST)
  • neuroendocrine (carcinoid) tumors
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20
Q

How common are gastric lymphomas? Types? Tx?

A
  • 5% of primary gastric neoplasms
  • 2 diff types of lymphoma (MALT: mucosa assoc lymphoid tissue)
  • tx: sensitive to radiation
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21
Q

Most common site for GIST?

A
  • mesenchymal neoplasms

- stomach is the most common site

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22
Q

Neurodendocrine tumors of the stomach?

A
  • carcinoids are tumors of resident neuroendocrine cells in the gastric glands
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23
Q

Gasric sacroma - how common, diff types?

A
  • 1-3% of gastric malignancies
  • wide variety of tumors:
    leiomyosarcoma
    leomyoblastoma
    GIST
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24
Q

Mortality of pancreatic cancer, incidence of it?

A
  • one of leading causes of cancer mortality
  • 28000 new cases/year
  • incidence increases with age
  • rarely b/f 50, usually 60-70
  • slightly more in men
  • less than 20% live longer than 1 yr
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25
Q

Etiology of pancreatic cancer?

A
  • exact cause is unknown
  • smokers at high risk
  • high fat, high protein, high alcohol diets
  • may be genetic
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26
Q

PP of pancreatic cancer?

A
  • usually arises from epithelial cells of pancreatic ducts
  • tumor typically discovered in late stages so has spread throughout pancreas
  • rapid growing with spread to surrounding tissue
  • most common site is head of pancreas
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27
Q

Signs and sxs of pancreatic cancer?

A
  • vague, dull, abdominal pain
  • painless jaundice
  • weight loss, weakness
  • anorexia, N/V
  • glucose intolerance
  • flatulence
  • GI bleeding
  • ascites
  • leg/calf pain
  • jaundice (if head of pancreas involved)
    clay colored stools
    dark urine
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28
Q

Dx pancreatic cancer?

A
  • no specific blood tests to dx
  • elevated amylase, lipase, AP, bili, CEA C19-9
  • CT, US
  • ERCP - most definitive dx test
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29
Q

Clinical management of pancreatic cancer?

A
  • goal is to prevent spread of tumor
  • chemo or radiation
  • pain control (opioids)
  • distal resection
  • whipple procedure
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30
Q

What is the whipple procedure?

A
  • radical pancreaticoduodenectomy
  • used for cancer of the pancreas head only: excision of all or part of the pancreas together with the duodenum and usually distal stomach
31
Q

What is ZES?

A
  • islet cell tumor of pancreas (or duodenum) - gastronome
  • hypergastrinemia: secreting excess levels of serum gastrin - consequences of acid hyper secretion - leads to PUD, GERD (w/ or w/o complications), hallmarks: chronic diarrhea, and malabsorption
32
Q

Epidemiology of ZES?

A
  • any age group (mean age: 43)
  • male: female 3:2
  • occurs in approx 0.1-1% of all pts with duodenal ulcers
33
Q

Sxs in pts with ZES?

A
  • pain and diarrhea (50-60%)
  • pain w/o diarrhea (25%)
  • diarrhea w/o pain ( 20%)
  • heartburn +/- dysphagia (30%)
  • MEN-1 features: 20-25%
34
Q

Dx ZES?

A
  • begins with clinical suspicion
  • fasting serum gastrin measurement:
    high sensitivity: greater than 95%
    poor specificity, even at high levels
35
Q

Management of ZES?

A
  • acid control (PPI) takes precedence over tumor search
  • prognosis is excellent in pts w/o met disease
  • tumor search is designed to find tumor and to stage its/their extent - CT
  • tumor search and possible resection for cure is only prudent for pts who are surgical candidates
36
Q

Other types of pancreatic cancers?

A
  • insulinoma

- glucagonoma: very rare

37
Q

Cancer of the liver: most common? Other type?

A
  • HCC is most common form and it comes form main type of liver cell, hepatocyte
  • about 3 out of 4 primary liver cancers are HCC
  • cholangiocarcinoma starts in small bile ducts that carry bile to the gallbladder
  • about 1 or 2 out of 10 cases of liver cance rare cholangiocarcinomas
38
Q

Incidence of liver cancer?

A
  • 35,660 new cases of liver cancer and bile duct cancer in US in 2015
  • 24, 550 est deaths in 2016
  • it is 2x as common in men as in women
  • 14th most common cancer in the US
39
Q

Causes of liver cancer?

A
  • chronic infection with HBV and HCV
  • cirrhosis (scar tissue in liver) due to alcohol, hepatitis
  • tobacco
  • aflatoxins from fungus that can contaminate peanuts, wheat, soybeans, groundnuts, corn and rice
40
Q

How can HBV transmission be prevented? How is it spread?

A
  • Prevent HBV transmission: found in body fluids - blood, saliva, semen, mucus, vaginal fluid, and breast milk, sharing injecting equip, toothbrushes or razors
  • it can be transmitted from mother to child at birth
  • wash hands after touching blood or bodily fluids
  • avoid sharing personal hygiene items that may come into contact with body fluids
  • cover all cuts and open sores with bandage
  • practice safe sex
  • HBV vaccination - for all kids and high risk adults
  • avoid alcohol use
41
Q

How is HCV spread?

A
  • by blood to blood contact only
  • transmission can occur through sharing needles, unsterile tattooing, body piercings, sharing razor blades and toothbrushes
  • certain sexual activities- - mother to baby
  • no vaccine
42
Q

Sxs of liver carcinoma?

A
  • loss of appetite and wt
  • jaundice
  • swelling of the abdomen
  • pain in the abdomen
43
Q

Dx liver cancer - labs and imaging

A
  • LFTs: will be elevated
  • AFP (alpha fetoprotein) blood test (tumor marker to help detect and dx cancers of the liver, testicles and ovaries)
  • blood tests for Hep B and C
  • bx
  • US
  • CT or MRI of liver
  • angiogram of liver
  • laparoscopy
44
Q

Staging of liver cancer?

A
  • stage 1: single small tumor less than 2 cm
  • stage 2: single large tumor or many small tumors confined to one lobe of the liver
  • stage 3: many large tumors confined to one lobe of the liver or cancer spread to lymph nodes
  • stage 4: cancer spread to both lobes of the liver
45
Q

Tx of liver cancer?

A 
- surgery:
curative intent in stages I, II
- liver wedge resection
- liver lobectomy
- liver tranplantation
  • chemo: drugs given by hepatic artery infusion, drugs given by chemo embolization
46
Q

Survival rates of liver cancer?

A
  • at 5 yrs:
    early localized cancer: 30-40%
    all stages combined: 10%
47
Q

How common are small bowel cancers? How big is the small intestine? Incidence?

A
  • SI accounts for approximately 75% of length of GI tract and more than 90% of mucosal surface
  • fewer than 2% of GI malignancies arise in SI
  • incidence: 1/100,000
  • est to be less than 5000 cases per year dx in US
48
Q

Types of small bowel malignancies?

A
  • 30-50% are adenocarcinomas
  • 25-30% are carcinoids
  • 15-20% are lymphomas
  • 10-20% are gi stromal tumors
49
Q

RFs for small bowel adenocarcinoma?

A
  • pre-existing adenoma, either single or multiple
  • crohns
  • celiac disease
  • IgA deficiency
  • alcohol abuse
  • neurofibromatosis
  • urinary diversion procedures
  • red meat
50
Q

Clinical presentation of small bowel CA?

A
  • abdominal pain
  • N/V
  • bleeding/anemia
  • wt loss
  • gastric outlet obstruction
  • diarrhea
51
Q

Dx small bowel malignancies?

A
  • UGI/SBFT
  • single contrast fluoroscopy: mass, mucosal defect
  • CT scan
  • capsule endoscopy
52
Q

Prognosis and tx of small bowel CA?

A
  • pretty good with surgery!!
53
Q

How common is colorectal cancer?

A
  • common in both sexes
  • can be lethal
  • 3rd most common cancer and 3rd leading cause of cancer death in both sexes. Up to 1/3 of pts ultimately succumb to this disease
  • prognosis improves the earlier the cancer is dx
  • commonly a preventable disease - get a colonoscopy
54
Q

Incidence of CRC?

A
  • infrequent b/f age 40
  • incidence rises progressively after age 40 to 3.7/1000 per year by age 80
  • lifetime incidence for pts at avg risk is 5%
  • 90% of all cases occur after age 50
55
Q

Screening for CRC?

A
  • purpose of screening - find cancer at earlier stage to improve survival
  • once colonoscopy became readily available, it ultimately became screening method of choice
  • colonoscopy drastically decreases the risk of colorectal cancer (over 90%)
56
Q

Adenoma-carcinoma sequence of progression?

A
  • DNA alteration - going to have normal epithelium - but will lead to adenoma and then to late adenoma and then to early cancer and late cancer
  • vast majority of colorectal cancers arise from adenomatous polyps
  • polyps grow from small to larger polyps ultimately accum. increasing dysplastic characteristics
  • current thought is that progression probably takes at least 10 yrs in most people
  • prevalence of adenomas is about 25% by age 50 and 50% by age 70
57
Q

Polyps that are harder to ID that can cause cancer? Two main types of colorectal polyps?

A
  • some cancers arise from flat adenomas (not polypoid)
  • 2 main types of colorectal polyps are either adenomas or hyperplastic polyps, these lesions can’t be distinguished reliably on gross appearance, bx is required for dx
  • 2/3 of polyps are adenomas
  • larger the polyp, the more likely is progression to cancer - impt because if you remove the polyps when they are smaller they can’t grow into cancer
  • hyperplastic polyps account for most of remaining polyps and are mainly distal. They are generally thought not to progress to cancer, although some may
58
Q

What are other screening tests for CRC?

A
  • FOBT and FIT: stool on a card to detect blood, helped to id those pts with large polyps and cancers
  • flex sigmoidoscopy: involves inspecting only last 1/3 of colon, largely has been replaced by complete colonoscopy
  • COLONOSCOPY
59
Q

Why has the colonoscopy become the screening test of choice?

A
  • looks at the entire colon
  • if a polpy is found, it can be removed through the scope and sent to pathology to determine the type of polyps and to rule out cancer
  • other abnormalities of teh colon can be ID’d
  • when polyps are removed they cant grow into cancer
60
Q

RFs for CRC?

A
  • polpys (Noncancerous or precancerous growth assoc with aging)
  • age
  • IBD
  • diet high in saturated fats such as red meat
  • personal or family hx of cancer
  • obesity
  • smoking
61
Q

What is HNPCC?

A
  • heriditary non-polypossi colorectal cancer, sometimes called lynch syndrome, accounts for approx 5-10% of all colorectal cancer cases
  • risk of colorectal cancer in families with HNPCC is 70-90%
  • people with HNPCC are dx with CRC at avg age of 45
62
Q

What is FAP?

A
  • familial adenomatous polpyosis accounts for 1% of colorectal cancer cases
  • people with FAP typically develop 100s to 1000s of colon polyps, polyps are initially benign but there is nearly a 100% chance that the polyp will develop into cancer if left untx
  • colorectal cancer usually occurs by age 40 in people with FAP
63
Q

Sxs of CRC?

A
  • change in bowel habits: diarrhea, constipation, or a feeling that the bowel does not empty completely
  • bright red or dark blood in the stool
  • abdominal discomfort
64
Q

How is CRC evaluated?

A
  • dx is confirmed by bx
  • stage of disease is confirmed by pathologist and imaging tests, CT - nodes, liver and lung involvement
  • endoscopic US and MRI may also be used to stage rectal cancer
65
Q

Tx of CRC cancer?

A
  • surgery: foundation of curative surgery, tumor along with adjacent healthy colon or rectum and lymph nodes, is typically removed to offer the best chance for cure
  • chemo: typical meds include fluorouracil (5-FU), oxaliplatin (eloxatin), irinotecan (camptosar), and capecitbaine (xeloda)
  • radiation: used to tx rectal cancer, eitehr before or after surgery, diff methods of delivery, external beam (outside the body)
  • antiangiogenesis: starves tumor by disrupting its blood supply, therapy is given along with chemo, Avastin was approved in 2004 for tx of stage IV colorectal cancer
66
Q

Staging TNM system?

A
  • T: the size (depth of penetration of tumor into the wall of bowel)
  • N: if cancer has spread to nearby lymph nodes
  • M: if cancer has metastasized
67
Q

What is stage I colorectal cancer?

A
  • cancer has grown through mucosa and invaded muscularis (muscular coat)
  • tx is surgery to remove tumor and surrounding lymph nodes
68
Q

Stage II colorectal cancer?

A
  • cancer has grown beyond muscularis of the colon or rectum but hasn’t spread to lymph nodes
  • stage II is tx with surgery and in some cases - chemo after surgery
69
Q

Stage III CRC?

A
  • cancer has spread to regional lymph nodes (near colon and rectum)
  • stage III colon cancer is tx with surgery and chemo
70
Q

Stage IV CRC?

A
  • cancer has spread outside of colon or rectum to other areas of the body
  • stage IV cancer is tx with chemo. Surgery to remove the colon or rectal tumor may or may not be done
71
Q

F/U care for CRC?

A
  • serial CEA measurements are recommended
  • colonoscopy one yr after resection of CRC
  • surveillance colonoscopy q 3-5 yrs to ID new polyps and/or cancers
72
Q

Rectal cancer?

A
  • better prognosis than colon
  • rx not beneficial for rectal cancer (problems with incontinence)
  • DRE/hemoccult
  • CEA
  • surgery
73
Q

How is anal cancer diff than colon or rectal cancer?

A
  • SCC
  • risk slightly higher in women
  • 2016: est 8000 more cases
  • bowel changes
  • bleeding
  • HPV assoc (major cause) - smokers/HIV
  • 10% mets
  • tx: often effective/cured: surgery, radiation, chemo
  • survival: better than CRC, 5 yr 65.7% overall, for localized disease with early dx: 80%

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