GI tumours (upper tract) Flashcards by sami sh

Identify the main types of oesophageal tumours (both benign, and malignant).

OESOPHAGUS
Benign (5%):
-Mesenchymal tumors
-Squamous papillomas

Malignant:

Squamous cell carcinoma (90%)
Adenocarcinoma
Others (carcinoid, malignant melanoma, lymphoma, sarcoma)

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Name examples of benign oesophageal tumours.

Leiomyomas
Fibromas
Lipomas
Haemangiomas
Squamous papillomas

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Identify the main types of stomach tumours (both benign, and malignant).

STOMACH
Benign:
-Polymps (non-neoplastic, and adenomas)
-Mesechymal

Malignant:

Carcinoma
Lymphoma
Carcinoid
Mesenchymal

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Describe the epidemiology of oesophageal squamous cell carcinoma.

Age >50
Male to female ratio 2:1 to 20:1
Geographic variation (especially common in Iran, Central China, South Africa)

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Identify risk factors for oesophageal squamous cell carcinoma.

1) Dietary
- Deficiency of vitamins (A, C, riboflavin)
- Fungal contamination of foodstuffs
- High content of nitrites/nitrosamines (preservatives in red meat, when fried, produce carcinogens )

2) Lifestyle
- Burning hot beverages or food
- Alcohol and tobacco

3) Oesophageal disorders
- Long standing oesophagitis (e.g. GORD) and achalasia (defective lower oesophageal sphincter)

4) Genetic predispositon

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Describe the usual location of oesophageal squamous cell carcinoma within the oesophagus.

20% of SCCs occur in upper 1/3
50% in middle third
30% in lower third

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Describe the macroscopic morphology of oesophageal SCC.

Small, grey-white, plaque like thickenings that become tumorous masses.

Three patterns:

1) Protruded polypoid exophytic (60%), grows towards ulcer lumen
2) Flat, diffuse, infiltrative (15%)
3) Excavated, ulcerated (25%)

Eventually, may result in complete obstruction of the eosophagus

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How do we diagnosis oesophageal/gastric cancer ?

Gastroscopy

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How would a oesophageal cancer of the middle third of the stomach look in a barium swallow X ray ?

Middle 1/3 narrow and squashed (due to tumor growth)

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Describe the histology of oesophageal SCCs.

♦ Squamous epithelium affected

♦ 3 main features characteristic of malignant tumours in human body:

Plemorphism
Hyperchromatism (darker color of some cells, because dividing faster)
Mitotic figures

♦ Different degrees of atypia (may be low or high grade dysplasia, with the latter having worse prognosis)

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Identify the main clinical features of oesophageal SCC.

Dysphagia
Extreme weight loss (cachexia)
Haemorrhage and sepsis (tumor eroding blood vessels around oesophagus)
Cancerous tracheoesophageal fistula
Metastases to lymph nodes (cervical, mediastinal, paratracheal, tracheobronchial, gastric and celiac)

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What is the prognosis of oesophageal SCC, in terms of 5-year survival ?

PROGNOSIS: 5% overall five-year survival

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Which part of the oesophagus is usually affected by adenocarcinomas ?

Lower 1/3 of oesophagus is usually affected by adenocarcinomas

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What ages does oesophageal adenocarcinoma affect ?

Starting with age 40, with a median age of 60

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Describe the pathophysiology of oesophageal adenocarcinomas.

First GORD (inflamed) with eosonophils, then metaplasia into columnar with goblet cells (intestinal epithelium) due to gastric reflux, then epithelium starts growing disorganised.
Overall, 10% of all oesophageal adenocarcinomas arise from Barrett mucosa.

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What are the main risk factors for oesophageal adenocarcinomas ?

Tobacco, and obesity

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Describe the morphology, and histology of an oesophageal adenocarcinoma.

-Flat or raised patches or nodular masses, which may be infiltrative or deeply ulcerative

-Histology:
Intestinal cells, disordered
Mucin producing glandular tumors

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Explain the TNM staging of oesophageal carcinoma.

Tis carcinoma in situ
T1 invasion of submucosa
T2 invasion of muscularis propria 
T3 invasion of adventitia
T4 invasion of adjacent structures

N0 no node spread
N1 regional node metastases

M0 no distant spread
M1 distant metastases

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Identify the main clinical features of oesophageal carcinoma.

Dysphagia
Progressive weight loss
Bleeding
Chest pain (because patients will have Barret eosophagus so still heatburn)
Vomiting
Heartburn
Regurgitation (food may go back)

What is the prognosis of oesophageal adenocarcinoma, in terms of 5-year survival ?

• PROGNOSIS: 20% overall five-year survival

Identify the main benign tumors of the stomach.

Polyps (non-neoplastic, and adenomas)

- Leiomyomas and Schwannomas (rare)

Define polyps.

Nodule or mass that projects above the level of the surrounding mucosa, usually in the antrum.

What proportion of all benign stomach tumors do non-neoplastic, and adenomas make up respectively ?

Non-neoplastic polyps (90%)

Adenomas (5-10%)

Identify the main differences between non-neoplastic polyps and adenomas, as two types of benign stomach tumors.

1) Non-neoplastic polyps
- Most are small and sessile (without a stalk)
- Hyperplastic surface epithelium
- Cystically dilated glandular tissue

2) Adenomas
- contains proliferative dysplastic epithelium
- malignant potential
- sessile (without a stalk) or pedunculated (stalked)

What are the signs and symptoms of polyps as benign stomach tumors ?

Usually asymptomatic

Do polyps have hyperchromatism, pleomorphism, or mitotic figures ?

What diagnostic tool may be used to diagnose benign stomach tumors ?

- Gastroscopy can be used to detect the presence of polyps | - Biopsy essential to determine the type of polyps

What is the most common malignant tumor of the stomach ? What proportion of all malignant tumors of the stomach does this make up ?

Gastric carcinoma | 90-95%

True or False: the gastric carcinoma is the second most common tumor in the world.

True

Identify countries in which gastric carcinoma is especially abundant, and give reasons why.

Japan, Colombia, Chile. Because use a lot of smoked fish and sometimes fish in process of smoking or drying can be contaminated with fungi, which is carcinogenic.

Identify risk factors for gastric carcinoma.

1) Environmental - Infection by H. Pylori - Diet - Low socioeconomic status - Cigarette smoking 2) Host - Chronic gastritis - Gastric adenomas - Barrett's oesophagus 3) Genetic factors - Slightly increased risk with blood group A - Family history - Hereditary non-polyposis colon cancer syndrome - Familial gastric carcinoma syndrome

Where in the stomach do gastric carcinomas take place ?

- Pylorus and antrum (50% to 60%;) - Cardiac (25%) - Remainder in the body and fundus (lesser curvature involved in about 40% and greater curvature in about 12%, probably due to differences in blood perfusion)

How are different gastric carcinomas classified ? (i.e. on the basis of what ?)

1) Depth and invasion (early and advanced) 2) Macroscopic growth pattern 3) Histological subtype

What are the different macroscopic growth patterns of gastric carcinomas ?

1) Exophytic 2) Flat or depressed → Linitis Plastica (diffuse infiltrative gastric carcinoma, with mucosal erosion, and markedly thickened gastric wall) 3) Excavated (ill-defined, central ulcer surrounded by irregular, heaped- up borders)

True or False: Gastric carcinomas that have a linitis plastica macroscopic growth pattern have a poor diagnosis because early stage can be missed.

True

What would be the Barium X ray appearance of a gastric carcinoma ?

Contrast defect filling, due to tumour

What are the main histological types of gastric adenocarcinomas ?

1) Intestinal type • Composed of neoplastic intestinal glands resembling those of colonic adenocarcinoma • Cells often contain apical mucin vacuoles, and abundant mucin may be present in gland lumens 2) Diffuse type • composed of gastric-type mucous cells, which generally do not form glands, but rather permeate the mucosa and wall as scattered individual cells or small clusters in an "infiltrative" growth pattern • mucin (in vacuoles) formation expands the malignant cells and pushes the nucleus to the periphery, creating a "signet ring" 3) Mixed type (combination of both)

Describe the spread of gastric carcinomas.

All gastric carcinomas eventually penetrate the wall and spread to regional and more distant lymph nodes: – Supraclavicular (Virchow) node (especially anterior aspect of posterior triangle ) – Local invasion of gastric carcinoma into the duodenum, pancreas, and retroperitoneum – metastases to the liver and lungs are common – metastases to the ovaries called Krukenberg tumour

Describe the TNM staging of gastric carcinomas.

T0 - no evidence of primary tumour Tis - carcinoma in situ (intraepithelial) T1 - invades lamina propria or submucosa T2 - invades muscularis propria or subserosa (not visceral peritoneum) T3 - penetrates visceral peritoneum but not adjacent structures T4 - invades adjacent structures (spleen, colon etc) N0 - no LN metastasis N1 - 1-6 lymph nodes N2 - 7-15 lymph nodes N3 - more than 15 lymph nodes M0 - no distant metastasis M1 - distant metastasis, in portal LN, mesenteric, retroperitoneal or more distant

Identify the main clinical features of gastric carcinomas.

* Asymptomatic until late * Weight loss * Abdominal pain * Anorexia * Vomiting * Altered bowel habits * Dysphagia * Anaemic symptoms * Haemorrhage

State the prognosis (5-year survival) of gastric carcinomas.

– Early gastric cancer is 90% to 95% | – Advanced gastric cancer < 15%

What proportion of all gastric malignancies do gastric lymphomas make up ?

What proportion of all gastric lymphomas are associated with chronic gastritis and H. Pylori infection ?

>80% of gastric lymphomas are associated with chronic gastritis and H. Pylori infection.

State the prognosis (5-year survival) of gastric lymphomas.

PROGNOSIS: 50% five-year survival

In gastric lymphoma, which cells become malignant ? Which type of lymphomas are gastric lymphomas ?

B cell lymphocytes | B-cell lymphomas of mucosa-associated lymphoid tissue (MALT lymphomas)

Describe the morphology of gastric lymphomas.

– Commonly occurs in the mucosa or superficial submucosa – B lymphocyte accumulation, with lymphocytic infiltrate of the lamina propria surrounds gastric glands massively infiltrated with atypical lymphocytes and undergoing destruction • the "lymphoid epithelioid" lesion