Lecture 5: GI Malignancies + Colorectal Cancer

Question 1

What are some common symptoms of GI malignancies?

Answer 1

1) dysphagia
2) pain
3) anemia
4) vomiting, diarrhea, obstruction
5) weight loss
6) jaundice

*frequently NO symptoms until late stages

Question 2

What are some treatment options for GI malignancies?

Answer 2

1) chemo
2) X-ray therapy
3) surgery
4) stents
5) endoscopic treatments (EMR, bleeding treatment, celiac plexus ablation)

Question 3

What are some post-treatment things to consider with GI malignancies?

Answer 3

1) complications of therapy (dysphagia, disgeusia, pain, altered bowel function)
2) surveillance for recurrence
3) reduce risk factors-stop smoking lady!
4) genetic evaluations? family counseling

Question 4

What problem am I describing?

1) you can get it from tumors AND from therapy
2) often required Percutaneous Endoscopy Gastrostomy for nutritional support (feeding tube through stomach)
3) post therapy fibrosis
4) decreased secretions

Answer 4

Dysphagia

Question 5

You have a patient with:

1) progressive dysphagia
2) vomit
3) fatigue
4) anemia
5) weight loss

How do you test him and stage him?

Answer 5

1) He has esophageal cancer
2) Test him-endoscopy with biopsies
3) Stage him with CT/PET/Endoscopic ultrasound

Question 6

How do you treat esophageal cancer if you wanna CURE that ish?

Answer 6

1) RARE to do only endoscopic therapy if very early stage
2) surgery (esophagectomy with gastric pull-up) +- chemo and radiation
3) nasogastric tube for nutritional support if needed

Question 7

How do you treat esophageal cancer if it has metastatic spread?

Answer 7

• Palliative therapy for mets
  1) esophageal stent-open blocked area
  2) tumor debulking
  3) Percutaneous Endoscopic Gastrostomy tube-directly into stomach, bypassing mouth and esophagus
  4) chemo and radiation to shrink tumor

Question 8

What is Esophageal Stent used for and what are the complications?

Answer 8

1) used for-mets in esophageal cancer to improve dysphagia (not perfect, limitations of intake)

2) complications:
- pain
- GERD
- dislocation (if tumor shrinks)
- perforation
- bleeding
- airway compromise

Question 9

What type of cancer am I describing?

1) jaundice (obstructive)
2) malabsorption
3) pruritis
4) abdominal pain

Answer 9

Pancreatic Cancer (malabsorption cuz of pancreatic enzymes)

Question 10

How do you evaluate pancreatic cancer?

Answer 10

1) tissue acquisition-EUS (endoscopic ultrasound)
2) ERCP (endoscopic retrograde cholangiopancreatography) with brushing
3) metastatic biopsy (CT guided biopsy)
4) staging with CT, endoscopic ultrasound
5) CA 19-9 (cancer antigen)

Question 11

How do you treat this patient?

1) jaundice
2) malabsorption
3) pruritis
4) abdominal pain

Answer 11

They have pancreatic cancer! PAINFUL=PANCREATIC
1) if curative intent-surgery +/-chemo

2) if palliative
- biliary stent (holds bile duct open if blocked) -celiac plexus ablation (stop pain in stomach from cancer)

3) pain management can be challenging
* surveillance with CT

Question 12

Patient presents with:

1) blood in stool, change in bowel pattern, abdominal pain
2) frequently asymptomatic until advanced

What does he have and what is the next step?

Answer 12

He has COLORECTAL CANCER!

Evaluation:

1) colonoscopy with biopsies
2) universal testing for Hereditary Non-Polyposis Colorectal Cancer ( DNA mismatch repair immunohistochemistry vs microsatellite instability)
3) CT, CEA (protein which is sign of cancer)
4) EUS (endoscopic ultrasound)
5) MRI if rectal cancer

Question 13

How do you treat colorectal cancer?

Answer 13

1) If you wanna cure that ish even if stage 4, do surgery +- chemo and x-ray therapy (Radiation) if rectal

2) If you wanna be Palliative
- chemo and x-ray therapy if rectal
- diverting ostomy (diverts bowel to opening in abdomen) vs stent if obstructing
- pain management for late ds (if using narcotics don’t forget bowel regimen to prevent constipation/obstruction)

*think about genetics evaluation and family counseling! (it is 90% cure rate for stage 1!)

Question 14

How do you screen for NON-INVASIVE Colorectal cancer?

Answer 14

1) fecal occult blood testing

2) stool DNA

Question 15

How do you screen for INVASIVE Colorectal cancer?

Answer 15

1) flexible sigmoidoscopy
2) colonoscopy
3) barium enema
4) CT colongraphy

*only endoscopies have ability to remove precancerous polyps and prevent cancer occurrence in the first place

Question 16

When to screen for endoscopic polypectomy?

Answer 16

1) average risk population-starting at age 50

2) first degree relatives with colorectal cancer-age 40 or 10 years younger than relative diagnosis

Question 17

When to screen for endoscopic polypectomy if you had ulcerative colitis?

Answer 17

ulcerative colitis-8 years after diagnosis

Question 18

When to screen for endoscopic polypectomy if you had primary sclerosing cholangitis and ulcerative colitis?

Answer 18

primary sclerosing cholangitis and ulcerative colitis-start when diagnosis made

Question 19

When do you screen for familial adenomatous polyposis?

Answer 19

1) starts at age 10

2) prophylactic colectomy (surgically removing part of colon)

Question 20

When do you screen for Hereditary non-polyposis colorectal cancer?

Answer 20

start at age 20 or 10 years younger than relative diagnosis

*don’t forget extracolonic cancer screening