Patho Final: GI, H&N

Question 1

Describe the fatality of esophageal cancer…

Answer 1

1% of all diagnosed cancers

Rapidly fatal, one of the most deadly, and rapidly increasing.

Question 2

What is the histology of cancer in the upper 2/3 of the esophagus?

Answer 2

Squamous cell carcinoma

Question 3

What is the lower 1/3 esophageal cancer histology?

Answer 3

Adenocarcinoma

Question 4

Who has the higher occurance of esophageal cancer?
- Men or Women?
- White of Black?

Answer 4

Men
White

Question 5

By how much does the risk of esophageal adenocarcinoma increase when you have reflux symptoms more than 3 times a week?

Daily GERD symptoms?

Answer 5

17 fold increase

5 times increase

Question 6

What is Barret’s Esophagus/Barrett’s Esophagitis?

Answer 6

Dysplastic changes in distal esophagus and gastroesophageal junction.

Barret’s Esophagitis means that the metaplastic version is no longer working for the acid, so those glandular cells are becoming damaged and dysplastic. They try to replace themselves quicker to make a barrier, which puts you at greater risk for mistakes in replication.

Question 7

By how much does a patient with Barrett’s Esophagus have an increased risk of developing adenocarcinoma of the esophagus?

Answer 7

30-40 fold increase
(10-15% of Barrett’s patients will develop adenocarcinoma.)

Question 8

What are the 3 types of Adenocarcinoma of the GE junction?

Answer 8

Type 1: Associated with HPV

Type 2: Associated with reflux leading to intestinal metaplasia (Barrett’s). May be associated with Helicobacter pylori.

Type 3: May be associated with infection with Helicobacter pylori.

Question 9

What are the presenting symptoms of esophageal cancer?

Answer 9

1. Retrosternal discomfort or indigestion.
2. Friction or burning when swallowing food.
3. Dysphagia, odynophagia
4. Weight loss
5. Hoarseness, cough
   6.Regurgitation, vomiting
6. Hematemesis or melena (uncommon)

Question 10

Explain the mechanism of how the hydrochloric acid can lead to cancer…

What role dose helicobacter pylori have in this?

What increases hydrochloric acid in the stomach?

Answer 10

The stomach contains hydrochloric acid, which never comes into direct contact with the epithelium due to the layer of mucous. When the acid reaches the epithelial barrier, it creates an ulcer. Side note, helicobacter pylori can often cause peptic ulcer disease. Stratified squamous cells don’t stand a chance against acid as the interaction causes inflammation which eventually leads to metaplasia if it occurs too often.

Alcohol and cigarette smoking increase hydrochloric acid in the stomach

Question 11

When does significant dysphagia occur?

What type of tumor can you infer it is, from the term “occluded”?

Answer 11

Occurs after 50-75% of the esophageal lumen is occluded

Extensive involvement of the esophagus and surrounding structures in 90% of cases.

Occluded = Fungating

Question 12

What symptoms point to a poor prognosis in esophageal cancer?

Answer 12

Significant dysphagia

Persistant substernal pain unrelated to swallowing.

Coughing after swallowing (indicates tracheoesophageal fistula is present)

Hiccups (indicates involvement of diaphragm)

Question 13

At what stage is esophageal cancer usually diagnosed in the U.S.? (General)

What percent experience locoregional extension or distant mets?

Answer 13

Advanced Stage

75%

Locoregional extension & distant mets prevent surgical care.

Question 14

What route of therapy is the goal for esophageal?

What are the alternatives if the goal cannot be achieved?

Answer 14

Complete resection

There is no survival benefit from palliative resection

Palliation of dysphagia w/stents or combined chemotherapy

Question 15

What are the 5 year survival rates in resected patients?

-confined to esophagus
-involvement of adjacent tissues
-involvement of regional nodes
-overall survival

Answer 15

Confined to esophagus : 50%

Adjacent tissues : 15%

Regional nodes : 10%

Overall survival : 20-25%

Question 16

How common is stomach cancer in the US?

Answer 16

Rare

Question 17

What area of the stomach do we find cancer the most?

Answer 17

Where the chyme lies against the mucosal barrier the longest

Question 18

How deadly is stomach cancer?

Answer 18

Almost as deadly as esophageal CA

Question 19

What are the 3 morphologic types of stomach carcinomas?

Answer 19

Fungating

Ulcerating

Diffuse: w/in the stomach lining

Question 20

What color is the gastric carcinoma when blood interacts w/hydrochloric acid?

Answer 20

Black

Question 21

What is the epidemiology of small bowel adenocarcinoma?

What is the incidence?

Answer 21

< 2% of GI malignancies

< 5000 cases per year in the US

incidence: 1 per 100,000

Question 22

What percent of the length of the GI tract is the small intestine?

Answer 22

75%

This is where most absorption of nutrients takes place

Question 23

Describe the anti-neoplastic environment of the small intestine?

Answer 23

1. Liquid contents cause less irritation than more solid contents of the large bowel (whatever is left for large bowel is very diluted)
2. Rapid transit of intestinal contents provides shorter exposure or mucosa to carcinogens
3. Lower bacterial load may result in decreased conversion of bile acids into potential carcinogens

4 Bensopyrene hydroxylate, enzyme responsible for the conversion of the known carcinogen benzopyrene (which is found in flamed foods: veggies, meat, bbq…), is present in higher concentrations in the small bowel.

5. Increased lymphoid tissue and higher levels of IgA.

For any cancer to manifest, there must be repeated damage

Environment doesn’t support cancer because it’s liquid & fast moving

Question 24

How does cancer of the small intestine present itself?

Answer 24

Abdominal
Nausea & bomiting
Bleeding/Amnesia
Weight loss
Gastric outlet obstruction
Diarrhea

Mean time of diagnosis -> initial complaint = 7mo

50% w/emergent obstruction or bleeding

Question 25

What techniques are used to diagnose small bowel malignancies?

Answer 25

Most malignancies probably occur closer to the stomach due to high concentrations.

Basic CT, MRI, Ultrasound

CT enteroclysis

Endoscopy/Enteroscopy (Intraoperative endoscopy)
**Push enteroscopy allows visuals for 40-60 cm of small bowel

Capsule endoscopy

Exploratory laparotomy/laparoscopy
**Most sensitive diagnostic modality
**Preop diagnosis of small bowel malignancy is made in 50%
**should be considered for all cases in patients with occult GI bleeding,, weight loss, unexplained abdominal pain.

Question 26

What are the clinical features of small bowel adenocarcinoma/

Answer 26

Majority arise in the duodenum and jejunum

Increased exposure to pancreatic and biliary secretions

Exception is in patients w/Crohn’s in whom the most common site is the terminal ileum

Question 27

What are the different types of neoplasms of the large intestines?

Answer 27

Nonneoplastic polyps (hyperplastic, juvenile)

Neoplastic polyps (adenomas)
- Tubular adenoma (adenomatous polyp)
- Villous adenoma
- Familial polyposis

Carcinoma

Question 28

What is the 5 yr survival rate of colorectal cancer?

Answer 28

50-55%

Question 29

Do men or women have a higher incidence of colorectal cancer?

Which race has higher incidence?

Answer 29

Equal

African Americans

High morbitity, mortality, and cost

Question 30

At what age are most colorectal cancers?

What fraction of these patients die?

What percent of patients are screened?

Answer 30

90% occur after age 50

1/3

50%

Question 31

Describe the etiology of colon cancer…

Answer 31

92% Sporadic Colon Cancer

5-6% Hereditary Nonpolyposis Colon Cancer

1% FAP & Rare syndromes

1% Chronic IBD
*Ulcerative cholitis
*Crohn’s disease

Question 32

What is familial adenomatous polyposis?

Answer 32

FAP occurs when a person is born with a mutation is specific gene called the APC gene

People born with FAP are at nearly 100% risk of developing colon cancer if they do not undergo surgery

Question 33

How does FAP cause colon cancer?

Answer 33

Individuals with FAP begin developing polyps teenage years. They will have hundreds of polyps by their 50’s

Normal individuals with colon cancer have around 10 polyps