Patho Final: GI, H&N Flashcards
Describe the fatality of esophageal cancer…
1% of all diagnosed cancers
Rapidly fatal, one of the most deadly, and rapidly increasing.
What is the histology of cancer in the upper 2/3 of the esophagus?
Squamous cell carcinoma
What is the lower 1/3 esophageal cancer histology?
Adenocarcinoma
Who has the higher occurance of esophageal cancer?
- Men or Women?
- White of Black?
Men
White
By how much does the risk of esophageal adenocarcinoma increase when you have reflux symptoms more than 3 times a week?
Daily GERD symptoms?
17 fold increase
5 times increase
What is Barret’s Esophagus/Barrett’s Esophagitis?
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.
By how much does a patient with Barrett’s Esophagus have an increased risk of developing adenocarcinoma of the esophagus?
30-40 fold increase
(10-15% of Barrett’s patients will develop adenocarcinoma.)
What are the 3 types of Adenocarcinoma of the GE junction?
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.
What are the presenting symptoms of esophageal cancer?
- Retrosternal discomfort or indigestion.
- Friction or burning when swallowing food.
- Dysphagia, odynophagia
- Weight loss
- Hoarseness, cough
6.Regurgitation, vomiting - Hematemesis or melena (uncommon)
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?
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
When does significant dysphagia occur?
What type of tumor can you infer it is, from the term “occluded”?
Occurs after 50-75% of the esophageal lumen is occluded
Extensive involvement of the esophagus and surrounding structures in 90% of cases.
Occluded = Fungating
What symptoms point to a poor prognosis in esophageal cancer?
Significant dysphagia
Persistant substernal pain unrelated to swallowing.
Coughing after swallowing (indicates tracheoesophageal fistula is present)
Hiccups (indicates involvement of diaphragm)
At what stage is esophageal cancer usually diagnosed in the U.S.? (General)
What percent experience locoregional extension or distant mets?
Advanced Stage
75%
Locoregional extension & distant mets prevent surgical care.
What route of therapy is the goal for esophageal?
What are the alternatives if the goal cannot be achieved?
Complete resection
There is no survival benefit from palliative resection
Palliation of dysphagia w/stents or combined chemotherapy
What are the 5 year survival rates in resected patients?
-confined to esophagus
-involvement of adjacent tissues
-involvement of regional nodes
-overall survival
Confined to esophagus : 50%
Adjacent tissues : 15%
Regional nodes : 10%
Overall survival : 20-25%
How common is stomach cancer in the US?
Rare
What area of the stomach do we find cancer the most?
Where the chyme lies against the mucosal barrier the longest
How deadly is stomach cancer?
Almost as deadly as esophageal CA
What are the 3 morphologic types of stomach carcinomas?
Fungating
Ulcerating
Diffuse: w/in the stomach lining
What color is the gastric carcinoma when blood interacts w/hydrochloric acid?
Black
What is the epidemiology of small bowel adenocarcinoma?
What is the incidence?
< 2% of GI malignancies
< 5000 cases per year in the US
incidence: 1 per 100,000
What percent of the length of the GI tract is the small intestine?
75%
This is where most absorption of nutrients takes place
Describe the anti-neoplastic environment of the small intestine?
- Liquid contents cause less irritation than more solid contents of the large bowel (whatever is left for large bowel is very diluted)
- Rapid transit of intestinal contents provides shorter exposure or mucosa to carcinogens
- 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.
- 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
How does cancer of the small intestine present itself?
Abdominal
Nausea & bomiting
Bleeding/Amnesia
Weight loss
Gastric outlet obstruction
Diarrhea
Mean time of diagnosis -> initial complaint = 7mo
50% w/emergent obstruction or bleeding
What techniques are used to diagnose small bowel malignancies?
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.
What are the clinical features of small bowel adenocarcinoma/
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
What are the different types of neoplasms of the large intestines?
Nonneoplastic polyps (hyperplastic, juvenile)
Neoplastic polyps (adenomas)
- Tubular adenoma (adenomatous polyp)
- Villous adenoma
- Familial polyposis
Carcinoma
What is the 5 yr survival rate of colorectal cancer?
50-55%
Do men or women have a higher incidence of colorectal cancer?
Which race has higher incidence?
Equal
African Americans
High morbitity, mortality, and cost
At what age are most colorectal cancers?
What fraction of these patients die?
What percent of patients are screened?
90% occur after age 50
1/3
50%
Describe the etiology of colon cancer…
92% Sporadic Colon Cancer
5-6% Hereditary Nonpolyposis Colon Cancer
1% FAP & Rare syndromes
1% Chronic IBD
*Ulcerative cholitis
*Crohn’s disease
What is familial adenomatous polyposis?
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
How does FAP cause colon cancer?
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
