Upper GI Cancers Flashcards
The most common Gastrointestinal stromal tumors (GISTs) occur in which locations?
Most often in stomach and proximal S intestine
What is meant by the term field defect?
Also called ‘‘field cancerization’’ - region of tissue that precedes and predisposes to development of cancer
list 6 investigations which may be performed for suspected or confirmed upper GI cancers?
- Routine investigations
- Contrast-enhanced CT, MRI
- PET scan
- MRCP
- ERCP
- Endoscopy followed by biopsy of suspicious tissue
- Endoscopic ultrasound (EUS)
What are the two main types of Oesophageal cancer and which is most common
At which location does each arise
Adenocarcinoma → near GOJ
Squamous cell carcinoma → mid-portion of esophagus
AC more common in developed countries
What is the main risk factor for ACs of the oesophagus, explain this pathology
How would it present
Barrett’s - metaplastic change of mucosa from squamous to columnar
May present as ulcers and nodules
What would be seen on endoscopy of Barrets oesophagus?
How is a diagnosis confirmed?
Endoscopy: red patch of tissue in generally pink lower oesophagus
Diagnosis confirmed by: metaplastic change of oesophageal mucosa from squamous to columnar mucosa with intestinal metaplasi
Which node group tend to be involved in AC of the oesophagus and why?
Celiac and perihepatic nodes because of location of tumor at GOJ
From where do SSC of the oesophagus arise?
How may these be diagnosed early?
Arises from denuded epithelium or plaques
Early lesions are usually subtle, so tissue staining with Lugol iodide solution during endoscopy may facilitate diagnosis of early lesions
List 3 risk factors for each of ACs and SSCs of the oesophagus
Squamous Cell: Long-standing GORD, Obesity, High fat intake
Adenocarcinomas: Barrets, Alcohol, Smoking, Chronic achalasia
List 4 symptoms of oesophageal cancer
Early stage lacks well-defined symptoms
Later stage
- Dysphagia (solids then liquids)
- Weight loss
- Odynophagia (painful swallowing)
- Hoarseness (RLn.)
List 2 late complications of oesophageal cancer
Acute upper GI bleed (rare): tumor erosion into aorta, pulmonary or bronchial arteries
Tracheobronchial fistulas: direct invasion through oesoph wall into the main stem bronchus
First line investigation for Oesophageal cancer
Upper GI endoscopy: biopsies
Following diagnosis, list 2 other investigations for oesophageal cancer
- CT TAP: staging and checking for metastatic disease
- Staging laparoscopy: to detect occult peritoneal disease
- Endoscopic USG
Treatment for Oesophageal cancer
Operable disease: surgical resection (most commonly an Ivor-Lewis type oesophagectomy) + adjuvant chemotherapy
Inoperable or metastatic disease: considered for chemo and maybe radiotherapy
Supportive measure for oesophageal cancer?
- stretching or dilation
- stent insertion
- radiation or laser ablation to reduce size of cancer
What is Extra-pulmonary Small Cell Cancer?
Small cell carcinoma arising outside the lungs - most commonly in oesophagus (1% of all oesophageal cancers)
What tumour of the stomach is the most common?
What is the second most common?
- Gastric adenocarcinoma (>95% of malignant neoplasms)
- Primary gastric lymphoma
List 2 Benign, non-neoplastic, tumours of the stomach?
- Polyps: hyperplastic, inflammatory fibroid, hamartomatous, juvenile
- Peutz-Jegher’s syndrome
- Cowden’s syndrome
List 2 Benign, neoplastic, tumours of the stomach?
- Epithelial adenomas
- Fundic gland polyps
- GISTs
- Lipomas, Leiomyomas
- Neural tumours (e.g. Schwannomas)
List 2 Malignant Tumours of the stomach
- AC
- Primary gastric lymphoma
- GIST
- Metastatic deposits
- Carcinoids
- Rare tumours e.g. Sarcomas, NE carcinoma, primary SCC and adenoacanthomas
Symptoms of Benign Gastric Polyps?
Usually asymptomatic but large polyps may:
- bleed due to erosions or ulceration
- or if very large may produce obstructive symptoms
Most common Benign Gastric Polyps?
- Small hyperplastic
- Fundic gland polyps
List 2 other types of benign gastric polyps
- Inflammatory fibroid polyps - a/w H. pylori
- Adenomatous polyps - a/w chronic atrophic gastritis, pre-malignant so excision required
Is gastric adenocarcinoma more common in men or women?
Men
List 4 risk factors for gastric cancer
- H pylori infection (non-cardia)
- Atrophic gastritis and GORD (cardia)
- Pernicious anaemia
- Diet, smoking, alcohol
+ Adenomatous gastric polyps, Partial gastrectomy, Abnormalities of E-cadherin gene, FxH
Why is there such a high association with gastric cancer and H. pylori?
H.pylori expresses cytotoxin-associated gene A antigen (CagA) which contributes to carcinogenesis
Clinical presentation of gastric cancer
Often non-specific and late in presentation. Late stage disease may incl:
- Dyspepsia
- Nausea and vomiting
- Anorexia and weight loss
- Dysphagia
List 2 signs on examination which may indicate gastric cancer
- Epigastric mass in late stage disease
- Troisier sign: presence of a palpable left supraclavicular node (Virchow node) → sign of metastatic abdo malignancy
First line investigation for diagnosis of suspected gastric cancer?
Staging investigation?
- diagnosis: endoscopy with biopsy
2/ staging: CT or endoscopic ultrasound
How are gastric cancers classified?
Histologically according to Laurén classification as being either intestinal or diffuse histological type
In an endoscopy clinic a disganosis of benign ulceration is made. What MUST we ensure to do?
Repeat endoscopy and biopsies after 4-8 weeks to confirm ulcer healing and benign nature of the lesion
What is the role of Barium studies in gastric cancer?
Gives a better impression of anatomy and degree of obstruction
Also helpful for diagnosis of linitis plastica, which may be missed at gastroscopy
What are the current NICE guidelines on referring for an urgent OGD?
- Any patients presenting with new-onset dysphagia
- Patients aged >55 presenting with weight loss and either upper abdominal pain, reflux, or dyspepsia
Treatment for gastric cancer?
Curative treatment is surgery + neoadjuvant and adjuvant chemo, if there is no evidence of local invasion or metastatic spread
Palliative treatment of gastric cancers
- chemotherapy
- best supportive care
- stenting (for gastric outlet obstruction)
- Palliative surgery (distal gastrectomy or gastrojejunostomy bypass)
What are the two most common Primary gastric lymphomas?
- MALT lymphomas: low-grade mucosa-associated lymphoid tissue
- Non-Hodgkin’s diffuse large B-cell lymphoma (DLBCL)
CHECK are these same/ subclasses
Common association/ risk factor for Primary gastric lymphoma?
H. pylori (>92% cases)
How may patient with primary gastric lymphoma present?
Non-specific dyspeptic symptoms or evidence of GI haemorrhage due to ulcerating disease
Symptoms may incl:
- abdominal pain
- nausea and vomiting
- weight loss
- symptoms of anaemia e.g, shortness of breath, fatigue or palpitations
What endoscopic change may be seen in MALT Lymphoma?
Lymphoid follicles with tumour cells located in marginal zone
Treatment of Primary gastric lymphoma?
- Eradication of H. pylori with antibiotics → cure in 75% of patients
- Lack of response to H. pylori eradication → treated with chemo (e.g. CHOP), immuno (e.g. Rituximab) and/or radiotherapy.
What defines gastrointestinal stromal tumours (GISTs)
Expression of c-KIT or platelet derived growth factor alpha gene (PDGFA)
Around 60% of GISTs arise in the _________ and 1⁄4 display malignant behaviour
stomach
Symptoms of GISTs (Incl small and large)
Small GISTs → asymptomatic, often found incidentally at upper GI endoscopy.
- Acute or chronic GI haemorrhage is commonest clinical presentation
Large GISTs may produce:
- pain/dyspepsia
- early satiety
- nausea
- symptoms of gastric outlet obstruction
What are the 2 subtypes of GISTs?
- Spindle cell
- Epithelioid
What is the Carney triad?
Rare syndrome defined by the coexistence of three tumours:
- extra-adrenal paraganglioma
- GIST
- pulmonary chondroma
What is neurofibromatosis type 1?
Genetic condition that causes tumours to grow along the nerves. They are usually benign but may cause a range of symptoms
A small percentage of GIST occur in context of NF-1
Treatment of GISTs?
Surgical resection is treatment of choice
Where do Gastrointestinal carcinoid tumours arise?
In oxyntic mucosa of gastric fundus and are comprised of non-functioning enterochromaffin-like cells
List 3 risk pathologies associated with gastrointestinal carcinoid tumours
May be sporadic or occur in context of:
- autoimmune atrophic gastritis
- ZE syndrome
- MEN-1 syndromes
What is carcinoid syndrome?
How does it present?
When metastasised cells of a carcinoid tumour oversecrete bioactive mediators ie. serotonin, prostaglandins, and gastrin
Present with symptoms of:
- flushing
- palpitations
- intermittent abdominal pain
- diarrhoea
Tumours of small intestine are rare and usually single. In which condition may may multiple be present?
Intestinal polyposis syndrome
Are tumours of the small intestine usually benign or malignant?
Can be either. Some benign tumors can progress and become malignant (adenomas, leiomyomas)
Symptoms of small intestine tumours?
Most are clinically silent for long periods and are found incidentally
Symptoms can be chronic and/or intermittent and may include:
- abdominal pain
- nausea
- weight loss
- bowel obstruction
Tumours can also become ulcerated and bleed
List 4 Tumours of Small Intestine
- Lipomas
- Hemangiomas
- Neurogenic Tumors
- Intestinal Lymphoma
- Leiomyoma
- Leiomyosarcoma
- Metastases
Describe the appearance of a lipoma in the small intestine
Are these benign or malignant:
Collections of fatty tissue within intestinal wall having a mild yellowish appearance → have a positive ‘pillow sign’
They are completely benign and do not need to be removed unless they become very large and cause obstructive symptoms (or bleeding due to ulceration)
What are Hemangiomas?
Are these benign or malignant?
Collections of blood vessels in wall of stomach or intestine
These are also benign but can cause GI bleeding and anemia so require treatment by endoscopy to burn the vessels
Read briefly on the following tumours:
- Neurogenic Tumors
- Intestinal Lymphoma
- Leiomyoma
- Leiomyosarcoma
What are adenomas vs adenocarcinomas of the small intestine?
Adenomas - benign tumors
- can cause symptoms due to blockage ie. if they arise near papilla, can cause jaundice
- Diagnosis confirmed by biopsy
- Removed by surgery or endoscopically due to risk of malignancy
Adenocarcinoma develops mainly from adenomas
What characterises Polyposis Syndromes affecting the small bowel?
Presence of multiple polyps affecting all or parts of GI tract
They are distinguished by the way they are inherited and microscopic appearance of the polyps
List 4 key Polyposis Syndromes Involving the Small Bowel
- Familial Adenomatous Polyposis
- Peutz-Jeghers Syndrome
- Generalized Juvenile Polyposis
- Cronkhite-Canada Syndrome
What is Familial Adenomatous Polyposis, Incl its inherritance?
What are these patients at a high risk of?
Autosomal dominant condition causing multiple pre- malignant adenomatous polyps in the colon
Pacing patient at high risk for colon cancer
Treatment of FAP?
Patients usually undergo total colectomy. Unfortunately, it is not possible to remove all the adenomas so:
- Surgical or endoscopic removal is used only for large polyps
- Certain medications e.g. aspirin appear to reduce growth of some of these adenomas
Patients are advised to have serial examinations of S intestine every few years
What is Peutz-Jeghers Syndrome, Incl its inherritance?
How does it present?
Autosomal dominant condition causing excessive growth of polyps in jejunum and ileum
Presents with:
- hamartomatous polyps in GIT
- pigmented lesions on lips, oral mucosa, face, palms and soles
- intestinal obstruction e.g. intussusception
- gastrointestinal bleeding
What is Generalized Juvenile Polyposis, Incl its inherritance
Autosomal dominant genetic condition characterized by the appearance of multiple juvenile polyps in the gastrointestinal tract
What is Cronkhite-Canada Syndrome
Extremely rare disease characterized by many intestinal polyps, pigmentation, diarrhoea, protein loss from intestine and alopecia.
Polyps do not usually become malignant
Main problem is malnutrition → agressive nutritional support is necessary
