Upper GI oncology Flashcards
What organs are contained in the upper GI? (4)
- stomach
- pancreas
- liver
- gallbladder
Where is the stomach located?
- lies directly inferior to diaphragm
- connects oesophagus to duodenum
What is the function of the stomach? (2)
- functions as mixing chamber and holding reservoir
- secretes a mixture of acid, mucus and digestive enzymes
What are the three parts of the stomach?
- cardia (fundus)
- body
- pyloric antrum
What is the stomach’s blood supply?
- branches of the coeliac axis
What are the stomachs regional lymphatics?
- coiliec axis nodes
- splenic hilar LNs
- porta hepatatis LNs
- gastroduodenal LNs
- suprapancreatic LNs
What is the venous drainage of the stomach?
- portal venous system into the liver
How do you differentiate a vein and artery in a CT image?
- arteries are circular due to the high pressure
- veins are oval shaped
What is epidemiology?
- study of population and spread of disease
What is aetiology?
- study of causes of disease
What is the epidemiology of stomach cancer? (4)
- 790 000 new cases annually worlwide
- In AUS M:F = 1314:865
- highest incidence rates 30-80/100 000 occur in far east, Russia, Eastern Europe and South America
- Incidence rises steeply with age to over 200/100 000 men aged over 80 years
What is the Aetiology of stomach cancer?
- diet
- lifestyle
- occupational
- medical
What is the diet Aetiology of stomach cancer? (6)
- low intake of animal fats and proteins
- high intake of carbs
- high salt intake
- low intake of fruits and vegetables
- diet rich in smoked food
- diet high in nitrates
What is the lifestyle Aetiology of stomach cancer? (4)
- poor nutrition
- low socioeconomic status
- alcohol
- smoking
What is the occupational Aetiology of stomach cancer?
- industrial dust exposure
What is the medical aetiology of stomach cancer? (3)
- Genetic (Blood group A)
- Pernicious anaemia due to B12 def (3-6x risk)
- helicobacter pylori infection
What are the signs and symptoms of stomach cancer? (10)
- vague epigastric discomfort
- loss of appetite (weight loss)
- nausea, vomiting
- haematemesis
- melena
- occult bleeding
- palpable epigastric mass
- ascites
- left supraclavicular adenopathy
- jaundice
- left axillary adenopathy
What percentage of cases of stomach cancer at presentation are metastatic?
- 1/3
What is the local spread of stomach cancer?
- many adjacent organs, omenta, pancreas
- regional lymph and blood channles in submucosa, subserosa
What is the chain of lymphatic spread of stomach cancer?
- via superficial lymphatic network into nodes in left gastric chain and splenic and hepatic chain
- then to nodes in coeliac plexus, splenic chain into hepatic chain around porta hepatis
Where is common blood born metastases for stomach cancer?
- liver and lung
What is the pathology and percentages for stomach cancer?
- adenocarcinoma (90-95%)
- lymphoma (~5%)
- carinoids
- gastrointestinal stromal tumours
What is the clinical management for stomach cancer?
- multi-disciplinary approach
- surgery
- neoadjuvant and adjuvant chemo
- palliative chemotherapy
- radiation
What should be in the CTV for stomach cancer?
- gastric/tumour bed
- gastric remnant
- nodal stations along lesser and greater curvature of stomach
- coeliac axis
- suprapancreatic, porta hepatis and splenic groups
What are the OAR to be contoured for stomach cancer?
- liver
- kidneys
- lung
- heart
What is the common dose for adjuvant therapy of stomach cancer?
- 45Gy in 25# with concomitant 5FU (5-fluoro-uracil) and leucovorin
What is the patient care for stomach cancer?
- weekly full blood counts
- dietetic assesment including weight
- measures for gastrointestinal toxicity (nausea, diarrhoea)
What are the three parts of the pancreas and where are they located?
- head at the c loop of duodenum
- body is posterior to stomach and anterior the the IVC
- tail terminated in splenic hilum
- @ L1-L2
What are the organs surrounding the pancreas?
- duodenum
- jejunum
- stomach
- major vessels (IVC)
- spleen
- kidney
What are the two main functions of the pancreas?
- exocrine
- endocrine
What is the exocrine function?
- adding digestive juices and enzymes to partially digested food via small ducts
What is the endocrine function?
- produces hormones insulin which helps control the amount of sugar in blood stream
What is the epidemiology of pancreatic cancer?
- 790 000 new cases annually worldwide
- in AUS M:F = 1408:1254
- incidence increases with age
- ubran and socioeconomically disadvantage populations higher incidence
What are the main signs and symptoms of pancreatic cancer?
- jaundice
- abdominal pain
- anorexia
- weight loss
What the the signs and symptoms of head/body pancreatic cancer?
- obstructive jaundice
- dark urine
- cay coloured stool
- abdominal pain
What the the signs and symptoms of tail pancreatic cancer?
- back pain
- weight loss
What is the aetiology of pancreatic cancer?
- smoking
- occupation (rubber industry, benzidine dye industry)
- medical (diabetes, chronic pancreatitis)
- familial trend (first degree relative)
- diet (high fat)
- lifestyle
What % of pancreatic patients present with locally advanced or metastatic cancer?
- 80%
What is the local spread of pancreatic cancer?
- throughout pancreas
- duodenum, stomach, colon
- obstructs common bile duct
- superior mesenteric artery
- portal vein
- celiac axis
What is the pathology of pancreatic cancer?
- adenocarcinoma (80%)
- islet cell tumours
- acinar cell carcinoma
- cystadenocarcinomas
- 50% diagnosed have distant mets
What is % location of pancreatic cancer?
- 60% in head
- 25% in body and tail
- 15% in tail alone
What is the clinical management of pancreatic cancer?
- primary resection which is only chance of cure
- less then 20% are resectable
- pancreaticoduodenectomy
- chemo with possible radiation
What is pancreaticoduodenectomy?
- resection of head of pancreas and duodenum, distal stomach, gall bladder and common bile duct
- has high local failure with 5% mortaility
What are the palliative therapies for pancreatic cancer?
- narcotics
- coeliac plexus nerve blocks
- biliary stenting
- drainage of ascites
- palliative chemo
- palliative RT (bone/brain mets)
What are the CTV margins for pancreatic cancer?
- sup = cover coeliac axis (1.5-2cm)
- inf = include superior mesenteric LNs
- post = 1.5cm beyond ant margin vertebral body
- ant = extend 1.5-2cm from GTV
What is the dose for radical and palliative pancreatic treatment?
RADICAL:
- 45-50.4GY in 25-28# in combination with chemotherpy, 5FU
PALLIATIVE:
- 30Gy in 10#
What are the acute side effects of pancreatic cancer?
- nausea/diarrhoea
- serve mucositis or ulceration of stomach/duodenum
What are the long term side effect of pancreatic cancer?
- renal failure
What region of the body is the liver located in?
- right hypochondriac region
- superior level of liver buldges into the diaphragm at level T7-8
What is the main role of the liver?
- removing toxins from body
- processing food nutrients
- helping to regulate body metabolism
What organs surround the liver?
- stomach
- pancreas
- IVC
- lung
What is the epidemiology of liver cancer?
- 5th most common in the world
- strong association with chronic viral hepatitis, esp. Hep B
- chronic liver infection
- ageing population
- increasing obesity
- 3 to 4 times more common in men
How much more likely are indigenous Australians more likely to develop and die from liver cancer?
- 3x more likely to develop
- 3.3x more likely to die
What are the presenting features of liver cancer?
- abdominal pain
- weight loss
OR if hepatic mass is present - hepatic failure
- ascites
- alpha-fetoprotein is elevated in 50-70% of these patients
What is the classification of primary hepatic tumours?
- unifocal expansive
- infiltrating
- multifocal (50%)
Where do hepatic tumours usually spread to?
- invade portal vein and hence spread to the lung
What is the management of hepatic cancer?
- surgical resection is the only hope for long-term survival (only possible in <20% cases)
- hepatectomy and transplantation
- doxorubibin (chemo) with 10-20% response rate
- Radiation but not used due to radiation hepatitis (most effective would be stereotactic delivery)
What is the max dose the liver can recieve before radiation hepatitis?
- 30Gy
What are the side effects of hepatic cancer and treatment?
- nausea and vomiting
What is the patient care for hepatic cancer?
- 5-HT antagonist antiemetics with or without steroids
- bilirubin, prothrombin time and albumin must be monitored
Where is the gallbladder located?
- below the lower border of the liver
- in contact with the anterior abdominal wall at the transpyloric plane
What is the gallbladders main function?
- store bile which helps with the body break down and digest fats
- presence of fatty foods in the body with trigger the gallbladder to squeeze its bile concentrate into the small intestine
What are the primary biliary tumours?
- gallbladder
- cholangiocarcinoma
What is a cholangiocarinoma?
- arises from the ductal epithelium of the bilary tree
- rare
What is the epidemiology of gallbladder cancer?
- equal M:F ratio
- older then 65
- chile, Japan and northern india
- gallstones, liver flukes
- 10% 5 yr survival rate
What are the signs and symtoms of gallbladder cancer?
- right upper quadrant pain
- in advanced cases (nausea, vomitting, weight loss, obstructive jaundice)
- asymptomatic tumour and advanced stage usually diagnosed by signs and symptoms of gallstones and chronic inflammation
What are the different types of gallbladder cancer and %?
- in body and cystic duct (4%)
- adenocarcinomas (85%)
- anaplastic (6%)
- squamous (5%)
Where does gallbladder cancer commonly spread?
- lymphatics (coeliac and aortic nodes)
- hepatic mets
- seed into peritoenum –> invade liver
What is the management of cholangiocarcinoma?
- surgical resection is the only curative treatment
- biliary stenting
- 5yr survival rate <5%
- EBRT effective for pain relief and relieve obstructive jaundice
What is the management of gallbladder cancer?
- surgical excision
- chemo-radiation
- intrabiliary stenting
- combination cisplatin and gemcitabine (chemo) show significant improvement of survivial rates
What is the side effects and patient care for gallbladder cancer?
- nausea and vomitting
- controlled with antiemetics (zofran, odancetron)
- with or without steriods (help with anti-inflammatory)
