Carcinoma of the GI Tract

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  • 1. Carcinoma of the GI Tract
    Elizabeth Bunting, MS, PA-C
    February 11, 2011
  • 2. Objectives
    Describe adenocarcinoma of the stomach in terms of etiology, epidemiology, signs and symptoms, diagnosis, treatment, and prognosis.
    List the risk factors for development of colorectal cancer.
    Outline the pathophysiologic development of colorectal cancer.
    Describe the following inheritable factors and syndromes for colorectal cancer:
    Polyposis
    Gardner’s syndrome
    Juvenile polyposis
    Describe the work-up and preventive measures for patients with familial polyposis.
    Discuss the appropriate screening techniques for colorectal cancer.
    Discuss the clinical features and presenting signs and symptoms of colorectal cancer.
    Summarize the Dukes classification of colorectal cancer and TNM classification and discuss the significance of staging.
    List and describe the factors that predict a poor outcome after total surgical resection for colorectal cancer.
    Discuss the treatment of other colorectal tumors.
    Identify the symptoms that may indicate small bowel tumors, and discuss appropriate diagnostic imaging techniques and treatment.
    Describe the following types of small bowel tumors:
    Adenomas
    Polypoid adenomas
    Leiomyomas
    Lipomas
    Angiomas
    Carcinoid tumors
  • 3. Gastric Adenocarcinoma
    Remains the second most common cause of cancer death worldwide
    More common in developing countries (Asia and South America). 70% decline in western countries because of food refridgeration, increase in fresh fruits and vegetables, decreased food toxins, decreased incidence of H. pylori
    Male:female 2:1
    Incidence increases with age
  • 4. Gastric Adenocarcinoma
  • 5. Gastric Adenocarcinoma
    • Can originate anywhere in the stomach
    • 6. “intestinal-type” 70-80% of gastric cancers, resembles intestinal cancers with glandular structures
    • 7. “diffuse” 20-30% of gastric cancers, poorly differentiated, signet-ring cells, lacks glandular structures
    • 8. Affects women and men equally
    • 9. Risk Factors:
    • 10. Smoking
    • 11. Pernicious anemia
    • 12. h/o partial gastric resection
    • 13. Diets high in nitrates, salt, and low in Vitamin C
  • Gastric Adenocarcinoma
    Signs and Symptoms
    ASYMPTOMATIC UNTIL LATE STAGES
    Dyspepsia and weight loss are most common presenting symptoms
    Anorexia
    Early satiety
    Vague epigastric pain
    GI bleeding
    Postprandial vomiting (tumor obstructing near pylorus)
    Progressive dysphagia (tumor near cardia)
  • 14. Gastric Adenocarcinoma
    Physical Exam:
    Often negative for findings
    Gastric mass palpated in 20% of cases
    Signs of Metastasis:
    Virchow’s node: L supraclavicular lymph node
    Sister Mary Joseph node: umbilical nodule
    Blumer shelf: a rigid rectal shelf
    Krukenberg tumor: ovarian metastasis
    Guaiac positive stools possible
  • 15. Gastric Adenocarcinoma
    Lab findings
    Iron deficiency anemia from blood loss or anemia of chronic disease
    Elevated LFTs if liver mets
    No specific tumor markers
  • 16. Gastric Adenocarcinoma
    Diagnostics:
    Upper endoscopy- indicated if new dyspepsia in pts > 55 years old, biopsy is important
    Barium upper GI is acceptable if endoscopy is not available, but no ability to distinguish benign from malignant lesions and no ability to bx
    Once gastric ca is dx, CT and EUS (endoscopic ultrasound) are needed to see extent of tumor, possible mets and nodal involvement
    PET scan or PET-CT combo needed for distant mets
    EUS superior to CT for determining depth of the tumor
  • 17. Gastric Adenocarcinoma
    Staging: look at classifications in your book
    Treatment
    Surgical resection: only curative tx for localized disease (stages 1-3, <1/3 of patients)
    Consider chemo/radiation for stage 3
    Palliative measures
    Surgical tumor debulking
    Chemo/Radiation for pain control
  • 18. Gastric Adenocarcinoma Staging
  • 19. Gastric Adenocarcinoma
    Prognosis
    Based on stage, location, and histology
    Long term survival <15%
    5 year survival for patients with curative gastric resection is 45%
    Stage 1 and 2 with curative resection 50% long term survival
    Stage 3 <20% survival
    Proximal tumors have 5-year survival <15%
  • 20. Gastric Lymphoma
    Sx: dyspepsia, weight loss, anemia
    Imaging on upper GI or endoscopy: thickened folds, ulcer, mass, or infiltrating lesions.
    Bx for diagnosis
    CT or EUS for staging
    Tx depends on tumor histology, grade, and stage
    Chemo
    Radiation
    Surgery not recommended
  • 21. Other gastric cancers
    Gastric Carcinoid Tumors
    <1% of gastric neoplasms
    Sporatic or secondary to hypergastrinemia
    Association with pernicious anemia and Zollenger-Ellison Syndrome
    Gastrointestinal Mesenchymal Tumors
    Derive from mesenchymal stem cells
    Generally incidental findings on imaging or endoscopy
    Surgery recommended
  • 22. Malignancies of the Small Intestine
    Adenocarcinoma
    Most commonly in the duodenum or proximal jejunum with most common site of all small intestine cancers is at the ampula of Vater
    Ampullary Carcinoma
    Incidence increased 200 fold for patients with Familial adenomatouspolyposis (FAP)
    Presents with jaundice, obstruction, and bleeding
    Surgical resection curative in 40% of cases
  • 23. Malignancies of the Small Intestine
    Non-Ampullary carcinoma
    <3% of all GI cancers
    Presents in 6th decade with obstruction, bleeding and weight loss
    Mets at diagnosis is common and resection is encouraged for control of sx
    Overall 5 year survival is 20-30%
    Lymphomas can involve the small intestines
  • 24. Malignancies of the Small Intestine
    Carcinoid Tumors
    Slow growing neuroendocrine tumor
    Secrete hormones: serotonin, somatostatin, gastrin and substance P
    Rare, account for 1/3 of small bowel cancers
    Commonly arise from the ileum
    Usually multiple tumors
    Signs and Symptoms
    Generally asymptomatic
    As they grow, they can obstruct or cause pain
  • 25. Malignancies of the Small Intestine
    Treatment
    Local excision is recommended
    Prognosis
    Depends on staging
    If excision, 85% cure rate
    Pt with lymph node involvement but resectable disease 5 year survival is 80%, however by 25 years, less than 25% remain disease free
  • 26. Malignancies of the Small Intestine
    Small intestine Sarcoma
    Stromal tumors (arise from smooth muscle) aka leiomyosarcomas
    Similar to gastrointestinal mesenchymal tumors
    Kaposi sarcoma was once common with AIDS
    Strongly associated with human herpesvirus 8
    Arise anywhere in the intestinal tract
    Visceral involvement generally seen with cutaneous involvement
    Generally asymptomatic
  • 27. Colorectal Cancer
    Incidence/Epidemiology
    2nd leading cause of cancer death in the US
    Almost all are adenocarcinomas
    50% of cases are located distal to the splenic flexure
    90% of cases in people >50 years old
    Risk Factors
    Age >50
    Family History ( FHx present in 20% of pts with CRC)
    Personal Hx
    IBD, 7-10 years after onset of disease
    cancer
  • 28. Colorectal Cancer
    Obesity
    Diabetes
    Tobacco use (>35 years)
    Race
    Black > white
    Diet
    High in animal fat and calories
    Low in fiber
  • 29. Colorectal Cancer
    Hereditary Factors and Syndromes for CRC
    Familial adenomatouspolyposis
    Juvenile polyposis
    Hereditary nonpolyposis colon cancer
  • 30. Colorectal Cancer
    Familial adenomatouspolyposis (FAP)
    Hereditary nonpolyposis colon cancer (HNCC)
    AKA polyposis coli
    Autosomal dominant mutation on chromosome 5
    Accounts for 0.5% of CRC
    Development of 1000’s of polyps
    Polyps evident by age 25
    Extraintestinal manifestations (skin, thyroid, liver, CNS tumors)
    AKA Lynch syndrome
    Autosomal dominant trait mutation on several genes
    Accounts for 3% of all CRC
    Development of only a few adenomas polyps, but they transform rapidly into cancer
    Mean age of appearance is 45
    Increased risk of other cancers (endometrial, ovarian, renal, hepatobiliary, small intestine
  • 31. Colorectal Cancer
    Familial adenomatouspolyposis (FAP)
    Hereditary nonpolyposis colon cancer
    Genetic counseling if 1st degree family member
    Test by age 10
    Total colectomy with ileoanalanastomosis is the primary therapy/prevention
    Rectum left in place- colonoscopy q3-6 months
    Upper endoscopy q1-3 years
    High frequency of cancer arising in the proximal large bowel
    Genetic testing if
    3+ relatives with CRC
    CRC in 2 successive generations
    1+ CRC in someone <50
    FAP is excluded
    Histology of tumor with DNA analysis if pt is <50
    Colonoscopy q1-2 years beginning at age 25 or 5 years younger than age of youngest affected family member
  • 32. FAP
  • 33. HNCC
  • 34. Colorectal Cancer
    Juvenile polyposis
    Autosomal dominant
    >10 hamartomatous polyps usually in the colon
    50% increased risk of adenocarcinoma due to synchronous adenomatous polyps or mixed hamartomatous-adenomatous polyps
    Genetic testing available
  • 35. Colorectal Cancer
    Signs and symptoms
    Adenocarcinoma grows slowly, so asymptomatic for years
    R-sided lesions: anemia, fatigue, weakness
    L-sided lesions: colicky abdominal pain, change in bowel habits (constipation and diarrhea alternating with blood streaks possible)
    Rectal cancers: tenesmus, urgency, recurrent hematocezia
    PE: unremarkable until late
  • 36. Colorectal Cancer
    Labs
    Anemia
    Elevated LFTs (suspicious for mets)
    CEA >5
    Colonoscopy
    Diagnostic procedure of choice
    Permits bx
    CT used for staging
    MRI used for rectal cancer or endorectal u/s
  • 37. Colorectal CancerTNM Staging
  • 38. Colorectal Cancer
    Treatment
    Resection of primary colonic or rectal mass is treatment of choice
    Regional dissection of 12 nodes is preferred
    Complications include colostomy, wound dehiscence, leaking, stricture
    Adjuvant therapy may be needed in stage 3+
    Chemotherapy
    Radiation
    Colonoscopy after surgery- after 1 year then every 3-5 years
  • 39. Colorectal Cancer
    Prognosis
    Stage I >90%
    Stage II 70-85%
    Stage III <4 nodes 67%
    Stage III >4 nodes 33%
    Stage IV 5-7%
  • 40. Colorectal Cancer SCREENING
    Reduces mortality
    Every person age 50 and above should be screened
    High risk persons should be screened earlier
    CRC can be PREVENTED
    Removal of adenomas prevents the majority of cancers
    Screening options
    Annual Fecal Occult Blood Test (FOBT)
    Flexible Sigmoidoscopy q5 years
    Colonoscopy q10 years
    Double contrast barium enema q5 years
  • 41. Colorectal Cancer SCREENING
    FOBT
    CHEAP!, fast, non-invasive
    Positive results need work-up with colonoscopy
    Can miss polyps and cancer
    High-false positive rate
    Needs to be done annually
    Not accurate when collected at time of DRE
  • 42. Colorectal Cancer SCREENING
    Flexible Sigmoidoscopy
    60cm
    May reach splenic flexure
    Discomfort is operator dependent
    Office procedure
    Little use of sedation
    Perforation risk <1:10,000
  • 43. Colorectal Cancer SCREENING
    Colonoscopy
    Visualization and eval of entire colon
    Diagnostic and therapeutic- polyp detection and removal
    Requires sedation
    Slightly increased risk, cost, and inconvenience compared to flex sig
  • 44. Colorectal Cancer SCREENING
    Double contrast Barium Enema
    Examination of the entire colon
    Widely available, relatively inexpensive, safe
    Sensitivity 50% for polyps >1cm and 55-85% for early ca
    Good choice if pt is unwilling/unable to undergo colonoscopy
  • 45. Colorectal Cancer SCREENING
    Colonoscopy
    Barium Enema
  • 46. Colorectal Cancer SCREENING
    CT Colonography AKA vitrual colonoscopy
    Simulates the view of a colonoscopy
    Fast, no sedation
    Risk: radiation exposure
    Sensitivity 50-90%
    Still need a colonoscopy if abnormalities
  • 47. Colorectal Cancer SCREENING
    Multitarget DNA assay
    Fecal DNA assay
    Looking for 22 gene mutations
    Detects 90% of cancers
    VERY high cost
    Cumbersome with stool collection and mailing
  • 48. Questions???
  • 49. References
    CMDT 2010
    Images:
    web2.airmail.net/.../images/gastcarc.html
    hopkinscoloncancercenter.org
    virtualmedicalcentre.com
    ourwebdoctor.com
    kevinmd.com
    healthkey.com
    rpop.iaea.org
  • 50. References
    Images Cont’d
    medscape.com
    drugs-expert.com
    radiographics.rsna.org
    cancertreatment-wecareindia.com
    genprice.com
    pathconsultddx.com