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Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
Carcinoma of the GI Tract
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Carcinoma of the GI Tract

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

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