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Carcinoma of the GI Tract


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Carcinoma of the GI Tract

  1. 1. Carcinoma of the GI Tract<br />Elizabeth Bunting, MS, PA-C<br />February 11, 2011<br />
  2. 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. 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. 4. Gastric Adenocarcinoma<br />
  5. 5. Gastric Adenocarcinoma<br /><ul><li>Can originate anywhere in the stomach
  6. 6. “intestinal-type” 70-80% of gastric cancers, resembles intestinal cancers with glandular structures
  7. 7. “diffuse” 20-30% of gastric cancers, poorly differentiated, signet-ring cells, lacks glandular structures
  8. 8. Affects women and men equally
  9. 9. Risk Factors:
  10. 10. Smoking
  11. 11. Pernicious anemia
  12. 12. h/o partial gastric resection
  13. 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. 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. 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. 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. 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. 18. Gastric Adenocarcinoma Staging<br />
  19. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 29. Colorectal Cancer<br />Hereditary Factors and Syndromes for CRC<br />Familial adenomatouspolyposis<br />Juvenile polyposis<br />Hereditary nonpolyposis colon cancer<br />
  30. 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. 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. 32. FAP<br />
  33. 33. HNCC<br />
  34. 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. 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. 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. 37. Colorectal CancerTNM Staging<br />
  38. 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. 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. 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. 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. 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. 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. 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. 45. Colorectal Cancer SCREENING<br />Colonoscopy<br />Barium Enema<br />
  46. 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. 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. 48. Questions???<br />
  49. 49. References<br />CMDT 2010<br />Images:<br /><br /><br /><br /><br /><br /><br /><br />
  50. 50. References<br />Images Cont’d<br /><br /><br /><br /><br /><br /><br />