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Gastrointestinal Cancers
Dr. Erwin P. Carabeo July 24, 2015
 Nitrates → nitrites
TOPIC OUTLINE  Opiate
A. Esophageal CA  Fungal toxins
a. Epidemiology  Hot tea
b. Etiologic factors Associated with Squamous Cell CA  Lye ingestion
c. Plummer-Vinson Syndrome  Chronic strictures
d. Etiologic factors Associated with Adenocarcinoma  Chronic infection
e. Natural History of SCC  Chronic esophagitis
f. Spread and Metastasis  History of head and neck malignancy (especially if patient
g. Clinical Features underwent radiation therapy)
h. Diagnostic Evaluation  Achalasia
i. TNM staging for Esophageal CA  Plummer-Vinson Syndrome
j. Stage Grouping  Celiac Disease
k. 5 year survival Rate  Tylosis
l. Treatment Modalities o Congenital keratosis with pitting of palms and soles
B. Gastric CA  History of gastrectomy
a. Risk Factors
b. Precursos conditions PLUMMER-VINSON SYNDROME
c. Genetic and Environmental Factors  Esophageal webs
d. Signs and Symptoms  Glossitis – inflammation of the tongue
e. Pathology  Iron deficiency anemia
f. Spread and Metastasis  Cheilosis (from Robbins)
g. Staging and Prognosis
h. Prognostic Features ETIOLOGIC FACTORS ASSOCIATED WITH
i. Good Prognosis ADENOCARCINOMA
ii. Poor Prognosis  Chronic GERD
iii. Low Prognostic value  Obesity
i. Surgical Resection  Barrett’s esophagus
C. Gastric Lymphoma  Male > Female
a. Primary  Cigarette Smoking
b. Secondary
c. Treatment Adenocarcinoma
D. Pancreatic CA  Frequency: 8-33% of esophageal malignancy
a. Pathology  Affected patient usually in mid-60’s
b. Clinical Symptoms  Hoarseness of voice is not a common presentation
c. Clinical Signs  BARRETT’S ESOPHAGUS
d. Laboratory Study o Single most important risk factor
e. Non-invasive imaging studies o Squamous to columnar epithelium change due to
f. Invasive imaging studies chronic irritation of esophagus caused by gastric contents
g. TNM staging
h. Resectable disease criteria
E. Colonic CA
a. Conditions predisposing to colonic CA
b. Distribution of Colorectal Ca
c. Clinical Presentation
d. Malignant Risk of Adenomatous Polyp
e. Modified Duke’s Classification
Barrett’s
f. 5-year Survival Rate after treatment
Esophagus
g. Treatment options
h. Rate of detection of adenomatous polyp and colorectal CA
i. Random false negative rate
j. Diet for Fecal Occult Blood Test
k. Poor Prognostic features in Colorectal CA
l. Refer to Harrison’s Chapter 110

ESOPHAGEAL CA
EPIDEMIOLOGY
 No other cancer whose incidence varies within countries as
much as esophageal CA
 Equal male and female ratio in endemic areas
 Squamous Cell CA & Adenocarcinoma together is >95% Esophageal
of esophageal tumors Adenocarcinoma
o Before: SCC > adenocarcinoma
o Now: Adenocarcinoma > SCC
 Adenocarcinoma is now 75% of all esophageal cancer
 Sixth and seventh decade of life
 In terms of dermographic:
o Now seen in people with lower economic status
 Incidence varies within countries
 Males = Females in endemic areas Natural History of SCC
 95% of all esophageal tumors are SCC and Adenocarcinoma  20 years or more
o 75% are adenocarcinoma  Basal cell hyperplasia
 6th – 7th decade of life INITIAL  Various degrees of dysplasia
 More common in lower socioeconomic status PHASE  Mild dysplasia develop SCC
 14.9% of severe dysplasia
ETIOLOGIC FACTORS ASSOCIATED WITH SQUAMOUS  Developed SCC in 1-12 years
CELL CARCINOMA  33.9 – 74 months (6-7 years)
DEVELOPING
 Alcohol intake (whiskey > wine and beer)  When severe dysplasia becomes early
PHASE
 Smiking carcinoma

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OVERT  Mass and lesion Squamous
PHASE  Mean survival time – 9.7 months Cell
Carcinoma
NATURAL HISTORY OF ADENOCARCINOMA
 Similar to SCC but fistulas and recurrent laryngeal nerve
involvement is less common Note: similar lang
 There is extension to: BARIUM yung itchura ng
o Diaphragm SWALLOW “wasting sign”
o Stomach
o Liver iscommon
 Adenocarcinoma: in distal 1/3

SPREAD AND METASTASIS

 Spreads by: TNM STAGING FOR ESOPHAGEAL CA
o Intraesophageal spread
PRIMARY TUMORS
o Direct extension
Tx Primary tumor cannot be assessed
o Lymphatic
Tis Tumor in situ
o Hematogenous
 Typically invades adjacent structures To No evidence of primary tumor
 Extension/metastasis to other sites would usually be T1 Tumor invades lamina propria or submucosa
the cause of the first signs and symptoms of the patient T2 Tumor invades muscularis propria
 Lymph Node (LN) metastasis: 42-67% bidirectional T3 Tumor invades adventitia
 Distant metastasis: 25-30% T4 Tumor invades adjacent structures
o Liver REGIONAL LYMPH NODES
o Lung Nx Regional LN cannot be assessed
o Bone No No regional LN metastasis
 Location N1 Regional LN metastasis
o Distal or lower portion – 75% DISTANT METASTASIS
o Middle – 20% Mx Presence of distant metastasis cannot be
o Proximal or upper portion – 5% assessed
Mo No distant metastasis
CLINICAL FEATURES M1 With distant metastasis
 Dysphagia (progressive) and weight loss – initial symptoms
but only for a very short period of time  Clinical
 Food intolerance – first from solid -> semisolid -> liquid STAGING  Involves tumor size, LN involvement &
 Vague retrosternal discomfort (GERD like) metastasis
 Anorexia  Histologic
 Odynophagia & back pains – d/t bone metastasis  Appearance of cells (types of cells seen)
 Hoarseness is ALWAYS a late manifestation  Differentiated vs. poorly differentiated
o Paralysis of the recurrent laryngeal nerve  Good Prognosis: when cells resemble that of
o Compared to laryngeal CA, it is early manifestation the normal parenchyma (well-differentiated)
 Hematemesis (tumor invaded vascular structure) GRADING o Responsive to treatment
 Location  Low grade: Resemble original cells
o 75% lower part  Bad Prognosis: when cells do not resemble
o 20% middle part the normal parenchyma (poorly differentiated)
o 5% upper part o Return to a more primitive cell type
 Dysphagia occurs when 60% of the esophageal circumference o High grade: A total disconnection of cells
is infiltrated with cancer
o Cancer: solid dysphagia first
o Achalasia: liquid dysphagia first

DIAGNOSTIC EVALUATION
 Microcytic anemia
 Result of chronic blood loss
 Low serum albumin
 Poor intake of protein Elevated alkaline
phosphatase (ALP)
LABORATORY
 Hypercalcemia
DATA
 Low cholesterol
 CA 19-9 (34% sensitivity) – so hindi daw
sya ganun kaspecific or sensitive
 Balloon cytology→ to derive sample of
cells
 Gold Standard

ENDOSCOPY

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 Lymphoma limited to GIT according to CT imaging or
laparatomy
 No liver or spleen involvement (except by direct extension)

SECONDARY
 50% of non-Hodgkin’s lymphoma has GI involvement
 Common sites of metastasis in decreasing order:
Stomach > small intestine > ileocecal > colon

*Primary lymphomas arise de novo in the GI tract; Secondary

lymphomas almost always arise in part with NHL

INTRODUCTION
 Relatively uncommon, accounting for <15% of gastric
malignancies and ~2% of all lymphomas
MACROSCOPIC  Mimics adenocarcinoma
PATHOLOGY  Consists of either: (1) a bulky ulcerated
lesion localized in the corpus or antrum
or (2) a diffuse process spreading
throughout the entire gastric submucosa
and even extending into the duodenum
MICROSCOPIC  Vast majority of gastric lymphoid
PATHOLOGY tumors are non-Hodgkin’s lymphomas of
B cell origin
 Hodgkin’s disease involving the stomach
is extremely uncommon
 Histologically, these tumors may range
from well-differentiated, superficial
processes [mucosa-associated lymphoid
tissue (MALT)] to high-grade, large-cell
lymphomas
 Infection with H. pylori increases the risk for gastric
lymphoma in general and MALT lymphomas in particular
 Gastric lymphomas spread initially to regional lymph nodes
(often to Waldeyer’s ring) and may then disseminate
 Gastric lymphomas are staged like other lymphomas

TREATMENT
 Surgery: 88% resectability rate (Primary lymphoma)
STAGE GROUPING
o 50-80% 5 year survival
 Radiotherapy
 Chemotherapy

*Further reading: Harrison’s 18th Edition Volume 1, Section 7

(Oncology and Hematology), Chapter 91, Page 767-768
PANCREATIC CA
 90% moderately differentiated mucinous adenocarcinoma
 5% islet cell origin
 Grows rapidly
 Nearly universally fatal
 Rare forms: acinar cell, giant cell, epidermoid, acanthomas,
sarcomas, lymphomas, cystadenocarcinoma
 One of the most painful cancers
 Detected late: usually when there is already biliary
obstruction

5 YEAR SURVIVAL RATE CLINICAL SYMPTOMS

Stage I 60.4% COMMON (>50% of patients)
Stage II 31.3%
 Jaundice, pruritus: due to obstruction of bile ducts
Stage III 19.9%
 Abdominal pain
Stage IV 4.1%
 Weight loss
TREATMENT MODALITIES RARE (<5% of patient)
 Management consist of:
 Back/leg pain
o Radiation
 Psychiatric disturbance, depression
o Chemotherapy
 Hematemesis/ melena
o Surgery
 Obstructive jaundice occurs frequently when the cancer is
o Combination
located in the head of pancreas.
 Surgery
 This may be accompanied by symptoms of abdominal
o Radiation
discomfort, pruritus, lethargy, and weight loss.
o Chemotherapy
 Less common presenting features include epigastric pain,
o Multimodality
backache, new onset diabetes mellitus, and acute pancreatitis
 Preoperative radiotherapy
caused by pressure effects on the pancreatic duct.
 Preoperative chemotherapy
 Nausea and vomiting, resulting from gastroduodenal
 Preoperative chemoradiation
obstruction, may also be a symptom of this disease.
 Preoperative radiotherapy, chemotherapy
 Patients can present with jaundice and cachexia, and scratch
o Endoscopic modality
marks may be present.
 Expandable metal stent on an inoperable CA
 Of patients with operable tumors 25% have a palpable gall
bladder (Courvoisier’s sign).
GASTRIC LYMPHOMA
 Physical signs related to the development of distant
PRIMARY: no palpable lymphadenopathy (LAD) elsewhere in metastases include hepatomegaly, ascites, left supraclavicular
the body lymphadenopathy (Virchow’s node), and periumbilical
 Normal cells in Peripheral Blood Smear & Bone Marrow lymphadenopathy (Sister Mary Joseph’s nodes).
 No visible mediastinal LAD by chest xray

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 Courvoisier's sign - in the presence of an enlarged (CRT), as it is superior to conventional imaging in detecting
gallbladder which is non-tender and accompanied with mild distant metastases.
jaundice, the cause is unlikely to be gallstones.
o This sign implicates possible malignancy of the gall SERUM MARKERS
bladder or pancreas.  Tumor-associated carbohydrate antigen 19-9 (CA 19-9) is
elevated in approximately 70–80% of patients with pancreatic
carcinoma, but is not recommended as a routine
CLINICAL SIGNS diagnostic or screening test as its sensitivity and specificity
COMMON are inadequate for accurate diagnosis.
 Icterus  Preoperative CA 19-9 levels correlate with tumor stage,
 Cachexia -> weight loss and post-resection CA 19-9 level has prognostic value.
 Excoriation of the skin -> due to scratching  It is an indicator of asymptomatic recurrence in patients with
completely resected tumors and is used as a biomarker of
RARE response in patients with advanced disease undergoing
 Palpable gallbladder chemotherapy.
 Abdominal mass, distension  A number of studies have established a high pretreatment CA
 Melena 19-9 level as an independent prognostic factor.
 Cholangitis
 Pancreatitis TNM STAGING FOR PANCREATIC CANCER
 Gastric outlet obstruction
 Venous thrombosis TNM STAGING OF PANCREATIC CANCER
ACCORDING TO THE
DIAGNOSTIC STUDIES AMERICAN JOINT COMMITTEE ON CANCER (AJCC)
LABORATORY STUDY Primary Tumor Description
Diagnostic study Abnormal Tx Primary tumor cannot be assessed
findings (%) T0 No evidence of primary tumor
Alkaline phosphatase* 80% Tis Carcinoma in Situ
Total bilirubin 55% T1 Tumor limited to the pancreas, 2 cm
Total protein 15% or less in greatest dimension
Amylase 15% T2 Tumor limited to the pancreas, more
Hematocrit 60% than 2 cm in greatest dimension
CEA (>4ng/L) 35% T3 Tumor extends beyond the pancreas
AFP** 3% but without involvement of the celiac
CA 19-9 (>100μ/ml) 61% axis or the superior mesenteric artery
Trypsin 80% T4 Tumor involves the celiac axis or the
K-ras oncogene mutation superior mesenteric artery
*↑in obstruction; ↑acid phosphatase in prostatic CA (unresectable primary tumor)
** More sensitive for hepatocellular CA Regional Lymph Description
Nodes
NON-INVASIVE IMAGING STUDIES Nx Regional LN cannot be assessed
Diagnostic study Abnormal findings (%) N0 No regional LN metastasis
Plain abdominal X-ray 1% N1 Regional LN metastasis
UGIS 5% Distant Description
US 60% Metastasis
Standard CT 90% M0 No distant metastasis
Helical CT 95% M1 With distant metastasis
MRI 90%
STAGE T N M
INVASIVE IMAGING STUDIES FOR PANCREATIC CA GROUPING
Diagnostic study Abnormal findings (%) STAGE 0 Tis N0 M0
ERCP 90% STAGE IA T1 N0 M0
CT/US guided 90-95% STAGE IB T2 N0 M0
needle aspiration STAGE IIA T3 N0 M0
EUS 95% STAGE IIB T1-3 N0 M0
STAGE III T4 any N M0
IMAGING STAGE IV Any T Any N M1
 Patients who present with clinical features suggestive of
pancreatic cancer undergo imaging to confirm the presence of RESECTABLE DISEASE CRITERIA
a tumor, and to establish whether the mass is likely to be  Absence of extrapancreatic disease
inflammatory or malignant in nature. o Tumor is confined in the pancreatic tissue
 Other imaging objectives include the local and distant staging o Absence of involvement of other organs
of the tumor, which will determine resectability and provide  Absence of direct tumor extension to SMA & celiac axis
prognostic information.  Patent superior mesenteric – portal vein confluence
 Dual phase, contrast-enhanced spiral CT is the imaging  Unresectable disease:
modality of choice. o Primary goal: relieve the biliary obstruction
 There is no advantage of magnetic resonance imaging (MRI) o Endoscopic stent placement or T-tube
over CT in predicting tumor resectability, but selected cases o Chemotherapy: Gemcitabine DOC
may benefit from MRI to characterize the nature of small o Pain control (like osteosarcoma, multiple myeloma)
indeterminate liver lesions and to evaluate the cause of biliary
dilatation when no obvious mass is seen on CT. TREATMENT
 Endoscopic retrograde cholangiopancreatography (ERCP) is  Approximately 10% of patients present with localized non-
useful for revealing small pancreatic lesions, identifying metastatic disease that is potentially suitable for surgical
stricture or obstruction in pancreatic or common bile ducts, resection.
and facilitates stent placement.  Those who undergo R0 resection (no microscopic or
 Magnetic resonance cholangiopancreatography (MRCP) is a macroscopic residual tumor), and who receive adjuvant
noninvasive method for accurately depicting the level and treatment have the best chance of cure, with an estimated
degree of bile and pancreatic duct dilatation. median survival of 20–23 months and a 5-year survival of
 EUS is highly sensitive in detecting lesions less than 3 cm in approximately 20%.
size, and is useful as a local staging tool for assessing  Outcomes are more favorable in patients with small ( 3cm),
vascular invasion and lymph node involvement. well differentiated tumors, and lymph node-negative disease.
 Positron-emission tomography with fluorodeoxyglucose  Patients should have surgery in dedicated pancreatic centers
positron emission tomography (FDG-PET) should be that have lower postoperative morbidity and mortality rates.
considered before surgery or radical chemoradiotherapy

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 The standard surgical procedure for patients with tumors of RANDOM FALSE NEGATIVE RATE
the pancreatic head or uncinate process is a pylorus- Fecal occult blood test 40%
preserving pancreaticoduodenectomy (modified Whipple’s  False positive if patient eats red meat, aspirin,
procedure). NSAID, peroxidase-containing food such as
 The procedure of choice for tumors of the pancreatic body turnips and horseradish, iron drugs
and tail is a distal pancreatectomy, which routinely  False negative if patient eats vitamin C, citrus
includes splenectomy. fruits, citrus juice
Sigmoidoscopy 15%
*Further reading: Harrison’s 18th Edition Volume 1, Section 7 Colonoscopy 5%
(Oncology and Hematology), Chapter 93, Page 786-789 Air contrast BE 15%
Single column BE 30%
COLONIC CARCINOMA
CONDITIONS PREDISPOSING TO COLONIC CA DIET FOR FECAL OCCULT BLOOD TEST
 Advancing age Avoid 3 days prior to test:
 Family history of colorectal Ca or polyp  Red meat
 High fat, low fiber diet  Aspirin, NSAIDs
 Bowel disorders  Peroxidase containing food
 Inflammatory bowel disease (Ulcerative colitis, Crohn’s  Vitamin C
disease)  Citrus juice
 Adenomatous polyp  Iron containing drugs (but not food)

DISTRIBUTION OF COLORECTAL CA POOR PROGNOSTIC FEATURES IN COLORECTAL CA

 Cecum/ascending colon 25%  Increased depth of bowel wall penetration
 Sigmoid colon 25%  > 4 nodes involved in tumor
 Rectum 20%  Poorly differentiated tumor
 Transverse 15%  Mucinous or signet ring histology
 Rectosigmoid 10%  Scirrhous histology
 Descending 5%  Venous invasion
 Lymphatic invasion
CLINICAL PRESENTATION  Perineural invasion
 Constitutional symptoms (fatigue, SOB, angina)  Aneuploidy
 Blood in the stools  Bowel obstruction
 Abdominal pain  Bowel perforation
 Change in bowel habits (e.g. goat’s stool-like, pencil like,  Age < 30
ribbon-like)  High CEA level (correlates with recurrence)
 Deletions in chromosome 18q and 17p
MALIGNANT RISK OF ADENOMATOUS POLYPS  Distant metastasis
Correlated with:
 Size of <1cm (nonmalignant) HARRISON
 Histological architecture – villous (40% if > 4cm)  Kindly read Harrison’s Chapter 110 Lower Gastrointestinal
 Severity of dysplasia Cancer pp. 537-544

MODIFIED DUKE’S CLASSIFICATION

A Cancer limited to mucosa or submucosa
B1 Cancer penetrates into but not through muscularis propria
B2 Cancer penetrates through muscularis propria
C1 B1 + Lymph node metastasis
C2 B2 + lymph node metastasis
D Distant metastasis
T3 Tumor extends directly to stomach, spleen, colon,
adjacent large vessels

5- YEAR SURVIVAL RATE AFTER TREATMENT

CLASSIFICATION 5 – YEAR SURVIVAL
A 90%
B1 80%
B2 70%
C1 50%
C2 50%
D <30%

TREATMENT OPTIONS
CLASSIFICATION TREATMENT
A Polypectomy/ en bloc resection
B En bloc resection, adjuvant chemotherapy
C En bloc resection, adjuvant chemotherapy
D Palliative surgery, treat metastatic
disease, usually bypass

RATE OF DETECTION OF ADENOMATOUS POLYP AND

COLORECTAL CA
DIAGNOSTIC STUDY ABNORMAL FINDINGS
Rigid sigmoidoscopy 30%
35 cm flexible sigmoidoscope 40%
60 cm flexible sigmoidoscope 55%
Colonoscope 95%
Air contrast Barium Enema (BE) 92%
Single column BE 85%
COLONOSCOPY IS THE GOLD STANDARD
 Can see the entire large intestine (cecum to anus)

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