Tumors of the digestive system

Teja Koswara, dr., Sp.PA

 Oral cavity
• Leukoplakia
• Squamous cell carcinoma
• Odontogenic cyst`s
• Odontogenic tumor
 Leukoplakia
• Whitish patch or plaque that cannot be
characterized clinically or pathologically as any
other disease, and is not associated with any
physical or chemical causative agent, except
the use of tobacco.
• 5% - 25% are premalignant (dysplasia)
Leukoplakia
 Leukoplakia
• No etiologic factor can be identified for most persistent oral
leukoplakias (idiopathic leukoplakia).
• Known causes of leukoplakia :
– Trauma (eg, chronic trauma from a sharp or broken tooth)
– Tobacco , chewing tobacco is probably worse than
smoking.
– Alcohol
– Infections (eg, candidosis, syphilis, Epstein-Barr virus
– Chemicals
– Immune defects
 Leukoplakia
• Histopathology :
- Hyperkeratosis
- Hyperplasia, or

- Atrophy
- Dysplasia
Oral Cancer-Progression
 Squamous cell carcinoma- Oral cavity
• ± 97% of all malignant tumor of oral cavity
• Location: - 38% lower lip
- 22% tongue
- 17% floor of mouth
- 6% ginggiva
- 5,5% palatum
- 5% tonsil
- 4% upper lip
- 2% buccal mucosa

• Age: 40-70 years old

• Metastasis : Regional lymph node (neck)
Squamous cell carcinoma- Oral cavity
 Odontogenic Cysts

• Odontogenic cysts arise from tooth development

epithelium
• Odontogenic cysts are true cysts occurring in the jaws.
• Arise from stimulation of epithelium left over from
tooth development.
 Odontogenic Cysts
• Radicular (periapical) cyst
• Residual cysts
• Dentigerous cyst
• Odontogenic Keratocyst
• Lateral Periodontal cyst
 Radicular Cyst (Periapical Cyst)

• A radicular cyst is a cyst that

most likely results when rests of
epithelial cells in the
periodontal ligament are
stimulated by inflammatory
products from non vital tooth.
• Lined by squamous epithelium
 Residual cyst

• A Residual cyst is a cyst that

develops after incomplete
removal of the original cyst.
 Residual Cysts
• It is a radicular cyst remaining
after the tooth has been
extracted.
• Usually asymptomatic. Usually
small size (less than 1 cm in
diameter).
• Unilocular, round or oval, well-
defined, usually well-corticated.
• It can cause bone expansion
and displacement of the
adjacent teeth.
 Dentigerous Cyst (Follicular Cyst)
• Around the crown of an unerupted tooth.

• Usually adolescents, 20-40 years old.

• Most common sites:

– Mandibular third molar,
– Maxillary canine,
– Maxillary third molar.

• Lined by squamous epithelium

 Odontogenic tumors
Epithelial
Odontogenic
Tumors

Calcifying
Adenomatoid
epithelial
Ameloblastoma odontogenic
odontogenic
tumor tumor
 Odontogenic tumors
Mesodermal
Odontogenic
Tumors

Odontogenic
Cemento- Odontogenic
myxoma
blastoma fibroma
(myxofibroma)
 Odontogenic tumors
Mixed
Odontogenic
Tumors

Ameloblastic
Ameloblastic
Odontomas fibro-
fibroma
odontoma
 Ameloblastoma

• True neoplasm of odontogenic

epithelium

• Benign, locally aggressive

• Slowly grows as painless swelling

of the affected site.

• Can occur at any age.

• 80-95% in the mandible

• In the maxilla mostly in the

premolar-molar region.
 Ameloblastoma
• Localized invasion into the
surrounding bone.

• Adjacent teeth are often

displaced and resorbed.

• Incomplete removal can

result in recurrence.

• Histopathology :
– Follicular type
– Plexiform type
– Unilocular cystic (varian)
 Ameloblastoma (microscopic)

Follicular type

Unicystic ameloblastoma
 Odontoma
• Characterized by the production of mature
enamel , dentin , cementum and pulp tissue .
 Odontoma
• Relatively common lesion.
• It usually occurs in young patients.
• Usually asymptomatic.
 Odontoma
• Two types: complex and
compound odontoma.
– Complex odontoma :
composed of haphazardly
arranged dental hard and
soft tissues.
– Compound odontoma :
composed of many small
"denticles" .
 Salivary gland tumors
• 75-85% : Parotid gland
10-20% : Submandibular.
5-15% : Minor salivary gland
• Minor salivary gland : Usually malignant !!!
 Benign salivary gland tumors
• Pleomorphic adenoma (mixed tumor) (*)
• Warthin tumor (Papillary Cystadenoma
Lymphomatosum , adenolymphoma) (*)
• Oxyphilic adenoma
• Basal cell adenoma
• Tubular adenoma
• Clear cell adenoma
 Pleomorphic adenoma / mixed tumor
• The most common salivary gland tumour and accounts for
about 60% of all salivary neoplasms
• The mean age at presentation is 46 years (the age ranges
from the first to the tenth decades-WHO)
• Slight female predominance.
• 80% arise in the parotid,
• 10% in the submandibular gland
• 10% in the minor salivary glands of the oral cavity
• Slow growing, painless masses.
• Problem: Recurence and risk of malignant transformation
 Pleomorphic adenoma

Histopathology : Epithelial, myoepithel and mesenchymal (myxoid, chondroid, hyalin,

bone, cartilage, matur fat)
 Warthin tumor
(Papillary Cystadenoma Lymphomatosum)

• Almost exclusively restricted to the parotid

glands and the periparotid lymph nodes.
• Low recurrence rates (about 2-5.5%)
• Malignant change is rare (about 1%)
• Primary treatment is surgical
 Warthin tumor

Histopathology :
1. Two layer epithelium : oncocytic luminal
cells and cuboidal/flat basal cells,
2. lymphoid follicle with germinal centre
 Malignant salivary gland tumors
• Mucoepidermoid carcinoma
• Adenoid cystic carcinoma
• Carcinoma in pleomorphic adenoma
• Acinic cell carcinoma
Mucoepidermoid carcinoma

Adenoid cystic carcinoma

Kribriformis Tubuler Solid

 ESOPHAGEAL TUMORS

• Malignant tumor is more common than

benign tumor.
• If discovered late , 5 years survival is < 10 %.
• Even for potentally resectable tumors, 5 years
survival is low (< 30%)
 Benign Neoplasms

• The most common : Gastrointestinal stromal tumour (GIST).

• Uncommon : leiomyoma, papilloma, lipoma, neurofibroma

• Usually asymptomatic but may cause bleeding or dysphagia
• When large, can cause dysphagia or chest pain from
obstruction or stretch.
 Squamous cell carcinoma of oesophagus

• Can arise in any part of the oesophagus

• Almost all tumours above the lower third of the
oesophagus are squamous cell carcinoma
 Adenocarcinoma of oesophagus

• Arises in the lower third of the oesophagus from Barrett's

oesophagus or from the cardia of the stomach.
• The incidence is increasing, possibly because of the high
prevalence of GERD or Barrett's oesophagitis
 SYMPTOMS.

• The most common is progressive dysphagia

• May be accompanied by pain.
• The obstruction does not occur until the cancer is far
advanced.
• Hematemesis & Hoarseness from involvement of the
recurrent laryngeal nerve (unusual symptoms).
 Gastric tumors
Malignant
Benign
• Polyps
Tumors
– Carcinoma
Hyperplastic
– Lymphoma
Fundic gland
– Sarcoma
Neoplastic
– Carcinoid
• Tumors
– Leiomyomas
– Lipomas
– Heterotopic pancreas
 GASTRIC POLYPS
• Hyperplastic polyps
– Most common type of polyp (65 – 90%)
– “Inflammatory or regenerative polyps”:
• In reaction to chronic inflammation
• Often found in Helicobacter Pylori infections
– Sessile, seldom pedunculated
– Mostly in the antrum
– Multiple in 50% of cases
– Varying in size but seldom < 2cm
– Malignant transformation : 1 – 3%
GASTRIC POLYPS
• Fundic gland polyp
• Hyperplasia of the normal fundic glands
GASTRIC POLYPS
• Neoplastic polyps (adenomatous polyp)
– Types
• Tubular
• Villous
– Macroscopically
• More often in antrum
• Pedunculated with malignant potential
• Solitary, large, sometimes ulcerated
GASTRIC LEIOMYOMA

• Incidence of 16% at autopsy

• Arise from smooth muscle of the GIT tract
• 75% benign
• Usually presents with bleeding
• Treatment is local excision
GASTRIC LIPOMA
• Rare !
• Submucosal lesions
• Usually require no treatment
 Gastric carcinoma
• Associated due to :
– Chronic atrophic gastritis (Helicobacter pylori)
– Diet (adequate intake of fresh fruits and vegetables lowers the risk)
– Bile reflux
• More common in males ( 3 : 1 )

• Early gastric cancer often causes no symptoms.

• Symptoms of advanced carcinoma include : Abdominal pain,

bleeding/ haematemesis, and tumours that obstruct the gastric
outlet may cause vomiting.
 Borrmann classification
(gross appearance)
• Type I : Polypoid
• Type II : Fungating
• Type III : Ulcerated
• Type IV : Diffuse (infiltrative)
 Gastric carcinoma - pathology (WHO)
• Adenocarcinoma (*)
• Papillary adenocarcinoma
• Tubular adenocarcinoma
• Mucinous adenocarcinoma
• Signet-ring cell carcinoma

• Adenosquamous carcinoma
• Squamous cell carcinoma
• Small cell carcinoma
• Undifferentiated carcinoma
 GASTRIC LYMPHOMA
• 5% of all primary gastric neoplasm's
• 2 different types of lymphoma
– Part of systemic lymphoma with gastric involvement (32%)
– Primary involvement of the GIT (MALT Tumors)
• Mostly involves the antrum
• 5 different types according to appearance
– Infiltrative - Ulcerative
– Nodular - Polypoid
– Combination
 GASTRIC LYMPHOMA

• At time of presentation :
– Larger than 10 cm (50%)
– More than 1 focus (25%)
– Ulcerated (30 – 50%)
• Pattern of metastasis similar to gastric carcinoma
 GASTRIC SARCOMA
• 1 – 3 % of gastric malignancies
• Common :
– Leiomyosarcoma
– Malignant GIST (Gastro Intestinal Stromal Tumor)
 Tumors of duodenum
Benign Malignant

• Brunners gland adenoma • Peri-ampullar adenocarcinoma

• Leiomyoma • Leiomyosarcoma
• Carcinoid tumor • Lymphoma
• Heterotopic gastric mucosa
 Colorectal carcinoma
• Peak incidence: 60 to 70 years old
• < 20% cases before age of 50
• Adenoma – precursor lesions for most tumors
• Rectal carcinoma more frequent in men
• Colon carcinoma slightly more common in women
 Etiology
• Genetic influences:
– Hereditary nonpolyposis colorectal cancer syndrome
(HNPCC, Lynch syndrome)
• Germ-line mutations of DNA mismatch repair genes
• Three or more members of family affected before age 50
• Often right sided (50%) and multiple (20%)
– Frequent mutation or deletion of tumor supressor
gene, located on chromosomal segment 5q, 17p
and 18q.
 Etiology
• Environmental influences:
– Dietary :
• Low content of vegetable fiber
• High fat content
• Decreased intake of protective micronutrients (vitamins
A, C, and E)
 Location
• 50%: Rectum and distal sigmoid
• 25%: Caecum or ascending colon
• 25%: Descending colon and proximal sigmoid
 Morphology
• Tumors in the proximal colon: polypoid, exophytic
masses that extend along one wall of the cecum and
ascending colon
 Morphology
• In the distal colon: annular, encircling lesions that produce
constrictions of the bowel and narrowing of the lumen
• Both forms of neoplasm eventually penetrate the bowel
wall and may appear as firm masses on the serosal surface
 Morphology
• Almost all : Adenocarcinoma
• Range from well-differentiated to undifferentiated,
frankly anaplastic masses
• Many tumors produce mucin
 Typical sites of incidence and sympoms of colon cancer

Clinical Features
 Clinical Features
• May remain asymptomatic for years
• Caecal and right colonic cancers:
– fatigue
– weakness
– iron deficiency anemia
• Left-sided lesions:
– occult bleeding
– changes in bowel habit
– crampy left lower quadrant discomfort

“iron deficiency anemia in an older man means gastrointestinal cancer

until proved otherwise”
 Clinical Features
• Spread by direct extension into
adjacent structures and by
metastasis through lymphatics and
blood vessels
• Favored sites for metastasis:
– regional lymph nodes
– liver
– lungs
– bones
– other sites including serosal
membrane of the peritoneal
cavity
TNM Staging of Colon Cancer
Tumor (T)
T0 = none evident
Tis = in situ (limited to mucosa)
T1 = invasion of lamina propria or submucosa
T2 = invasion of muscularis propria
T3 = invasion through muscularis propria into
subserosa or nonperitonealized perimuscular
tissue
T4 = invasion of other organs or structures
Lymph Nodes (N)
0 = none evident
1 = 1 to 3 positive pericolic nodes
2 = 4 or more positive pericolic nodes
3 = any positive node along a named blood vessel
Distant Metastases (M)
0 = none evident
1 = any distant metastasis
5-Year Survival Rates
T1 = 97%
T2 = 90%
T3 = 78%
T4 = 63%
Any T; N1; M0 = 66%
Any T; N2; M0 = 37%
Any T; N3; M0 = data not available
Any M1 = 4%
 Dukes staging system

A Mucosa 80%
B Into or through M. propria 50%
C1Into M. propria, + Lymph Node 40%
C2Through M. propria, + Lymph Node 12%
D Distant metastatic spread <5%
 Tumors of anal canal
• Squamous cell carcinoma (*)
• Adenocarcinoma
• Malignant melanoma
• Mesenchymal tumor (rare)
Haemangioma, lymphangioma , leiomyoma,
leiomyosarcoma, Rhabdomyosarcoma,
fibrosarcoma, schwannoma, neurofibroma
• Lymphoma (rare)
 Squamous cell carcinoma- Anal canal

• Most common
• Women are more frequently affected
• Symptoms : Bleeding, pain, mass.
• Precursor lesion : dysplasia/ carcinoma in situ
(Bowen`s disease)
 Liver tumors
Benign Malignant

• Hemangioma 1. Primary liver

• Focal nodular
cancers
hyperplasia
• Hepatocellular carcinoma
• Adenoma
• Fibrolamellar carcinoma
• Liver cysts
• Hepatoblastoma
2. Metastases
 Hepatocellular carcinoma
• Hepatocellular carcinoma is the 5th most common malignancy
worldwide & the 3rd cause of cancer related death
• Etiology :
• Hepatitis B
– Increase risk 100 -200 fold
– 90% of HCC are positive for HBs Ag
• Hepatitis C
• Cirrhosis
- 70% of HCC arise on top of cirrhosis
• Toxins (alcohol, aflatoxins)
• Autoimmune hepatitis
 Incidence HCC according to etiology

Abbreviations: WD, Wilson′s disease; PBC, primary biliary cirrhosis, HH, hereditary hemochromatosis; HBV, hepatitis
B virus infection; HCV, hepatitis C virus infection.
 Signs & symptoms
• Nonspecific symptoms
– abdominal pain
– Fever, chills
– anorexia, weight loss
– jaundice

• Physical findings
– abdominal mass in one third
– splenomegaly
– ascites
 HCC: Diagnosis
• Clinical presentation
• Elevated AFP
• USG
• CT scan
• MRI
• Biopsy
 AFP (Alfa feto protein)
– Tumor marker for HCC
– Values more than 100 ng/ml are highly suggestive
of HCC
– Elevation seen in more than 70% of patients
Hepatocellular carcinoma
• Macroscopic :
– Nodular
– Massive
– Diffuse
– Pedunculated
Hepatocellular carcinoma

• Microscopic :
More than 2-3 cell-thick
hepatocellular plates/cords,
nuclear atypia, and absence
of portal tracts.
 Carcinoma of gallbladder
• Most patients are in the 6th or 7th decades of life.
• 1-3% of all GI malignancy
• Gallbladder carcinomas have a strong female predominance
• Risk factor : Gallstones, anomaly of pancreaticobiliary junction
(reflux of pancreatic enzymes to bile duct)
• Histopathology :
– Adenocarcinoma (*)
– Signet ring cell carcinoma
– Adenosquamous carcinoma
– Squamous cell carcinoma
– Undifferentiated carcinoma
• Prognosis : Poor (5 years survival rate < 5%)
Benign tumor of gallbladder (rare)
• Papillary adenoma
• Tubulo-papillary adenoma
• Biliary cystadenoma
TUMORS OF THE PANCREAS

A. Non-Endocrine neoplasms
B. Endocrine neoplasms
 Benign non-endocrine neoplasms :
• Adenoma,
• Mucinous cystadenoma,
• Lipoma,
• Fibroma,
• Haemangioma,
• Lymphangioma
 Malignant non-endocrine neoplasms.
1. Ductal adenocarcinoma

2. Cystadenocarcinoma
Adenocarcinoma of pancreas (ductal adenocarcinoma)

 Arising from ductal epithelium

 Account for 90% of pancreatic tumour
 60-70% : Head (caput) of pancreas.
 10-15% : Corpus
 5-10 % : Tail
 Etiologic factors :
 Cigarette smoking, diabetes melitus, chronic pancreatitis.
 Clinical features :
 Midgastric pain, vomitting, hematemesis, melena, acute pancreatitis,
jaundice
 Metastasis : regional lymph node, liver, lung, peritoneum
Endocrine neoplasm of pancreas :

• Less common than non-endocrine tumours

• Generally benign , sometimes multiple

- Insulinoma
- Glucagonomas
- Gastrinomas
- Somatostatatinomas