Upper Git tumors

Dr Alex Mogere
Consultant Physician
Cancer of the oesophagus:
incidence and aetiology
Cont. incidence and aetiology
• Almost all esophageal cancers are either squamous cell carcinomas or
adenocarcinomas;
• The 2 histologic subtypes have a similar clinical presentation but
different causative factors.
• SCC is the more common cell type, having an incidence that rises
strikingly in association with geographic location
• It occurs frequently within a region extending from the southern
shore of the Caspian Sea to northern China , encompassing parts of
Iran, central Asia, Afghanistan, Siberia, and Mongolia
Cont. incidence and aetiology
• Gene associations are not yet defined
• High-incidence “pockets” of the disease are also present in such
disparate locations as Finland, Iceland, Curaçao, southeastern Africa,
and northwestern France.
• In North America and western Europe, the disease is more common in
blacks than whites and in males than females
• It appears most often after age 50 and seems to be associated with a
lower socioeconomic status
Adenocarcinomas
• Adenocarcinomas arise within dysplastic columnar epithelium in the
distal esophagus.
• These adenocarcinomas behave clinically like gastric
adenocarcinomas, although they are not associated with Helicobacter
pylori infections.
• Approximately 15% of esophageal adenocarcinomas overexpress the
HER2/neu gene.
Clinical presentation
• About 5% of esophageal cancers occur in the upper third of the
esophagus (cervical esophagus),
• 20% in the middle third,
• 75% in the lower third
• SCC and adenoCas cannot be distinguished radiographically or
endoscopically.
• Progressive dysphagia
• Wt loss of short duration
Clinical presentation
• Dysphagia initially occurs with solid foods and gradually progresses to
include semisolids and liquids.
• Dysphagia does not occur until >60% of the esophageal circumference
is infiltrated with cancer.
• The disease most commonly spreads to adjacent and supraclavicular
lymph nodes, liver, lungs, pleura, and bone.
• Tracheoesophageal fistulas may develop, primarily in patients with
upper and mid-esophageal tumors
• As with other SCCs, hyperCa 2+ may occur in the absence of osseous
mets, probably from PTH-rP secreted by tumor cells
DX SCC
• Esophagoscopy
• endoscopic inspection of the larynx, trachea, and bronchi should also
be carried out-to check spread
• A thorough examination of the fundus of the stomach (by retroflexing
the endoscope) is imperative as well
• CT scan chest and abdomen
• Endoscopic u/s
• PET scan for distant mets
Tx esophageal Ca
• The prognosis for patients with esophageal carcinoma is poor.
• Approximately 10% of patients survive 5 years after the diagnosis
• Surgical resection of all gross tumor (i.e., total resection) is feasible in
only 45% of cases, with residual tumor cells frequently present at the
resection margins.
• Experienced thoracic surgeons are now favoring minimally invasive
transthoracic esophagectomies
• About 20% of pts who survive a total surgical resection live for 5 years
Tx esophageal Ca
• 15–25% of patients given single-agent treatment ,show significant
tumor size reduction
• While there is a greater response of 30–60% of patients treated with
drug combinations that include cisplatin
• For tumors that overexpress the HER2/neu gene, the addition of the
monoclonal ab trastuzumab (Herceptin) is beneficial, esp in pts with
gastroesophageal lesions.
• Combination chemotx and radiation tx as the initial therapeutic
approach, either alone or followed by an attempt at operative
resection
Cont tx esophageal Ca
• The use of preoperative chemotherapy and radiation therapy
followed by esophageal resection appears to prolong survival
compared with surgery alone
• Approaches to palliation include repeated endoscopic dilatation, the
surgical placement of a gastrostomy or jejunostomy for hydration and
feeding, endoscopic placement of an expansive metal stent to bypass
the tumor, and radiation therapy.
Tumors of the stomach
Aetiological factors for Gastric Ca
Ct. aetiology Gastric Ca
• The long-term ingestion of high concs of nitrates found in dried,
smoked, and salted foods appears to be associated with a higher risk
• The nitrates are thought to be converted to carcinogenic nitrites by
bacteria
Incidence & epidemiology
• The disease is the 2nd most frequent cause of worldwide cancer-
related death.
• Although the incidence of gastric Ca has decreased w/wide, it
remains high in Japan, China, Chile, and Ireland.
• The risk of gastric Ca is greater among lower socioeconomic classes
• Migrants from high- to low-incidence nations maintain their
susceptibility to gastric Ca, whereas the risk for their offspring
approximates that of the new homeland
Pathology
• 85 % are adenocarcinomas,
• 15% due to lymphomas, gastrointestinal stromal tumors (GISTs), and
leiomyosarcomas
• Gastric adenoCa- can be diffuse type or intestinal type
• The diffuse carcinomas occur more often in younger patients, develop
throughout the stomach , result in a loss of distensibility of the gastric wall
(so-called linitis plastica, or “leather bottle” appearance), and carry a poorer
prognosis.
• Intestinal-type lesions are frequently ulcerative, more commonly appear in
the antrum and lesser curvature of the stomach, and are often preceded by
a prolonged precancerous process, often initiated by H. pylori infection.
Cont. pathology
• The intestinal type tends to predominate in the high-risk geographic
regions
• In US, ∼30% of gastric Cas originate in the distal stomach, ∼20% in
the mid portion, and ∼40% originate in the proximal third of the
stomach. The remaining 10% involve the entire stomach.
Cont. clinical presentation
• Gastric Cas, when superficial and surgically curable, usually produce
no symptoms.
• Unusual clinical features include migratory thrombophlebitis, MAHA,
diffuse seborrheic keratoses (Leser-Trélat sign), and acanthosis
nigricans.
• The liver is the most common site for hematogenous spread of tumor
Clinical presentation ;in advanced stage
• Anemia(bleeding from tumor)
• Asthenia(septic absorption from the tumor)
• Anorexia
• Recent onset early satiety, dyspepsia, epigastric discomfort
• Specific symptoms depending on site of tumor
• Gastric outlet obstruction symptoms-if in pyloric rgn
• Dysphagia,hematemesis if in proximal rgn
• Mass per abdomen if in the body of the stomach
• Jaundice, ascites –in mets
Clinical signs
• Pallor-anemia
• Cachexia
• Epigastric mass, liver secondaries
• Virchows nodes
• Sister mary joseph node(metastatic nodules to periumbilical region)
• Krukenberg’s tumor(ovarian mets)
• Blumer shelf secondaries(peritoneal cul-de-sac)
• Irish node
Morphological features
• Polypoid
• Ulcerative
• Superficial spreading
• Infiltrative(linitis plastic,leather bottle stomach)
Staging for Gastric Ca
Japanese’s classification for early gastric Ca
Spread of gastric Ca
INVXs
• FBC
• LFT, RFT
• Stool examination for occult blood
• Cxr
• Tumor markers- CA 19-9, CEA,
• CA 72-4
• UGI endoscopy(of choice)-high diagnostic accuracy ,if upto 7 samples
taken(98%)
• Ct scan/US/mri- check wall thickness, mets
• Laparascopy- detection of peritoneal mets
Endoscopy
Endoscopy findings
• Ulcer- 25%
• Polypoid mass- 25%
• Superficial spreading-10%
• Infiltrative – difficult to detect
• Accuracy – 50-95 %,depending on gross appearance,location and
number of biopsies
ULCER ON ENDOSCOPY

Benign Malignant
• Round to oval punched out lesion • Irregular outline with necrotic or
with straight walls and flat hemorrhagic base
smooth base • Irregular and raised margins
• smooth margins with normal
• Anywhere
surrounding mucosa
• Mostly on lesser curvature(most
• Any size
<2cm) • Prominent and irregular rugal
• Normal adjoining rugal folds usu folds that don’t usu extend to
extending to the base margins the margins
MANAGEMENT
• SURGERY
• CHEMOTHERAPY
• RADIOTHERAPY
Supportive care
• Correct anemia
• IVF, electrolytes
• Nutritional support-parenteral/enteral

• Preoperative staging to avoid unnecessary surgery

Cont . Surgery Tx
• Complete surgical removal of the tumor with resection of adjacent
lymph nodes offers the only chance for cure(third of pts)
• A subtotal gastrectomy is the treatment of choice for patients with
distal carcinomas
• Total or near-total gastrectomies are required for more proximal
tumors
• Reduction of tumor bulk is the best form of palliation
Radiotherapy
• Gastric adenocarcinoma is a relatively radioresistant tumor
• Adequate control of the primary tumor requires doses of external-
beam irradiation that exceed the tolerance of surrounding structures,
such as bowel mucosa and spinal cord
• As a result, the major role of radiation therapy in patients has been
palliation of pain.
Chemotherapy
• Administration of combinations of cytotoxic drugs to patients with
advanced gastric carcinoma has been associated with partial responses in
30–50% of cases(responders)
• Agents include: cisplatin combined with epirubicin or docetaxel and
infusional 5-FU or capecitabine, or with irinotecan
• Despite the encouraging response rates, complete remissions are
uncommon
• The median survival time for patients treated in this manner remains < 12
months.
• Addition of bevacizumab (Avastin) to chemotherapy regimens in treating
gastric cancer appears to provide limited benefit.
Cont. Chemotherapy
• Preliminary results utilizing another antiangiogenic cpd—
ramucirumab (Cyranza)—in the Tx of gastric Ca are encouraging.
• The use of adjuvant chemotx alone following the complete resection
of a gastric cancer has only minimally improved survival.
• Neoadjuvant,and adjuvant Tx combined with radiation therapy
reduces the recurrence rate and prolongs survival
• 3 WKS, 6 cycles
Prognostic factors (in resectable gastric Ca)
• Depth of Ca invasion
• Regional LN involvement

• 5 yrs survival rate in US- 10%, Japan- 50%

Stage 5 yr Survival(%)
T1N0M0 95+
T1N1M0 70-80
T2N1MO 45-50
T3N2M0 15-25
M1 0-10
PRIMARY GASTRIC LYMPHOMA
• Is relatively uncommon,
• Accounts for <15% of gastric malignancies and 2 % of all Lymphomas
• The stomach is, however, the most frequent extranodal site for
lymphoma
• Often detected during the sixth decade of life, just like gastric
adenocarcinoma
• Present with epigastric pain, early satiety, and generalized fatigue;
and are usually characterized by ulcerations with a ragged, thickened
mucosal pattern
CONT.PRIMARY GASTRIC LYMPHOMA
• The diagnosis of lymphoma of the stomach may occasionally be made
through cytologic brushings of the gastric mucosa but usually requires
a biopsy at gastroscopy or laparotomy
• The macroscopic pathology of gastric lymphoma may mimic
adenocarcinoma
• Microscopically, the vast majority of gastric lymphoid tumors are
lymphomas of B-cell origin
• Histologically, they may range from well-differentiated, superficial
processes (mucosa-associated lymphoid tissue [MALT]) to high-grade,
large-cell lymphomas(DLBCL)
Cont . PRIMARY GASTRIC LYMPHOMA
• Infection with H. pylori increases the risk for gastric lymphoma in
general and MALT lymphomas in particular
• Large cell lymphomas of the stomach spread initially to regional
lymph nodes (often to Waldeyer’s ring) and may then disseminate.
PATHOGENESIS
Treatment Gastric Lymphoma
• Primary gastric lymphoma is a far more treatable disease than
adenocarcinoma of the stomach
• Abx tx to eradicate HP infection has led to regression of about 75% of
gastric MALT lymphomas and should be considered before surgery
• A lack of response to such antimicrobial treatment has been linked to
a specific chromosomal abnormality, i.e., t(11;18).
• Responding patients should undergo periodic endoscopic surveillance
Treatment Gastric Lymphoma
• Subtotal gastrectomy, usually followed by combination chemotherapy,
has led to 5-year survival rates of 40–60% in pts with localized high-
grade lymphomas
• (CHOP [cyclophosphamide, doxorubicin, vincristine, and prednisone])
plus rituximab is highly effective therapy for DLBCL
Other non Lymphoma gastric tumors
• Leiomyoscarcomas and GISTs-1-3% of gastric neoplasms
• GISTs are unresponsive to conventional chemotherapy; yet ∼50% of
pts experience objective response and prolonged survival when
treated with imatinib mesylate (Gleevec) (400–800 mg PO daily)
TUMORS OF THE SMALL INTESTINE
Small-bowel tumors should be considered in the ddx in the following
situations:
• recurrent, unexplained episodes of crampy abdominal pain;
• intermittent bouts of intestinal obstruction, especially in the absence
of inflammatory bowel disease (IBD) or prior abdominal surgery;
• intussusception in the adult; and
• evidence of chronic intestinal bleeding in the presence of negative
conventional and endoscopic examination.
Benign intestinal tumors
• Adenomas
• Polypoid adenomas
• Leiomyomas
• Lipomas
• angiomas
Malignant intestinal tumors
• Adenocarcinomas
• Lymphomas
• Carcinoid tumors
• leiomyosarcomas
THANK YOU!