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