Siloam Hospital Lippo Village Faculty Medicine of Pelita Harapan University 2010

INTRODUCTION

Gastrointestinal cancer refers to malignant conditions of the gastointestinal tract, including

the esophagus, stomach, liver, biliary system, pancreas, bowels, and anus.

Prognosis is variable,
esophageal cancer dismal prognosis largely (detected late) colon cancer excellent prognosis (when detected early) pancreatic cancer very poor prognosis (only 5% of patients surviving more than 5 years after diagnosis)

TUMORS: DIGESTIVE SYSTEM NEOPLASIA

GI tract Upper GI tract Esophagus Stomach Squamous cell carcinoma, adenocarcinoma Gastric carcinoma, signet ring cell carcinoma, gastric lymphoma (MALT) lymphoma, Linitis plastica Duodenal cancer (adenocarcinoma) Carcinoid, pseudomyoma peritonei Colorectal polyp : Peutz-Jeghers syndrome, Juvenile polyposis syndrome, Familial adenomatous polyposis (FAP) or Gardner's syndrome, CronkhiteCanada disease Neoplasm : adenocarcinoma, Familial adenomatous polyposis , Hereditary nonpolyposis colorectal cancer Squamous cell carcinoma Gastointestinal stromal tumor, Krukenberg tumor (metastatic) Malignant : Hepatocellular carcinoma (Fibrolamellar), hepatoblastoma Benign : Hepatocellular adenoma, cavernous hemangioma Hyperplasia : Focal nodular hyperplasia, nodular regenerative hyperplasia Bile duct Gallblader Cholangiocarcinoma, Klatsin Tumor Gallblader cancer Exocrin pancreas : adenocarcinoma Pancreatoblastoma

Lower GI tract

Small Intestine Appendix Colon/rectum

Anus Upper and/lower GI Accessory Liver

Billiary tract Pancreas

ESOPHAGEAL CANCER

There are two main types,

Squamous cell carcinoma more commonly in the upper or middle part of the esophagus. Adenocarcinoma occurs in the lower part of the esophagus.

Incidence

More commonly diagnosed > 55 years old Men : women= 2 : 1 Squamous cell esophageal cancer African Americans > Caucasians. Adenocarcinoma more common in middle-aged Caucasian men.

Etiology : unknown Risk factors:

Alcohol, smoking and obesity. The risk increased by irritation of the lining of the esophagus

Barrett's esophagus. Less common : swallowed caustic cubstances

Sometimes adenocarcinoma of the esophagus runs in families.

Symptoms,
Very small tumors at an early stage do not generally cause symptoms. Common symptoms is experience difficulty swallowing

At first, trouble swallowing solid foods such as meats, breads or raw vegetables As the tumor grows the esophagus becomes more narrowed difficulty in swallowing even liquids. Other symptoms : indigestion, heartburn, vomiting and choking, coughing and hoarseness of the voice, Involuntary weight loss.

STAGING OF ESOPHAGEAL CANCER

Diagnosis,
History taking Physical examination Diagnostic test,

Esophagram / barium swallow series of x-rays of the esophagus Endoscopy and biopsy CT scan of the neck, chest and abdomen identify iany spread of the cancer to other organs in the body

Treatment depend on the stage

Surgery, Radiation, Chemotherapy, Stretching or dilation (tube prosthesis (stent)) combination with radiation or laser treatment Combination .

DIAGNOSTIC TEST
ENDOSKOPI BARIUM SWALLOW

SURGERY

STENT

STOMACH CANCER (GASTRIC CANCER)

Stomach cancer
can develop in any part of the stomach can spread throughout the stomach and to other organs (small intestines, lymph nodes, liver, pancreas and colon)

Incidence
More commonly > of 55 years old Men : women = 2 : 1 African Americans > Caucasians.

Etiology unclear Risk factors:

Infection of Helicobacter pylori cause inflammation and ulcers in the stomach Associating condition : pernicious anemia, or gastric atrophy (result in lower than normal production of digestive juices) Smoking

Symptoms
In the early stages may not have any symptoms The most common symptoms include:

pain or discomfort in the abdomen nausea and vomiting loss of appetite fatigue or weakness bleeding (vomiting blood or passing blood in stools) weight loss early satiety (cannot eat a complete meal because of a full feeling)

Diagnosis
History taking Physical examination Diagnostic test,

Esophagram / barium swallow series of x-rays of the esophagus Endoscopy and biopsy CT scan of the neck, chest and abdomen identify any spread of the cancer to other organs in the body

Treatment depend on the size, location, extent of tumor and the patient's overall health. T
Surgery gastrectomy partial or total Chemotherapy , Radiation therapy Combination.

HEPATOCELLULAR CARCINOMA OR LIVER CANCER

Hepatocellular carcinoma,
arises in the liver known as hepatoma or primary liver cancer the fifth most common cancer in the world.

Etiology : infection of chronic hepatitis C Risk factors,

Alcohol Ascociation chemicals :

Aflatoxin product of a mold called Aspergillus flavus , found in foods such as peanuts, rice, soybeans, corn and wheat. Thorotrast Vinyl chloride found in plastics.

Hemochromatosis. Alpha-1-antitrypsin deficiency

Symptoms,

abdominal pain present when the tumor is very large or has spread, unexplained weight loss or unexplained fevers, sudden appearance of abdominal swelling (ascites), yellow discoloration of the eyes and skin (jaundice), muscle wasting.

Diagnosis,
History taking Physical ecamination Diagnostic test

Routine blood tests. Blood test for the tumor marker, alpha-fetoprotein (AFP), Radiological imaging must be performed. CT scan MRI (magnetic resonance imaging) Angiography. Ultrasound examination. Biopsy no needed in patients with a risk factor for HCC and elevated AFP.

Prognosis
Depends on the stage of the tumor and the severity of the associated liver disease. If the patient is able to undergo surgery successfully, the five year survival is 30-40%.

Some factors that predict poor outcome,

Demographics: male gender, older age, alcohol consumption Symptoms: weight loss, decreased appetite Signs of impaired liver function: jaundice, ascites or mental confusion related to liver disease (encephalopathy) Blood tests: elevated liver tests, low albumin, high AFP, low sodium, high blood urea nitrogen Staging of tumor: tumor over 3 cm, multiple tumors, tumor invasion of local blood vessels, tumor spread outside of liver.

Treatment
Chemotherapy + embolization (injestion of anticancer chemicals) provide some relief of symptoms and possibly decrease tumor size (in 50% of patients) but it is not curative. Ablation (tissue destruction) therapy in the form of using radiofrequency waves, alcohol injection into the tumor or proton beam radiation to the tumor site are other options for treatment. Surgery

PANCREATIC CANCER
Etiology : not known Risk factors:

Smoking major risk factor. Alcohol consumption. Chronic pancreatitis. Condition of hereditary pancreatitis.

Symptoms,
Early pancreatic cancer usually does not cause symptoms (the "silent" disease). As the tumor gets larger, one or more of these symptoms can appear:

Jaundice Abdominal pain Nausea Decreased appetite Weight loss

Diagnosis
History taking Physical examination Diagnostic test

CT scan or ultrasound. Endoscopic ultrasound + biopsy ERCP (endoscopic retrograde cholangiopancreatogram)

Treatment
Only curable if it is found in the early stages. Surgery Radiation Chemotherapy Pain control

COLORECTAL CANCER

Kinds of colorectal cancer,

adenocarcinoma, leiomyosarcoma, lymphoma, melanoma, neuroendocrine tumors.

Cancer lower GI tract that begins,

in the colon colon cancer in the rectum rectal cancer in either of these organs may also be called colorectal cancer.

Incidence:
The second leading cause of death from cancer in the United States. Men > women.

Etiology : not completely understood

Environmental, Genetic, Dietary factors

Believed to be responsible for 85% to 90% of all cases.

Risk factor,
> 50 years old. Having a personal history of any of the following:

colorectal cancer polyps in the colon or rectum cancer of the ovary, endometrium, or breast ulcerative colitis or Crohn disease

Having a parent, brother, sister, or child with colorectal cancer or polyps. Having certain hereditary conditions, such as familial adenomatous polyposis (FAP) and hereditary nonpolyposis colon cancer (HNPCC; Lynch Syndrome).

Diagnosis,

History taking Physical examination digital rectal examination Diagnostic test,

fecal occult blood test barium Enema colonoscopy, sigmoidoscopy DNA stool test

Treatment

Surgery Chemotherapy Radiotherapy Combination

There are a number of factors that help decision of treatment plan :

The type and size of the cancer Your general health Your age Whether the cancer has spread (the stage) What the cancer cells look like under the microscope (the grade)

DIAGNOSTIC TEST

ADENOCARCINOMA
A malignant tumor in epithelial tissue, specifically in a gland. Two subtypes,

Signet ring cell adenocarcinoma Mucinous adenocarcinoma

Symptoms,
occult fecal blood anemia, fatigue and weakness obstructive symptoms left colon tumor >> right colon tumor

Colicky abdominal pain Change in bowel habits. constipation may alternate with periods of increased frequency and loose stools.

tenesmus, urgency, and recurrent hematochezia rectal cancer weight loss is uncommon. hepatomegaly metastatic spread.

STAGING OF COLORECTAL CANCER

AJCC stage TNM stage
Stage 0 Stage I Stage I Stage II-A Stage II-B Stage III-A Stage III-B Stage III-C Stage IV Tis N0 M0 T1 N0 M0 T2 N0 M0 T3 N0 M0 T4 N0 M0 T1-2 N1 M0 T3-4 N1 M0 any T, N2 M0 any T, any N, M1

TNM stage criteria for colorectal cancer[39]

Tis: Tumor confined to mucosa; cancer-in-situ T1: Tumor invades submucosa T2: Tumor invades muscularis propria T3: Tumor invades subserosa or beyond (without other organs involved)

T4: Tumor invades adjacent organs or perforates the visceral peritoneum N1: Metastasis to 1 to 3 regional lymph nodes. T1 or T2. N1: Metastasis to 1 to 3 regional lymph nodes. T3 or T4. N2: Metastasis to 4 or more regional lymph nodes. Any T.
M1: Distant metastases present. Any T, any N.

POLYPS OF THE COLON AND RECTUM

An intestinal polyp any mass of tissue that arises from the bowel wall and protrudes into the lumen. Most are asymptomatic except for minor bleeding. Types,

Adenomatous (neoplastic) polyps, are classified histologically as,

tubular adenomas 1.5-cm tubular adenoma has 2% risk of containing a cancer tubulovillous adenomas (villoglandular polyps), or villous adenomas 3-cm villous adenomas has 35% risk of containing a cancer

Nonadenomatous (neoplastic) polyps

hyperplastic polyps, hamartomas, juvenile polyps, pseudopolyps, lipomas, leiomyomas, and other rarer tumors.

Symptoms,

most asymptomatic, rectal bleeding the most frequent complaint, cramps, abdominal pain, obstruction large lesion. large villous adenomas watery diarrhea result in hypokalemia.

The main concern is malignant transformation; most colon cancers arise in a previously benign adenomatous polyp. Diagnosis

History taking Physical examination rectal polyps may be palpable Diagnostic test

colonoscopy biopsy

Treatment colonoscopy removal.

FAP (FAMILIAL ADENOMATOUS POLYPOSIS)

A hereditary disorder causing numerous colonic polyps and resulting in colon carcinoma by age 40. Patients are usually asymptomatic but may have hemepositive stool. Diagnostic test

colonoscopy genetic testing.

Treatment colectomy.