GASTROINTETINAL

CANCERS
 CANCER OF THE ESOPHAGUS
• Estimated to have caused 2% of the overall cancer deaths but
about 4% cancer deaths in men
• Is the eighth lading cause of cancer worldwide
• Sixth leading cause of cancer death
• Worldwide, esophageal cancer is 3-4 times more common in men
than in women
 ETIOLOGY AND RISK FACTORS
• Environmental factors
• Conditions that includes chronic irritation of the esophagus
• Age
• Race
• Obesity and Smoking
• Dietary risk factors
• Genetics
• Barret’s Esophagus, Achalasia, Tylosis, Esophageal webs, Plummer-Vinson syndrome
 Barret’s Esophagus
• is a serious complication of GERD, which stands for gastroesophageal
reflux disease. In Barrett's esophagus, normal tissue lining the esophagus --
the tube that carries food from the mouth to the stomach -- changes to
tissue that resembles the lining of the intestine.
 Achalasia
• is a rare disorder that makes it difficult for food and liquid to pass into your
stomach. Achalasia occurs when nerves in the tube connecting your mouth
and stomach (esophagus) become damaged.
 Tylosis
• Tylosis is a rare autosomal dominant disease caused by a mutation
in TEC (tylosis with esophageal cancer), a tumor suppressor gene located on
chromosome 17q25. Tylosis is associated with hyperkeratosis of the palms
and soles (see the images below) and a high rate of esophageal SCC (40% to
90% by the age of 70 years).
 Esophageal webs
• are thin membranes that grow across the inside of the upper part of
the esophagus and may cause difficulty swallowing (dysphagia)
 Plummer-Vinson syndrome
• is a rare disease characterized by difficulty swallowing, iron-deficiency
anemia, glossitis, cheilosis and esophageal webs.
 PREVENTION, SCREENING AND
DETECTION
• Avoiding controllable risk factors
• Balloon cytology
• Endoscopic mucosal staining
• Surveillance endoscopy
• Education
 CLASSIFICATION
1. Adenocarcinoma
- occurs in the lower portion of the esophagus
- frequently arise from the gastroesophageal junction,
where metaplasia and eventual dysplasia occur in the
epithelium as a result in acid exposure
2. Squamous Cell Carcinoma
• - 2nd most common subtype
• - rise from the surface of the epithelium
Uncommon esophageal tumors:

1. Mucoepidemoid Carcinoma
- is the most common type of minor salivary gland malignancy
in adults.
- develops when a cell randomly acquires changes ( mutations )
in genes that regulate how the cell divides such that it begins to
grow quickly, forming a cluster of cells (a mass or lump)
2. Small Cell Carcinoma
- is a type of highly malignant cancer that most commonly
arises within the lung, although it can occasionally arise in
other body sites, such as the cervix, prostate, and
gastrointestinal tract.
- small cell carcinoma has a shorter doubling time, higher growth
fraction, and earlier development of metastases.
3. Sarcoma
- is a type of cancer that can occur in various locations in your
body. Sarcoma is the general term for a
- broad group of cancers that begin in the bones and in the soft
(also called connective) tissues (soft tissue sarcoma).
4. Melanoma
- is a type of cancer that develops from the pigment-containing
cells known as melanocytes. Melanomas typically occur in the
skin, but may rarely occur in the mouth, intestines, or eye.
5. Adenoid Cystic Carcinoma
- is an uncommon form of malignant neoplasm that arises
within secretory glands, most commonly the major and minor
salivary glands of the head and neck.
6. Lymphoma
- is cancer that begins in infection-fighting cells of the immune
system, called lymphocytes. These cells are in the lymph nodes,
spleen, thymus, bone marrow, and other parts of the body.
 CLINICAL FEATURES

• Dysphagia
• Heartburn (GERD)
• Weight loss
• Pain (may be related to swallowing)
 DIAGNOSIS

1. Barium Swallow –

Barium is used during a swallowing test to make certain areas of the body
show up more clearly on an X-ray.
2. Flexible Endoscopy –
a flexible tube with a light and camera on the tip is inserted through the
area of concern. The endoscopy allows to visualize the organs for
diagnoses, to take biopsies, or to make repairs.
• CT SCAN
• Endoscopic ultrasound
• PET scan
Medical Treatment Modalities and Nusing Care
Considerations
1. Surgery
- gold standard for cure
- used for early-stage lesions for curative intent
the choice of surgical approach for esophagectomy remains controversial
 Approaches to resection depending upon the location of tumor:
1. Transthoracic
a.) Ivor Lewis Approach
In the Ivor Lewis esphagectomy, the esophageal tumor is removed through an
abdominal incision and a right thoracotomy (a surgical incision of the chest wall). The
esophagogastric anastomosis (reconnection between the stomach and remaining
esophagus) is located in the upper chest.

b.) McKeown modification of the Ivor Lewis

The McKeown (tri-incisional) esophagectomy is appropriate in patients with tumors
located above the gastroesophageal junction up to the level of the clavicles (12). This
technique involves a right thoracotomy, laparotomy, and left neck incision for creation of
a cervical anastomosis
2. Transhiatial
- Is used in the cervical region or the upper esophagus
3. Minimally invasive procedure
a.) Thorascopically assisted esophagectomy
b.) Laparoscopically assisted esophagectomy
c.) combination of the two approaches

Potential Complication:
Port-site metastasis - early recurrent tumorous lesions
Post-op Nursing Care:
• Preventing further morbidity and mortality (preventing and/ treating pneumonia)
• Maintaining nutrition
• Enhancing quality of life

2. Radiation Therapy
- appropriate for patients with obstructing tumors who are not able to receive
chemotherapy alone or surgery in combination with chemotherapy
- may be used in patients who have localized disease
 Dysphagia (difficulty swallowing) is relieved by radiation therapy alone or used in
combination therapy

• Intraluminal Brachytherapy
- allows high doses of radiation to be administered locally to a small volume of tissue

• Preoperative (neoadjuvant) radiation

- Treatment given as a first step to shrink a tumor before the main treatment, which is usually surgery
- Is done with the hope of improving respectability and decreasing local recurrenc
• Neoadjuvant combined chemo radiation
- Has been found to provide improved disease-free survival and a higher frequency of curative
resections than either surgery, chemotherapy or radiation alone

Nursing Care:
• Assessing for complications and educating the patient on how to manage these
• Esophagitis management
- Traditional management includes a combination of viscous xylocaine, aluminum hydroxide-
`magnesium carbonate, and diphenhydramine, or oral liquid narcotics
- Histamine-2 receptor antagonists or proton pump inhibitors are also used to reduce injury
from gastric acid
3. Chemotherapy
- several agents have been used as single agent therapy in esophageal cancer; these
agents include 5-FU and cisplatin (most common agents), methotrexate, paclitaxel,
mitomycin, vindesine,

Common side effects:

- nausea, vomiting, myelosuppression, nephrotoxicity, peripheral neuropathy,
mucositis, diarrhea and hand-foot syndrome

Nursing Care:
- monitoring for side effects and teaching patients for side effects management
 CANCER OF THE STOMACH
• Second leading cause of death worldwide, second to lung cancer
• An estimated 875,000 new cases are diagnosed annually
• The lifetime risk of developing stomach cancer in a person’s lifetime is 1 in
100
 Etiology and Risk Factors
• Nutritional (obesity, GERD, poor drinking water, lack of refrigeration, consumption of
foods high in nitrates, smoked or salt cured food preparation, low dietary fiber, low dietary
intake of vitamin A and C)

• Environmental (EBV, H. Pylori)

• Social (smoking and alcohol intake)
• Genetic
• Medical
 Prevention, Screening and Detection
Prevention:
- nutritional measures, smoking cessation, use of NSAIDS, eradication of
H. Pylori infections, dietary measures
- education and public advocacy
- identifying appropriate candidates for screening
- identifying signs and symptoms that warrant investigation
Screening and Detection:
- Mass screening and early detection programs
- Mas endoscopic screening
• Esophagogastroduodenoscopy - is a procedure during which a small flexible
endoscope is introduced through the mouth (or, with smaller-caliber endoscopes,
through the nose) and advanced through the pharynx, esophagus, stomach, and
duodenum.
 Classification
Adenocarcinomas
- represent approximately 95% of the malignant tumors of the stomach
 Classification Systems

1. Borrman Classification System

2. Siewart and Stein
3. WHO system
4. Lauren Systems (Intestinal and Diffuse)
- most widely accepted
 Clinical Features
• Dyspepsia
• Weight loss
• Anorexia
• Dysphagia
• Vomiting
• Hematemesis
 Diagnosis and Staging
• EGD (Esophagogastroduodenoscopy)
- Most sensitive and specific test for gastric cancer
- if roperly performe. An EGD is 92% to 96% accurate
• EUS (Endoscopic ultrasound)
- is a minimally invasive procedure to assess digestive (gastrointestinal) and lung
diseases. A special endoscope uses high-frequency sound waves to produce
detailed images of the lining and walls of your digestive tract and chest, nearby
organs such as the pancreas and liver, and lymph nodes
 - allows for more accurate assessment of tumor depth and perigastric lymph node
involvement when used in combination with EGD
• CT Scan
-Are not useful in determining the depth of the tumor penetration but are very
accurate in identifying distant metastasis and somewhat accurate in identifying lymph
node involvement

• Laparoscopy
- Can be used in combination with CT Scan and EUS for more accurate assessment of
serosal infiltration, peritoneal seeding and hepatic metastasis
- PET
- Three dimensional CT scanning
- CBC
- Electrolytes
- Liver function test
- Serum albumin
- Tumor markers CEA (Carcinoembryonic antigen is a protein found in many types of
cells ), CA-125 (measures the amount of the protein cancer antigen 125 in your blood)
and CA 19-9 (is a type of antigen released by pancreatic cancer cells)
 Medical Treatment Modalities and Nursing
Consideration
• Surgery
- Is the mainstay of treatment in local and regional gastric cancers
- The only curative modality

• Radiation Therapy –
- To control or eliminate recurrent or residual disease may be us either
intraoperatively, as an adjuvant, or in neoadjuvant setting, for treatment of pain,
bleeding or obstruction
- is often combined with chemotherapy such as 5-FU as a radio-sensitizer
Toxicities:
EARLY
- nausea
- vomiting
- difficulty in maintaining adequate nutrition
LATE
- Bleeding
- Ulceration
- Stricture
• Chemotherapy
- is used for gastric cancer as a single agent, in combination, and with or without
radiation for adjuvant and palliative therapy.
- 5-FU, tegafur, doxorubicin, epirubicin, mitomycin C, the nitrosouras, trimextrexate,
methotrexate and cisplatin
- FAM
- The current standard of care is 5-FU in combination of cisplatin for all stages of
disease
 Chemotherapy Complications:

EARLY
• Myelosuppressin
• Oral mucositis/diarrhea
• Nausea/vomiitting
• Neuropathy

LATE
• Alopecia
• Fatigue
• Nephrotoxicity
• Hand-foot syndrome
 Disease-related Complications:
• Anorexia
• Pain
• Obstruction/vomiting/dysphagia
• Bleeding/hematemesis/melena
• Ascites
• Jaundice
• Bone pain
 Post-operative Complications:

EARLY LATE
• Infection Dumping Syndrome
• Hemorrhage Reflux esophagitis
• Acute pancreatitis Weight loss
• Ileus Anemia
• Anastomotic leak Hypoproteinemia
• Thromboembolism Osteomalacia