GI Neoplasms Part II PDF

Usually a complication ESSENTIALS of cirrhosis. OF DIAGNOSIS Liver Imaging CT or mRI Neoplasms with Biopsy confirms diagnosis  2 Categories Benign Cavernous hemangiomas Liver Hepatic adenomas...

Usually a complication ESSENTIALS of cirrhosis. OF DIAGNOSIS Liver Imaging CT or mRI Neoplasms with Biopsy confirms diagnosis  2 Categories Benign Cavernous hemangiomas Liver Hepatic adenomas Focal nodular hyperplasia Neoplasms Malignant Can be primary or metastatic Liver is mets site for other primary cancers including lung and breast Cavernous Most common benign neoplasm of the liver Hemangiomas Often incidental finding on imagery What is an incidental finding? Mass of small blood vessels Using Hormone treatment/OCPs can increase its size Treatment in most cases is to observe for symptoms and size growth, Rarely requires surgical intervention  Benign Most commonly occurs in 3rd/4th decades of life Hepatic Usually caused by OCPs Adenomas Abdominal pain usually secondary to tumor necrosis or tumor hemorrhage  Another benign tissue type Occurs in all ages Focal Nodular Typically seen in women Probably not caused by oral Hyperplasia contraceptives Often asymptomatic  You may feel the mass on physical exam, you may not; LFTs are typically normal Benign Liver Neoplasms Benign neoplasms are treated according to the symptoms of the patient; risk of capsular rupture should be discussed when deciding to observe and not surgically remove  Malignant Liver Neoplasms Malignant neoplasms of the liver that arise from Those that originate in the parenchymal cells are ductular cells are called called hepatocellular cholangiocarcinomas (15% carcinomas (accounting for or less) 85% of liver cancers) General Worldwide, hepatocellular carcinomas are the fourth most common cause of Consideration cancer-related deaths  Can be primary or metastatic Liver is metastatic site for other Malignant Liver primary cancers including lung and breast Neoplasms Rare tumors of the liver include angiosarcoma and lymphoma.  Primary liver cancer associations Hepatocellular Cirrhosis = 85% of cases Hep B Carcinoma Hep C  Risk factors in Western countries with known cirrhosis Male gender Age > 55 years Hep C infection Obesity Hepatocellular DM ETOH Carcinoma Family history Asian and Hispanic ethnicity Risk factor in parts of Asia and Africa Hep B Hepatocellular Carcinoma Clinical findings Cachexia Weakness Weight loss Ascites Hepatic tenderness Bruit/friction rub Africa = young patient with rapidly growing abdominal mass  Labs Leukocytosis Elevated α-feta protein level > 200 ng/mL Seen in 70% of patients with hepatocellular carcinoma Imaging with US, CT Abdomen or Hepatocellular angiography CT abdomen or MRI abdomen with Carcinoma contrast preferred imaging of choice Liver biopsy is diagnostic seeding of the needle tract by tumor is a potential risk DO NOT use needle biopsy if tumor is resectable  Screening and prevention recommended for patients with Chronic Hep B Cirrhosis caused by Hep C Hepatocellular Cirrhosis caused by ETOH abuse Carcinoma Get a screening AFP and Ultrasound every 6 months in these patients  Treatment Primary without cirrhosis Surgery Mets Hepatocellular Treat primary lesions Carcinoma Liver transplantation Overall prognosis is poor 1- and 5- year survival rates are 23% and 5% respectively Pancreatic Neoplasms  Obstructive jaundice (may be painless) Enlarged gallbladder (may be painful) Pancreatic Upper abdominal pain with radiation to Cancer back, weight loss, and thrombophlebitis are usually late manifestations  Pancreatic Cancer Carcinoma is the most common neoplasm of the pancreas About 75% are in the head 25% in the body and tail of the organ account for 2% of all cancers and 5% of cancer deaths Pancreatic Age tobacco use (which is diabetes mellitus prior abdominal radiation Cancer-Risk thought to cause 20–25% of cases) family history Factors heavy alcohol use possibly gastric ulcer exposure to arsenic and obesity cadmium chronic pancreatitis  Pancreatic Cancer Courvoisier sign-enlarged gallbladder which is nontender and accompanied with mild painless jaundice In advanced cases, a hard periumbilical (Sister Mary Joseph’s) nodule may be palpable.  Pancreatic Cancer-Labs CA 19-9 tumor marker-can also be elevated with pancreatitis Amylase and Lipase Occult blood in the stool is suggestive of carcinoma of the ampulla of Vater combination of biliary obstruction and bleeding may give the stools a distinctive silver appearance Pancreatic Cancer- Imaging  TNM classification Tis: carcinoma in situ T1: tumor limited to the pancreas, 2 cm or less in greatest dimension T2: tumor limited to the pancreas, Pancreatic more than 2 cm in greatest dimension Cancer-Staging T3: tumor extends beyond the pancreas but without involvement of the celiac axis or the superior mesenteric artery T4; tumor involves the celiac axis or the superior mesenteric artery (unresectable primary tumor)  TNM classification N1: metastasis to one to Pancreatic three regional lymph nodes; Cancer-Staging N2: metastasis to four or more regional lymph nodes; M1: distant metastasis.  Pancreatic Cancer-Treatment The best surgical results are achieved at centers that specialize in the multidisciplinary treatment of pancreatic cancer. When resection is not feasible, endoscopic stenting of the bile duct is performed to relieve jaundice. Chemotherapy has been disappointing in metastatic pancreatic cancer  Carcinoma of the pancreas, especially in the body or tail, has a poor prognosis 80–85% of patients present with advanced unresectable disease with a 5-year survival rate of 2-5% Pancreatic Tumors of the ampulla have a better Cancer- prognosis 5-year survival rates of 20–40% after Prognosis resection jaundice and lymph node involvement are adverse prognostic factors Resection of cancer of the pancreatic head is feasible and results in reasonable survival  All patients with carcinoma involving When To Refer the pancreas and the ampulla of Vater should be referred to a specialist.  Patients who require surgery and When To Admit other interventions should be hospitalized. Colorectal  Personal or family history of adenomatous or serrated polyps or colorectal cancer are important risk factors. Symptoms or signs depend on tumor Colorectal location. Cancer Proximal colon: fecal occult blood, anemia. Distal colon: change in bowel habits, hematochezia. Diagnosis established with colonoscopy.  Colorectal Colorectal cancer is the second leading cause of death due to malignancy in the United States Colorectal cancers are almost all adenocarcinomas tend to form bulky exophytic masses or annular constricting lesions Colorectal Adenomatous polyp Serrated polyp tubular hyperplastic polyp Cancer-polyps tubulovillous traditional serrated adenoma villous adeoma sessile serrated adenoma Colorectal Polyps that are “advanced” are associated with a greater risk of cancer—this includes Cancer- polyps at least 1 cm in size, adenomas with villous features or high-grade dysplasia, or polyps serrated polyps with dysplasia Colorectal Cancer-Risk Factors Age Family History Inflammatory Bowel Disease Blacks/African American Diet and Lifestyle Colorectal Obstruction Constipation Cancer-Signs Blood in stool and Abdominal pain Symptoms  CBC-anemia Colorectal Elevated ALP-suspicious for metastatic Cancer-Signs disease Carcinoembryonic antigen (CEA) should be and measured in all patients diagnosed Symptoms with colorectal cancer but is not appropriate for screening to rule out cancer.  ”Apple Core” Lesion seen on Barium Study Barium studies are not used anymore because colonoscopy is a better test Colorectal Colonoscopy Cancer is the diagnostic procedure of choice in patients with a clinical history suggestive of colon cancer or in patients with an abnormality suspicious for cancer detected on radiographic imaging  Staging The TNM system is the commonly used classification to stage colorectal cancer Surgery Colorectal Resection of the primary colonic or rectal cancer is the treatment of choice for almost all patients Cancer who have resect-able lesions and can tolerate general anesthesia Systemic Chemotherapy improves overall and tumor-free survival in selected patients with colorectal cancers depending on stage.  Screening People at average risk (no family history) begin screening at 45 yo Continue through age 75 as long as life expectancy is greater than 10 years Colonoscopy is the recommended test of choice and should be done every ten years For patients who can’t undergo colonoscopy patients could choose either Fecal Immunochemical Testing (FIT) repeated annually looking for occult blood OR CT Colonography every 5 years