Gastrointestinal Tract Malignancy - University of Babylon

UNIVERSITY OF BABYLON HAMMURABI MEDICAL COLLEGE GASTROINTESTINAL TRACT S4 - PHASE 1 2024-2025 Malignancy of GIT Prof. Dr. Hadeel A. Karbel  Objectives The aims of this session are: to give an impression of the relative incidence of gastro...

UNIVERSITY OF BABYLON HAMMURABI MEDICAL COLLEGE GASTROINTESTINAL TRACT S4 - PHASE 1 2024-2025 Malignancy of GIT Prof. Dr. Hadeel A. Karbel  Objectives The aims of this session are: to give an impression of the relative incidence of gastrointestinal tumors and their age and sex distribution to demonstrate some of the ways in which a gastrointestinal tumour may draw attention to itself and thus how the patient may present. describe common GI cancers and their clinical presentations describe how G.I. derived infection or cancers may spread within the body. describe the incidence of various common cancers of the G.I. tract describe the histological appearance of common gastro-intestinal cancers  Common GI cancers and their clinical presentations Common GI malignancies include cancers of the Oesophagus, Stomach, Large Intestine, Pancreas and Liver. Oesophageal Carcinoma Epidemiology Wide Geographical variation Incidence low in USA, and high around Caspian sea and parts of China 2% of malignancies in the UK Males > Females Clinical Features Dysphagia Progressively worsening as tumour grows and occludes lumen Direct invasion of the surrounding structures is common and patients may experience weight loss, anorexia, and lymphadenopathy Odynophagia Investigation o Endoscopy, Biopsy, Barium study Pathological Features o Squamous cell carcinoma § Commonest type § May occur at any level mostly upper 2/3. § It has a link to HPV, Vitamin A deficiency, low fibre diet, and smoking and drinking all increase the risk o Adenocarcinoma § Uncommon § Lower third § Association with Barrett’s oesophagus Prognosis o Advances disease at presentation in most cases o Direct spread through the oesophageal wall o Only 40% resectable 5% five year survival Barium study showing stricture with shouldering  Gastric Cancer Gastric cancer is the fourth most common cancer worldwide and second leading cause of cancer deaths worldwide. Epidemiology Common 15% of Cancer deaths worldwide Men > Women Geographical variation Common in Japan, Columbia, Finland Associated with Gastritis Commonest in Blood Group A. There is also a link seen between dietary factors (high salt), smoking, and genetic / familial links to an increased risk of gastric cancer. Clinical Features Symptoms often vague Epigastric pain, vomiting, weight loss  Investigations Endoscopy, Biopsy, Barium study Macroscopic Features Fungating Ulcerating Infiltrative Linitis plastica Microscopic Features There are two main types of gastric cancers: Intestinal (type 1) with variable degree of gland formation. The tumours are ulcerating lesions and are often associated with H. Pylori infection diffuse (type 2) with single cells and small groups of signet ring shape that tend to infiltrate the gastric wall and have a worse prognosis Type. 1 Type 2 Early Gastric Cancer Confined to mucosa/sub-mucosa, superficial (elevated , flat , depressed) Good Prognosis Advanced Gastric Cancer Further spread , polypoid (fungating), ulcerative,I nfiltrative Common in the UK ~10% 5 year survival Spread Direct Through gastric wall into duodenum, transverse colon, pancreas Lymph nodes Liver Trans-Coelomic to v peritoneum v Ovaries Clinical staging of gastric cancer: Stage 0: node negative; limited to mucosa. Stage 1: node negative; invasion of submucosa and part of muscularis propria. Stage 2: node negative with invasion up to serosa or node positive with invasion up to muscularis propria. Stage 3: node positive; invasion of serosa. Stage 4: node positive; invasion up to adjacent structures with or without distant metastasis. H. Pylori and Gastric Cancer There is a general association of chronic inflammation with cancer. Gastric cancer is common in countries with high H. Pylori prevalence, e.g. Columbia. The association is supported by serological and epidemiological evidence Gastric Lymphoma The commonest GI Lymphoma Starts as a low-grade lesion Strong association with H. Pylori Eradication of H. Pylori may lead to regression of tumour Prognosis much better than gastric cancer Gastrointestinal Stromal Tumours Uncommon Derived from interstitial cells of Cajal The causative mutation, C-kit (CD117) makes it vulnerable to targeted treatment Unpredictable behaviour Pleomorphism Mitoses Necrosis  Tumours of the Large Intestine Adenomas Benign, neoplastic lesions in the large bowel (Dysplasia) Familial Adenomatous Polyposis (FAP) Gardner’s Syndrome Adenocarcinomas Polyps Anal Carcinoma  Large Intestinal Adenomas Benign, neoplastic lesions in the large bowel (Dysplasia) Macroscopic Sessile or pedunculated Microscopic Variable degree of dysplasia malignant Potential Incidence increases with age in western population Genetic Syndromes Familial Adenomatous Polyposis (FAP) FAP An autosomal dominant condition on Chromosome 5. By the time the patient is 20 there are thousands of adenomas in the large intestine, giving a high risk of cancer. Gardner’s Syndrome Gardner’s is similar to FAP, with: Colonic adenomatous polyposis Bone (skull, mandible and tibia) Soft tissue tumours(fibroma,epidermoid tumor and desmoid)  Asymptomatic Symptomatic - Diarrhea, passage of blood and mucus, abdominal pain, DX. Colonoscopy, biopsy, genetic testing - Presence of >100 colorectal adenoma - Gene APC 5 Treatment - Risk of colorectal carcinoma - Surgery at age 17 to 18 y/o or symptomatic or multiple polyps develop - Colectomy + ileorectal anatomosis or - Restorative protocolectomy + ileoanal anastomosis - Follow up  Colorectal Adenocarcinoma Colorectal cancer is the commonest GI malignancy, with ~25,000 new cases reported each year in England and Wales. Incidence Peak at 60-70 High in UK/USA, low in Japan Polyposis syndromes UC and Crohn’s  Macroscopic 60-70% recto-sigmoid fungating /stenotic Microscopic Moderately different adenocarcinomas Mucinous Signet ring cell type Spread Direct through bowel wall to adjacent organs (e.g. bladder) Via lymphatics to mesenteric lymph nodes Via portal venous system to liver  Risk factors Incidence Aging 3rd most common cancer among Hereditary and genetic USA factors males and females Incidence Inflammatory bowel disease steadily Diet: red meat components Rising after the age of 50 except (haem and N- in hereditary case which present in early poor in fibers, Alcohol APC, K-Ras, P53, gene mutation Others: radiation, cigarette, cholecystectomy, ureterosigmoidostomy  Clinical feature Asymptomatic Change in bowel habit. Bleeding :overt or covert (manifested as anemia) Abdominal mass Abdominal pain Feel like incomplete.. Rectal cancers may present with tensemus in addition to bleeding Patient with villous adenoma may present with diarrhea (with hypokalemia) Lt-sided tumors tend to obstruct while Rt-sided tumors tend to bleed diagnosis Endoscopy with biopsy Barium study(enema) Apple-core appearance  Staging Duke’s A – Confined to Bowel Wall B – Through wall, lymph nodes clear C – Lymph node involvement C1/C2 – Highest node clear/involved TREATMENT SURGERY - Primary RADIOTHERPY - Adjuvant CHEMOTHERAPY -Adjuvant and metastatic TARGETED / IMMUNOTHERAPY - Adjuvant and metastatic Other Large Intestine Tumours Carcinoid Tumour – Rare and unpredictable neuro-endocrine tumour Lymphoma – Rare, may be primary or spread from elsewhere Smooth muscle/stromal tumours - Rare and unpredictable  Carcinoma of the Pancreas Morphology 2/3 in the head Firm pale mass with a necrotic centre May infiltrate adjacent structures, e.g. the spleen Histology 80% are ductal adenocarcinomas Well formed glands Some acinar tumours contain zymogen granules All types have poor prognosis  diagnosis Labs LFT. U.S Mass ,liver metastasis CT Mass; help in determining operability by showing extent of disease ERCP/MRCP Double-duct sign EUS Carcinoma of the Ampulla of Vater The bile duct is blocked with only a small tumour, leading to jaundice and early presentation when the tumour is still treatable. Islet Cell Tumours Rare Insulinoma o Hypoglycaemia Glucagonoma o Characteristic skin rash Gastrinoma o Zollinger-Ellison syndrome Tumours of the Liver Benign tumours are fairly rare Hepatic adenoma Bile duct adenoma/hamartoma Haemangioma Malignant Hepatocellular carcinoma Cholangiocarcinoma Hepatoblastoma Common à Rare  Hepatic hemangioma Hepatic adenoma Most common solid benign tumor Young women Spontaneous rupture is rare Clear association with OCP No malignant potential Usually solitary Biopsy is associated with great Risk of : danger due bleeding spontaneous rupture and bleeding Transformation into HCC Malignant tumors HCC Associated with cirrhosis , viral hepatitis(B,C) Usually in middle-aged people. á -fetoprotein is a tumor marker May present lately Secondary liver tumors More common than the primary. Any malignancy may metastasize into the liver Generally are associated with poor prognosis from colorectal cancer are common and are resectable in certain circumstances THANK YOU