Transcript nowotwory-przewodu-pokarmowego

Digestive system cancers
PhD Tomasz Wiśniewski
Esophageal Cancer
PEARLS
• Incidence increases with age, peaks at sixth to seventh
decade.
• Male:female = 3.5:1.
• Four regions of the esophagus:
– Cervical = cricoid cartilage to thoracic inlet (15–18 cm
from the incisor).
– Upper thoracic = thoracic inlet to tracheal bifurcation (18–
24 cm).
– Midthoracic = tracheal bifurcation to just above the GE
junction (24–32 cm).
– Lower thoracic = GE junction (32–40 cm).
Esophageal Cancer
Adenocarcinoma:
• Rapid rise in incidence.
• Predominately white
men.
• Associated with Barrett’s,
GERD, and hiatal hernia.
• Locations: 75% in the
distal esophagus and 25%
in the upper and
midesophagus.
Squamous cell carcinoma:
Associated with tobacco,
alcohol, or prior history of
H&N cancers.
Locations:
50% midesophagus
and 50% distal
esophagus.
Esophageal Cancer
Treatment
Surgery
-every resectable and medically-fit
inoperable when:
T4b
large tumor and N+
cervical esophagus lesions
M+
non-responder after induction chth
Esophageal Cancer
Chemo-RT (5-FU + cisplatin,50 Gy).
definitive
- inoperable
- cervical esophagus lesions
pre-op
- tumor potentialy resected
post-op
- adenocarcinoma
- ca planoepitheliale after R1
Gastric Cancer
Tumor localization
• GE junction, cardia, and fundus 35% (diffuse
subtype, incidence rising).
• Body 25%.
• Antrum and distal stomach 40% (intestinal
subtype, incidence falling).
Gastric Cancer
Presentation (non specific nad late)
• dysphagia,
• indigestion,
• loss of appetite,
• nausea,
• abdominal pain,
• weight loss,
• obstruction (pyloric lesion),
• anemia,
• hematemesis (10–15%),
• melena
Gastric Cancer
•
•
•
•
•
Krukenberg tumor = ovarian met.
Sister Mary Joseph node = periumbilical node.
Virchow’s node = left SCV.
Irish’s node = axillary lymphadenopathy.
Blumer’s shelf = metastatic tumor in the pelvic
cul-de-sac, frequently palpable on rectal
exam.
Gastric Cancer
• T1N0 Surgery alone
• T2–4 and/or LN+ resectable and operable
• Surgery → concurrent chth-RT (45 Gy)
• Alternatively, pre-op ECF chemo (epirubicin, cisplatin,5FU) × 3c → surgery → post-op ECF chemo × 3c for GE
junction tumor
• T2–4 and/or LN+ unresectable or inoperable
• Concurrent chemo-RT (5-FU and 45–50.4 Gy).
Pancreatic Cancer
• Fifth leading cause of cancer mortality, although only the
ninth most common cancer.
• Known risks include
– tobacco use, diets high in animal fat, ionizing radiation,
chemotherapy,
• Possible links between alcohol use, coffee use, chronic
pancreatitis, and diabetes are less clear.
• Four parts:
– head (including uncinate process),
– neck,
– body,
– tail.
Two-third cancers present in the head.
Pancreatic Cancer
Most common presenting symptoms
jaundice (due to common bile duct obstruction),
most common in patients with lesions in the head
weight loss (due to malabsorption from pancreas exocrine
dysfunction),
diabetes (related to pancreas endocrine dysfunction), gastric outlet
obstruction,
abdominal pain.
Infrequently present
Trousseau’s sign (migratory thrombophlebitis)
Courvoisier’s sign (palpable gallbladder).
• Peritoneal and liver mets are most common. Lung is most common
location outside the abdomen.
Pancreatic Cancer
For practical purposes, tumors are generally
classified as
resectable (Stage I, II),
unresectable (Stage III),
and metastatic (Stage IV).
• Prognostic markers: surgical margins, nodal
status, tumor grade.
Pancreatic Cancer
Resectable (10–15% of patients)
• Pancreaticoduodenectomy.
– Mortality <5% when performed by experienced surgeons.
– Pylorus-preserving pancreaticoduodenectomy improves GI function and does
not appear to compromise efficacy.
– Body/tail cancers (when resectable) should have a distal pancreatectomy with
en bloc splenectomy
• Recommendations about adjuvant treatment are controversial. Options
include
– Clinical trial
– Systemic gemcitabine followed by concurrent chemo-RT (5-FU based, 50.4 Gy)
– Chemotherapy alone (gemcitabine based)
• Due to post-op complications ~25% of patients do not receive intended
post-op therapy
Pancreatic Cancer
• Unresectable
– Clinical trial preferred.
– Alternatively, definitive concurrent chemo-RT (5-FU based,
50–60 Gy) ± gemcitabine,
– Or gemcitabine based chemotherapy alone.
• Metastatic
– Palliation with stents, surgical bypass, chemo, RT,
supportive care, or some combination of the above.
– Most randomized studies favor the use of gemcitabine
over the use of 5-FU based chemo in the treatment of
metastatic disease.
– Celiac nerve block is an effective palliative tool for local
pain
Colorectal Cancer
PEARLS
• Third most frequently diagnosed cancer in the US
men and women.
• Rectum begins at the rectosigmoid junction at
level of S3. Cancer of rectum is defined as those
straddling or inferior to the peritoneal reflection
• Hematochezia most common presentation in
rectal and lower sigmoid CA;
• abdominal pain common with colon CA
Colorectal Cancer
Localization
• Rectal
• Sigmoid
• Ascending colon
• Transvere colon
• Descending colon
30-50%
15-20%
14%
9%
6%
Colon cancer
• I
• IIA
• IIB
• III
• IV
Colectomy + LND
Colectomy + LND. For adverse
pathologic features, consider
adjuvant chemo
Colectomy + LND. Consider adjuvant
chemo
Colectomy + LND adjuvant chemo
Consider resection and neoadjuvant/
adjuvant chemo
Rectal Cancer
T2N0 - resection
T3 or N0-1 – pre OP RT (short course)
5x5Gy /pelvis and then resection
in 1st week after RT (before acute
radiation toxicity)
T4N0-1 - pre OP RT-CHT (long course)
RT 45-50 Gy + 2 cycles chth (5Fu
+Leucovorin)
and then resection after 6
weeks (after acute radiation toxicity +
time to downsize tumor)
Anal Cancer
• Anatomy: anal canal is 3–4 cm long. Extends from anal verge to the
anorectal ring.
• Majority are SCC (75–80%); others are adenocarcinoma or melanoma.
• HPV: strongly associated with SCC and may be requisite for disease
formation. High-grade intraepithelial lesions are precursors. In particular
HPV-16, 18 as in cervical cancer.
• AIDS is associated with anal cancer, likely through an association with
immunodeficiency in the setting of HPV coinfection. Increased risk if CD4 <
200.
• Presentation: bleeding, anal discomfort, pruritis, rectal urgency
Anal Cancer
Staging
• Labs: CBC, HIV test if any risk factors. CD4 counts
if HIV-positive.
• Proctoscopy with biopsy.
• May biopsy inguinal nodes if clinically suspicious.
Only FNA, avoid open biopsy.
• CXR or Chest CT. CT abdomen and pelvis or MRI.
• PET/CT recommended to evaluate extent of
disease including lymph nodes and/or distant
metastases
Anal Cancer
Concurent Chemo-RT (standard treatment)
• No randomized data of chemo-RT vs. surgery alone, but chemo-RT
produces better survival with sphincter preservation as compared
to historical controls.
•
•
•
•
Chemotherapy -concurrent 5-FU/mitomycin.
Plan to treat inguinal nodes.
Minimize breaks (try to keep under 2 weeks)
Total dose: 50-60 Gy
Follow up after treatment:
• If tumor decreasing in size, continue to follow. Median time to
regression ~3 months, but may take 12 months !!!
• If tumor progression – salvage surgery
Resume -treatment
• Colon
- surgery +/- CHTH
• Rectum
-surgery +/- RT-CHTH
• Anal canal
-RT-CHTH