Oncology- Colon, Gastric, and Pancreatic Carcinoma



Oncology- Colon, Gastric, and Pancreatic Carcinoma

I. Colorectal Cancer

a. Risk factors

i. Age- most commonly over 50 y.o.

ii. Personal history of neoplasia (Previous colorectal ca, edematous polyposis)

iii. Family history (familial polyposis, Peutz-Jeghers syndrome, familial juvenile polyposis, hereditary nonpolyposis colorectal cancer- HNPCC)

iv. Inflammatory bowel disease

v. Dietary factors

vi. Ethnicity

b. Signs and symptoms associated with colorectal cancer

i. May be asymptomatic (importance of screening)

ii. Fecal occult blood

iii. Iron deficiency anemia

iv. Fatigue, weakness

v. Abdominal pain (may be colicky in nature)

vi. Change in bowel habits

vii. Bowel obstruction

viii. Diarrhea, constipation, blood streaking stool

ix. Palpable abdominal mass

x. Hepatomegaly

xi. Unexplained/unintentional weight loss

c. Diagnostic/Laboratory work-up for colorectal cancer

i. Complete blood count/differential

ii. Serum chemistries, liver function tests

iii. CEA levels (baseline and monitoring- i.e. pre and post resection)

iv. Barium enema

v. CT scanning

vi. Colonography- virtual colonoscopy

vii. Colonoscopy- diagnostic procedure of choice

viii. CXR

ix. Abdominal/pelvic CT

x. Pelvic US/Pelvic MRI- useful when evaluating depth f invasion and/or pararectal invasion of lymph nodes with rectal cancer

d. Differential diagnosis of colorectal cancer

i. Irritable bowel disease

ii. Diverticular disease

iii. Ischemic colitis

iv. Inflammatory bowel disease (ulcerative colitis, crohn’s disease)

v. Infectious colitis (salmonella, shigella)

vi. Chronic iron deficiency anemia- r/o malignancy

e. Staging Colorectal Cancer

|American Joint Committee Classification |T |N |M |Dukes Class |

|Stage 0- Carcinoma in situ |TIS |N0 |M0 | |

|Stage 1- Tumor invades submucosa, tumor invades muscularis propria |T1, T2 |N0, N0 |M0, M0 |Dukes A, Dukes |

| | | | |B1 |

|Stage 2- Tumor invades into subserosa or nonperitonealized pericolic or Perirectal tissues; Tumor perforates |T3, T4 |N0, N0 |M0, M0 |Dukes B1 or B2, |

|visceral peritoneum or directly invades other organs or structures | | | |Dukes B2 |

|Stage 3- any degree of bowel wall perforation with lymph node metastasis; 1-3 pericolic or perirectal lymph |Any, T, T, T|N1, N2, T |M0, M0, M0|Dukes C1, Dukes |

|nodes involved; 4 or more pericolic or Perirectal lymph nodes involved; metastasis to lymph nodes along a | | | |C2 |

|vascular trunk | | | | |

|Stage 4- Presence of distant metastasis |Any T |Any N |M1 |Dukes D |

f. Treatment/Palliation of colorectal cancer

i. Resection of primary colon or rectal tumor (may include regional lymph node dissection)

1. Colectomy- with or without diverting colostomy- depends on location/length of bowel removed

2. Rectal carcinoma- type of resection depends on stage and if well or poorly differentiated cellular constitution- may involve transanal to abdominal perineal resection , or palliative diverting colostomy

ii. Adjuvant chemo/radiotherapy for colorectal cancer

1. Stage 1- surgical resection- no recommended adjuvant therapy, 5 year survival rate 80-100% (certifiable surgical cure)

2. Stage 2 (node negative disease)- surgical resection- adjuvant chemotherapy no established benefit- controversial ongoing study trials, 5 year survival rate 50-75% (primarily due to surgical intervention)

3. Stage 3 (node positive disease)- depends on number of nodes involved- combination chemo/radiation seems promising (i.e. improves survival rates), 5 year survival rate 30-50%

4. Stage 4- metastatic disease, approximately 20% of patients have metastatic disease at the time of initial diagnosis, 30% eventually develop metastasis, long term survival is 5% in these patients

a. Resectable metastatic masses of the liver or lung with adjuvant therapy- 5 year survival rate is 20-40%

b. Non-resectable metastatic masses (may include cryosurgery, embolization, chemotherapy); survival average rate 15 months

c. Post surgical follow-up- yearly, colonoscopy, abdominal CT, CXR-3-6 months 1st year post-operative

i. Sample protocol

1. 3-5 years- every 6-12 months as above and every 3-6 months history, physical FOBT, LFT’s, CBC, CEA levels (i.e. cancer free)

2. Patients with rectal carcinoma should have bi-annual sigmoidoscopy and CBC, LFT, CEA levels- any fluctuation warrants CXR, and/or abdominal/pelvic CT

Gastric Carcinoma- 2nd most common cause of cancer death worldwide

I. Mostly in the antrum of the stomach

II. Risk factors associated with gastric carcinoma

a. Age- uncommon 60y.o.

b. Ethnicity

c. Chronic H. Pylori gastritis

d. Chronic atrophic gastritis

e. Pernicious anemia

f. History of partial gastric resection >15 years previously

III. Signs and symptoms associated with gastric carcinoma

a. May be asymptomatic

b. Dyspepsia

c. Vague, epigastric pain

d. Anorexia

e. Early satiety

f. Unintentional/unexplained weight loss

g. G.I. bleed- (hematemesis, melena)-ulcerating lesions- Guiac + stools

h. Postprandial vomiting- pyloric obstruction

i. Progressive dysphagia- lower esophageal (LES) obstruction

j. Palpable gastric mass

IV. Diagnostic/laboratory work-up for gastric carcinoma

a. Complete blood count/differential- anemia

b. Serum chemistries, liver function tests

c. Upper GI endoscopy- cytologic brushings/biopsy

d. Barium studies- upper GI series- with or without small bowel follow-through

e. Abdominal CT- useful for pre-op evaluation- extent/spread of lesion (i.e. local extent of primary tumor, invasion of adjacent structures, nodal and/or distal metastasis)

V. Differential Diagnosis of gastric carcinoma

a. Benign gastric ulcer, peptic ulcer disease

b. Dyspepsia

c. Perforated gastric ulcer

d. Hypertrophic gastropathies- may resemble cancer-thickened gastric folds

VI. Types of gastric carcinoma

a. Adenocarcinoma- most common type- 95%

b. Lymphoma- 2nd most common gastric malignancy- can be associated with H. pylori

c. Leiomyosarcoma- stromal tumor

d. Carcinoid tumors- rare- make up less than 1% of gastric neoplasms; strong propensity for metastasis

VII. Staging Gastric Carcinoma

|Staging Criteria For Gastric Adenocarcinoma |

|Stage 1 |T1 N0, T1 N1, T2 N0, all M0 |

|Stage 2 |T1, N2, T2 N1, T3 N0, all M0 |

|Stage 3 |T2 N2, T3 N1, T4 N0, all M0 |

|Stage 4 |T4 N2 M0, Any M1 |

VIII. Treatment of Gastric Carcinoma- adenocarcinoma

a. Surgical resection- the only therapy with curative potential

i. Stage 1-3- surgical exploration to confirm localized disease- radical surgical excision (subtotal/total Gastrectomy with lymph node dissection)

ii. Adjuvant chemo/radiotherapy- controversial, no established survival benefit; apply risk:benifit ration

IX. Overall, long term survival rate of gastric carcinoma is less than 15%. Stage 1 and 2 patients who undergo curative resection, 5 year survival rate are 45-50%. Stage 3, poor prognosis- 80% of cases to delineate extent of tumor

c. MRI of the abdomen- helpful in >80% of cases to delineate extent of tumor

i. Both CT and/or MRI may be used for fine needle aspiration biopsy procedure

d. Superior mesenteric or celiac artery angiogram- may demonstrate vessel invasion- these patients would not be considered for surgical resection of mass

e. Endoscopic ultrasonography- abdominal sonography is NOT reliable

f. ERCP- may clarify ambiguous CT or MRI results- delineates pancreatic and biliary ductal system

g. Abdominal exploration- laparotomy- indicated if other tests are not decisive

V. Staging Pancreatic Carcinoma- Majority of patients will present with terminal disease

|Stage |Location of Tumor in Pancreas |

|TIS |Carcinoma in situ |

|T1 |Tumor limited to pancreas: 2cm or less in greatest dimension |

|T2 |Tumor limited to pancreas: >2cm in greatest dimension |

|T3 |Tumor extends beyond the pancreas but without involvement of the celiac axis or superior mesenteric artery |

|T4 |Tumor involves the celiac axis or the superior mesenteric artery; unresectable primary tumor |

VI. Treatment of Pancreatic Carcinoma

a. Localized mass in the head of pancreas, periampullary zone, and duodenum (T1, N0, Mo) - Whipple procedure (radical pancreaticoduodenal resection)-gastric entrectomy, cholecystectomy, duodenectomy, common bile duct resection, partial pancreatectomy; 5 year survival rate 20-25%. In patients with negative resection margins and node negative disease, 5 year survival rate may be as high as 40%

b. Adjuvant radiation therapy

c. Adjuvant chemotherapy (fluorouracil, gemcitabine)

d. Palliative procedures

i. Cholecystojejuostomy

ii. Endoscopic stenting of the duodenum

iii. Gastrojejunostomy

iv. Palliative radiation and chemotherapy

VII. Carcinoma of the pancreas, especially of the body or tail, has a poor prognosis. Five- year survival rates range from 2-5%

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