Digestive Tumors

Principles of Oncology Exam 3

What cancer is Skip Mets associated with?

Esophageal Cancer

What are skip mets?

• cancerous lymph node groups at distant sites from primary tumor

• longitudinal lymph fluid along esophagus

• make lymph spread unpredictable

What are the 4 regions of the esophagus?

1. Cervical

2. Upper thoracic

3. Middle thoracic

4. Lower thoracic

At what levels is the cervical portion of the esophagus?

Cricorid cartilage (C6) to SSN (T2-3)

At what levels is the upper thoracic portion of the esophagus?

SSN (T2-3) to Carina (T4-5)

At what levels is the middle thoracic portion of the esophagus?

Carina (T4-5) to EG junction

At what levels is the lower thoracic portion of the esophagus?

EG junction to T10-T11

What is the etiology/risk factors of esophageal cancer?

• Excessive smoking and alcohol (most common)

• Barrett’s syndrome

• Achalasia

What is Barrett’s syndrome?

Mucosal changes (stratified squamous to columnar) in distal esophagus due to long-term GERD

What is Achalasia?

• Esophagus loses the ability to contract and relax

• Have an increased risk of dysphagia and regurgitation

Clinical presentations of Esophageal cancer?

• weight loss

• dysphagia

What detections are used for esophageal cancers?

• Barium swallow test/ GI upper series

What is the purpose of Barium swallow test/ GI upper series?

Allows the clinical staff to visualize the tumor

What is the most common site of occurrence for esophageal cancers?

the lower 1/3 of esophagus (lower thoracic)

What is the pathology for the Upper 2/3rds of the esophagus?

Squamous Cell Carcinoma

What is the most common pathology for esophageal cancers and where does it occur?

Adenocarcinoma

• occurs in distal 1/3 (lower thoracic)

• associated with barrett’s syndrome

What are the most common mets for esophageal cancers?

• liver

• lung

What are the primary goals of treatment for esophageal cancers?

• provide relief for dysphagia

• a chance for a cure

What is the most common treatment method for esophageal cancers?

Chemo + radiation = chemoradiation

What are the radiation techniques for esophageal cancers?

• AP/PA with off-cord boost at 45 GY

• VMAT

What are the organs at risk for esophageal cancers?

1. heart

2. lungs

3. esophagus

4. spinal cord

5. liver

6. kidneys

What is the TD 5/5 for the heart?

40 Gy (4000 cGy)

What is the TD 5/5 for the lungs?

17.5 Gy (1750 cGy)

What is the TD 5/5 for the esophagus?

55 Gy (5500 cGy)

What is the TD 5/5 for the spinal cord?

47 Gy (4700 cGy)

What is the TD 5/5 for the liver?

30 Gy (3000 cGy)

What is the TD 5/5 for the kidney?

23 Gy (2300 cGy)

Surgery is the option for which esophageal cancers?

• middle and lower thoracic tumors

• If entire esophagus is removed, stomach/ left colon is placed in thoracic cavity

Acute side effects of esophageal cancers

• Esophagitis (most common)

• decreased blood count

• Nausea and vomiting (chemo)

What does esophagitis result in for esophageal cancers?

• dysphagia (eat small food/many small meals, frequent weight checks)

• odynophagia (liquid analgesics before food, TB)

Chronic side effects associated with esophageal cancers

• pneumonitis

• pericarditis

• fistula

• stenosis and stricture

What is the etiology/risk of stomach cancer?

Diet:

• salted/pickled food

• high nitrites

• low fruit and veggies

What is the pathology for stomach cancer?

Adenocarcinoma (most common)

What chemotherapy drug is used for stomach cancer?

5-FU (fluorouracil)

What are the parts of the small intestine?

• duodenum (upper)

• jejunum (middle)

• ileum (lower)

What is the most common histology/pathology of small intestine cancer

Adenocarcinoma

What is the main treatment for small intestine cancers?

• Surgery

What anatomical structures are involved in colorectal cancers

• colon

• rectum

• anus

What does it mean when we say organs are located intraperitoneally?

• anterior

• organs are completely covered by visceral peritoneum

• organs are freely mobile 

Examples of intraperitoneal organs

• transverse colon

• sigmoïd colon

• stomach

• liver

• spleen

• cecum
  

What does it mean when we say organs are located retroperitoneally?

• located behind the peritoneum

• only covered anteriorly by parietal peritoneum; posterial and lateral lack covering (easier spread)

• organs are fixed

Examples of retroperitoneal organs

• ascending/descending colon

• hepatic/splenic fixtures

• lower half of rectum

What are the 4 layers of the bowel?

Innermost to outermost layer:

• Mucosa (innermost)

• submucosa

• muscularis

• serosa (outermost)

What structures are located in the submucosa layer?

It’s a layer of lymphatic and hematologic spread 

• blood vessels

• lymphatics

What is the most common GI malignancy?

Colorectal cancer (best prognosis)

What is the etiology/risk factors of colorectal cancer?

• diet high in animal fat (processed/red meat) and low fiber

• Hereditary: Family adenomatous polyposis (FAP)

• Chronic ulcerative colitis

What are the clinical presentations for colorectal cancer?

• hematochezia (rectal bleeding)—1st sign

• tenesmus (spasm with desire to empty bowel)

• obstructive symptoms

What are the ACS screening recommendations for colorectal cancer?

• fecal occult blood test annually

• fecal DNA test every 3 years

• flex sigmoidoscopy, barium enema, CT colonography-5 years

• colonoscopy- 10 years

ACS age recommendation for colorectal cancer

45 years

What is the carcinoembryonic antigen (CEA) tumor marker?

lab studies—the higher the number of CEA proteins present in blood, the more the disease is present

What is the most common pathology/histology for colorectal cancer?

Adenocarcinoma

TNM staging system (previously Duke’s)

What are the routes of spread for colorectal cancers?

rectal-perirectal

colorectal- peritoneal seeding

What is peritoneal seeding?

• tumor grows through walls of the bowel onto peritoneal surface of the colon.

• Tumor cells shed into abdominal cavity

• find their way to other organ surfaces and grow

What are the mets for colorectal cancer?

• liver (most common)

• lung

Treatment techniques for colorectal cancer

• surgery (treatment of choice)- first

• Radiation (Pre and Post OP)

What surgeries are done for colorectal cancer?

• colon-hemicolectomy

• rectal: 

  • Low Anterior Resection (LAR)

  • Abdominoperineal Resection (APR)

What is a hemicolectomy procedure of the colon?

segment of colon + nodes/blood vessels removed

What is the Low Anterior Resection (LAR) procedure for rectal?

• removal of tumor/margin and nodes (upper rectum)

• bowel is reanastomosed; no colostomy

• What is the Abdominoperineal Resection (APR) procedure for rectal?

• lower 1/3rd of rectum and anus removed

• colostomy needed

Why is radiation done preoperatively (neoadjuvant) for colorectal cancer?

The goal is to shrink the tumor so that LAR can be done to spare the patient from APR (colostomy)

Why is radiation done postoperatively for colorectal cancer?

• Gets rid of microscopic disease and prevents chance of reoccurrence

• includes chemo (5-FU continuous infusion—fanny pack)

What are the organs at risk for colorectal cancer?

• small bowel

• liver

• kidney

• femoral heads 

• colon

TD 5/5 for small bowel

40 Gy (4000 cGy)

TD 5/5 for Colon

45 Gy (4500 cGy)

TD 5/5 for femoral heads

52 Gy (5200 cGy)

What is intraoperative radiation therapy (IORT)?

• A concentrated dose of radiation is delivered directly to a tumor bed or area at high risk for recurrence during surgery, immediately after the tumor is removed.

• a boost/supplement to external beam radiation therapy

Acute side effects of colorectal cancer

• enterits (small bowel inflammation)

• diarrhea

• abd cramps

• bloating

• proctitis (rectal inflammation)

• bloody/mucosal discharge

• dysuria (painful urination)

• decreased blood count

• most desquamation in perineum

chronic side effects of colorectal cancer

• bladder atrophy

• fistula

• persistent diarrhea

• chronic enteritis

• obstruction of small bowel

Management of side effects of colorectal cancer

• sitz baths (inflammation relief for skin irritation)

• Domeboro soak (inflammation relief for skin irritation)

• Low-residue diet

• Anti-diarrheal meds (Imodium, Lomotil)

Lymph nolvement for anal cancer

inguinal

Etiology for anal cancer

• Human papillomavirus (HPV)-16

• genital warts

Clinical presentation for anal cancer

bright red rectal bleeding

Most common pathology for anal cancer

squamous cell carcinoma

Organs at risk for anal cancer

• small bowel

• femoral heads

• bladder

TD 5/5 for bladder

65 Gy (6500 cGy)

What is the anatomy of the pancreas?

• head (in duodenum)

• body

• tail 

What is one of the deadliest malignancies?

• Pancreatic cancers, have high mortality rate

• found in advanced stages—poor prognosis

Clinical presentations of pancreatic cancers?

• abdominal pain

• anorexia

• weight loss

• jaundice

Most common pathology for pancreatic cancers?

Adenocarcinoma

Is surgical removal an option for pancreatic cancers?

No, due to the location of the ,pancreas near critical structures

What surgical procedure can be done for pancreatic cancers?

Whipple procedure = pancreaticoduodenectomy

What structures are removed during a Whipple procedure?

• head of pancreas

• entire duodenum

• distal stomach

• gallbladder

• common bile duct

What is the most common chemotherapy agent used for pancreatic cancers?

Gemcitabine

Acute side effects of pancreatic cancer

• nausea and vomiting

• decreases blood count, diarrhea

What is the common chemo agent for digestive cacners

5- FU

TD 5/5 for rectum

60 Gy (6000 cGy)

What helps to displace small bowel out treatment field for the pelvic irradiation?

• having a full bladder

• belly board

What does the ileum of the small intestine connect to?

cecum of the colon (ileocecal junction)