CARCINOMA OF UPPER

GASTROINTESTINAL
SYSTEM

T.S. VINNOLI
MSc(N)
 INTRODUCTION
 CANCER:

Cancer is a group of more than 200

diseases characterized by uncontrolled
growth of cells

 Most cancer occur in people older than 65

years
 More common in men than women
CARCINOMA OF UPPER GI
TRACT

Salivary gland cancer

Oral cavity cancer

Esophageal cancer

Stomach or gastric cancer

SALIVARY GLAND TUMORS
DEFINITION:
Unknown neoplasm's (tumors or growth) of
almost any type may develop in the salivary
gland. Tumors occur more often in the parotid
gland.

INCIDENCE:
 Similar in both sex
 Annual incidence of both benign and malignant
of salivary gland is 0.4 to 6.5 cases/ 1,00,000
population.
ETIOLOGY:
 Prior exposure to radiation to the head and
neck
 Cigarette smoking
PATHOPHYSIOLOGY:
Slow growing painless
masses
↓
Advanced stage- large
preauricular mass accompained
by facial nerve palsy
↓
Tumor invasion of the
hypoglossal nerve
↓
Impaired movement of
tongue & loss of sensation
CLINICAL FEATURES:
 Trouble in swallowing or opening the mouth
widely. Impaired movement of tongue
 Slow growing painless masses

 Involvement of facial nerves

 Facial weakness and pain & tenderness in

submandibular and minor salivary gland cancer.
 Paralysis on the affected side (partial or total)

 A lump (usually painless) in the area of the ear,

cheek, jaw, lip or inside the mouth
 Fluid draining from the ear

 Loss of sensation of tongue

STAGES OF SALIVARY
GLAND TUMOR
DIAGNOSTIC FINDINGS
 History and physical examination:
History of swallowing, pain, exposure to
radiation and cigarette smoking.
Any lumps that seems unusual
 PET (positron emission tomography): to find
malignant tumor cells in the body by injecting
radioactive glucose dye.
 Endoscopy
 Fine needle aspiration: removal of tissue or fluid
by using a thin needle
COMPLICATION:
 Involvement of facial nerve
 Involvement of hypoglossal nerve

MANAGEMENT:
Cancer should have their treatment planned by
a team of doctors who are experts in treating
head and neck cancer.
 Head & neck surgeon
 Radiation oncologist & dentist
 Speech therapist, dietitian & psychologist
 Rehabilitation specialist & plastic surgeon.
SURGICAL MANAGEMENT:
 Partialexcision of salivary gland with removal of
wide margin surrounding tissues.
 In some cases lymphadenectomy (removal of lymph
nodes)
 Surgery with radiation therapy

RADIATION:
 High energy rays to kill cancer cells or to keep them
from growing
i. External radiation therapy
ii.Internal radiation therapy like needles, seeds,
wires, catheters are placed directly into or near the
cancer.
 FASTNEUTRON  PHOTON-BEAM
RADIATION RADIATION
THERAPY: THERAPY:
 High energy  Linear accelerators
external radiation that is high-energy x-
therapy. rays reaches the deep
 This machine aims tumors.
tiny, invisible  Total doses divided
particles called into small doses
neutrons, to kill the  Treatment given more
cancer cells. than once a day.
CHEMOTHERAPY:
 Use of chemo therapeutic drugs to stop
the growth of cancer cells, either by killing
the cells or by stopping them from
dividing.
NURSING DIAGNOSIS
 Imbalanced nutrition less than body
requirement related to oral pain,
Dysphagia or surgery
 Chronic pain related to the tumor, surgery
and radiation.
 Anxiety related to disease progress,
potential for recurrence and prognosis.
 Disturbed body image related to changes
in facial contour, cranial nerve defect.
NURSING INTERVENTIONS:
 Assess the nutritional pattern.
 Maintain adequate nutritional intake to promote
wound healing.
 Check weight periodically.
 Provide rest
 Maintain I/O chart and provide analgesics to
relieve pain.
 Promote oxygen to reduce breathing difficulty.
 Provide psychological support to patient and
family.
 Educate about the treatment modalities.
 JOURNAL REVIEW
Histological reclassification of intraoral
salivary gland tumors by WHO
 Polymorphous low grade adenocarcinoma
 Mucoepidermal carcinoma
 Adenoid cystic carcinoma
 Pleomorphic adenoma
 Salivary duct cyst
 Intraductal papiloma.

J.W. VAN DER WAI, journal of clinical

pathology.
ORAL CAVITY CANCER
DEFINITION:
Oral cancer is a subtype of head and
neck cancer, is any cancerous tissue
growth located in the oral cavity.

It may arise as a primary lesion from

the lips, buccal mucosa, gums, hard
palate, floor of the mouth, salivary gland,
anterior two third of tongue
EPIDEMIOLOGY:
 More than 90% of all cancers of the oral
mucosa and lips which are squamous cell
carcinoma and other forms of cancer
sarcomas, melanomas & lymphomas

INCIDENCE:
 Greater in men than women
 The rate in both increase dramatically with
advancing age.
RISK FACTORS:
 Increasing age: 95% oral cancer occur in
people over 40years of age
 Tobacco use
 Alcohol use
 Occupational exposure
 Diet
 Other factors like poor oral hygiene and
dental care.
PREDISPOSING FACTORS:
PATHOPHYSIOLOGY:
Oral cavity mucosa constantly undergoes repair and
restructuring
↓
The cancer starts from surface of epithelium
Premalignant changes or dysplasia
( disorganized cell growth, vary in size, shape &
appearance)
↓
Prior to the occurrence of malignancy the surface
epithelium initiation, promotion & progression will
occur
 ↓
Alterations in the thickness of the lining of
the oral epithelium result in atrophy
↓
Mucosal erythroplasia and other symptoms
ROUTES OF METASTASIS

REGIONAL
DISTANT
CLINICAL MANIFESTATION:
 Leukoplakia-white patch or smokers patch
whitish patch on the oral mucosa &
tongue
o Lips –presence of a lesion that fails to heal

 Tongue-swelling ulceration, areas of

tenderness or bleeding abnormal tongue,
limited movement of the tongue,
increased salivation & slurred speech
 Floor of mouth- red slightly elevated mucosal
lesion with ill defined borders, Leukoplakia,
ulceration wart like growth.
 Difficulty in chewing
 Difficulty in swallowing
 Difficulty in speaking
 Coughing of blood tinged sputum
 Enlarged cervical lymph nodes.
DIAGNOSTIC EVALUATION:
 CT scan- determine the extent of tumor and
bone involvement.
 MRI scan- evaluate the thickness of oral cancer
of the tongue. Define soft tissue planes
perineural involvement.
 Tissue biopsy- determine extend of carcinoma
 TOLUDINE BLUE- 1% aqueous solution of
toludine blue painted on the suspicious area in
the oral cavity. It stains the malignant tissue
 Chest X-Ray & LFT
COMPLICATIONS:
 Leads to primary cancers of the larynx, hypo
pharynx, esophagus and lungs.
 Due to surgery:
 Transient salivary, outflow obstruction
 Voice changes, infection, fistula formation
 Loss of swallowing & cosmetic defects
 Radiation:
 Temporary loss of taste
 Xerostomia
 Nasopharyngeal stenosis
 COLLABORATIVE CARE
 SURGICAL MANAGEMENT
 CHEMOTHERAPY
 RADIATION

SURGICAL MANAGEMENT:
Remains the most effective treatment
 Mandibulectomy: removal of mandible
 Hemiglossectomy: removal of half tongue
 Glossectomy: removal of tongue
 Resection of buccal mucosa & floor of the
mouth & radical neck dissection
 The following structure may also be removed
or transected depend upon the extent of
primary lesion
 Sternocleidomastoid muscle
 Closely associated muscles
 Internal jugular vein
 Mandible & sub maxillary gland
 Part of thyroid & parathyroid
 Spinal accessory nerve
 Tracheostomy along with neck radical
dissection.
RADIATION THERAPY:
 Local radiation therapy
 External beam radiation
 Interstitial beam radiation or brachytherapy:

Brachytherapy includes the placement of

radioactive materials directly into or the tumor
 For maximum effect postoperative radiation is
administered within 6 weeks after surgery
 In older patient with coexisting cardiac or
pulmonary problem, surgery is contraindicated.
Radiation is the only choice of treatment
CHEMOTHERAPY:
 Used for patient with recurrent metastatic oral
cavity cancer.
 Chemotherapeutic agents are:
 Carboplatin
 Cisplatin
 Bleomycin
 Methotrexate
 5- fluorouracil

GENE THERAPY
NUTRITIONAL THERAPY:
 Percutaneous Endoscopic Gastrostomy (PEG)
placement, before radiation or surgical treatment.
 Parentral fluids for first 24 to 48 hours after Radical
neck surgery.
 After 48 hours tube feedings via NG, Gastrostomy,
or Nasointestinal tube.
 Observe feeding tolerance, nausea, vomiting,
diarrhea, distention.
 When patient can swallow, small amount of water
given.
 Close observation of choking.
 Suctioning to prevent aspiration.
 NURSING DIAGNOSIS
 Acute pain related to malignant infiltration, lesions,
difficulty swallowing,surgery,radiation therapy.
 Imbalanced nutrition less than body requirements
related to oral pain, difficulty chewing, swallowing,
surgical resection, radiation treatment.
 Disturbed body image related to change in facial contour,
cosmetic defect from surgery, cranial nerve defect.
 Anxiety related to diagnosis of cancer, uncertain future
potential for disfiguring surgery ,recurrence and
prognosis.
 Ineffective health maintenance related to lack of
knowledge of disease process and therapeutic regimen.
NURSING INTERVENTION:
 Encourage verbalization of feelings to relieve
anxiety.
 Provide anticipatory guidance on hair alternatives
for alopecia (e.g) suggest to purchase of a wig.
 Refer to support group although family and friends.

 Serve supplement between meals to prevent

nausea, vomiting.
 Place the patient in fowler’s position or side-lying
position during vomiting to prevent aspiration.
 Explain to perform mouth care before and after
meals, to improve ability to tolerate foods.
 JOURNAL REVIEW
PHOTODYNAMIC THERPY OF ORAL CANCER:
A certain period of time after the photosensitive dye
has been administered, tumor tissue contain more of
the sensitizer than the surrounding normal tissue.
When tissue containing sensitizer is exposed to light of
a proper wavelength and dose, a photochemical
reaction will occur between sensitizer and light will
occur.
The activated photosensitizer react with available
oxygen which subsequently damage cells and cause
necrosis of the tumor cells.
JAN.M.NAUTA,EUROPEAN JOURNAL OF
ORAL SCIENCES
ESOPAGEAL CANCER
DEFINITION:
Malignant neoplasm of the esophagus is a growing health
concern.
INIDENCE:
 Quite high in India than western countries.
 In Assam cancer is second leading in men, third leading in
women.
 5-year survival rate is less than 20%

ETIOLOGY:
 Smoking, Exposure to asbestos and metal.
 Excessive alcohol intake,
 Tobacco chewing,
 Low diet like fruits, vegetables, minerals, vitamins.
 Strong drain cleaners
 History of delayed emptying of lower esophagus (achalasia).
 PHATHOPHYSIOLOGY
Due to smoking, excessive alcohol, diet that low in
fruits, vegetables
↓
Ulcerated lesions are located in the middle and
lower portion of the esophagus
↓
Tumor may penetrate the muscular layer
↓
Extend outside of esophageal wall
↓
In later stage obstruction of esophagus
PATTERNS OF SPREAD:
 Squamous cell carcinoma, and adenocarcinoma
commonly penetrate through the wall of the
esophagus, frequently involve nodes.
 Brain metastasis in adenocarcinoma.

CLINICAL MANIFESTATION:
 Progressive Dysphagia, initially it occurs with
meat, then with soft foods then with liquids.
 Globus sensation,
 Pain develops late in the substernal, epigastric,
back areas usually increase with swallowing.
 Pain radiate to the neck, jaw, ears, and
shoulders.
 Sore throat, choking, hoarseness,
 Regurgitation of blood-flecked esophageal
content while esophageal stenosis
 Progressive weight loss,
 Later symptoms- hiccups, respiratory difficulty,
foul breath, regurgitation of food and saliva.
DIAGNOSTIC EVALUATION:
 Endoscopy with Biopsy and Cytology: diagnosis of
carcinoma by identification of malignant cells.
 Endoscopic Ultrasound: To determine cancer
spread to the nodes and mediastinal structures.
 Barium swallow with Fluoroscopy: To determine
narrowing of esophagus
 Branchoscopic Examination: To detect malignant
involvement of the lung.
 MRI,CT Scan: To identify the presence of adjacent
tissue invasion and metastasis.
COMPLICATION:
o Cancer erode through the esophagus and into
the aorta cause hemorrhage.
o Esophageal perforation with fistula formation

into the lung or trachea.

o Enlarged tumor cause esophageal obstruction.
o Cancer spread to lung, liver via lymph system.
 COLLABORATIVE CARE
 ENDOSCOPY

 SURGICAL TREATMENT
 CHEMOTHERAPY

 RADIATION

ENDOSCOPY:
 Utilizing photodynamic or laser therapy
 Photofrin (photo sensitizer) intravenously injected.
This absorbed by neoplastic tissue.
 The activator transmitted through endoscope
 To remove superficial lesions or sub mucosal
neoplasm's.
SURGICAL MANAGEMENT:
 ESOPHAGEAL RECONSTRUCTION WITH FREE JEJUNAL
TRANSFER: A portion of jejunum is grafted between
esophagus and pharynx to replace the abnormal
esophagus part. The vascular structure also
anastomosed.
 ESOPHAGECTOMY: Removal of the part or all of the
esophagus with use of Dacron graft.
 ESOPHAGOGASTROSTOMY: Resection of a portion of
the esophagus, remaining portion anastomosis with
stomach.
 ESOPHAGOENTEROSTOMY: Resection of a portion of
the esophagus and remaining portion anastomosis
with segment of colon.
RADIATION THERAPY:
Radium as a single treatment modality, it is effective
when used to control.
BRACHYTHERAPHY:
 Intraluminal brachytherapy is delivering a high dose of
radiation directly to the esophageal cancer.
 External Beam Radiotherapy is supplemented by
intracavitary brachytherapy.
CHEMOTHERAPHY:
 Bleomycin, Palitaxel

 Cisplatin, Vindesine

 5-fluorouracil

 Methotrexate

 Methyl-GAG
NUTRITIONAL THERAPHY:
 Parentral fluid after surgery
 Jejunostomy feeding
 A swallowing study before oral fluids started
 30 to 60ml of fluid started hourly then slowly
small, frequent, bland meals given.
 Upright position to prevent regurgitation
 Observe signs of intolerance of feeding like
pain, increased temperature.
 Gastrostomy performed for feeding.
ENDOSCOPIC ENDOCAVITARY PALIATION:
 Esophageal Dilation: To relief Dysphagia, commonly
used dilators are Polyvinyl ,rubber bougienage
catheters, hydrostatic balloons.
 Esophageal stending: Conventional plastic stends
reinforced metal coils, that placed across the malignant
structure after dilation.
 Endoscopic laser therapy: Used to open malignant
esophageal structures.
 Bicap Tumor Probe: Application of electrical current
through vertical metal strip, to treat and shrink tumors.
 Photodynamic Therapy: Use IV administration of
sensitizer like Dihematoporphyrin either, after use light
of wavelength.
NURSING DIAGNOSIS:
 Imbalanced nutrition less than body
requirements related to Dysphagia, weakness,
chemotherapy, radiation therapy.
 Fluid volume deficit related to inadequate intake

 Disturbed body image related to loss of hair,

discoloration of finger nails.
 Risk for aspiration related to chronic disease,
invasive procedure, treatment.
 Ineffective coping related to dealing with cancer

 Chronic pain related to compression of tumor on

surrounding tissue, esophageal stenosis.
NURSING ITERVENTION:
 Oral hygiene
 Dietary intake of fruits, vegetables
 High calorie, high protein diet
 IV fluids, Parentral nutrition
 Maintain I/O chart
 Check weight weekly twice
 Explain procedures like radiation therapy
 Teach deep breathing exercise to do every 2 hours,
incentive spirometer
 Observe drainage.
 Provide semi fowler’s position to prevent aspiration
 JOURNAL REVIEW
 PERIOPERATIVE MANAGEMENT OF
ESOPHAGEAL CANCER:
Surgery alone is associated with poor
Prognosis and is only appropriate in very
early stage disease.
Survey says neoadjuvant chemotherapy
and chemo radiation is treatment choice
for esophageal cancer.
-PRAJNAN ,JOURNAL OF
GASTROENTROLOGY.
GASTRIC CANCER
DEFINITION:
Gastric cancer is an adenocarcinoma of the
stomach wall.
INCIDENCE:
 More prevalent in men, low socio economic
class,
 In India cancer more in Bangalore, Bhopal,
Chennai, Delhi.
EPIDEMIOLOGY:
INTESTINAL TYPE GASTRIC CANCER:
Tumors develop in the intestinalized mucosa
termed intestinal-type mucosa.
DIFFUSE GASTRIC CANCER:
 Less than 50 years of age
 Severe superficial gastritis due to H pylori
 Common in Blood type A
PERNICIOUS ANEMIA:
 Family history of gastric cancer
 Blood type A
 Low socio economic status
RISK FACTERS:
 Increased age
 Gender differences
 Chronic atrophic gastritis, Intestinal metaplasia
ROUTES OF METASTASIS:
Regional:
Lymph spread, directly into adjacent
structures like spleen, gallbladder
Distant:
Lungs, adrenal gland,bones,peritoneal
cavity
PATHOPHYSIOLOGY:
 Due to H Pylori
 Acute and chronic inflammation
 Epithelial proliferation
 Inflammatory related mutagens, mitotic
error, dietary mutagens, dietary antioxidants
 Mutation
 DNA Repair
 Gastric cancer
CLINICAL FEATURES:
EARLY:
 Progressive loss of appetite

 Gastric fullness, dyspepsia

 Occult blood, vomiting(coffee brown)

 Shortness of breath, fatigue, dizziness,

weakness.
 Constipation

LATER:
 Pain induced by eating, relieved by vomiting

 Weight loss, anemia, hemorrhage, obstruction

 Abdominal or epigastric mass

DIAGNOSTIC EVALUATION:
 Upper Gastrointestinal Examination
 Flexible Endoscopic Gastroscopy: to view lesion
directly, obtain biopsy
 CT: To determine metastasis

 MRI: To evaluate hepatic metastasis

 Tumor markers:

Carcinoembryonic antigen
Carbohydrate antigen
COMPLICATION:
 Hemorrhage, infection

 Metastasis and death

 COLLABORATIVE CARE
 SURGICAL MANAGEMENT
 RADIATION THERAPY

 CHEMOTHERAPY

SURGICAL MANAGEMENT:
Total gasrectomy: The entire stomach is
removed
Subtotal gastrectomy:
 BILLROTH-I (Gastroduodenostomy)

 BILLROTH-II
Subtotal Esophagogastrectomy: Removal of lower
portion of esophagus, greater lesser omentum,
sometimes total gastrectomy.
RADIATION THERAPY:
 Post operative radiation alone helps to 5 year
survival of patient
 Tumors decrease in size in doses of 4 to 5 week
period
CHEMOTHERAPY:
 5-Fluoroaracil
 Doxorubicin,Etoposide
 Cisplatin, Mitomycin-c
NUTRITIONAL THERAPY:
 Small frequent feeding
 Low carbohydrate, high fat, high protein foods
 Give liquids for 30 to 40 mins before and after
eating to aviod dumping syndrome
 Parentral replacement therapy for vitamin
B12 deficiency.
EMOTIONAL SUPPORT
NURSING DIAGNOSIS:
 Imbalanced nutrition less than body
requirements related to inability to ingest,
digest
 Activity intolerance related to weakness,
abdominal discomfort, nutritional deficit
 Anxiety related to lake of knowledge of
diagnostic test, treatment
 Acute pain related to surgery, chemotherapy,
radiation therapy
 Grieving related to perceived unfavorable
diagnosis.
NURSING INTERVENTION:
 Asses pernicious anemia, weight loss, fatigue,Hb level
 Provide emotional and physical support
 Provide liquids, supplement of vitamin C,D,K, B complex
 IV fluids, Parentral nutrition
 Maintain I/O chart
 Check weight weekly twice
 Explain procedures like radiation therapy
 Teach deep breathing exercise to do every 2 hours,
incentive spirometer
 Observe drainage.
 Provide semi fowler’s position to prevent aspiration