G.

I TUMORS-1
STOMACH, LARGE GUT,
PANCREAS

DR. AJEET KUMAR LOHANA

SR GASTROENTEROLOGY
DEPARTMENT OF MEDICINE
ATMC, KARACHI
 OBJECTIVES
• Introduction, prevalence
• Discuss the classification
• Describe the pathophysiology of esophageal &
• Discuss the clinical features Gastric tumors
• Justify the laboratory investigations
• List the complications
• Discuss the management
INTRODUCTION

• The most common malignant esophageal neoplasms are

squamous cell carcinoma and adenocarcinoma, the latter
typically arising in Barrett epithelium.
• Benign tumors
• Most common is a leiomyoma
• Usually asymptomatic but may cause bleeding or dysphagia
PREVALENCE
 INTRODUCTION

SCC
• lower socioeconomic groups
African American males
• Tobacco and alcohol use, although in
high-incidence areas of the world
(northern China, India, Iran, southern
Russia, South Africa, and some parts of
South America) other factors appear
more critical, such as
• Exposure to nitrosamines and
EAC
• Esophageal adenocarcinoma
invariably develops in the setting
of Barrett esophagus
• An important factor in the
development of Barrett
esophagus is gastroesophageal
reflux, although other
unidentified

• Concomitant nutritional (minerals and

vitamins) deficiencies
RISK FACTORS: SQUAMOUS CELL
CARCINOMA
• Smoking & excess alcohol consumption (80% - 90%)
• Other ingested carcinogens
• Nitrates (converted to nitrites)
• Smoked foods
• Fungal toxins in pickled vegetables
• Mucosa l damage from physical agents
• Hot tea
• Radiation-induced strictures
• Chronic achalasia
• Esophageal web with glossitis & iron deficiency (i.e. Plummer-
Vinson syndrome)
 RISK FACTORS:
ADENOCARCINOMA
• Barrett's esophagus
• GERD & hiatal hernia
• Obesity (3 to 4 fold risk)
• Smoking (2 to 3 fold risk)
• Male sex

• Barrett’s esophagus
• Metaplasia of esophageal epithelial lining
• Squamous epithelium is replaced by columnar
epithelium
PATHOLOGICAL
CLASSIFICATION
 CLINICAL FEATURES
• Progressive, painless dysphagia
(> 90%) for solid food
• Acutely: food bolus obstruction
• Late stages:
• Weight loss is often extreme
• Chest pain
• Hoarseness of voice
 CLINICAL FEATURES
• Fistulation b/w esophagus & trachea or
bronchial tree leads:
• Coughing after swallowing
• Pneumonia
• Pleural effusion

• Physical signs:
• Cachexia
• Cervical lymphadenopathy
  INVESTIGATIONS
• Investigation of choice is upper GI endoscopy with biopsy

• Barium swallow demonstrates site & length of stricture

• After diagnosis investigations to stage tumor & define operability

• Thoracic & abdominal CT

• These investigations will define the TNM stage of disease

INVESTIGATIONS

• Barium swallow: irregular filling defect

• Esophagoscopy: for lesion type & extent
HISTOLOGY-LOW/HIGH GRADE
DYSPLASIA TO INVASIVE
CARCINOMA
OTHER INVESTIGATIONS

• Chest X-ray: to look for aspiration pneumonia

• Bronchoscopy: to see invasion in upper third growth

• Laryngoscopy: To identify vocal cord palsy

 INVESTIGATIONS
• Esophageal ultrasonography:
• To look for depth of tumor, L. nodes involvement & left lobe of liver
• Nodes < 5 mm can be very well visualized by EUS which may be
missed in CT scan

• CT scan:
• To look for local extension, nodal status, periesophageal,
diaphragmatic, pericardial & vascular infiltration
ENDOSCOPIC ULTRASOUND
STAGING

• EUS guided
• T1a ( Mucosa)
• T1b ( Tumor Reaching to Sub mucosa)
• Sm1, Sm2, Sm3 ( based on Involvement of extent of Sub mucosa)
• T2 Involving Muscularis Propria
• T3 Involving Serosa
• T4 involving adjacent structures such as Trachea, Bronchi, Aorta, Mediastinus
• CT scan
• TNM , AJCC
• PET CT scan
  MANAGEMENT
• Treatment of choice is surgery if resection is possible ( stage II)
• Tumors extended beyond the wall of esophagus (T3, Stage >II)
have a 5-year survival of 10%.
• Neo-adjuvant Chemo radiotherapy, followed by surgical
resection ( stage III)
• Stage IV, Never surgical resection. Radiotherapy and other
palliative options to ease the discomfort
MANAGEMENT

• 70% have extensive disease at presentation & option is

palliative treatment
• Relief of dysphagia & pain
• Endoscopic laser therapy or self-expanding metallic stents can be
used to improve swallowing
• Palliative radiotherapy may induce shrinkage of both squamous
cancers & adenocarcinomas but symptomatic response may be slow
• Quality of life can be improved by nutritional support & appropriate
analgesia
Gastric Tumors
 GASTRIC CARCINOMA:
I
INTRODUCTION
• It is 5th most common cancer of human with 3rd most deadly
cancer
• Marked geographical variation in incidence
• Most common in China, Japan, Korea (40/100 000
males)
• Eastern Europe & South America (20/100 000)
• UK are 12/100 000 for men
• Overall prognosis is poor, with < 30% surviving 5
years
  CLINICAL FEATURES
• Early gastric cancer usually asymptomatic
• Incidental finding/discovered during endoscopy for dyspepsia
• Weight loss: 2/3 of advanced cancers
• Ulcer like pain: in 50% cases of advanced cancers
• Anorexia & nausea (1/3)
• Early satiety
• Hematemesis
• Melaena
• Dyspepsia
• Dysphagia occurs in tumors of the gastric cardia which obstruct the gastro-
esophageal junction.
• Anemia from occult bleeding is also common
 EXAMINATION
• Anemia
• Palpable epigastric mass
• Jaundice
• Ascites signify metastatic spread
• Troisier’s sign: Tumor spread to the supraclavicular
lymph nodes
• Sister Joseph’s nodule: Tumor spread to the umbilicus
• Krukenberg tumor: Tumor spread to the or ovaries
• Paraneoplastic phenomena:
– Acanthosis nigricans
– Dermatomyositis
– Metastases arise most commonly in
the liver, lungs, peritoneum & bone
marrow.
ENDOSCOPY
PARIS CLASSIFICATION II
GASTRIC CANCER

[A] Endoscopic image of small [B] Appearance after endoscopic

superficial pre-pyloric cancer mucosal resection (EMR)
(arrows) Tumor has been completely removed.
  MANAGEMENT
Surgery

• Resection offers the only hope of cure:

• Early gastric cancer (cure achieved in 90% of patients)

• Total gastrectomy with lymphadenectomy (operation of choice:

• For majority of patients with locally advanced disease

• Distal esophagectomy:
• Proximal tumors involving esophago-gastric junction

• Partial gastrectomy with lymphadenectomy:

• For small, distally sited tumors
 OTHER GASTRIC TUMORS
• Gastrointestinal stromal cell tumors (GIST):
• Arising from interstitial cells of Cajal & Usually benign & asymptomatic
• Occasionally found at upper gastrointestinal endoscopy
• May occasionally be responsible for dyspepsia, ulceration & G.I bleeding
• Small lesions (< 2 cm) are usually followed by endoscopy
• Larger ones require surgical resection

• Polyps:
• Hyperplastic polyps & fundic cystic gland polyps are common & of no consequence
• Adenomatous polyps are rare but have malignant potential & should be removed
endoscopically.

• Gastric carcinoid tumors:

• Seen in fundus & body in long-standing pernicious anemia patients
• Often multiple but rarely invasive
 OTHER GASTRIC TUMORS
• Gastric lymphoma
• Rare tumor < 5% of all gastric malignancies

• Stomach is most common site for extranodal non-Hodgkin lymphoma & 60% of
all primary G.I lymphomas

• H. pylori infection associated with low grade lymphoma

• Clinical presentation is similar to gastric cancer

• Initial treatment of low-grade lesions: H. pylori eradication & close observation

• High-grade B-cell lymphomas treated with combination of rituximab,

chemotherapy, surgery & radiotherapy