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UGI Cancers
Upper GI Cancers
OesophagealJunctionalGastric
Urgent OGD Referral (within 2 weeks)Any age with dyspepsia and:Progressive DysphagiaChronic GI BleedingPersistant VomitingUnexplained Weight LossIron Deficiency AnaemiaEpigastric Mass
55yrs with persistant recent onset dyspepsia
Oesophageal Cancer
Oesophageal Anatomy25cm longMuscular tubeCricoid cartilage (C6) to gastric cardia (T10)Upper, middle & lower thirdsDiffering blood supply & lymph drainageStratified squamous epithelium
EpidemiologyAdenocarcinoma > SCC (in Western World)3M : 1FAgeGeographical variation
3% of UK Cancer8,173 new cases 2008 (13.3 per 100,000)7,606 death 2008 (12.4 per 100,000)7th leading cancer death worldwide
ACA account for 65% of oes Ca in UK.Other Ca include small cell, melanoma, carcinoidIncreased incidence in Far East, Russia & South Africa6
Risk FactorsREFLUX(Barretts x30-60 risk)ObesityCigarettes & alcoholNitrosaminesVit A & C deficiency?HPV infectionStrictures/WebsAchalasia
Barretts Oesophagus
Barretts
HistologySquamous Cell Carcinoma (SCCs)Higher lesions, frequency in West
AdenocarcinomaLower lesions, frequency in West
(Small Cell Carcinoma, Melanoma, Carcinoid)
SymptomsDysphagia/OdynophagiaChest PainHaematemesisLymphadenopathyRLN palsyDisseminated diseaseResp symptoms
SignsWeight loss / CachexiaPalorCervical LNHepatomegalyPleural effusion
DiagnosisImagingOGDContrast SwallowsHistologyOGDFNA LNOtherFBC, U&E, LFTs
StagingCT TAPPositionLN statusMetastatic diseaseEUST stageN stagePosition
PETN stageM stage
CPEX(Echo)(PFTs)
Oesophageal T StageT StageLayerTisHGDT1To submucosaT2To muscularis propriaT3To adventitia (no serosa present)T4 - a - bInto adjacent structures - that can removed - that cannot be removed
N & M StageN StageNo of Local LN InvolvedN0No involved LNN11-2 LNN23-6 LNN3>7 LN
M StageM0No MetsM1Distant Metastases
AJCC Group StagingStage 0Tis, N0, M0Stage IT1, N0, M0Stage IIAT2 or 3, N0, M0Stage IIBT1 or 2, N1, M0Stage IIIT3 , N1, M0T4, any N, M0Stage IVAny T, any N, M1
ManagementMDT
PalliationOncologicalSurgical
PalliationSymptom controlDysphagia Metal stent insertion (APC)Wgt loss SupplementsPain Analgesia / DXT
Chemotherapy (+/- radiotherapy)FitNo jaundiceCompliance
OncologicalRadical chemoradiotherapy
Neo-adjuvant chemotherapyAdjuvant chemotherapy
EndoscopicEndoscopic Mucosal Resection (EMR)High grade dysplasia or solitary T1 tumours
Radiofrequency Ablation (RFA)Used after EMR to destroy any further areas of dysplasia
SurgicalTranshiatal OesophagectomyLaparotomy & neck anastomosisBlunt dissectionEarly diseaseIvor Lewis OesophagectomyLaparotomy & right thoracotomyMore advanced diseaseMcKeown 3-Stage OesophagectomyLaparotomy, thoracotomy & neck dissectionHigher lesions
Oesophageal ConduitsGastric pull-upJejunal flapColonic transposition
Pre-sternal
Prevention & ScreeningBarretts Surveillance?beneficialTechnique
Gastric Cancer
Gastric AnatomyMuscular sacCardia, fundus, body, pylorus/antrumDiffering blood supply & LN drainageImportant for surgeryColumnar epithelium
Lesser curvature left and right gastricsFundus & upper greater curvature short gastrics (from splenic artery)Greater curvature left & right gastro-epiploics29
EpidemiologyAdenocarcinoma2M : 1FAgeGeographical variation JapanIncidence falling in UK & USA2% of all UK cancers7,610 new cases 2008 (12.4 per 100,000)5,178 deaths 2008 (10.6 per 100,000)2nd leading cause of cancer death worldwide
ACA account for 65% of oes Ca in UK.Other Ca include small cell, melanoma, carcinoidIncreased incidence in Far East, Russia & South Africa30
Risk FactorsH.PYLORIHigh salt intakePrevious gastric surgeryCigarettes & alcoholAdenomatous polypsAtrophic gastritis(Pernicious anaemia)
Menetriers disease (hypertrophic gastropathy)Blood group AFH
SymptomsEpigastric PainHaematemesis / MalaenaVomiting / Early SatietyDysphagiaAnorexiaWgt LossGastric PerforationDisseminated Disease
SignsWeight loss / CachexiaEpigastric massPalorCervical LN (Virchows node)HepatomegalyAscites
DiagnosisOGD & biopsyBarium mealLinitis PlasticaOtherFBC, U&E, LFTsFOB +ve
Malignant Gastric Ulcer
Abnormal Barium Swallow
PathologyMalignant ulcerRaised, everted edgesPolypoid tumourLinitis plasticaLeather-bottle stomachSub-mucosal infiltration
HistologyAdenocarcinoma (95%)Intestinal typeMalignant glandsDiffuse typeSingle or small groups of malignant cells
Lymphoma (5%)GISTs (2%)Neuroendocrine (3%)
Adenocarcinoma develops in glandular tissue. Lymphoma develops in lymphatic tissue of gastric wall. Carcinoid hormone-producing tissues. GISTs intestinal cells of Cajal, anywhere in GI tract41
SpreadLocalDirect invasion, up into oesophagusLymphaticLesser & greater curvature LNMediastinal to supraclavicular (Virchows)DistantPortal vein liver / lungs / skeletalTrans-coelomic peritoneal / Krukenberg tumour
Trans-Coelomic SpreadKrunkenburg syndromeSister Mary Josef nodulesMalignant ascitesBlumers Shelf
StagingCT TAPPositionLN statusMetastatic disease
Staging LaparoscopySerosal involvementFixedPeritoneal spread(Anaesthetic test)CPEX(Echo)(PFTs)
Gasric Cardia Cancer & Liver MetsInfiltrating Carcinoma
Gastric T StageT StageLayerT1To SubmucosaT2To Muscularis PropriaT3To SubserosaT4 - a - bInvades Serosa - Visceral peritoneum - Into adjacent organs
N & M StageN StageNo of Local LN InvolvedN0No involved LNN11-2 LNN23-6 LNN3>7 LN
M StageM0No Distant MetsM1Distant Metastases
AJCC Group StagingStage 0Tis, N0, M0Stage IAT1, N0, M0Stage IBT2, N0, M0T1, N1, M0Stage IIAT3, N0, M0T2, N1, M0T1, N2, M0Stage IIBT4a, N0, M0T3, N1, M0T2, N2, M0T1, N3, M0Stage IIIAT4a, N1, M0T3, N2, M0T2, N3, M0Stage IIIBT4b, N0-1, M0T4a, N2, M0T3, N3, M0Stage IIICT4b, N2-3, M0T4a, N3, M0Stage IVAny T, any N, M1
ManagementMDT
PalliationSurgical
PalliationSymptom controlWgt loss Supplements / JejunostomyPain Analgesia / DXTHaematemesis DXT / Tranexamic Acid
SurgeryObstructionHaemorrhage
Chemotherapy
OncologicalNeo-Adjuvant ChemotherapyAdjuvant Chemotherapy
SurgicalSubtotal GastrectomyDistal lesionsRemoves pylorus
Total GastrectomyProximal lesionsLinitis Plastica
D1 vs D2 lymphadenectomy
TG with Roux-en-Y Oesophagojejunostomy
STG with Roux-en-Y Gastrojejunostomy
STG with Billroth II Gastrojejunostomy
Overall 5-yr Relative Survival RatesStage IA71%Stage IB57%Stage IIA45%Stage IIB33%Stage IIIA20%Stage IIIB14%Stage IIIC9%Stage IV4%
NCI database, based on pts diagnosed and treated with surgery between 1991 & 2000
ScreeningHigh incidence countriesJapan, Venezuela, etcHigh-risk individuals
No definite UK guidelines
Junctional Tumours
Younger menIncreasing incidence
Junctional TumoursSiewertType ITrue lower oesophageal ACAType IITrue junctional tumourType IIIGastric cardia tumour
Staged as oesophageal tumoursCT, EUS, PET (Laparoscopy)Type I Transhiatal or TGType II & III TG
Summary
Oesophageal Cancer RisingGastric Cancer Decreasing
Main RF = Reflux & H.Pylori, respectively
Surgical vs Oncological vs Endoscopic Mx
Poor outcomes, anyway!