UPPER G.I MALIGNANCIES BY M.S.AL-AMOODI,MMedSci,FRCSI

1. UPPER G.I MALIGNANCIESBYM.S.AL-AMOODI,MMedSci,FRCSI

2. UPPER G.I Malignancies

3. INTRODUCTION In all of the above condition one should familiarize one self with the different symptoms of presentation and apply them to the appropriate organ. For example dysphagia could be due to oesophageal condition or condition at the cardia of the stomach, heartburn almost always signifies an oesophageal reflux.

4. One should be able to take a very good history and try to connect it to the physical examination. In a good number of cases the presentation of upper G.I malignancies is late hence only palliative treatment is possible. One should also be familiar with the Anatomy of the organ concerned plus the common sites for malignancies

5. Oesophageal ca. Definition Oesophageal carcinoma: malignancies of the epithelial lining of t he oesophagus. Epidemiology Male/female ratio 5:1 Age 50-70 years

6. High incidence in areas of China, Iran, Russia, Scandinavia and among the Bantu in south Adenocarcinoma has the fastest increasing incidence of any carcinoma in the UK.

7. Aetiology Alcohol consumption and cigarette smoking. Chronic oesophagitis and Barrett's oesophagus. Stricture from corrosive agent oesophagitis or human papilloma virus infection.

8. Achalasia Plummer � Vinson syndrome (oesophageal web. Mucosal lesions of mouth and pharynx, iron-deficiency anaemia) Nitrosamines.

9. Pathology Histological type: 90% squamous carcinoma (upper two-thirds of oesophagus): 10% adenocarcinoma (lower third of oesophagus). Macroscopically may be stenosing, polypoid or ulcerative . Spread : hymphatics, direct extension, vascular invasion.

10. Clinical features Majority of patients in West present with advanced disease. Dysphagia progressing from solids to liquids Weight loss and weakness

11. Aspiration pneumonia Evidence of distant disease (cervical nodes, hepatic or cutaneous metastases)

12. Investigation To make the diagnosis Barium swallow : narrowed lumen with �shouldering� Oesophagoscopy and biopsy: malignant structure

15. To assess whether tumour is operable Transluminal ultrasound may help assess local invasion. Bronchoscopy : assess bronchial invasion with upper third lesions CT (helical): assess degree of spread if surgery is being contemplated Laparoscopy to assess liver and peritoneal involvement prior to surgery.

16. Management Only a minority of tumours are successfully cured Palliation Recanalization Photocoagulation by Nd:YAG laser plus dilatation Photodynamic ablation using haematoporphyrin plus red light irradiation

17. Endoscopic-guided fulguration with BICAP probe Endoscopic intratumour injection of absolute alcohol Brachytherapy: intraluminal irradiation with caesium or iridium wires

18. Intubations Most widely used method of palliation Intubation with expanding endoprosthesis (has replaced Atkinson or Celestin tubes)

19. Curative treatment Surgical resection is curative only if lymph nodes are not involved Reconstruction is by gastric �pull-up� or colon interposition

20. Other treatment Combination therapy with preoperative external beam irradiation and chemotherapy followed by surgery may offer survival advantage

23. Prognosis Following resection, 5-year survival rate is about 15% Overall 5-yeaar survival (palliation and resection) is only about 4%

24. Carcinoma of the stomach Key points Majority of tumours are unresectable at presentation Tumours considered candidates for resection should be staged with CT and laparoscopy to reduce the risk of an �open and shut� laparotomy Most tumours are poorly responsive to chemotherapy

26. Epidemiology Male/female ratio 2:1 Age 50+years Incidence has decreased in western world over last 50 years; still common in Japan, Chile and Scandinavia

27. Aetiology H. pylori gastritis Diet (smoked fish, pickled vegetables, benzopyrene, nitrosamines) Atrophic gastritis Pernicious anaemia

28. Previous partial gastrectomy Familial hypogammaglobulinaemia Gastric adenomatous polyps Blood group A

29. Pathology Multistep process: chronic gastritis atrophy intestinal metaplasia dysplasia carcinoma Histology : adenocarcinoma Advanced gastric cancer (penetrates muscularis propria): polypoid, ulcerating or infiltrating (i.e linitus plastica)

30. Early gastric cancer : confined mucosa or submucosa Spread: lymphatic (e.g Virchow`s node); haematogenous to liver, lung, brain ; transcoelomic to ovary (Krukenberg tumour)

32. Clinical features Often asymptomatic History of recent dyspepsia (epigastric discomfort, postprandial fullness, loss of appetite) Anaemia Dysphagia Vomiting Weight loss Presence of physical signs usually indicates advanced (incurable) disease

33. Investigations Full blood count Urea and electrolytes Liver function tests OGD: see the lesion and obtain biopsy to distinguish from benign gastric ulcer

34. Barium meal: space-occupying lesion/ulcer with rolled edge. Best for patients unable to tolerate OGD Helical CT : stages disease locally and systemically Laparoscopy: excludes undiagnosed peritoneal or liver secondaries prior to consideration of resection

36. Management Early gastric cancer )10%) Cancer is limited to mucosa and submucosa Aggressive treatment with resection. Curative treatment (resectable primary and local nodes) involves surgical excision with clear margins and locoregional lymph node clearance (D2 gastrectomy) With adequate resection, Prognosis is good (80% 5-years) survival)

37. Advanced gastric cancer (90%) Cancer involves muscularis propria of the stomach wall Majority of tumours are unresectable at presentation Palliation (metastatic disease or gross distal nodal disease at presentation): Gastrectomy: local symptoms, e.g bleeding Gastroenterostomy: malignant pyloric obstruction Intubation: obstructing lesions at the cardia

38. SMALL BOWEL CA Although small bowel contains 90% of the mucosal surface area and 75% of the length of the alimentry tract and is located between two organs with high cancer prevalence,cancer here is rare. 64% malignant with 40% adeno ca Sarcoma 15% part of the G.I. STROMAL TUMORS(GIST) 30% carcinoid 15% lymphomas

39. SITES 50% DUODENUM 30% JEJUNUM 20% ILEUM

40. M>F 1.4:1 AGE >60

41. HISTORY Typically asymptomatic in its early stages Non- specific hence the delay in dx Abdominal pain plus weight loss are commonest symptoms Bleeding,nausea and vomiting less common

42. CAUSES Familial adenomatous polyposis(colon then duodenum) Hereditary Diet such as fat,red meat or smoked food Chrons(mainly ileum) Celiac disease

43. Investigation/diagnosis CBC,LFT,CEA AXR Upper g.i series with small bowel follow through CT Endoscopy

44. TX SURGERY IS THE ONLY HOPE 5yr survival for adeno ca is 40-60% Sarcoma 25%

45. THAN YOU