CANCER CHEMO MIDTERMS: Gastrointestinal Cancers

ESOPHAGEAL CANCER
8th most common cancer in the world
2 common forms of EC
1. Squamous cell carcinoma
2. Adenocarcinoma
Squamous cell carcinoma
Squamous cell (thin, flat cells lining the esophagus)
Upper and middle pain of the esophagus
Adenocarcinoma
Glandular (secretory) cells
Lower part of the esophagus, near the stomach
Risk factors
Heavy alcohol use
Older age
Tobacco use
Barrett esophagus cells lining the lower part of the esophagus have
changed
GERD backing of stomach contents into the lower section; may cause
Barretts Esophagus overtime
Signs and Symptoms
Dysphagia
Weight loss
Bleeding
Pain behind the breastbone
Hoarseness and cough
Indigestion and heat burn
Hepatomegaly
Lymphadenopathy
Pathophysiology
Arises in the mucosa of the esophagus
Invade submucosa and muscular layer
Staging
Stage 0
abnormal cells in the innermost layer of tissue lining the
esophagus
Stage 1
cancer formed and spread beyond the innermost layer to the
next layer
Stage 2
spread to the layer of esophageal muscle
Stage 3
spread to the outer wall of the esophagus
Stage 4A
spread to nearby or distant lymph nodes
Stage 4B
spread to organs in other parts of the body
Diagnosis
Esophagogastroduodectomy
Endoscopic ultrasonography
periesophageal lymph nodes
Computed tomography

direct visualization of tumor

depth in penetration of tumor, enlarged
assess lung and liver metastasis

CANCER CHEMO MIDTERMS: Gastrointestinal Cancers

PET Scan
for staging
Laparoscopy & Thorasoscopy
staging regional nodes
Barium swallow
detect structures and intraluminal masses
Esophagoscopy
inserted through mouth/nose down to throat
Treatment
Surgery (most common treatment for esophageal cancer
Esophagectomy a portion is removed and the stomach is pulled up and
joined to the remaining esophagus
Esophageal stent stent is placed to keep esophagus open
Radiation
External radiation therapy uses a machine outside the body to seal
radiation toward the cancer
Internal radiation therapy uses a radioactive substance sealed n needles
Chemotherapy
Cyranza (ramucirumab) given if 1st line failed, given alone or with Paclitaxel
Herceptin (trastuzumab) used for patients with metastatic esophageal
adenocarcinoma
Taxotere (docetaxel)
Targeted therapy
Stage 0 & 1 surgery
Stage 2 & 3 surgery, chemoradiation (squamous cell cancer)
Stage 4
chemotherapy, esophageal stent, external/internal radiation
therapy
Prognostic factors
Early stage disease
Complete resection
LIVER CANCER
5th most diagnosed cancer
Secondary to Hep B, Hep C, and alcohol
Etiology
Alcohol abuse
Birth defects
Chronic infection
Cirrhosis
Hemochromotasis
Risk factors
Gender
Race
Anabolic steroid use
Weight
Histori of diabetes
Inherited metabolic disease
Classification

CANCER CHEMO MIDTERMS: Gastrointestinal Cancers

Hepatocellular carcinoma
most common form of liver cancer
abdominal mass and pain, emesis, anemia, back pain
jaundice, itching, weight loss, and fever
Cancer of the bile duct
sweating jaundice, abdominal pain, weight loss, and liver enlargement
o Cholangiocarcinoma - due to presence of liver fluke
o cholangiocellular cystadenocarcinoma
Tumors of the blood vessel
formed by immature liver cells
formed in the right liver
produced from a type of connective tissue known as mesenchyme
o Angiosarcoma
o hemangioendothelioma,
o embryonal sarcoma
o fibrosarcoma
Diagnosis
MRI
MRA
ERCP endoscopic retrograde cholangiopancreatography
Liver scan
Ct Scan
Hepatic angiography
Treatment
Liver cancer treatment depends on the livers condition, size, location, and number
of tumors. Metastasized, age and overall health

Translpalnt if the cancer has not spread

Surgery if the cancer has been found early
Partial hepatectomy
Radiofrequency ablation for tumor of less than 1.5 inches. Needle electrode is
placed through the skin into a liver tumor
Radiation therapy
Oral med For cancer that has spread outside the liver
Bland embolization or chemoembolization for tumor that is blocked given in
blood vessels near the tumor
Cryosurgery/cryotherapy used of liquid nitrogen or argon gas used to treat
external tumors. Applied directly with a cotton swab or sprayed device
Percutaneous ethanol injection treats tumors less than 5 cm and less then 3
lesions. Effective agisnt hepatoma lesions. 1 to 2 sessions per week; post
procedural imaging conducted after 1 month then every 4 months
Chemotherapy
o Floxuridine
o Cysplatin
o Mitomicin c
o Doxorubicin

CANCER CHEMO MIDTERMS: Gastrointestinal Cancers

GALL

BLADDER
Sits just under the liver
Stores bile
Bile helps digest fats
When u remove gallbladder it results to diarrhea and malabsorption

Risk factors
Gallstones
Pebble like collections of cholesterol
Porcelain gallbladder covered with calcium deposits, occurs after long term
inflammation of gall bladder, cholecystitis caused by gallstones
Obesity
Female
Signs and symptoms
Nausea
Abdominal pain
Jaundice
Lumos in the belly
Weight loss
Loss of appetite
Diagnosis
Test of liver and gallbladder function
Bilirubin chemical that gives the bile its yellow color
Tumor markers CEA CA19-9 proteins found in the blood when certain cancers
are present
Treatment
Surgery
Potentially curative surgery good chance of removing all the cancer
Palliative surgery relieve pain and prevent complications
Chemotherapy
Fluouracil
Capecitabine
STOMACH CANCER
Stomach holds food and start to digest it
Duodenum first part of intestine
Parts of stomach
Cardia first portion
Fundus upper part of the stomach next to cardia
Corpus main part, also called as body
Anthrum lower portio near intestine, food is mixed with gastric juice
Pylorus last part acts as a ball to control emptying of the stomach contents
into the small intestine
Proximal stomach makes acid and pepsin, makes a protein called intrinsic factor

CANCER CHEMO MIDTERMS: Gastrointestinal Cancers

Stomach wall layers
Mucosa inner most layer, acid and enzymes are made. It is where most
stomach cancers start
Submucosa supporting layer
Mascularis propria thick layer of muscle that moves and mixes the stomach
contents.
It has two layers: (They wrap the stomach and determine the stage and
determine the pprognosis)
1. subserosa
2. serosa. Types of stomach cancer
Types of Stomach Cancer
1. Adenocarcinoma (90-95%) - developed from mucosa
2. Lymphoma (4%) - cancers of immune system tissue that are sometimes
found in the wall of the stomach
3. Gastrointestinal stromal tumor - start in interstetial cells of cajal
4. Carcinoid tumors (3%) - start in hormone making cells of the stomach, do not
spread to other organs
5. Squamous cell carcinoma
6. Small cell carcino ma
7. Leiomyosarcoma
Risk factors
Gender
Age
Diet
Tobacco use
Overweight
Type A blod
Ethnccity
Geography
Pernicious anemia
H pylori
Menetrier disease also called hypertrophic gastropathy
Symptoms
Pain in the stomach
Dysphagia
NV
Wt loss
Vomiting blood
Blood in stool
Stages In Stomach Cancer
Stage 0
only present in mucosa
Stage 1
extended into the underlining submucosa
Stage 2,3
grown deeper into the stomach wall
Stage 4
grown outside of the stomach

CANCER CHEMO MIDTERMS: Gastrointestinal Cancers

Diagnosis
Endoscope
Mouth guard prevents from endoscopic from damaging
Treatments
Surgery used in all stages of gastric cancer
endoscopic resection for very early stage cancers
subtotal gastrectomy only part of the stomach is removed
total gastrectomy end of the esophagus is attached to part of the small
intestine
Chemotherapy
5fu with leucovirin
Capicitabin (Xeloda)
Carboplatin
Cisplatin
Doxipaxel (taxotere)
Apirubicin (ellence)
Irinotican (camptosar)
Oxaliplatin (eloxatin)
Paclitaxel (taxol)
Radiation therapy
delay or prevent cancer recurrence after surgery
Slow the growth and ease of the symptoms of advanced stomach cancer
Targeted therapy
Stage 1
surgery
o Gastric bypass
o Subtotal gastrectomy
Stage 2
Stage 3
o
o

Chemo-radiation
Targeted therapy
Trastuzumab (Herceptin)
Ramucirumab (cyramza)

4 nutrition
Nutritional counseling and tpn

Stage

COLON CANCER
Colorectal cancer (also known as colon cancer, rectal cancer, or bowel cancer) is the
development of cancer from the colon or rectum (parts of the large intestine). It is
due to the abnormal growth of cells that have the ability to invade or spread to
other parts of the body
Etiology

CANCER CHEMO MIDTERMS: Gastrointestinal Cancers

greater than 7595% of colon cancer occurs in people with little or no genetic
risk.
Risk factors :
older age
male gender
high intake of fat
Alcohol
red meat
processed meats
Obesity
Smoking
lack of physical exercise.
Genetics
two or more first-degree relatives (such as a parent or sibling).
A number of genetic syndromes are also associated with higher rates of
colorectal cancer.

Genetic Syndromes
o most common of these is hereditary nonpolyposis colorectal cancer (HNPCC
or Lynch syndrome) which is present in about 3% of people with colorectal
cancer.
o Gardner syndrome
o Familial adenomatous polyposis (FAP).
1. Lynch syndrome (HNPCC or hereditary nonpolyposis colorectal cancer)
o Accounts for 3% of all colon cancer
o Age less that 50 or strong family history
o Skips the polyp step in cancer formation
o Those with the gene have an 80% chance of developing colon cancer
o High risk of uterine cancer
2. Gardner Syndrome
o also known as familial colorectal polyposis
o autosomal dominant form of polyposis characterized by the presence of
multiple polyps in the colon together with tumors outside the colon
o caused by mutation in the APC gene located in chromosome 5q21 (band q21
on chromosome 5).
3. Familial adenomatous polyposis
o inherited condition in which numerous adenomatous polyps form mainly in
the epithelium of the large intestine.
o start out benign, malignant transformation into colon cancer occurs when
they are left untreated.
Clinical Manifestation
o Signs and symptoms of colorectal cancer can be extremely varied, subtle,
and nonspecific.
o Patients with early-stage colorectal cancer are often asymptomatic, and
lesions are usually detected by screening procedures.
o Blood in the stool is the most common sign
o change in bowel habits
o vague abdominal discomfort

CANCER CHEMO MIDTERMS: Gastrointestinal Cancers

o
o
o

abdominal distension may be a warning sign

Less common signs and symptoms include nausea, vomiting
Anemia if severe,fatigue

Diagnosis
o When colorectal carcinoma is suspected, a careful personal and family history
and physical examination should be performed
o The entire large bowel should be evaluated by colonoscopy or flexible
sigmoidoscopy with double-contrast barium enema
Staging
Stage I
Stage II.
Stage III
Stage IV

Your cancer has grown through the superficial lining (mucosa) of the
colon or rectum but hasn't spread beyond the colon wall or rectum.
Your cancer has grown into or through the wall of the colon or rectum
but hasn't spread to nearby lymph nodes.
Your cancer has invaded nearby lymph nodes but isn't affecting other
parts of your body yet.
Your cancer has spread to distant sites, such as other organs for
instance, to your liver or lung

Early-stage
o Removing polyps during colonoscopy.
o Endoscopic mucosal resection.
o Minimally invasive surgery.
Surgery for invasive colon cancer
Partial colectomy
o Surgery to create a way for waste to leave your body
o removes the part of your colon that contains the cancer, along with a margin
of normal tissue on either side of the cancer. Your surgeon is often able to
reconnect the healthy portions of your colon or rectum.
Targeted drug therapy
Bevacizumab (Avastin)
o First line treatment
o Angiogenesis inhibitor
o Inhibiting vascular endothelial growth factor
o (VEGF-A)
o Acute Toxicity : HTN
o Delayed Toxicity:
Arterial thromboembolic events
GI perforation
Wound healing complication
Proteinuria
VEGF-A is a chemical signal that stimulates angiogenesis in a variety of
diseases, especially in cancer. Bevacizumab was the first clinically
available angiogenesis inhibitor in the United States.
Cetuxumab (Erbitux)

CANCER CHEMO MIDTERMS: Gastrointestinal Cancers

epidermal growth factor receptor (EGFR) inhibitor
Enhances response to chemotherapy and radiotherapy
Acute Toxicity :
o Infusion Reaction
Delayed Toxicity:
o Skin rash
o Hypomagnesimia
o fatigue
Camptosar (Irinotecan Hydrochloride)
Capecitabine.
Cetuximab.
Cyramza (Ramucirumab)
Eloxatin (Oxaliplatin)
Erbitux (Cetuximab)
PANCREATIC CANCER
Trends in Incidence and Survival
Risk Factors:
Smoking
Obesity
Personal history of diabetes or chronic pancreatitis
Family history of pancreatic cancer or pancreatitis
Certain hereditary conditions
Symptoms
Most patients present with pain (in the back) weight loss or jaundice
Tumors in the head of the pancreas are more likely to have jaundice.
Pathophysiology
Bile
yellowish fluid produced in the liver that aids in digestion of fat in the small
intestine
passes through the common bile duct through the head of the pancreas on
its way to the duodenum
Bile duct
carries the bilirubin through the head of the pancreas on its way to the
duodenum
Tumors in the head of the pancreas are more likely to have jaundice
Tumors in the body or tail are more likely to present with pain or weight loss
Ductal adenocarcinoma accounts for about 85% of all neoplasms. And more than
95% of all pancreatic cancers arise from the exocrine (digestive enzymes) elements.
Cancers that arise from the endocrine cells (neuroendocrine, islet cells) account for
5% or less
Location of Pancreas Cancer

CANCER CHEMO MIDTERMS: Gastrointestinal Cancers

Tests

60 to 70 percent of exocrine pancreatic cancers are localized to the head

20 to 25 percent are in the body/tail and
the remainder involve the whole organ
used to evaluate and stage pancreas cancer
Routine blood tests e.g. liver products like bilirubin
Elevated tumor markers (CA 19-9 or Carcinoembryonic antigen [CEA])
MRI, CT scans, Ultrasound
Endoscopy including endoscopic ultrasound or ERCP
Laparoscopy
Biopsy
ERCP or Endoscopic retrograde cholangiopancreatography Inject dye into
the duct system and look for compression
EUS (Endoscopic Ultrasound
Endoscopic Placement of a Stent

TNM Stage:
Stage IA (T1N0M0) The tumor is confined to the pancreas and is 2 cm across the
pancreas or smaller
N0-M0 cancer has not spread to nearby lymphnodes or distant
sites
Stage IB (T2N0M0) T2- cancer has not grown OUTSIDE the pancreas but is larger
than 2 cm
Stage IIA (T3N0)
beyond the pancreas T3- cancer has grown OUTSIDE the
pancreas into nearby surrounding structures but not into nearby
blood vessls or nerves
Stage IIB (T1-3N1M0)
N1- cancer has spread to nearby lymphnodes
Stage III (T4)
Unresectable
Cancer has spread to the major blood vessels near the pancreas.
These include the superior mesenteric artery, celiac axis,
common hepatic artery, and portal vein.
Stage IV
Metastasis
Chemotherapy
Chemotherapy for Metastatic Pancreas Cancer
FOLFIRINOX (oxaliplatin (Eloxatin), irinotecan (Camptosar) , leucovorin,
fluorouracil)
Gemzar (gemcitabine) + Abraxane (albumin bound paclitaxel)
Gemzar + erlotanib (Tarceva, EGFR drug)