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Esophageal Cancer

Esophageal Cancer. Presented by: Dr . Nasser Ebrahimi Daryani Professor of Gastroenterology Tehran University of Medical Sciences. Incidence. Esophageal cancer is uncommon but extremely lethal malignancy Disease is more common in blacks than whites and in males than females

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Esophageal Cancer

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  1. Esophageal Cancer Presented by: Dr. Nasser EbrahimiDaryani Professor of Gastroenterology Tehran University of Medical Sciences

  2. Incidence • Esophageal cancer is uncommon but extremely lethal malignancy • Disease is more common in blacks than whites and in males than females • It appears most often after age 50 • associated with a lower socioeconomic status

  3. Etiology • Etiology of SCC esophageal cancer is related to excess alcohol consumption and/or cigarette smoking • The relative risk increases with the amount of tobacco smoked or alcohol consumed, with these factors acting synergistically

  4. Etiologic factors of esophageal cancer

  5. Alcohol and tobacco smoking • …are two of the most important risk factors for SCC in western world responsible for 90 % of CAs. • The risk increases with a rising number of cigarettes and increasing duration of the smoking habit. • Cessation of smoking reduces the risk of esophageal SCC after 10 yrs.

  6. Esophageal cancer: • Squamous cell carcinomas • Adenocarcinomas

  7. Incidence of SCC decreased in both the black and white population in the US over the past 30 yrs • The rate of adenocarcinoma has rise dramatically, particularly in white males (M:F 6:1) • Adenocarcinomas arise in the distal esophagus in the presence of chronic GERD and Barrett's esophagus, which is more common in obese persons

  8. Iran is one of the known areas with a high incidence of esophageal cancer. • Consumption of wheat flour, exposure to residues from opium pipes, drinking hot tea, and chewing nass are the suspect etiologic agents for esophageal cancer in Iran. Ghavamzadeh A, et al. Semin Oncol. 2001 Apr;28(2):153-7.

  9. Clinical Features • About 10% of esophageal cancers occur in the upper third of the esophagus, 35% in the middle third, and 55% in the lower third • SCC and AC cannot be distinguished radiographically or endoscopically • Progressive dysphagiaand weight loss of short duration are the initial symptoms in the vast majority of pts

  10. Dysphagia initially occurs with solid foods and gradually progresses to include semisolids and liquids • Difficulty in swallowing does not occur until >60% of the esophageal circumference is infiltrated with cancer • Dysphagia may be associated with: - Odynophagia - Regurgitation or vomiting - Aspiration pneumonia

  11. The disease most commonly spreads to: - Adjacent and supraclavicular lymph nodes - Liver - Lungs & pleura - Bone • Tracheoesophageal fistulas may develop as the disease advances • As with other SCC, hypercalcemia occur in the absence of osseous metastases, probably from parathormone-related peptide

  12. Diagnosis • Routine contrast radiographs identify esophageal lesions large enough to cause symptoms • Esophageal carcinomas show ragged, ulcerating changes in the mucosa in association with deeper infiltration, producing a picture resembling achalasia • Smaller, potentially resectable tumors are often poorly visualized despite technically adequate esophagograms

  13. Barium swallow showing irregular filling defect in middle one-third of esophagus suggestive of malignancy

  14. Esophagoscopy should be performed in all pts suspected of having an esophageal abnormality, to visualize the tumor and to obtain histopathologic confirmation of the diagnosis • The extent of tumor spread to the mediastinum and para-aortic lymph nodes should be assessed by CT scans of the chest and abdomen and by endoscopic ultrasound • PET scanning provides a useful assessment of resectability, offering accurate information regarding spread to mediastinal lymph nodes

  15. Esophageal cancer(Esophagoscopy)

  16. Treatment • Prognosis for esophageal carcinoma is poor • < 5% of pts survive 5 yrs after the diagnosis • Surgical resection of all gross tumor (i.e., total resection) is feasible in only 45% of cases • The efficacy of radiation therapy (5500–6000 cGy) for SCC is similar to that of radical surgery

  17. Combination chemotherapy and radiation therapy as the initial therapeutic approach, either alone or followed by an attempt at operative resection, seems to be beneficial • For the incurable, surgically unresectable pt, palliation include: - Repeated endoscopic dilatation - Surgical placement of a gastrostomy or jejunostomy for hydration and feeding - Endoscopic placement of an expansive metal stent to bypass the tumor

  18. Gastric Adenocarcinoma

  19. Gastric cancer remains the second leading cause of cancer-related death in the world • Incidence has fallen over time in developed nations • Chronic helicobacter pylori infection is a significant contributory factor (Primarily in noncardiac gastric cancer)

  20. Prevalence in Iran • After cardiovascular disease and accidents, cancer is the third most frequent cause of death in Iran. • In 1968 annual age-adjusted incidence rate of esophageal Ca (mainly SCC) was >100 in 100 000 in Gonbad. • A case-control study revealed a pattern of very low consumption of fresh fruit and vegetables in northeastern Iran.

  21. Risk factors for gastric cancer - Age (older > younger) - Gender (male > female) - Geredity Sporadic: family history, blood group A Syndromic: HNPCC, CDHI, Peutz-Jeghers, FAP - Geography Japan, China, Thailand, Finland, Colombia, - Diet Smoked, salted, pickled foods High fat, low fiber - Inflammation Chronic gastric Hlicobacter pylori Subtotal gastrectomy - Gastric polyps Adenomatous Hyperplastic?

  22. Incidence and Epidemiology • Incidence and mortality rates for gastric cancer decreased markedly worldwide during past 75 yrs • 21,000 new cases of stomach cancer were diagnosed in the US, and 10,570 Americans died of the disease in 2010 • Risk of gastric cancer is greater among lower socioeconomic classes

  23. Gastric adenocarcinoma pathologic classification

  24. Pathology • 85% of stomach cancers are adenocarcinomas • 15% due to lymphomas and gastrointestinal stromal tumors (GIST) and leiomyosarcomas • Gastric adenocarcinomas subdivided into two categories: - diffuse type: in which cell cohesion is absent, so that individual cells infiltrate and thicken the stomach wall without forming a discrete mass - intestinal type: characterized by cohesive neoplastic cells that form gland like tubular structures

  25. Malignant gastric ulcer in the antrum.The nodular heaped-up margins are particularly suggestive of malignancy

  26. The characteristic rigidity, irregular contour, and narrowed luman of linitis plastica are seen affecting the entire stomach

  27. This benign looking gastric ulcer proved to be malignant after multiple biopsies

  28. Pathology • 85% of stomach cancers are adenocarcinomas • 15% due to lymphomas and gastrointestinal stromal tumors (GIST) and leiomyosarcomas • Gastric adenocarcinomas subdivided into two categories: - diffuse type: in which cell cohesion is absent, so that individual cells infiltrate and thicken the stomach wall without forming a discrete mass - intestinal type: characterized by cohesive neoplastic cells that form gland like tubular structures

  29. Diffuse Carcinomas • Occur more often in younger pts • Develop throughout the stomach (including the cardia) • Result in a loss of distensibility of the gastric wall (so-called linitisplastica/"leather bottle" appearance) • Carry a poorer prognosis • have defective intercellular adhesion, mainly as a consequence of loss of expression of E-cadherin

  30. The characteristic rigidity, irregular contour, and narrowed luman of linitis plastica are seen affecting the entire stomach

  31. Intestinal-type lesions • Are frequently ulcerative • More commonly appear in the antrum and lesser curvature of the stomach • Often preceded by a prolonged precancerous process,initiated by Helicobacter pyloriinfection

  32. Etiology • long-term ingestion of high concentrations of nitrates in dried, smoked, and salted foods appears to be associated with a higher risk • The nitrates are thought to be converted to carcinogenic nitrites by bacteria • Effect of H. pylorieradication on the subsequent risk for gastric cancer in high-incidence areas is under investigation

  33. The presence of extreme hypertrophy of gastric rugal folds (i.e., Ménétrier's disease), associated with a striking frequency of malignant transformation • Individuals with blood group A have a higher incidence of gastric cancer than persons with blood group O • Duodenal ulcers are not associated with gastric cancer.

  34. A germ-line mutation in the E-cadherin gene (CDH1), linked to a high incidence of occult diffuse-type gastric cancers • K-ras mutations appear to be early events in intestinal-type gastric cancer • About half of intestinal-type tumors have mutations in tumor suppressor genes such as TP53, TP73, APC(adenomatouspolyposis coli), TFF (trefoid factor family), DCC (deleted in colon cancer), and FHIT (fragile histidine triad).

  35. Clinical Features • When superficial and surgically curable, usually produce no symptoms • As the tumor becomes more extensive, pts complain of an insidious upper abdominal discomfort varying in intensity from a vague, postprandial fullness to a severe, steady pain • Anorexia, often with slight nausea, is very common

  36. Nausea and vomiting are prominent with tumors of the pylorus • Dysphagia and early satiety are the major symptoms caused by diffuse lesions in the cardia • Weight loss may eventually be observed • Metastases to intraabdominal and supraclavicular lymph nodes occur frequently, as do metastatic nodules to the ovary (Krukenberg's tumor), periumbilical region (Sister Mary Joseph node), or peritoneal cul-de-sac (Blumer's shelf palpable on rectal or vaginal examination)

  37. Unusual clinical features associated with gastric ACa include: - Migratory thrombophlebitis - Microangiopathic hemolytic anemia - Diffuse seborrheickeratoses (Leser-Trélat sign) - Acanthosisnigricans

  38. Diagnosis • Presence of iron-deficiency anemia in men and of occult blood in the stool in both sexes mandates a search for an occult gastrointestinal tract lesion • We recommend gastroscopic biopsy and brush cytology for all pts with a gastric ulcer in order to exclude a malignancy • Since gastric carcinomas are difficult to distinguish clinically or radiographically from gastric lymphomas, endoscopic biopsies should be made as deeply as possible

  39. Early gastric cancer

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