ࡱ> qsp@ b0bjbjFF `x,,b(T:!:!:!:!<v!W1N"N"N"N"N"N"N"N"0000000$I2R40#N"N"##0N"N"1 & & &# N"N"0 &#0 & &V-@V.N"B" p"(X;:!# - .D'10W1-xi5#ni5V.i5V.<N">", &"$"N"N"N"00D:!& :!Oncology- Colon, Gastric, and Pancreatic Carcinoma Colorectal Cancer Risk factors Age- most commonly over 50 y.o. Personal history of neoplasia (Previous colorectal ca, edematous polyposis) Family history (familial polyposis, Peutz-Jeghers syndrome, familial juvenile polyposis, hereditary nonpolyposis colorectal cancer- HNPCC) Inflammatory bowel disease Dietary factors Ethnicity Signs and symptoms associated with colorectal cancer May be asymptomatic (importance of screening) Fecal occult blood Iron deficiency anemia Fatigue, weakness Abdominal pain (may be colicky in nature) Change in bowel habits Bowel obstruction Diarrhea, constipation, blood streaking stool Palpable abdominal mass Hepatomegaly Unexplained/unintentional weight loss Diagnostic/Laboratory work-up for colorectal cancer Complete blood count/differential Serum chemistries, liver function tests CEA levels (baseline and monitoring- i.e. pre and post resection) Barium enema CT scanning Colonography- virtual colonoscopy Colonoscopy- diagnostic procedure of choice CXR Abdominal/pelvic CT Pelvic US/Pelvic MRI- useful when evaluating depth f invasion and/or pararectal invasion of lymph nodes with rectal cancer Differential diagnosis of colorectal cancer Irritable bowel disease Diverticular disease Ischemic colitis Inflammatory bowel disease (ulcerative colitis, crohns disease) Infectious colitis (salmonella, shigella) Chronic iron deficiency anemia- r/o malignancy Staging Colorectal Cancer American Joint Committee ClassificationTNMDukes ClassStage 0- Carcinoma in situTISN0M0Stage 1- Tumor invades submucosa, tumor invades muscularis propriaT1, T2N0, N0M0, M0Dukes A, Dukes B1Stage 2- Tumor invades into subserosa or nonperitonealized pericolic or Perirectal tissues; Tumor perforates visceral peritoneum or directly invades other organs or structuresT3, T4N0, N0M0, M0Dukes B1 or B2, Dukes B2Stage 3- any degree of bowel wall perforation with lymph node metastasis; 1-3 pericolic or perirectal lymph nodes involved; 4 or more pericolic or Perirectal lymph nodes involved; metastasis to lymph nodes along a vascular trunk Any, T, T, TN1, N2, TM0, M0, M0Dukes C1, Dukes C2Stage 4- Presence of distant metastasisAny TAny NM1Dukes D Treatment/Palliation of colorectal cancer Resection of primary colon or rectal tumor (may include regional lymph node dissection) Colectomy- with or without diverting colostomy- depends on location/length of bowel removed Rectal carcinoma- type of resection depends on stage and if well or poorly differentiated cellular constitution- may involve transanal to abdominal perineal resection , or palliative diverting colostomy Adjuvant chemo/radiotherapy for colorectal cancer Stage 1- surgical resection- no recommended adjuvant therapy, 5 year survival rate 80-100% (certifiable surgical cure) Stage 2 (node negative disease)- surgical resection- adjuvant chemotherapy no established benefit- controversial ongoing study trials, 5 year survival rate 50-75% (primarily due to surgical intervention) Stage 3 (node positive disease)- depends on number of nodes involved- combination chemo/radiation seems promising (i.e. improves survival rates), 5 year survival rate 30-50% Stage 4- metastatic disease, approximately 20% of patients have metastatic disease at the time of initial diagnosis, 30% eventually develop metastasis, long term survival is 5% in these patients Resectable metastatic masses of the liver or lung with adjuvant therapy- 5 year survival rate is 20-40% Non-resectable metastatic masses (may include cryosurgery, embolization, chemotherapy); survival average rate 15 months Post surgical follow-up- yearly, colonoscopy, abdominal CT, CXR-3-6 months 1st year post-operative Sample protocol 3-5 years- every 6-12 months as above and every 3-6 months history, physical FOBT, LFTs, CBC, CEA levels (i.e. cancer free) Patients with rectal carcinoma should have bi-annual sigmoidoscopy and CBC, LFT, CEA levels- any fluctuation warrants CXR, and/or abdominal/pelvic CT Gastric Carcinoma- 2nd most common cause of cancer death worldwide Mostly in the antrum of the stomach Risk factors associated with gastric carcinoma Age- uncommon <40y.o.; most >60y.o. Ethnicity Chronic H. Pylori gastritis Chronic atrophic gastritis Pernicious anemia History of partial gastric resection >15 years previously Signs and symptoms associated with gastric carcinoma May be asymptomatic Dyspepsia Vague, epigastric pain Anorexia Early satiety Unintentional/unexplained weight loss G.I. bleed- (hematemesis, melena)-ulcerating lesions- Guiac + stools Postprandial vomiting- pyloric obstruction Progressive dysphagia- lower esophageal (LES) obstruction Palpable gastric mass Diagnostic/laboratory work-up for gastric carcinoma Complete blood count/differential- anemia Serum chemistries, liver function tests Upper GI endoscopy- cytologic brushings/biopsy Barium studies- upper GI series- with or without small bowel follow-through Abdominal CT- useful for pre-op evaluation- extent/spread of lesion (i.e. local extent of primary tumor, invasion of adjacent structures, nodal and/or distal metastasis) Differential Diagnosis of gastric carcinoma Benign gastric ulcer, peptic ulcer disease Dyspepsia Perforated gastric ulcer Hypertrophic gastropathies- may resemble cancer-thickened gastric folds Types of gastric carcinoma Adenocarcinoma- most common type- 95% Lymphoma- 2nd most common gastric malignancy- can be associated with H. pylori Leiomyosarcoma- stromal tumor Carcinoid tumors- rare- make up less than 1% of gastric neoplasms; strong propensity for metastasis Staging Gastric Carcinoma Staging Criteria For Gastric AdenocarcinomaStage 1T1 N0, T1 N1, T2 N0, all M0Stage 2T1, N2, T2 N1, T3 N0, all M0Stage 3T2 N2, T3 N1, T4 N0, all M0Stage 4T4 N2 M0, Any M1Treatment of Gastric Carcinoma- adenocarcinoma Surgical resection- the only therapy with curative potential Stage 1-3- surgical exploration to confirm localized disease- radical surgical excision (subtotal/total Gastrectomy with lymph node dissection) Adjuvant chemo/radiotherapy- controversial, no established survival benefit; apply risk:benifit ration Overall, long term survival rate of gastric carcinoma is less than 15%. Stage 1 and 2 patients who undergo curative resection, 5 year survival rate are 45-50%. Stage 3, poor prognosis- <20%. In general proximal tumors (fundus and cardia) have a far worse prognosis Palliative procedures for gastric adenocarcinoma- indicated for bleeding and/or obstruction Gastrojejunostomy Endoscopic laser or stent procedures Radiation therapy Angiographic embolization Chemotherapy- fluorouracil, doxyrubacin, cisplatin, mitromycin Treatment of gastric lymphoma- 95% are non-Hodgkins B cell lymphomas Stage 1E, 2E- excellent prognosis- treatment of H. pylori may result in complete regression of low grade lymphoma, surgical resection, and/or local radiation therapy Stage 1E, 2E- resection and combination CHOP (Cyclophosphamide, Hydrophosphamide (doxyrubacin), Oncovin (vincristine), Prednisone) Stage 3, 4- combination chemotherapy Long term survival rate of primary gastric lymphoma for stage 1 is over 85% Treatment of Gastric Leiomyosarcoma Endoscopic ultrasound with fine needle aspiration biopsy; benign leiomyoma and Leiomyosarcoma both appear as submucosal mass with central umbilication Surgical resection for localized malignant tumors- 5 year survival rate 30%. Metastatic tumors are aggressive and carry poor prognosis Pancreatic Carcinoma Most common neoplasm of the pancreas itself; 75% of pancreatic cancers are located in the head; very aggressive- at the time of discovery it is usually already too late Risk factors associated with pancreatic carcinoma Age- 6th to 7th decade of life Obesity- lifelong obesity; inc. function Tobacco use Chronic pancreatitis Family history- 7-8% of pancreatic cancer patients have 1st degree relative with pancreatic cancer, 0.6% incidence in control subjects Signs and symptoms associated with pancreatic carcinoma Abdominal pain (may be vague, LUQ or epigastric) Indicative of spread Diarrhea Unexplained/unintentional weight loss- common but late finding Jaundice- hepatobiliary system obstr. Palpable gallbladder (Courvoisiers sign) Hard, palpable periumbilical nodule-Sister Mary Josephs Diagnostic/laboratory work-up for pancreatic carcinoma Upper GI series- may show widening of the duodenal loop or mucosal abnormalities of the duodenum Abdominal CT- helpful in >80% of cases to delineate extent of tumor MRI of the abdomen- helpful in >80% of cases to delineate extent of tumor Both CT and/or MRI may be used for fine needle aspiration biopsy procedure Superior mesenteric or celiac artery angiogram- may demonstrate vessel invasion- these patients would not be considered for surgical resection of mass Endoscopic ultrasonography- abdominal sonography is NOT reliable ERCP- may clarify ambiguous CT or MRI results- delineates pancreatic and biliary ductal system Abdominal exploration- laparotomy- indicated if other tests are not decisive Staging Pancreatic Carcinoma- Majority of patients will present with terminal disease StageLocation of Tumor in PancreasTISCarcinoma in situT1Tumor limited to pancreas: 2cm or less in greatest dimensionT2Tumor limited to pancreas: >2cm in greatest dimensionT3Tumor extends beyond the pancreas but without involvement of the celiac axis or superior mesenteric arteryT4Tumor involves the celiac axis or the superior mesenteric artery; unresectable primary tumorTreatment of Pancreatic Carcinoma Localized mass in the head of pancreas, periampullary zone, and duodenum (T1, N0, Mo) - Whipple procedure (radical pancreaticoduodenal resection)-gastric entrectomy, cholecystectomy, duodenectomy, common bile duct resection, partial pancreatectomy; 5 year survival rate 20-25%. 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