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GI Malignancies

Trisha Marsolini RN, BS, OCN, CMSRN Septmeber 2014

Objectives

Review pathophysiology of GI systems

Discuss risk factors

Discuss presenting signs and symptoms

Discuss and Identify current treatment options

Review side effects and nursing management

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GI Malignancies Worldwide

Type Diagnosed Cases

Deaths US cases

Esophageal

482,300 406, 800 17, 460

Stomach

989,600 738,000 21,320

Pancreatic # fall under other

800,230 43, 920

Colorectal

1,167,020 602,958 143,460

Combined: 25% of all diagnosis and 32% of deaths

worldwide

•Numbers are based data collected by ACS in 2008

http://blogs.abcnews.com

Esophageal

Cancer

Anatomy and Function

• Located behind the trachea, at the hypopharynx • Starts at thoracic inlet, ending at GE junction

muscular tube 10-13 inches long • Facilitates swallowing and moves food and fluids • Movement controlled by sphincters and peristalsis

Esophageal Anatomy

• Mucosa – two components

• Epithelial layer – squamous cells

• Lamina layer – connective tissue

• Sub mucosa

• Glandular layer

• Muscularis Propria

• Muscle layer

• Adventia

• Connective tissue layer

• Lymph Nodes

•Types of Esophageal Cancer

• Squamous cell carcinoma (SCC)

Originate from mucosal layer

Usually occurs from mid to upper esophagus

90% used to be SCC now < 30%

More common in black men

Types of Esophageal Cancer

• Adenocarcinoma

• Does anyone remember where this type originates from?

• Originate from glandular cells of sub mucosa

• Squamous cells are replaced by

glandular cells

• Usually occurs near the stomach

• Increasing about 1% a year in white men

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Incidence of Esophageal Cancer

• 2% of U.S. cancer deaths

• 17, 460 estimated new cases - 2012 US

• 15,070 estimated deaths – 2012 US

• 8th most common cancer Worldwide

• 7th most common cancer death Worldwide

• 3 to 4 higher in men than women

startoncology.net

• Stats from 2004

Highest incidence :

•South Africa

•China

•Malawi

•Mongolia

•These areas have 20

to 30 times higher

than US

Worldwide Incidence 2008

Risk Factors for Esophageal Cancer

Age - most cases occur > 65

Male – 3 to 4x higher than women

Tobacco

44X risk more significant in SCC

Alcohol – heavy

Synergic relationship with smoking

Obesity/ High BMI

More significant in adenocarcinoma

Risk Factors for Esophageal Cancer

HPV – predisposes to adenocarcinoma

Diet

Diet low in fruits and vegetables Drinking hot fluids frequently Diet high in processes meats (high salt), pickled vegetables

Decline of h. pylori in esophagus

In squamous cell

Presenting Signs & Symptoms • Asymptomatic in early stage • Late Symptoms

• circumference of esophagus less than 13mm – Difficulty/painful swallowing – Weight loss – Chest or Epigastric Pain – Hoarse Voice – Hiccups – Hematemesis – Melena

• No screening tests available in US

Risk Factors for Esophageal Cancer

Barrett’s Esophagus

• 10% of people with GERD have Barrett’s

– GERD asst with high BMI

• Squamous cells replaced with glandular cells

• 30-125 times increased risk of adenocarcinoma

• Cancer risk higher when there is dysplasia

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Case Study • Jim a 67 yr old

– Hx: HTN, Hyperlipidemia, DM, GERD, obese and Barrett’s

• Progessive dyspaghia for last 4 to 6 weeks

– Previous 2 weeks only eating soft food

– 50 pd weight loss last 6 mo.

• Previous EGD 2 yrs ago – WNL

• 3/26 Had EGD

– Obstructing mass distal esophagus

– Biopsy

• High grade poorly differentiated adenocarcinoma

Diagnostic Work-up

Initial diagnostic exams

• Baruim Swallow

• Endoscopy and Biopsy

Staging exams

• CT chest and abdomen

• Bronchoscopy

• PET scan

• MRI

• Bone scan

• Laparoscopy

Diagnostic Work-up

Endoscopic Ultrasound

Identifies unseen

tumors and depth of

tumors

Can do biopsies

Even of lymph nodes

http://www.barrettsadvice.com

Case Study

• 4/4 CT/PET

– Obstructing mass distal esophagus and junction

– Enlarged perigastric node

– Bulky upper R mediastinum/paratracheal node

– No distant mets

• Family Hx

– Dad passed from esophageal ca

– Brother passed from a brain tumor

Metastatic Patterns

Local Spread through esophageal layers

Lymph Nodes

Surrounding organs

Distant Metastases

Liver

Lung & Pleura

Stomach

Peritoneum

NCCN Esophageal Staging

• TNM used

– Plus add Grade

• Makes difference in early stages

• Squamous Vs Adenocarcinoma

– Squamous staging

adds location

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TNM Staging - Squamous TNM staging - Adenocarcinoma

Staging TX Primary tumor cannot be assessed.

T0 No evidence of primary tumor.

Tis High-grade dysplasia.c

T1 Tumor invades lamina propria, muscularis mucosae, or submucosa.

T1a Tumor invades lamina propria or muscularis mucosae.

T1b Tumor invades submucosa.

T2 Tumor invades muscularis propria.

T3 Tumor invades adventitia.

T4 Tumor invades adjacent structures.

T4a Resectable tumor invading pleura, pericardium, or diaphragm.

T4b Unresectable tumor invading other adjacent structures, such as aorta, vertebral body, trachea, etc.

Nodes

Nx = unable to

assess LN

N0 = no LN

N1= 1-2 LN

N2 = 3-6 LN

N3 = >7 LN

Esophageal tumor

5 Year Survival Rates

• Localized disease survival rate is 37%

• Regional staged is 19%

• Distant metastasis 3%

Survival rates doubled last 40 years but remain poor

NCCN Treatment Guidelines • Surgery alone

– Early Stage - rare

• Chemotherapy

– Pre and postoperative

• Chemoradiation – Primary treatment

– Used alone in locally advanced SCC

– Combined with surgery in adenocarcinoma

• Radiation –

– Alone if tumor is locally advanced

– Palliative for symptom management

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Case Study • Jim is not a surgical candidate

– Why?

• 4/9 Port placed and chemo started

– Carboplatinum, taxotere and 5-FU

• 4/14 admitted to onc unit

– Dehydration, diarrhea and stomatitis/esophagitis

– WBC 8.8

– HCT 34.6

– Crt 1.7

• Stopped 5-FU 8 hrs early

– Time frame in general early for SE

NCCN Treatment Guidelines Combination Chemotherapies most common

Xeloda or 5-FU paired with Cisplatin Irinotecan Oxaliplatin Carboplatin Pacilataxel Docetaxel

Locally advanced or metastatic setting Trastuzamab and Lapitinib

2 drug regimens most common with Radiation 3 drug regimens most common when Radiation is not

indicated

Ongoing trials to find the best chemo and radiation combo Trials ongoing with radiosensitizers

NCCN Treatment Guidelines Surgery

Esophago-gastrectomy

Less invasive approaches Thoracoscopy with limited laparotomy or laparoscopy & possible cervical incision

More invasive approaches

Thoracotomy with laparotomy & possible cervical incision

NCCN Treatment Guidelines Tumor can be unresectable – due to location

Close to cricopharyngeaus – cervical area

Extensive EGJ involved

Bulky tumor that involves surrounding organs

Bulky lymphadenopthy

Distant mets

Nursing Management

Post Surgical care

Pneumonia Obstruction or paralytic ileus Bleeding Anastomosis Leakage Blood clots Infection Pain management Recurrent laryngeal nerve paralysis (cervical

sites)

Nursing Management

Later phase surgical issues

Slow emptying and chronic nausea/vomiting Strictures Heartburn

Patient are going to have to learn to eat different

Nutrition Consult

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Case Study • Jim is not a surgical candidate

– Why?

• 4/9 Port placed and chemo started

– Carboplatinum, taxotere and 5-FU

• 4/14 admitted to onc unit

– Dehydration, diarrhea and stomatitis/esophagitis

– WBC 8.8

– HCT 34.6

– Crt 1.7

• Stopped 5-FU 8 hrs early

– Time frame in general early for SE

Case Study

• 4/17 Labs

– WBC 2.2

– HCT 25.1

• Treatment

– 2 units PRBCs

– GCSF

• Next treatment dosed reduced

Palliative Therapy

• Esophageal Dilatation

• Esophageal Stents

• PEG or PEJ placement

• Photodynamic Therapy

• Laser Endoscopy

Treatment

Photodynamic Therapy Used on superficial and mucosal lesions Procedure Given photosensitizing agent

Wait a few days Via endoscopy

Special laser is pointed at cancer cells causing cell death

Little harm to normal cells Patients need to stay inside for 4- 6 weeks

Case Study

• 5/22 CT showed

– Mild improvement in obstructing mass

• Dysphagia improved – Reg diet

– Creatinine climbing 2.7

• No more GCSF

• Stopped chemo except 5-FU

• 6/1 palliative radiation started

– Total 25 treatments

Case Study • 6/9 admitted

– increased confusion, dehydration, weakness

– Mucositis/dysphagia

– Currently on 5-FU CADD pump

– Labs

• Crt 2.06

• K 3.1

• BS 388

– Finished 5-FU took a few days off Radiation TX

• 7/8 last dose of 5-FU

• 7/26 finished radiation

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Case Study

• 8/4 CT – T12 compression fx

– New bulky distal esophageal adenopathy

• 8/9 started rad tx to new area

• 8/20 admitted LBP compression L-5 and constipation – IV narcotics for pain control

– Kyphoplasty – pain not improved after

– Relistor relieved constipation

Summary – Esophageal cancer

• Overall 5 yrs survival is 11 to 18%

• Males much higher risk than women

• Tobacco significant risk in SCC

• GERD significant risk in Adenocarcinoma

• Healthy weight and active lifestyle best defense

• Adenocarcinoma increasing in white men

• SCC decreasing in US but still significant problem worldwide

Colorectal Cancer

Colon Anatomy •Primary Function is water and mineral absorption and stool formation.

•70% of tumor occurrences are in the colon and 30% are in the rectum.

•Colon is approx. 5 to 6 ft long

•Rectum is 10 to 12 inches long

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Normal to Adenoma to Carcinoma Human colon carcinogenesis

progresses by the dysplasia/adenoma to carcinoma pathway

•How long do you think this pathway takes?

Genetic Model of Colon Cancer

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p53

Late Adenoma

Optimum phase for early detection

Many decades

APC

K-ras Mutation

Courtesy of Barry M. Berger. MD, FCAP EXACT Sciences

Late Cancer

Early Cancer

Adenoma Norma l Epithelium

Dwell Time: 2-5 years 2-5 years

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1 in 19 men and 1 in 20 women lifetime risk

143, 460 new cases - 2012 US

51,690 death – 2012 US

3rd leading cause of cancer death men and women

World-wide incidence similar in developed countries

African Americans have 20% higher incidence, 45% higher mortality

Colon cancer has decreased 15 years due to screening

1 million survivors of colorectal cancer in the US

Incidence of Colorectal Cancer

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World-wide Incidence 2008

Risk Factors Age over 50

Obesity - especially abdominal obesity

High fat and red meat

Type II Diabetes

Smoking

Inflammatory Bowel Disease: Crohns, Ulcerative colitis

Previous cancerous polyps

Family history – 20% of all CRC

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Risks Factors

• Familial Adenomatous Polyposis (FAP)

– 1% of CRC

– Adenomatous polyposis coli (APC) gene mutation

– Hundreds of polyps by age 39

– Not necessarily just located in colon and rectum

– 100% lifetime risk of CRC

– Autosomal dominant

Risks Factors

Hereditary Nonpolyposis Colorectal Cancer (HNPCC)

• 3-5% of CRC

• Also known as Lynch Syndrome

• Mismatch repair gene mutation

• Average age of onset is 44

• 70-80% lifetime risk of CRC

• Women have very high risk of endometrial cancer

• Increased risk of other cancers

Presenting Symptoms - Generalized

Persistent abdominal discomfort

Changes in bowel habits (over several weeks)

Rectal bleeding/Blood in the stool

A feeling that your bowel doesn't empty completely

Unexplained weight loss

Fatigue

Anemia

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Presenting Symptoms – Location

Ascending Large bulky tumor

Palpable mass uncommon

Dull pain

Tarry dark stool Late Symptoms:

Transverse Palpable mass

Occult blood in stool

Obstruction

Descending

Maroon colored in stool

Incomplete stool evacuation

Obstruction

Tenesmus

Sigmoid Constipation

Pencil-like stool

Tenesmus

Presenting Symptoms - Rectal

Mucous discharge/diarrhea

Bright red rectal bleeding (most common)

Tenesmus – spasmodic contraction

Sense of incomplete evacuation

Late Symptoms:

Feeling of rectal fullness

Constant ache

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Screening

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American Cancer Society-Screening Guidelines

Screening should begin at the age of 45 to 50 If there is no previous history of polyps or cancer

Tests that find polyps and cancer Flexible sigmoidoscopy every 5 years*, or Colonoscopy every 10 years, or Double-contrast barium enema every 5 years*, or CT colonography (virtual colonoscopy) every 5 years*

Tests that primarily find cancer Yearly fecal occult blood test (gFOBT)**, or Yearly fecal immunochemical test (FIT) every year**, or Stool DNA test (sDNA), interval uncertain** * If the test is positive, a colonoscopy should be done. ** The multiple stool take-home test should be used. One test done by the doctor in the office

is not adequate for testing. A colonoscopy should be done if the test is positive.

Colon Polyps Colon Cancers

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Diagnostic & Lab Procedures

• Barium Enema

• CAT Scan/PET Scan

• Colonoscopy, Sigmoidoscopy, Protoscopy

• MRI

• Hematocrit

• Liver Function Tests

• Carcinoembryonic Antigen (CEA) – Monitor for response to therapy and recurrence – not presence

of cancer

Case Study Jane 33 weeks of pregnancy

CT showed large obstructing mass in rectum and liver mets.

Flex sig showed innumerable polyps.

She was to have a C-Section at 36 weeks

contractions at 35 weeks

C-section = healthy boy

Pathology from flex sig

Familial Adenomatous Polyposis (FAP)

She has 10 other children at home.

What are their risk of getting FAP?

50/50

Case Study

CEA (Reference Range: 0-3 NG/ML)

Jan. 23 Result: 2126.94

Feb. 25 Result: 4176.6

• After delivery sent home

• Return to hospital 1 week later in terrible pain

• After about a week had to have a debulking surgery – Diverting ileostoy

– TPN

– PCA, frequent large boluses and pain consult

• DC home about 2 weeks later

Metastatic Patterns Local extension through penetration of layers of bowel

Invasion of submucosal layer: direct access to vascular and

lymphatic system

Distant metastasis most frequent in liver, then the lungs Less frequent in brain, bone and adrenal glands

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Staging for Colon Cancer TNM – Staging

System

Tumor Nodes Metastasis 5 yr Survival

Stage 0 - Polyp Tis N0 M0

Stage I Tumor involves the inner lining of the intestine.

T1

T2

N0

N0

M0

M0 93%

Stage IIA Tumor invades muscle wall of the intestine but no LN.

T3 N0 M0 85%

Stage IIB T4 N0 M0 72%

Stage IIIA Lymph nodes are involved.

Any T N1 M0 83%

Stage IIIB Any T N2 M0 64%

Stage IIIC Any T N3 M0 44%

Stage IV Tumor spread to other organs.

Any T Any N M1

8%

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NCCN Treatment Guidelines

Recommendations for treatment by stage

Surgery

Primary treatment 75% of colorectal cancers goal being cure!

Chemotherapy

Monoclonal antibodies/Targeted Agents

Radiation – Rectal cancer mostly

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Treatment: Chemotherapy

Used in combination with surgery in colon cancer

Can be adjuvant or neoadjuvant Fluorouracil (5-FU)/Xeloda and Leucovorin remains mainstay Other agents:

Irinotecan (Camptosar) oxaliplatin (Eloxatin), Cisplatin

Targeted therapy

Avastin – k-ras mutation Erbitux Vectibix

Treatment- Radiation

• Used in combination with chemo in rectal cancer

• Endocavitary radiation

• Early rectal cancers in low-rectal and mid-rectal regions

• Early anal cancers

• External Beam radiation

• Can be before or after surgery in rectal cancer

• Limited use in colon cancer

• Not used in metastatic setting

• Palliative – symptom management

Treatment: Surgery Colon

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Right Hemicolectomy Left Hemicolectomy

•Laproscopic-assited colectomy – early stage colon cancer

•Hemicolectomy - sometimes many need temporary colostomy -rarely are

the permanent

•Debulking – pallative/symptom management – often ends up with

colostomy

Treatment: Surgery Rectum

Early stage surgeries

Transanal endoscopic microsurgery

Local Transanal Resection

Surgical procedure determined by location

Lower Anterior Resection – lesion in upper third of the rectum

temporary ileostomy may be neccessary

Treatment: Surgery Rectum Colo-anal Anastomosis – lesion in the middle and lower

third of the rectum

J-pouch and temporary ileostomy

Abdominoperineal (AP) Resection – lesion in the middle and lower third of the rectum, large and bulky

Permanent colostomy

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Nursing Management – Post Op Post Surgical care

Pneumonia

Obstruction or paralytic ileus

Bleeding

Anastomosis Leakage

Stoma complications

TPN

Discharge teaching

Ostomy Care

Self image

New and Exciting Treatments

Immunotherapy Using patients T-cells to attack antigens on the surface

of the colorectal cancer cells

Her-2/neu expression in GI

Malignancies

Vit D is being studied in recurrent

disease

An Aspirin a day may decrease risk of developing

recurrent colorectal cancer

Case study

• Jane started chemo 4 weeks after surgery – 5Fu. Leucovorin and oxaliplatin

• Tolerated treatment for many months

• CEA started to rise in November – Added Avastin

• Early on too much bleeding worry

• April following year tumor began to progress – Passed way in August

Summary – Colon cancer

3rd leading cause of cancer death

Most significant risk age & smoking!

Early detection SO IMPORTANT!

Get your colonoscopy

Stage is most significant prognostic indicator

Surgery is primary treatment

Cure is the goal!

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Pancreatic Cancer Anatomy of Pancreas

Pear shaped dual-function gland

6 in long/about 15 cm

Located between stomach and spine

3 Parts

• Head - 78%

• Body – 11%

• Tail – 11%

• Tumor more resectable in the head

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Function of the Pancreas

Endocrine Function

Islets of Langerhans –

produce insulin and glucagon

Neuroendocrine tumors originate here

1% of pancreatic cancers

Exocrine Function Comprised of ducts and acini

Enzymes help in digestion

95% pancreas

95% are adenocarcinomas

Incidence of Pancreatic Cancer

10th most common cancer

4th leading cause of cancer deaths

43, 920 new cases – 2012 US

37,330 deaths – 2012 US

Lifetime risk 1 in 72

Higher incidence in African Americans

• At time of diagnosis > 50% have distant mets

Incidence the same worldwide – developed countries

World-wide incidence Risk Factors

Age – 55 and greater

Smoking – 2 to 3x greater risk Obesity Type 2 diabetes

Cirrhosis of the Liver Chronic pancreatitis – often related to smoking Helicobacter pylori (H. pylori) infection Genetic Syndromes 10% of pancreatic cancers

Presenting Signs & Symptoms

• Abdominal and back pain

• Dull and constant

• Radiates to mid or upper back

• Worse while supine

• Weight Loss and Poor Appetite

• Blockage of digestive enzymes

• Pale, bulky, greasy stool that may float

• Nausea and vomiting

Presenting Signs & Symptoms

Jaundice – usually painless

DVT/PE – paraneoplastic syndrome

Fatigue

Depression

Ascites

♦ Once there are signs and symptoms the disease is already advanced!!!

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Diagnostic Procedures • CT

• ERCP -No mass on CT

– Stent obstruction

– biopsies

• Endoscopic Ultrasound (EUS)

• MRCP- If ERCP can’t be done

• Total Bilirubin

• CA 19-9 – not pancreas specific

• Liver Enzymes

• PET scan

• Laparotomy

Case Study • Jill healthy 60 yr old was admitted Nov. 2011 with painless

jaundice

• HCT 24.2

• Total Bilirubin 8.8 (0.1-1.5)

• Alkaline Phosphate 444 (20-140)

• CA 19-9 = 125, 328

• EGD -showed bleeding duodenal mass

ERCP not possible D/T mass

• CT – mass at head of pancreas obstructing of biliary system and mets to the liver

• IR – biopsy done with biliary stent placement

Metastatic Pattern

• Local spread/invasion to surrounding tissue and organ

• Small bowel, CBD, Stomach

• Most common distant metastatic sites

• Liver

• Lungs

• Peritoneum/abdominal cavity

Staging/TNM Classification TNM Tumor Nodes Metastasi

s

5 YR Survival

Stage 0 Tis N0 M0

Stage IA T1 N0 M0 37%

Stage IB T2 N0 M0 21%

Stage IIA T3 N0 M0 12%

Stage IIB T1 N1 M0 6%

T2 N1 M0

T3 N1 M0

Stage III T4 Any N M0 2%

Stage IV Any T Any N M1 1%

Staging •T1 is a tumor < 2cm

•T2 is a tumor > 2cm

•T3 tumor beyond pancreas, major arteries or veins

not involved

•T4 tumor involves major arteries and veins

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NCCN Treatment Guidelines Chemotherapy – usually at all stages

• Gemcitabine and 5FU/Xeloda– Gold standard • proven to be chemo-resistant

Others you may see Xeloda, cisplatin, irinotecan,CPT-11, Taxol, docetaxol,

oxaliplatin

Targeted Therapy

• Erlotinib

Radiation – limited use

• After surgery to help prevent recurrence

• Tumor too large for surgery

Intra-operative Radiation

Clinical trials

Surgery – Whipple Procedure (Pancreaticoduodenectomy)

– Cancer much be contained with in the pancreas – Only potential cure and only 1 and 10 case

• A series of three anastomoses are created • Gastrojejunostomy tube

• 5 year survival even with surgery is 20%

Surgery

• Gastrojejunostomy

– Bypass tumor and attach stomach

to jejunum

– Second anastomoses done

from biliary systemt to if possible

• A palliative procedure for symptom management

Nursing Management Post operative care

Pneumonia

Bleeding

Infection

Anastomotic leaking

Blood sugar and electrolyte imbalances

TPN

Ileus

Dumping Syndrome

• Pain control

• Insulin Dependence – surgically induced

Nursing Management • Malnourishment/Malabsorption

• Anorexia

• Nausea

• Pancreatic insufficiency

• Blockage

• Interventions

• Pancreatic enzyme tablets

• Nutritional consult

• Feeding tube

Palliation treatment

• Biliary obstruction – in IR or by ERCP

• Permanent biliary stent

• Percutaneous biliary

stent with drain

• Gastric outlet obstruction

• Enteral stent

• PEG/PEJ tube

• Gastrojejunostomy

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Case Study • Jill was admitted in January for N/V and

weakness • Current Treatment

• Gemcitabine and Xeloda

• CA 19-9 = 513,626 (125, 328)

• Received bowel rest and IV hydration

• After several day N/V started again Upper GI series showed gastric outlet obstruction

Laprascopic Gastrojejunostomy with Moss tube placement and cholecystectomy

Summary – Pancreatic cancer

• Overall 5 yr survival is 3%

• Smoking increases risk 3 to 4 fold

• One of the most lethal cancers – in US

• Median survival is 9-12 months

After resection 15-19 months

• Treatment for majority pain and symptom management

• Pancreatic cancer has proven to be fairly chemo resistant

Chemotherapy Side Effects Side effect Management Drug

Mucositis Good Oral Care Magic Mouthwash

5 –Fu

Diarrhea Anti-diarrheal Hydration

Irinetecan 5-FU

Hand Foot Syndrome Monitor Patient education

5-FU/Xeloda Targeted therapies

Acne like rash Monitor Creams/antibotics

Erlotinib Oxaliplatin

Thrombocytopenia Patient Education on risk and signs and symptoms

Gemcitabine

Neurotoxicity (tingling/numbness)

Monitor Patient education

Oxaliplatin

Cold Sensitivity No cold food Scarf in cold weather

Oxaliplatin

Patient Education -Chemotherapy

• Nausea & Vomiting

• Antiemetic, keeping hydrated and when to call

• Myelosuppression

• Growth factors, blood transfusion, hand hygiene

• Fatigue

– > than 99% of patients complaining of fatigue

• Encourage mild exercise and energy conservation

• Decreased libido

Patient Education - Radiation

Inflammation of bowel or bladder

Blood in stool or urine

Ulceration of GI mucosa – pain

Necrosis of GI tract

Skin irritation/burns

Changes in sexual activity

Please refer to your handouts for nursing and patients resources.

Thankyou!

Q & A