UGI Cancers

Upper GI Cancers

OesophagealJunctionalGastric

Urgent OGD Referral (within 2 weeks)Any age with dyspepsia and:Progressive DysphagiaChronic GI BleedingPersistant VomitingUnexplained Weight LossIron Deficiency AnaemiaEpigastric Mass

55yrs with persistant recent onset dyspepsia

Oesophageal Cancer

Oesophageal Anatomy25cm longMuscular tubeCricoid cartilage (C6) to gastric cardia (T10)Upper, middle & lower thirdsDiffering blood supply & lymph drainageStratified squamous epithelium

EpidemiologyAdenocarcinoma > SCC (in Western World)3M : 1FAgeGeographical variation

3% of UK Cancer8,173 new cases 2008 (13.3 per 100,000)7,606 death 2008 (12.4 per 100,000)7th leading cancer death worldwide

ACA account for 65% of oes Ca in UK.Other Ca include small cell, melanoma, carcinoidIncreased incidence in Far East, Russia & South Africa6

Risk FactorsREFLUX(Barretts x30-60 risk)ObesityCigarettes & alcoholNitrosaminesVit A & C deficiency?HPV infectionStrictures/WebsAchalasia

Barretts Oesophagus

Barretts

HistologySquamous Cell Carcinoma (SCCs)Higher lesions, frequency in West

AdenocarcinomaLower lesions, frequency in West

(Small Cell Carcinoma, Melanoma, Carcinoid)

SymptomsDysphagia/OdynophagiaChest PainHaematemesisLymphadenopathyRLN palsyDisseminated diseaseResp symptoms

SignsWeight loss / CachexiaPalorCervical LNHepatomegalyPleural effusion

DiagnosisImagingOGDContrast SwallowsHistologyOGDFNA LNOtherFBC, U&E, LFTs

StagingCT TAPPositionLN statusMetastatic diseaseEUST stageN stagePosition

PETN stageM stage

CPEX(Echo)(PFTs)

Oesophageal T StageT StageLayerTisHGDT1To submucosaT2To muscularis propriaT3To adventitia (no serosa present)T4 - a - bInto adjacent structures - that can removed - that cannot be removed

N & M StageN StageNo of Local LN InvolvedN0No involved LNN11-2 LNN23-6 LNN3>7 LN

M StageM0No MetsM1Distant Metastases

AJCC Group StagingStage 0Tis, N0, M0Stage IT1, N0, M0Stage IIAT2 or 3, N0, M0Stage IIBT1 or 2, N1, M0Stage IIIT3 , N1, M0T4, any N, M0Stage IVAny T, any N, M1

ManagementMDT

PalliationOncologicalSurgical

PalliationSymptom controlDysphagia Metal stent insertion (APC)Wgt loss SupplementsPain Analgesia / DXT

Chemotherapy (+/- radiotherapy)FitNo jaundiceCompliance

OncologicalRadical chemoradiotherapy

Neo-adjuvant chemotherapyAdjuvant chemotherapy

EndoscopicEndoscopic Mucosal Resection (EMR)High grade dysplasia or solitary T1 tumours

Radiofrequency Ablation (RFA)Used after EMR to destroy any further areas of dysplasia

SurgicalTranshiatal OesophagectomyLaparotomy & neck anastomosisBlunt dissectionEarly diseaseIvor Lewis OesophagectomyLaparotomy & right thoracotomyMore advanced diseaseMcKeown 3-Stage OesophagectomyLaparotomy, thoracotomy & neck dissectionHigher lesions

Oesophageal ConduitsGastric pull-upJejunal flapColonic transposition

Pre-sternal

Prevention & ScreeningBarretts Surveillance?beneficialTechnique

Gastric Cancer

Gastric AnatomyMuscular sacCardia, fundus, body, pylorus/antrumDiffering blood supply & LN drainageImportant for surgeryColumnar epithelium

Lesser curvature left and right gastricsFundus & upper greater curvature short gastrics (from splenic artery)Greater curvature left & right gastro-epiploics29

EpidemiologyAdenocarcinoma2M : 1FAgeGeographical variation JapanIncidence falling in UK & USA2% of all UK cancers7,610 new cases 2008 (12.4 per 100,000)5,178 deaths 2008 (10.6 per 100,000)2nd leading cause of cancer death worldwide

ACA account for 65% of oes Ca in UK.Other Ca include small cell, melanoma, carcinoidIncreased incidence in Far East, Russia & South Africa30

Risk FactorsH.PYLORIHigh salt intakePrevious gastric surgeryCigarettes & alcoholAdenomatous polypsAtrophic gastritis(Pernicious anaemia)

Menetriers disease (hypertrophic gastropathy)Blood group AFH

SymptomsEpigastric PainHaematemesis / MalaenaVomiting / Early SatietyDysphagiaAnorexiaWgt LossGastric PerforationDisseminated Disease

SignsWeight loss / CachexiaEpigastric massPalorCervical LN (Virchows node)HepatomegalyAscites

DiagnosisOGD & biopsyBarium mealLinitis PlasticaOtherFBC, U&E, LFTsFOB +ve

Malignant Gastric Ulcer

Abnormal Barium Swallow

PathologyMalignant ulcerRaised, everted edgesPolypoid tumourLinitis plasticaLeather-bottle stomachSub-mucosal infiltration

HistologyAdenocarcinoma (95%)Intestinal typeMalignant glandsDiffuse typeSingle or small groups of malignant cells

Lymphoma (5%)GISTs (2%)Neuroendocrine (3%)

Adenocarcinoma develops in glandular tissue. Lymphoma develops in lymphatic tissue of gastric wall. Carcinoid hormone-producing tissues. GISTs intestinal cells of Cajal, anywhere in GI tract41

SpreadLocalDirect invasion, up into oesophagusLymphaticLesser & greater curvature LNMediastinal to supraclavicular (Virchows)DistantPortal vein liver / lungs / skeletalTrans-coelomic peritoneal / Krukenberg tumour

Trans-Coelomic SpreadKrunkenburg syndromeSister Mary Josef nodulesMalignant ascitesBlumers Shelf

StagingCT TAPPositionLN statusMetastatic disease

Staging LaparoscopySerosal involvementFixedPeritoneal spread(Anaesthetic test)CPEX(Echo)(PFTs)

Gasric Cardia Cancer & Liver MetsInfiltrating Carcinoma

Gastric T StageT StageLayerT1To SubmucosaT2To Muscularis PropriaT3To SubserosaT4 - a - bInvades Serosa - Visceral peritoneum - Into adjacent organs

N & M StageN StageNo of Local LN InvolvedN0No involved LNN11-2 LNN23-6 LNN3>7 LN

M StageM0No Distant MetsM1Distant Metastases

AJCC Group StagingStage 0Tis, N0, M0Stage IAT1, N0, M0Stage IBT2, N0, M0T1, N1, M0Stage IIAT3, N0, M0T2, N1, M0T1, N2, M0Stage IIBT4a, N0, M0T3, N1, M0T2, N2, M0T1, N3, M0Stage IIIAT4a, N1, M0T3, N2, M0T2, N3, M0Stage IIIBT4b, N0-1, M0T4a, N2, M0T3, N3, M0Stage IIICT4b, N2-3, M0T4a, N3, M0Stage IVAny T, any N, M1

ManagementMDT

PalliationSurgical

PalliationSymptom controlWgt loss Supplements / JejunostomyPain Analgesia / DXTHaematemesis DXT / Tranexamic Acid

SurgeryObstructionHaemorrhage

Chemotherapy

OncologicalNeo-Adjuvant ChemotherapyAdjuvant Chemotherapy

SurgicalSubtotal GastrectomyDistal lesionsRemoves pylorus

Total GastrectomyProximal lesionsLinitis Plastica

D1 vs D2 lymphadenectomy

TG with Roux-en-Y Oesophagojejunostomy

STG with Roux-en-Y Gastrojejunostomy

STG with Billroth II Gastrojejunostomy

Overall 5-yr Relative Survival RatesStage IA71%Stage IB57%Stage IIA45%Stage IIB33%Stage IIIA20%Stage IIIB14%Stage IIIC9%Stage IV4%

NCI database, based on pts diagnosed and treated with surgery between 1991 & 2000

ScreeningHigh incidence countriesJapan, Venezuela, etcHigh-risk individuals

No definite UK guidelines

Junctional Tumours

Younger menIncreasing incidence

Junctional TumoursSiewertType ITrue lower oesophageal ACAType IITrue junctional tumourType IIIGastric cardia tumour

Staged as oesophageal tumoursCT, EUS, PET (Laparoscopy)Type I Transhiatal or TGType II & III TG

Summary

Oesophageal Cancer RisingGastric Cancer Decreasing

Main RF = Reflux & H.Pylori, respectively

Surgical vs Oncological vs Endoscopic Mx

Poor outcomes, anyway!