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Dr. khorram

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Esophagus cancer

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Most esophageal tumors are malignant, fewer than 1% are benign

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Esophagus cancer Squamous cell carcinoma Adenocarcinoma

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Squamous cell carcinoma 95% of esophageal cancer worldwide Commonly 7 th decade of life, 1.5-3 times more common in men Thought to occur from prolonged exposure of esophageal mucosa to noxious stimuli in persons with a genetic predisposition to the disease.

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Squamous cell carcinoma The incidence of esophageal SCC varies considerably among geographic regions. The highest rates are found in Asia, Africa, and Iran

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EPIDEMIOLOGY Incidence rates vary internationally by nearly 16- fold, with the highest rates and the lowest rates in Western and Middle Africa and Central America in both males and females. In the highest-risk area, 90 percent of cases are squamous cell carcinomas

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EPIDEMIOLOGY Rates for SCC have been decreasing because of long-term reductions in tobacco use and alcohol consumption.

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ETIOLOGIC FACTORS

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Squamous cell carcinoma Demographic and socioeconomic factors Smoking and alcohol Dietary factors Underlying esophageal disease Prior gastrectomy Atrophic gastritis Human papilloma virus Tylosis Bisphosphonates Upper aerodigestive tract cancer

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Risk Factors CONSUMPTION OF: Tobacco, Alcohol

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Risk Factors Squamous cell still persists in patients with the usual risk factors for other aerodigestive tract carcinomas, specifically smoking (5-fold) and alcohol (5-fold) abuse. Heavy smoking and heavy drinking combine to increase the risk 25- to 100-fold.

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Risk Factors UNDER-CONSUMPTION OF: Fruits, Fresh meat, Riboflavin. Beta-carotene, Vitamin C, Magnesium, Vegetables, Fresh fish, Niacin, Vitamin A, Vitamin B complex, Zinc

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Risk Factors PREDISPOSING CONDITIONS: Caustic injury, Esophageal webs, Achalasia, Esophageal diverticula OTHER EXPOSURE: Asbestos, Ionizing radiation, Exceptionally hot beverages (tea), Location: Middle East, South Africa, northern China, southern Russia, India

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Adenocarcinoma

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EPIDEMIOLOGY Incidence rates for adenocarcinoma of the esophagus have been increasing in several Western countries, in part due to increases in known risk factors such as overweight and obesity.

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Risk Factors Gastroesophageal reflux disease Smoking Alcohol Obesity Helicobacter pylori infection Increased esophageal acid exposure Use of drugs that decrease lower esophageal sphincter pressure Cholecystectomy Nitrosative stress

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Risk Factors Possible protective effect of cereal fiber and other nutrients Diets high in fiber, beta-carotene, folate, and vitamins C and B6 were protective while diets high in dietary cholesterol, animal protein and vitamin B12 were associated with an increased risk.beta-carotene

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Risk Factors Possible protective effect of NSAIDs Epidemiological data suggest that aspirin and other NSAIDs, which inhibit cyclooxygenase (COX), might protect against development of esophageal cancer, particularly in the setting of Barrett's esophagus.

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Clinical Findings Both adenocarcinoma and SCC have similar clinical presentations except that adenocarcinoma arises much more commonly in the distal esophagus/GEJ.

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Clinical Findings Dysphagia in more than 90% of patients with esophageal cancer Nonspecific retrosternal discomfort Indigestion Weight loss Pain Regurgitation, resp symptoms, hoarseness

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Clinical Findings SymptomPercent Dysphagia87-95 Weight loss42-71 Vomiting or regurgitation29-45 Pain20-46 Cough or hoarseness7-26 Dyspnea5

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Clinical Findings Dysphagia is the most common presenting symptom. Dysphagia is initially experienced for solids, but eventually it progresses to include liquids. Weight loss is the second most common symptom and occurs in more than 50% Pain can be felt in the epigastric or retrosternal area. Hoarseness caused by invasion of the recurrent laryngeal nerve is a sign of unresectability. Patients may have a persisting cough. Respiratory symptoms can be caused by aspiration of undigested food or by direct invasion of the tracheobronchial tree by the tumor.

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Clinical finding The examination findings are often normal. Hepatomegaly may result from hepatic metastases. Lymphadenopathy in the laterocervical or supraclavicular areas represents metastasis.

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Differential Diagnoses Achalasia Esophageal Stricture Gastric Cancer

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DIAGNOSTIC TESTING Barium studies may suggest the presence of esophageal cancer Barium It is now rarely used. It may be useful to study the distal anatomy in obstructive tumors inaccessible by endoscopy.

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screening

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Barrett's esophagus People with Barrett's esophagus should be treated to decrease reflux symptoms. The first follow-up endoscopy should be done one year after Barrett's is diagnosed. Endoscopy may then be done every 3 years People with low grade dysplasia generally are advised to have repeat endoscopy at 6 and 12 months, followed by annual endoscopy if the lesion does not appear to progress.

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Gastric neoplasms

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Polyps are common but usually not neoplastic (hyperplastic polyps. Hamartomas, ectopic pancreas) Adenomas occur but are rare

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Carcinoma of the stomach The second most common fatal malignancy in the world Commonest in Far East (Japan) High mortality unless disease detected early

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Less common gastric neoplasms Lymphoma Gastrointestinal stromal tumour (GIST) Neuroendocrine (carcinoid) tumours

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Trend analysis of gastric cancer incidence in iran and its six geographical areas during 2000-2005. Haidari M, Nikbakht MR, Pasdar Y, Najaf F. Haidari MNikbakht MRPasdar YNajaf F The overall incidence rate increased from 2.8 in 2000 to 9.1 per 100,000 persons per year in 2005. The average six-year incidence of gastric cancer in the central and northwestern border of Caspian Sea was 7.8 per 100,000 persons per year, while it was 0.9 per 100,000 persons per year in the border of the Persian Gulf. Generally the incidence rate in men was higher than in women. Iran is one of the high-risk areas for gastric cancer. Increase in incidence might continue in the future.

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Knowledge about Gastric Carcinoma in North of Iran, A High Prevalent Region for GastricCarcinoma: A Population-Based Telephone Survey. Mansour-Ghanaei F, Joukar F, Soati F, Mansour-Ghanaei A, Naserani SB. Mansour-Ghanaei FJoukar FSoati FMansour-Ghanaei ANaserani SB Totally the mean knowledge level of the respondents toward gastric carcinoma would be 17.13.97 from the maximum grade of 29. The age group of 45-55 y/o, bachelor degree and higher, physicians and nurses There is a general lack of awareness of cancer risk factors, symptoms and signs, methods of prevention, and importance of early diagnosis and treatment.

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CLINICAL FEATURES Abdominal pain A feeling of fullness in the stomach area Dark stools Nausea Vomiting Loss of appetite Excessive belching Feeling bloated after eating Indigestion Unintentional weight loss Fatigue Weakness

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CLINICAL FEATURES Weight loss and persistent abdominal pain are the most common symptoms at initial diagnosis Dysphagia is a common presenting symptom in patients with cancers arising in the proximal stomach or at the esophagogastric junction. They may also present with a GOO from an advanced distal tumor. pseudoachalasia syndrome Approximately 25 percent of patients have a history of gastric ulcer. All gastric ulcers should be followed to complete healing, and those that do not heal should undergo resection

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Signs of tumor extension or spread Peritoneal spread can present with an enlarged ovary (Krukenberg's tumor) or a mass in the cul-de-sac on rectal examination (Blumer's shelf). Ascites can also be the first indication of peritoneal carcinomatosis. A palpable liver mass can indicate metastases Jaundice or clinical evidence of liver failure is seen in the preterminal stages of metastatic disease

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Paraneoplastic manifestations Dermatologic findings The sudden appearance of diffuse seborrheic keratoses Acanthosis nigricans Microangiopathic hemolytic anemia Membranous nephropathy Hypercoagulable states (Trousseau's syndrome) Polyarteritis nodosa

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Risk factors Some of the risk factors for stomach cancer are related to lifestyle choices, such as: Eating a diet high in salty or smoked foods Eating a diet low in fruits and vegetables Eating foods contaminated with aflatoxin fungus Smoking

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Risk factors family history of stomach cancer Stomach polyps Infection with Helicobacter pylori long-term stomach inflammation pernicious anemia

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DIAGNOSIS Barium studies Barium studies can identify both malignant gastric ulcers and infiltrating lesions and some early gastric cancersBarium false-negative barium studies can occur in as many as 50 percent of cases. In early gastric cancer where the sensitivity of barium meals may be as low as 14 percent. Upper endoscopy is the preferred initial diagnostic test for patients in whom gastric cancer is suspected. The barium study may be superior to upper endoscopy is in patients with linitis plastica.barium

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Screening Consensus has not been achieved on screening recommendations for many conditions that predispose to gastric cancer. Optimal methods and intervals for screening and the risks and benefits of screening in these populations have not been clearly established.

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Screening Screening recommendations for specific groups of patients

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Screening Elderly patients with atrophic gastritis or pernicious anemia Partial gastrectomy Sporadic gastric adenoma Immigrant ethnic populations from countries with high rates of gastric cancer Familial adenomatous polyposis or hereditary nonpolyposis colorectal cancer (particularly if gastric cancer has occurred in the kindred)

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Colorectal cancer

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CRC is the third most commonly diagnosed cancer in males and the second in females Rates are substantially higher in males than in females

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Colorectal cancer Trends in incidence of gastrointestinal tract cancers in Western iran, 1993-2007. Najafi F, Mozaffari HR, Karami M, Izadi B, Tavvafzadeh R, Pasdar Y. Najafi FMozaffari HRKarami MIzadi BTavvafzadeh RPasdar Y A decrease in the incidence of gastric and esophageal cancers and an increase in the incidence of colorectal cancer are in line with reports from other developing countries in epidemiologic transition

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Risk factors

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Gender Overall age-standardized incidence rates were 65.1 per 100,000 for men and 47.6 per 100,000 for women Male-female ratio=1.37 Mortality rates were also higher in men than women 25.4 versus 18.0 per 100,000

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Other demographic factors Race and Ethnicity Higher rates and mortalities among blacks than whites Socioeconomic status Possible association between low SES and colorectal cancer mortality

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Screening One in four patients with colorectal cancer has a family history of colorectal cancer. 3 to 4 percent of patients with CRC have one of two genetic syndromes (HNPCC) and (FAP).

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Screening Clinicians can screen for a family history of colorectal cancer by asking a simple set of three questions: Have any blood relatives had colorectal cancer or a precancerous polyp? How many, and were these first-degree relatives (parent, sibling, or child) or second-degree relatives)? At what age were the cancers or polyps diagnosed?

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Screening If the patient is at risk for earlier onset CRC (eg, first- degree relative with onset of CRC before age 50), screening should begin earlier. If the patient is at risk for more rapid progression of disease (eg, HNPCC or FAP), screening should be performed more frequently. If the patient is at substantially increased risk (eg, HNPCC or FAP), screening should be with the best available test, colonoscopy.

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Screening Screen with colonoscopy. If a single first-degree relative was diagnosed at age 60 years or older with CRC or an advanced adenoma (1 cm, or high-grade dysplasia, or villous elements), screening with colonoscopy is recommended every 10 years beginning at age 50 If a single first-degree relative was diagnosed before 60 years with CRC or an advanced adenoma, or two or more first-degree relatives had colorectal cancer or advanced adenomas at any age, screening with colonoscopy is recommended at age 40 or 10 years before the youngest relative's diagnosis, to be repeated every five years.

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Screening Individuals at highest risk with familial syndromes (HNPCC, FAP) should be screened for CRC with colonoscopy at frequent specified intervals.

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