upper gastro-intestinal malignancies dr paddy niblock consultant clinical oncologist 13 th october...

Upper Gastro-Intestinal Malignancies

Dr Paddy Niblock Consultant Clinical Oncologist

13th October 2010

Sites

• Oesophagus

• Stomach

Oesophageal Cancer – Incidence

• UK 4000 deaths/year

• Male (2) : Female (1)

• Peak 60-80 years

• Median 72 years

• Increasing prevalence

• Geographical variation

Oesophageal Cancer - Incidence

Figure 1.1: Numbers of new cases and age-specific incidence rates by sex, cancer of the oesophagus, UK 2002

0

300

600

900

0-4

5-9

10

-14

15

-19

20

-24

25

-29

30

-34

35

-39

40

-44

45

-49

50

-54

55

-59

60

-64

65

-69

70

-74

75

-79

80

-84

85

+

Age at diagnosis

Nu

mb

er

of c

ase

s

0

35

70

105

140

Ra

te p

er

10

0,0

00

p

op

ula

tion

Male cases

Female cases

Male rates

Female rates

Oesophageal Cancer - Incidence

0 5 10 15 20 25 30

CyprusGreeceFinland

M altaSweden

CzechAustriaPoland

ItalyEstonia

Latv iaSloveniaGermanyDenmarkLithuaniaPortugal

SpainLuxembo

EUBelgiumSlovakiaNetherla

Ire landHungary

FranceUK

Rate per 100,000 population

Females

Males

Figure 1.2: Age-standardised incidence rates, oesophageal cancer, by sex, EU, 2002

Oesophageal Cancer - Aetiology

Oesophageal Cancer – Aetiology

• Smoking• Alcohol• Barrett’s• Tylosis palmaris• Chemical/Radiation exposure• Achalasia• Obesity• Diet

Oesophageal cancer - Symptoms

Alarm Symptoms: (Refer for early endoscopy)

• Dysphagia }

• Vomiting } 60-85%

• Anorexia }

• Weight loss } 60-70%

• GI blood loss } 20-40%

Oesophageal Cancer - Diagnosis

• Barium swallow

• Upper GI endoscopy + biopsy

Diagnosis - Barium Swallow

Diagnosis - Upper GI Endoscopy

Oesophageal Cancer - Pathology

Oesophageal Cancer - Classification

• Squamous carcinoma

• Adenocarcinoma– Type 1

• Intestinal metaplasia of tubular oesophagus

– Type 2• True junctional tumours of the gastric cardia

– Type 3• Subcardial tumours which infiltrate superiorly

Oesophageal Cancer - Staging Investigations

Routine

• CT• EUS

Selected

• CXR• Abdominal US• MRI• Bronchoscopy• Laparoscopy• PET

Staging – CT scan

Staging - EUS

Staging – EUS

Oesophageal Cancer - TNM StagingPrimary Tumour (T) invadesT1 l.propria/submucosaT2 m.propriaT3 adventitiaT4 adjacent structures

Regional LNs (N)N1 1/2 nearby nodesN2 3-6 nearby nodesN3 >7 nearby nodes

Metastases (M)M1 distant spread

Oesophageal Cancer – Treatment

Multidisciplinary Approach

• Surgery

• Radiotherapy

• Chemotherapy

• Stent

Oesophageal Cancer - Surgery

• A) Ivor-Lewis approach resulting in an anastomosis in the chest

• B) Three-field

oesophagectomy with anastomosis in the neck,

• C) Transhiatal approach, avoids a thoracotomy.

Surgery cont.

• Other approaches

– Endoscopic mucosal resection– Limited resection for early disease– Laparoscopic oesophagectomy

• AIM : R0 resection

However ….

• Irrespective of histology

• 5 year OS with surgery alone 5 – 20%

Radiotherapy

Radiotherapy

• High energy photon X-rays

• CT plan patient in treatment position

• Targeted to include tumour +/- nodes

• Treats microscopic disease

• Radical v palliative

Radiotherapy - Side Effects

• Fatigue

• Dysphagia / odynophagia

• Nausea

• Skin reaction

Chemotherapy

• Neoadjuvant / Peri-operative

• Concurrent with radiotherapy

• Palliative

Other Treatments

Palliative

• Brachytherapy

• Stents

• Laser / PDT

• Dilation

Oesophageal Stent

Survival

0

10

20

30

15-39 40-49 50-59 60-69 70-79 80-99

Age at diagnosis

% s

urv

ivin

g

Males Females

Figure 3.2: Five-year relative survival for patients diagnosed with oesophageal cancer in England and Wales during 1986-1990 by age at diagnosis

Gastric Cancer - Incidence

• 6th commonest cancer in men

• 7th in women

• Male (3) : Female (2)

• Declining incidence

• Geographical variation

Gastric Cancer - Aetiology

• Diet

• H. pylori

• Smoking

• F.A.P.

• Barrett’s oesophagitis

• Pernicious Anaemia

Helicobacter pylori

Gastric Cancer – Diagnosis

• UGIE

• Japanese routinely screen

Upper GI Endoscopy T1

Gastric Cancer T2N1

Linitis Plastica

Gastric Cancer - Pathology

• Adenocarcinomas 90%

• Lymphomas up to 8%

• Leiomyosarcomas 1-3%

• GISTs

Gastric Cancer – Staging

• CT

• EUS

• Laparoscopy

Gastric Cancer – Treatment

Multidisciplinary Approach

• Surgery

• Chemotherapy

• Radiotherapy

Treatment - Curative

SURGERY

Stomach• Oesophagogastrectomy• Gastrectomy• Partial gastrectomy

Nodes• Limited (UK)• Extensive (Japan)

CHEMOTHERAPY

Consider peri-operative

chemotherapy in fit

patients

Treatment - Chemotherapy

Peri-operative

• survival advantage in fit patients

Palliative

Treatment - Palliative

Radiotherapy

• Bleeding

• Painful bone metastases

Chemotherapy

Stents

Laser

Surgery

Useful Websites

www.sign.ac.uk

www.cancerbacup.org.uk