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Less Common Cancers Series: Upper GI Cancers

MR KRISHNA EPARI

Introduction

Mr Krishna Epari Upper GI and HPB Surgeon

Fiona Stanley Hospital SJOG Murdoch - www.uppergiwest.com.au

ANZGOSA Board Member Lead Clinician WACPCN Upper GI Tumour

Collaborative

Cancer incidence and mortality in Western Australia, 2014

http://www.health.wa.gov.au/wacr/statistics/stats_full.cfm

Cancer incidence and mortality in Western Australia, 2014

http://www.health.wa.gov.au/wacr/statistics/stats_full.cfm

Current Status – Upper GI Cancer Surgery

8th June 2016

Current Status – Upper GI Cancer Surgery

FSH* SCGH* RPH

Oesophagus ✔ ️ ✔ ️

Stomach ✔ ️ ✔ ️

Pancreas ✔ ️ ✔ ️

Liver ✔ ️ ✔ ️ ✔ ️

* Comprehensive Cancer Centres

Optimal Care Pathways

https://www.cancer.org.au/ocp

Optimal Care Pathways

https://www.cancer.org.au/ocp

Resources

https://www.cancerwa.asn.au

Patient Resources

https://www.cancerwa.asn.au/resources/publications/patients/

Pancreatic Cancer

Pancreatic Ductal Adenocarcinoma 4th highest cause of cancer deaths in WA 6% overall 5 year survival 80% metastatic/inoperable at presentation 20% are surgically resectable 20-25% 5 year survival post resection

Histopathology – Pancreatic Tumours

Primary Pancreatic Ductal Adenocarcinoma Cholangiocarcinoma Ampullary Adenocarcinomas Duodenal Adenocarcinomas Pancreatic Neuroendocrine Tumours (NETs) Pancreatic Cystic Tumours Intraductal Papillary Mucinous Neoplasms (IPMN) Other rare tumours

Secondary Renal Cell Carcinoma

Risk Factors

Smoking Age Dietary factors Environmental factors Alcohol Chronic Pancreatitis Genetic factors IPMN (Main duct > mixed > side branch type)

Familial Syndromes

Breast Cancer (BRCA2) Peutz-Jeghers Syndrome Familial Atypical Mole Melanoma (FAMMM) Hereditary Non-Polyposis Colorectal Cancer (HNPCC) Familial Adenomatous Polyposis (FAP) Hereditary Pancreatitis

These only account for a small percentage of cases. Most pancreatic cancers are sporadic cases.

Diagnosis - Symptoms

High index of suspicion

OBSTRUCTIVE JAUNDICE Unexplained abdominal pain Loss of Appetite Loss of Weight New onset diabetes Pancreatitis

Diagnosis – Primary Investigations

Blood Tests U&E, FBE, LFTs, Coags, Amylase, Lipase CA19-9, CEA (Tumour Markers)

Imaging Abdominal Ultrasound Triple Phase CT scan*

Refer to Specialist

Referral – Suspected Upper GI/HPB Cancers

Central Referral Service

Upper GI Cancer Nurse Specialist Briony McBride (Full Time @ FSH) Mobile 0434 679 679 Email briony.mcbride@health.wa.gov.au

Private Rooms

Pancreatic Surgeon

2 years post fellowship subspecialty training in Upper GI/HPB surgery (ANZHPBA)

Roles Confirm diagnosis Staging the tumour Assess fitness for surgery Present cases to Multidisciplinary Team Perform Pancreatic surgery Palliate biliary & duodenal obstruction

Pancreatic Surgery

High risk, complex, low volume procedures Difficult to manage complications

Pancreatic leak/fistula Sepsis/Collections Haemorrhage Delayed gastric emptying

~3% mortality >50% morbidity

Pancreatic Surgery Centres

Centralisation Better outcomes with higher volume surgeons and

higher volume institutions Availability of resources required for peri-operative

management and complications

WA Health has mandated that all Pancreatic Surgery must now be performed at the 2 metro comprehensive cancer centres (FSH, SCGH)

Assessment

Fitness for Surgery/Treatment Cardiac Disease Respiratory Disease Renal Disease

Tips

Cease Clopidogrel Cease Smoking Nutrition

Staging Investigations

US CT MRI/MRCP PET ERCP/PTC Endoscopic Ultrasound Laparoscopy / Laparoscopic Ultrasound

Pancreatic Surgery

Surgical candidates Fit for surgery No metastatic disease No vascular invasion*

Cystic, neuroendocrine, ampullary, duodenal

tumours have a better prognosis compared with adenocarcinoma

Pancreatic Surgery

Whipple’s Procedure (Pancreatico-duodenectomy)

Distal Pancreatectomy / Splenectomy Total Pancreatectomy Enucleation

Pancreatic Surgery

Whipples Surgery takes 6-8 hours Average LOS 10-14 days 6-12 months to recover QOL Pancreatic Exocrine Insufficiency

Very common Pancreatic Enzyme Supplementation (‘Creon’) Nutritional Support

Diabetes (~10%)

Pancreatic Surgery - Whats New?

Borderline resectable cases Extended resection/vascular reconstruction

Better Chemotherapy regimens Neoadjuvant therapies Minimally invasive surgery

Laparoscopic assisted Whipples

Enhanced recovery after surgery (ERAS)

Enhanced Recovery After Surgery

Palliative Treatment

Avoid resection with palliative intent Palliative Chemotherapy &/or Radiotherapy Median Survival usually > 12 months Palliation of Obstruction

ERCP / PTC / Biliary Stents Endoscopy / Duodenal Stents Surgical Bypass

Laparoscopic Open

Biliary Stents

Incidental Pancreatic cyst

Benign Pseudocyst Serous Cystadenoma

Malignant Potential Mucinous Cystadenoma Intraductal Papillary

Mucinous Neoplasm (IPMN)

Investigations Tumour Marker

CA 19-9 Fine Cut Triple Phase CT

Pancreas MRI/MRCP Endoscopic Ultrasound

+/- FNA/Biopsy

Incidental Pancreatic cyst

Must consider risk of pancreatic surgery versus risk of malignancy

Low risk lesion – Observation with serial imaging and tumour markers (CA 19-9)

High risk lesion – Consider surgical resection

Various International Guidelines based on low levels of evidence

Oesophageal Cancer

Western Countries Incidence 5-10/100,1000 Male>Females Increasing age Mostly Adenocarcinoma Mostly lower third / GOJ

Asian countries More common Mostly Squamous Cell Carcinomas

Oesophageal Cancer

Presentation Dysphagia Reflux Weight loss

Risk factors Smoking, alcohol Barrett’s Oesophagus (Reflux Oesophagitis, Obesity) Achalasia Caustic/Corrosive injury

Barrett’s Oesophagus

Barretts Oesophagus

Journal of Gastroenterology and Hepatology 30 (2015) 804–820

Oesophageal Cancer

Curative Treatment options Surgery (Oesophagectomy) Endoscopic mucosal resection (EMR)

Barretts/HGD (Tis) Early tumours confined to mucosal layer (T1m)

Chemoradiotherapy Not fit for surgery Proximal tumours SCC > Adeno

HALO Ablation

Oesophagectomy

Minimally Invasive Oesophagectomy

Oesophageal Cancer

Neoadjuvant therapy (Improves survival) Pre-operative chemotherapy Pre-operative chemoradiotherapy

Outcomes Most patients Stage 3 (T3N1) 20-25% 5 year survival

Oesophageal Cancer

Palliative therapy Chemotherapy (Systemic disease) Chemoradiotherapy (Locally advanced disease) Endoscopic Stent Supportive care

Gastric Cancer

2nd Commonest cause of cancer deaths worldwide

High incidence in Eastern countries (Japan, China), South America

Western countries Less common Shift towards more proximal tumours

Gastric Cancer

Presentation Epigastric Pain Dyspepsia Nausea, Vomiting Bleeding Early satiety

Risk factors Smoking, alcohol Dietary (high salt, smoked foods) Helicobacter Pylori

Gastric Cancer

Pathology Adenocarcinoma

Intestinal type Diffuse type (Linitus plastica)

Carcinoid (Neuroendocrine tumour) Lymphoma Gastrointestinal Stromal Tumour (GIST)

Gastric Cancer

Curative Treatment options Surgery (Gastrectomy)

Total or Subtotal Radical lymphadenectomy (D2) Reconstruction

Endoscopic mucosal resection (EMR)

Early tumours confined to mucosal layer (T1m)

Gastrectomy Reconstruction

Bilroth II Roux-en-Y

Gastric Cancer

Post-Gastrectomy problems B12 and Iron deficiency Diarrhoea Dumping

Early Late

Bile Reflux

Gastric Cancer

Peri-operative chemotherapy MAGIC trial demonstrated survival advantage with

chemo before and after surgery 36% vs 23% 5 year survival

Post-operative chemoradiotherapy

Intergroup trial Benefit for node positive disease

Gastric Cancer

Palliative treatment Chemotherapy Chemoradiotherapy Radiotherapy Endoscopic Stent Supportive care

Liver Lesions

Benign Cyst(s) Haemangioma Focal Nodular

Hyperplasia (FNH) Hepatic Adenoma Focal fatty sparing Abscess Hydatid Cyst

Malignant Primary

Hepatocellular Carcinoma (HCC)

Cholangiocarcinoma

Secondary COLORECTAL LIVER

METASTASES Neuroendocrine Tumours Melanoma Others

Colorectal Liver Metastases

50% of colorectal cancers develop liver metastases

40% liver only site of initial progression 20% liver only site at death 10-20% resectable

20-60% 5 Year Survival

Curative Surgery Fit for Surgery Liver Tumour(s) all resectable with clear margins No Unresectable Metastatic Disease Adequate Functional Remnant Liver Volume (FRLV)

>25% Healthy Liver >40% Cirrhosis/NASH/Post Chemo

Preserve portal venous inflow, hepatic arterial inflow and hepatic venous outflow

Thank You

MR KRISHNA EPARI Upper GI / HPB Surgeon

Fremantle Hospital SJOG Murdoch / Mount www.uppergiwest.com.au