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Disease prevention, early detection and effective management.

22.5 Gastrointestinal Malignancies

Table of Contents

22.5.1 Esophageal Cancer

Esophageal cancer is the 4th most common cause of cancer death in developing countries and is more common in men. Histologically there are two types; SCC and adenocarcinoma. Tobacco and alcohol abuse are major risk factors for SCC whereas obesity, gastroesophageal reflux disease (GERD) and Barrett’s esophagus are the major risk factors for adenocarcinoma.

Diagnostic Criteria

  • Difficult in swallowing (dysphagia) is the commonest symptom which is associated with weight loss and poor performance status

Investigation

  • FBC, LFTs, urea, creatinine
  • Barium swallow and meal
  • Chest and Abdominal CT scan
  • Abdominal USS
  • Rigid oesophagoscopy or oesophagoduodenoscopy (OGD) and biopsy for histology

Staging: TNM

Management: Surgery and radiotherapy

Surgery is a major component of treatment for resectable disease. Surgery and or radiotherapy may be curative in early diseases. However, most patients present in late stages, hence the goal of treatment is to prolong survival and relieve symptoms. Radiation (alone or in combination with chemotherapy) is given as a definitive, preoperative or postoperative therapy.

Chemotherapy

There are several chemotherapy drug combinations given as neo-adjuvant, adjuvant or palliative, these include:

S: 5–FU IV 1000 mg/m2day 1–day 5 plus cisplatin IV 75 mg/m2 day1 given every 3 weeks up to 6 cycles

OR

S: Paclitaxel IV 175 mg/mDay 1 plus cisplatin 75 mg/m2 Day 1 given every 3 weeks, 6 cycles

OR

S: Paclitaxel IV 175mg/m2 day 1plus IV carboplatin AUC 5 on day 1 every 3 weeks, 6 cycles

OR

S: Docetaxel IV 75mg/m2 day 1 plus IV cisplatin 75mg/m2 day 1 every 3 weeks, 6 cycles

OR

S: Capecitabine 1000mg/m2 (PO) 12 hourly on day 1–14, cycled every 3 weeks, 6 cycles or until disease progression or intolerable toxicity

Note:

● All patients should be referred to cancer specialized centers for proper management.
● Stenting, gastrostomy and parenteral nutrition are employed to provide feeding when there is total dysphagia.

22.5.2 Gastric Cancer

Gastric cancer is often diagnosed at an advanced stage. Among the risk factors include age, gender, genetic factors, smoking, smoke or salt preserved food, diet less of fruits and vegetables, infection with H.Pylori and Epstein Barr Virus. About 90–95% of the tumors are adenocarcinoma.

Diagnostic Criteria:

  • Epigastric pain worsened by food intake, early satiety
  • Distal tumours may present with obstructive symptoms
  • Occult of manifest bleeding may be a feature
  • Other symptoms include epigastric mass, pallor, weight loss, supraclavicular nodes, hepatomegaly, periumbilical nodes

Investigations:

  • FBC, LFTs, stool for occult blood, carcinoembryonic antigen
  • CXR, Ba meal (double contrast), abdominal USS
  • Abdominal and pelvic CT scan
  • Endoscopy and biopsy for histology

Staging: TNM

Management:

Surgery is the primary treatment for early stage gastric cancer. Total or partial gastrectomy is performed together with lymph node dissection. Bypass surgery is done to relieve obstructive symptoms.

Pharmacological Treatment

There are several chemotherapy regimens for locally advanced and metastatic gastric adenocarcinoma. Few of them include

S: Paclitaxel 175mg/mIV plus carboplatin AUC 5 IV on day 1, cycled every 3 weeks for 6 cycles

OR

S: Docetaxel IV 60mg/m2 day 1 +IV cisplatin 60mg/m2 day1 + 5–FU 750mg/m2 IV continuous infusion over 24 hours on day1–4, cycled every 3 weeks for 6 cycles

Note:
Radiotherapy with IMRT technic may be given as adjuvant to surgery otherwise is used in palliative setting to control bleeding and pain
Gastric lymphoma are primarily managed with chemotherapy.
Patients with CD 117 positive gastro intestinal stromal tumor respond well to imatinib.

22.5.3 Hepatocellular Carcinoma

Associated with chronic Hepatitis B infection

Diagnostic criteria

  • An arterial bruit and ascites may be present
  • Right upper abdominal swelling and pain often associated with weight loss, fever, jaundice

Investigation

  • FBC, LFTs, biochemistry, serum alpha feto protein, HBsAg, HBcore antibody,partial thromboplastin time (PTT)
  • CXR, Abdominal and pelvic USS or CT Scan
  • Biopsy or FNAC of the liver

Staging: TNM

Management

Lobectomy where feasible but in the abscess of regular health check-up almost all patients present with advanced disease hence palliative therapy.

Pharmacological Treatment

Single agent doxorubicin is used for palliation

S: Doxorubicin IV 60 mg/mDay1 given every 3 weeks for 4–6 cycles

Prevention: Vaccination for Hepatitis B

22.5.4 Colorectal Cancer

Risk factors include: inherited genetic syndromes, diet high in red and processed meat, smoking and alcohol abuse, having inflammatory bowel disease, type ll diabetes and obesity. Histology; commonest is adenocarcinoma – 95%.

Diagnostic Criteria:

  • Change in bowel habit eg constipation or diarrhea, sense of incomplete bowel emptying.
  • Rectal bleeding or blood in stool.
  • Abdominal mass with or without obstructive symptoms
  • Unexplained weight loss and other symptoms of advanced disease.

Investigations:

  • FBC, ESR, LFTs,CEA, Stool for occult blood
  • CXR, Barium enema (double contrast), abdominal and pelvic USS.
  • Digital rectal examination
  • EUA and biopsy
  • Colonoscopy
  • Biopsy at colonoscopy or laparatomy
  • Abdominal and pelvic CT scan

Staging: TNM

Management

Surgery is the primary treatment for early disease. Hemicolectomy with lymphnode dissection is commonly performed in colon cancer. Give preoperative chemotherapy for locally advanced disease to shrink the tumor. Radiotherapy plays a role in rectal tumor as neo–adjuvant, adjuvant or palliative.

Pharmacological Management:

Management of locally advanced and metastatic colorectal cancer involves various active chemotherapy drugs, either in combination or as single agents: 5–FU, leucovorin, capecitabine, oxaliplatine, irinotectecan and bevacizumab are available for various combination regimens and schedules.

Neo-adjuvant chemo radiotherapy in rectal tumors

S: 5–FU IV 350 mg/m2 over 20 min + Leucovorin IV 20 mg/m2 Day1–Day 5 given on 1st and 5th weeks of RT, concurrent with RT: 45 Gy/25#/5weeks followed by surgery in 4–10 weeks.

3–10 weeks after surgery continue with chemo as below:

S: 5–FU IV 350 mg/mover 20 min Day1–Day5 + Leucovorin IV 20 mg/m2 Day1– Day5 every 3 weeks for 4 cycles

Adjuvant chemo Radiotherapy

  • 3–10 weeks after surgery
    Bolus IV 5–FU 500 mg/m2 day1–5 & day 29–33, concurrent with RT:45 Gy/25#/5 weeks.
  • Four weeks after completion of chemo radiation; continue with chemo: IV 5–FU 450 mg/m2 bolus D1–D5, Every 4 weeks for 2 cycles

Note: colorectal cancers are usually asymptomatic until advanced stage hence regular screening with annual digital rectal examination, stool for occult blood + colonoscopy and is recommended starting at 50 years of age.

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