GI CANCER

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GI CANCERDr. khorramKnowledge aboutGastricCarcinoma in North of Iran, A High Prevalent Region forGastricCarcinoma: A Population-Based Telephone Survey.Mansour-Ghanaei F,Joukar F,Soati F,Mansour-Ghanaei A,Naserani SB.Totally the mean knowledge level of the respondents towardgastriccarcinoma 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 ofcancerrisk factors, symptoms and signs, methods of prevention, and importance of early diagnosis and treatment.

Esophagus cancer

Esophagus cancerMost esophageal tumors are malignant, fewer than 1% are benign

Esophagus cancerSquamous cell carcinoma

AdenocarcinomaSquamous cell carcinoma95% of esophageal cancer worldwide

Commonly 7th 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.

Squamous cell carcinomaThe incidence of esophageal SCC varies considerably among geographic regions.

The highest rates are found in Asia, Africa, and Iran

ETIOLOGIC FACTORS Squamous cell carcinomaDemographic and socioeconomic factors Smoking and alcoholDietary factors Underlying esophageal diseasePrior gastrectomy Atrophic gastritis Human papilloma virus TylosisBisphosphonates Upper aerodigestive tract cancer Risk FactorsCONSUMPTION OF:Tobacco, Alcohol

Risk Factorssmoking (5-fold) and alcohol (5-fold)abuse.

Heavy smoking and heavy drinking combine to increase the risk 25- to 100-fold.

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

Risk FactorsPREDISPOSING 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

Adenocarcinoma EPIDEMIOLOGYIncidence 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.

Risk FactorsGastroesophageal reflux diseaseSmokingAlcoholObesityIncreased esophageal acid exposureUse of drugs that decrease lower esophageal sphincter pressureCholecystectomyNitrosative stressRisk FactorsPossible 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 .

Clinical FindingsBoth adenocarcinoma and SCC have similar clinical presentations except that adenocarcinoma arises much more commonly in the distal esophagus/GEJ. Clinical FindingsSymptomPercentDysphagia87-95Weight loss42-71Vomiting or regurgitation29-45Pain20-46Cough or hoarseness7-26Dyspnea5

Clinical FindingsDysphagia 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. Clinical findingThe examination findings are often normal.

Hepatomegaly may result from hepatic metastases.

Lymphadenopathy in the laterocervical or supraclavicular areas represents metastasis.Differential DiagnosesAchalasia

Esophageal Stricture

Gastric Cancer

DIAGNOSTIC TESTINGBariumstudies may suggest the presence of esophageal cancer

It is now rarely used.

It may be useful to study the distal anatomy in obstructive tumors inaccessible by endoscopy.

screeningBarrett's esophagusPeople 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 withlow 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.

Gastric neoplasmsGastric neoplasmsPolyps are common but usually not neoplastic (hyperplastic polyps. Hamartomas, ectopic pancreas)

Adenomas occur but are rare

Carcinoma of the stomachThe second most common fatal malignancy in the world

Commonest in Far East (Japan)

High mortality unless disease detected early

Trend analysis ofgastric cancerincidence in iran and its six geographical areas during 2000-2005.Haidari M,Nikbakht MR,Pasdar Y,Najaf 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 ofgastric cancerin 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 forgastric cancer. Increase in incidence might continue in the future.CLINICAL FEATURESAbdominal painA feeling of fullness in the stomach areaDark stoolsNauseaVomitingLoss of appetiteExcessive belchingFeeling bloated after eatingIndigestionUnintentional weight lossFatigueWeaknessCLINICAL FEATURESWeight 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

Paraneoplastic manifestationsDermatologic findingsThe sudden appearance of diffuse seborrheic keratosesAcanthosis nigricans

Microangiopathic hemolytic anemia

Membranous nephropathy

Hypercoagulable states (Trousseau's syndrome)

Polyarteritis nodosaRisk factorsSome of the risk factors for stomach cancer are related to lifestyle choices, such as:

Eating a diet high in salty or smoked foodsEating a diet low in fruits and vegetablesEating foods contaminated with aflatoxin fungusSmoking

Risk factorsfamily history of stomach cancer

Stomach polyps

Infection with Helicobacter pylori

long-term stomach inflammation

pernicious anemia

DIAGNOSISBarium studiesBariumstudies can identify both malignant gastric ulcers and infiltrating lesions and some early gastric cancersfalse-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 bariumstudy may be superior to upper endoscopy is in patients with linitis plastica. ScreeningConsensus 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.ScreeningScreening recommendations for specific groups of patientsScreeningElderly patients with atrophic gastritis or pernicious anemiaPartial 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)

Colorectal cancerColorectal cancerCRC is the third most commonly diagnosed cancer in males and the second in females

Rates are substantially higher in males than in femalesColorectal cancerTrends in incidence of gastrointestinal tract cancers in Westerniran, 1993-2007.Najafi F,Mozaffari HR,Karami M,Izadi B,Tavvafzadeh R,Pasdar Y.An increase in the incidence of colorectalcancerare in line with reports from other developing countries in epidemiologic transition

Risk factors

GenderOverall age-standardized incidence rates were 65.1 per 100,000 for men and 47.6 per 100,000 for womenMale-female ratio=1.37Mortality rates were also higher in men than women25.4 versus 18.0 per 100,000

ScreeningOne 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).ScreeningClinicians 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?

ScreeningIf 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.

ScreeningScreen 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.

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