Most esophageal tumors are malignant, fewer than 1% are
benign
Slide 5
Esophagus cancer Squamous cell carcinoma Adenocarcinoma
Slide 6
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.
Slide 7
Squamous cell carcinoma The incidence of esophageal SCC varies
considerably among geographic regions. The highest rates are found
in Asia, Africa, and Iran
Slide 8
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
Slide 9
EPIDEMIOLOGY Rates for SCC have been decreasing because of
long-term reductions in tobacco use and alcohol consumption.
Slide 10
ETIOLOGIC FACTORS
Slide 11
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
Slide 12
Risk Factors CONSUMPTION OF: Tobacco, Alcohol
Slide 13
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.
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
Slide 16
Adenocarcinoma
Slide 17
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.
Slide 18
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
Slide 19
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
Slide 20
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.
Slide 21
Clinical Findings Both adenocarcinoma and SCC have similar
clinical presentations except that adenocarcinoma arises much more
commonly in the distal esophagus/GEJ.
Slide 22
Clinical Findings Dysphagia in more than 90% of patients with
esophageal cancer Nonspecific retrosternal discomfort Indigestion
Weight loss Pain Regurgitation, resp symptoms, hoarseness
Slide 23
Clinical Findings SymptomPercent Dysphagia87-95 Weight
loss42-71 Vomiting or regurgitation29-45 Pain20-46 Cough or
hoarseness7-26 Dyspnea5
Slide 24
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.
Slide 25
Clinical finding The examination findings are often normal.
Hepatomegaly may result from hepatic metastases. Lymphadenopathy in
the laterocervical or supraclavicular areas represents
metastasis.
Slide 26
Differential Diagnoses Achalasia Esophageal Stricture Gastric
Cancer
Slide 27
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
Slide 33
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.
Slide 34
Gastric neoplasms
Slide 35
Polyps are common but usually not neoplastic (hyperplastic
polyps. Hamartomas, ectopic pancreas) Adenomas occur but are
rare
Slide 36
Carcinoma of the stomach The second most common fatal
malignancy in the world Commonest in Far East (Japan) High
mortality unless disease detected early
Slide 37
Less common gastric neoplasms Lymphoma Gastrointestinal stromal
tumour (GIST) Neuroendocrine (carcinoid) tumours
Slide 38
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.
Slide 39
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.
Slide 40
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
Slide 41
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
Slide 42
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
Slide 43
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
Slide 44
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
Slide 45
Risk factors family history of stomach cancer Stomach polyps
Infection with Helicobacter pylori long-term stomach inflammation
pernicious anemia
Slide 46
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
Slide 47
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.
Slide 48
Screening Screening recommendations for specific groups of
patients
Slide 49
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)
Slide 50
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Colorectal cancer
Slide 52
CRC is the third most commonly diagnosed cancer in males and
the second in females Rates are substantially higher in males than
in females
Slide 53
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
Slide 54
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Risk factors
Slide 57
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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
Slide 59
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
Slide 60
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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).
Slide 72
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?
Slide 73
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.
Slide 74
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.
Slide 75
Screening Individuals at highest risk with familial syndromes
(HNPCC, FAP) should be screened for CRC with colonoscopy at
frequent specified intervals.