Oesophageal and Gastric Neoplasms

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Oesophageal and Gastric Neoplasms

• Eamon Mackle

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Barretts Oesophagus
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Barretts Oesophagus Dysplasia

• Specialised Columnar Epithelium
• Low Grade Dysplasia
• High Grade Dysplasia
• Cancer

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Risk of Cancer in Barretts Oesophagus

• c. 1 per annum (0.2 - 2)
• Time dependent but ? straight line
• Predominately white males
• Likely to be related to length of Barretts

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Summary of Endoscopic Management of Barretts

• Current diagnostic tools Experimental (Optical
• biopsy, OCT, Chromoscopy)
• Current endoscopic therapy of Barretts
• oesophagus is experimental
• Cancer Deep injury (PDT, Laser)
• Nodules within Barretts (EMR)
• High grade dysplasia Deep injury (PDT,
  Laser)
• Low grade dysplasia Superficial injury
  (Argon plasma coagulation or multipolar
  coagulation)

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Carcinoma Oesophagus
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Oesophageal Cancer

• Incidence is increasing
• 7th most common cancer in males
• 12th most common cancer in females
• Incidence USA Europe x4 to x10 3rd World
• High in France Italy wine producing areas

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Oesophageal Cancer

• Histology Adeno commoner in West
• Squamous commoner in 3rd World
• and far East
• Adeno rising
• Squamous steady

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Oesophageal Cancer
Site

• Lower 1/3 Adenocarcinoma
• Middle 1/3 Squamous

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Oesophageal CancerAetiology 1

• West SCC
• Smoking Pipes, Handrolled High Tar
• Alcohol
• Nutritional Factors
• Lack of fresh veg, fruit, dairy products
• Pickles
• Green tea protects against SCC

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Oesophageal CancerAetiology 2

• Increased with reflux
• Barretts oesophagus predisposes to cancer
• increases risk x40
• Reflux increases Barretts oesophagus
• Reflux Agent ? Acid, pepsin, bile, pancreatic
  secretions

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Oesophageal CancerAetiology 3

• Achalasia
• Highest in first year after diagnosis
• After first year x16 increase in risk of SCC
• No benefit in screening
• 406 males, 2220 females for one cancer

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Oesophageal CancerDiagnosis

• Contrast Studies
• not great for early Carcinoma
• Endoscopy
• Rigid No place in Diagnosis
• Flexible Method of choice

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Oesophageal CancerStaging

• Essential Modalities
• Video-endoscopy
• Abdominal ultrasound
• Chest X-ray
• Spiral CT chest and abdomen
• Endoscopic ultrasound

• Other Modalities
• Laparoscopy
• MRI
• Bronchoscopy
• Thoracoscopy

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Endoscopic USS at level of Cardia
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Oesophageal CancerWhy Operate?

• Quality of life improved
• 30 to 40 benefit from resection
• Life prolonged by 18 months
• Stage 1 disease gt80 5 year survival

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Oesophageal CancerPre-Operative Assessment

• Cardiovascular
• Pulmonary Function
• Renal Function
• Hepatic Function
• Nutritional Status

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Oesophageal CancerPre-Operative Care

• Smoking
• Physiotherapist
• Teeth
• DVT prophylaxis
• Antibiotic prophylaxis
• Cross-match Blood
• ?pre-op chemoradiotheraphy

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Oesophageal CancerPost-Operative Care

• ICU/HDU
• Extubate at end of Operation
• Adequate pain relief
• Thoracic epidural
• Early mobilisation

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Oesophageal CancerPost-operative Complications

• Respiratory lt25-50 cases
• Anastomotic leakage lt5
• Chylothorax 2-3
• Recurrent laryngeal nerve palsy lt2
• Benign anastomotic stricture
• Hospital mortality lt5

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Oesophageal CancerNon-operable

• Stent
• Laser
• Argon Diathermy
• Inject alcohol
• Squamous ?DXT
• Adeno ?Chemo

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Oesophageal CancerSurgical Procedures

• Left Thoraco-abdominal Oesophagogastrectomy
• Ivor-Lewis Oesophagogastrectomy
• Total Thoracic Oesophagectomy
• Transhiatal oesophagectomy (Orringer)

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Gastric Cancer
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Gastric CancerEpidemiology

• Asians have better prognosis vs. Westerners
• ?more distal disease
• ?more signet cell histology

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Gastric Cancer

• Increased risk
• post partial gastrectomy
• pernicious anaemia
• lower social class
• dietary
• salted fish, starches, pickled vegetables,
  meat, smoked foods, nitrates, nitrites

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Malignant gastric neoplasms
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Gastric carcinoma
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Endoscopic ultrasound confirms the depth of
invasion
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Endoscopic view reveals presence of obviously
ulcerated mass
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Carcinoma in the body of the stomach
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Resected specimen showing an ulcer
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Operations for gastric carcinoma (a)
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Operations for gastric carcinoma (b)
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Overall survival of operation for gastric cancer
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N1 and N2 Lymph nodes

• N1 nodes
• perigastric
• N2 nodes
• left gastric
• common hepatic
• coeliac axis
• splenic hilum
• splenic artery

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Level of lymph node dissection
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Management of patients after total gastrectomy
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Post Gastric Surgery

• Dumping
• Diarrhoea
• Bile reflux
• Nutrition
• B12 deficiency
• decreased Fe absorption

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Intergroup Study

• Operable Gastric Cancer
• Surgery
• followed by adjuvant chemotherapy and
  radiotherapy
• MacDonald et al NEJMed 2001345725-730

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Early Gastric Cancer

• More than 40 of gastric cancer in Japan is EGC
• EGC not confined to Japan
• Lymph node metastases 3 for mucosal and 20-25
  for submocosal cancer

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Early Gastric Cancer

• Some cases of EGC diagnosed in Japan were not
  really malignant
• Lancet 19973491725
• no invasion of lamina propria

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Natural course of EGC

• Long-term follow-up of EGC demonstrated that it
  eventually progressed to an advanced stage with
  time and eventually lead to death
• Tsukuma et al Gut 200047618

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Treatment of EGC

• Gold standard for treating EGC in Japan has been
  gastrectomy with lymph node dissection up to n2
  nodes

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Lymph node dissection EGC

• Although the clinical significance of lymph node
  dissection on survival has not been clarified, n0
  lesions do not need lymph node dissection
• Noguchi DDW 2002

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The lesions which do not have lymph node
metastases n0

• Mucosal cancer
• Histology differentiated adenocarcinoma
• Ulceration/ulcer scar absent
• Size less than 2cm
• Noguchi DDW 2002

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Non-traditional treatments for EGC

• Endoscopic mucosal resection (EMR)
• Laparoscopic endogastric mucosal resection
• Partial resection
• Laparoscopic-assisted gastrectomy
• Modified radical gastrectomy
• limiting extent of node dissection
• preserving vagus and/or pylorus

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Gastric lymphoma
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Thickened gastric folds and mass noted involving
the stomach
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Image demonstrating gastric involvement with
lymphoma
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Gastric Lymphomas

• lt5 of gastric neoplasms
• Treatment chemotherapy
• Surgery if chemotherapy fails
• 50 5 year survival

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Leiomyomas and leiomyosarcomas are usually
asymptomatic
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Large submucosal intramural mass
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Scan shows no evidence of extragastric disease
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Lesion arising from the muscularis propria
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Lesion arising from the muscularis propria
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Gastrointestinal Stromal Tumours (GIST)

• Leiomyoma vs leiomyosarcoma
• endoscopic diagnosis
• endoscopic ultrasound
• small observe
• Large or growing excision and/or gastrectomy