GI CANCER PART 1 CH
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What is a straight, collapsible tube about 25cm (10in) long that functions as a passageway through thorax?
Where does esophagus begin and end?
It begins at the base of the pharynx at the level of C6 and descends behind the trachea, passing thru the mediastinum
The esophagus penetrates the diaphragm thru an opening called the _______, and is continuous with the stomach on the abdominal side of the diaphragm.
The esophagus is close to the ____ and _____ and can be divided into various areas.
aorta and trachea
Where is the cervial esophagus located?
about 5 cm long and extends from the level of C6 to the level of T1.
Not only can the esophagus be broke up into and called the cervical esophagus and the thoracic esophagus, it can also be broken up into an
upper third, middle third, and lower third.
Esophageal cancers are least common in the _____ and most common in the _____
- upper third
- middle or lower third
The lymphatic drainage of the esophagus is unpredictable and there are a large # of widely seperated collections of lymph nodes. Drainage does not always follow a
A distance of as much as _____ of normal esophagus may be interposed between the site of gross tumor and lymphatic metastases.
What is a J-shaped pouch-like organ that lies under the diaphragm in the upper left portion of the abdominal cavity?
Describe the stomach and location
J-shapped, pouch-like organ that lies under the diaphragm in the upper left portion of the abdominal cavity
What is the stomach's function
to receive food from the esophagus, mix it with gastric juice, and initiate the digestion of proteins, carry on a limited amt of absorption and move food into the small intestine.
Where does the stomach receive food from?
Where does the food go once it leaves the stomach?
The stomach can be divided into what 4 regions
- pyloric regions
What region of the stomach is a small area near the esophageal opening?
What region of the stomach balloons above the cardiac portion, acts as a temporary storage area and sometimes becomes filled with swallowed air?
What is the main part of the stomach and is located between the fundic and pyloric regions?
What region of the stomach narrows and becomes the canal as it appoaches the junction with the small intestine
- pyloric region
- and it becomes the pyloric canal
What is at the end of the pyloric canal?
pyloric sphicter or pylorus
What is a thickend wall muscle that forms a powerful circular muscle at the end of the pyloric canal?
pyloric sphincter or pylorus
What muscle serves as a valve that prevents regurgiation of food from the intestine back into the stomach?
pyloric sphincter or pylorus
What part of the stomach is located on the short, right curved border that extends from the cardiac to the pyloric openings of the stomach?
What part of the stomach is the much longer left curved border of the stomach?
What lines the stomach?
Rugae or gastric folds
What do the Rugae or gastric folds do when the stomach is filled with food or fluids?
What do gastric juices contain? which one is most important?
- several digestive enzymes
Following a meal, the mixing movements of the stomach wall aid in producing a semifluid paste of food particles and gastric juice called?
What push the chyme toward the pyloric sphincter?
What happens when the peristaltic waves push the chyme toward the pyloric sphincter?
the muscle begins to relax, allowing the chyme to move a little at a time into the small intestine.
What begins the digestive process?
- There may be some water, glucose, certain salts, alcohol, or some drugs
- absorbed by the stomach, but for the most part, the stomach wall is not
- well adapted to carry on the absorptive digestive products.
What part of the small intestine does the stomach enter into?
Once the stomach enters the duodenum, accessory organs add their ____ to the chyme.
Which organs add their secretions to the chyme in the duodenum?
pancreas, liver, gall bladder
What is a tubular organ that extends from the pyloric sphincter to the opening of the large intestine, the ileocecal oepning, found in the right lower abdomen?
Where does most of the absorption of the digestive process occur?
It is called the small intestine because its ______ is smaller than that of the large intestine.
Which is longer, the large or small intestine?
The small intestine has smaller walls than the large intestine but it is over 4 times as long as the large and it fills much of the abdominal cavity. It is 18-20 feet long in a cadaver where the muscular wall is relaxed but maybe only 1/2 that in a living person.
What are the 3 parts of the small intestine?
What makes up the 1st 10 inches of the small intestine and is the most fixed portion of the small intestine?
Where does the duodenum being and end?
it begins that pyloric opening of the stomach and eventually joins the jejunum posterior to the stomach.
Where does the duodenum receive its digestive juices from and how?
From the pancreas via the pancreatic duct and from the gall bladder and the liver via the common bile duct.
Where do the pancreas duct and the common bile duct converge at to get into the duodenum?
at a single opening thru the sphincter of Oddi; also called ampulla of Vater
What forms about 2/5 of the small intestine and is about 9 feet in length
What extends from the duodenum behind the stomach to the ileum and lies in the upper abdomen and is quite mobile?
Both the jejunum and ileum are suspended from the posterior abdominal wall by a double layered fold of peritoneum called
What supporting tissue contains the blood vessels, neves and lymphatic vessels that supply the intestinal wall.
What forms the end of the small intestine and extends from the jejunum to the junction of the large intestine, at the cecum, either in the right lower abdomen or in the pelvis?
What is the opening called that is between the terminal part of the ileum and the cecum?
What is the innumerable tiny projections of mucous membrane that line the inner wall of the small intestine?
The intestinal villi are the passage way or lumen of the ____ _____, where they come in contact with the intestinal contents.
What plays an important role in mixing chyme with intestinal juice and in the absorption of digestive products?
The villi are covered with ____ ____ epithelium and contain a core of ____ tissue containing blood capillaries and nerve fibers.
- simple columnar
The ______ cells posses many fine extensions, called ______ which create a brush like border and greatly increase the surface area of the cells.
the presence of microvilli enhance the _____ of ______
process of absorption
What are inside the villi and function to carry away substances absorbed by the villus
blood and lymph capillaries
What in the villi act to stimulate or inhibit activities?
Between the bases of the villi are tubular intestinal glands called the
crypts of Lieberkuhn
Where do the stem cells for the columnar epithelium reside?
in the crypts of Lieberkuhn
Collections of lymphatic tissue are found where in the small intestine?
The lymphatic tissues that are found in the mucosa of the small intestine are called____ _____
What are most numerous in the terminal ileum and become involved during infections such as typhoid fever and tuberculosis of the intestine
Like the stomach, the small intestine carries on mixing movements and
Chyme is propelled thru the small intestine by ____ ____
How slow do food materials travel thru the small intestine to the large intestine?
Where is food eventually pushed through to get to the large intestine?
What is another word for large intestine?
How long is the large intestine and where does it begin?
It is about 5 feet long and begins in the lower right side of the abdominal cavity, where the ielum joins the cecum.
Describe the way the long intestine travels
it travels upward toward the right side called the ascending colon, hepatic flexure, crosses obliquely to the left (transverse colon), splenic flexure, and then descends into the pelvis (descending colon).
At the brim of the pelvis, the descending colon makes an S-shaped curve called the
sigmoid colon and then becomes the rectum.
What lies next to the sacrum and generally follows its curvature
The rectum is firmly attached to the sacrum by the periteneum and ends about 2 inches below the tip of the coccyx, where it then becomes the ____ _____
What is formed by the last 2 to 3 inches of the large intestine?
At the distal end of the anal canal , it opens to the outside as the
The anus is guarded by and _____ _____ and an ____ ____ _____
internal sphincter and an external anal sphincter
The large intestine lacks the villi that is present in small instestine but instead is made up of several pouches called
What inhabits the colon and can break down some of the substances that escape the actions of the enzymes?
Since the large intestine has little to no digestive fucntion, what does it do?
It serves to reabsorb water and electrolytes from the remaining chyme.
What froms and stores the feces until defecation?
what are the 3 areas that the pancreas is divided up into?
the head, the body, and the tail
Where is the head of the pancreas?
It lies against the c shaped loop of the duodenum
Where does pancreatic cancer generally arise from?
the head of the pancreas
The liver is divided up into how many lobes?
- the larger portion is on the right and the smaller is on the left
Where is the liver?
RUQ of the abdomen
The liver is considered and ____ _____
what does the liver do?
secretes bile, produces bilee, and filters toxins
What are the 2 main nodes for esophageal cancer that are affected alot?
Super clav nodes and the celiac nodes
What % of cancers is esophageal?
only 1% not a very common cancer
What % of esophageal cancers lead to death?
Men are ___ to ____ times more affected by esphageal cancer than women
3 to 4
Who is has a 50 % higher risk to get esphageal cancer than whites?
What is the age of diagnosis for esophageal cancer?
Where is the greater frequency of esophageal cancer
northern China, northern Iran and South Africa and mainly due to diet
What are some incidence and etiology of esophageal cancer? (5)
- Alcohol use
- tobacco use
- Barrett's esophagus
- Plummer-vinson Syndrome
What is Barrett's esophagus
Distal esophagus is lined with columnar epithelium instead of the stratified squamous like at the top of the esophagus. Barrett's is a disorder that is caused by the lining of the esophagus is damaged by the stomach acid and lining changes similar to that of the stomach. People with reflux (GERD) get this. Chronic stomach acid changes the cells to cancerous cells
What is Achalasia
This is when the lower 2/3 of the esophagus loses the normal peristaltic activity and you have a hard time swallowing.
What is Plummer-Vinson syndrome
This occurs in people who have a long term iron deficient anemia and end up having a hard time swallowing.
What are the clinical presentations of esophageal cancer? (8)
- Dysphagia and weight loss is #1
- chest pain
- regurgitation and aspiration
- odynophagia (painful swallowing)
- hematemesis (vomitting blood)
- hemoptysis (spitting up blood)
What tests can be done to detect esophageal cancer?
- Barium swallow
40-50% and the #1 place for a tumor location in the esophaus is
what % of esohageal tumors are located in the middle third?
25-50% of tumors in the esophagus are located
in the lower third
What % of esophageal tumors are located in the lower third?
10-25% of tumors in the esophagus are located in the
What % of esophageal tumors are located in the upper third?
What is the most common pathology for esophageal cancer?
Squamous cell in the upper and middle
In esophageal cancers, where are adenocarcinomas typically found?
in the distal esophagus and GE junction. Typically adenocarcinomas are all the way down until the anus
What are some rare esophageal cancers?
Adenoid cystic carcinoma, mucoepidermoid carcinoma, leimyosarcoma, melanoma, lymphoma, and rhabdomyosarcoma
How is staging based in esophageal cancers?
- based on extension outward TNM
- basically, how many layers has it penetrated
What is the 5 year survival rate for esophageal cancer?
How do Esophageal cancers spread
they spread longitudinal fashion and skip lesions (mets) are present at a significant distance from primary lesion. Submucosal spread. Once in the mucosal layer they can skip all around even all the way up to the super clav
Esophageal can also spread via local invasion which is
- where they can grow in the esophagus and basically burn through to the trachea etc.
- trachoesphageal and bronchoesophageal fistulas
Where does esophageal spread to?
- Liver #1
What are some treatment techniques for esophageal cancer?
multimodality approach- surgery- chemo, radiation, and surgery
When is surgery used for esophageal cancers
in the middle and lower third only and usually reserved for small non-metastatic lesions
What are some complications from surgery for esophageal cancer?
anastomic leaks, PE, myocardial infarction, strictures, and GE reflux
What are the most common drugs for esophageal cancers?
5-FU and Cisplatin
For esophageal cancer radiation what margin do you use?
5cm margin superior and inferior and 2-3 cm laterally
If you have a lesion in the upperthird esophagus where is your treatment field set up around?
it begins at the level of the thyroid cartilage and ends at the level of the carina to include the super clav nodes, low anterior cervial and mediastinal nodes
If you have a lesion in the lower third esophagus where is your treatment field set up around?
treat with fields that include the mediastinal nodes and the celiac axis.
If you have a lesion in the middle third esophagus where is your treatment field set up around?
you include the periesophageal and the mediastinal nodes.
What treatment field beam do you use to treat the initial large fields followed by shrinking fields for esophageal cancer?
What boost field beams do you use to treat esophageal cancer
you can use a 3 field technique (AP and 2 posterior obliques), Obliques, Laterals, or IMRT
How is the patient positioned to treat esophageal cancer
- Supine with arms by side or over head
- Prone with arms above head
If treating esophageal cancer alone without chemotherapy, what is your radiation dose on and off the cord?
6500 cGy with offcord at 3600-4500 cGy
If treating esophageal cancer with chemotherapy, what is your radiation dose on and off the cord?
5040 cGy with off cord at 3600-4500 cGy
What critical structures do you need to watch out for when treating esophageal cancer?
- Lungs 2000 cGy
- Heart 5000 cGy
- Spinal Cord 4500 cGy
What are side effects for esophageal radiation
- Esophagitis #1
- ulceration of the esophagus
- decreased blood counts (because alot of bone marrow will be treated
- radiation pneumonitis
- perforation of the esophageal-trachea wall
- transverse myelitis (sever spinal cord)
Stomach cancers incidence is higher in which nationalities
African American and Native Americans
Stomach cancer is more common in (men or women)
What is the peak incidence age for stomach cancer?
What is the stomach pathology?
- Adenocarcinoma 90%
- Other 10% are rare and include lymphoma, sqaumous cell, and leiomyosarcoma
Where are 50% of stomach lesions found?
Where are 25% of stomach lesions found?
Where are 5% of stomach lesions found?
Whare are 10-15% of stomach lesions found?
- In the distal portion of the stomach
- In the cardiac region (up around the GE junction)
- In the greater cruvature
- In the entire stomach which would be then called lymphoma
What is the etiology of stomach cancer (risk factors)
- Diet (red meat)
- coal mining
- Blood type A
- rubber working
- gastric ulcers/polyps
- poor nutrition
- inadequate sanitation
- H pylori (bacteria that lives in the stomach acid and causes refulx and pain in stomach)
What are the symptoms of stomach cancer
- Persistent indigestion
- epigastric distress or pain
- loss of appetite
- weight loss
- abnormal mass or bloating (most likely well spread, a late stage)
How are stomach cancers often diagnosed
- Physical Exam
- Upper GI series
What is the workup for stomach cancer testing?
- CBC (most will have anemia)
- Guaiac stool test (is there blood)
- Upper GI
- Endoscopy with biopsy
- CT scan of chest and abdomen
The staging for stomach cancer is TNM. How may have distant mets already at diagnosis
30% or 1/3
Which lymphnodes are typically affected with stomach cancer
greater and lesser curvature, splenic, celiac, and hepatic nodes
Stomach cancers are usually a direct spread. Where do they spread to?
Bowel, omenta (lining of the abdomen wall), pancreas, colon, and regional nodes
When stomach cancer is spread through the blood, where does it go
What is the 5 year survival rate for stomach cancer
What are the treatment options for stomach cancer
- Surgery if no mets are present
- chemotherapy can be done anytime and be combined with radiation
What are the complications for stomach cancer surgery
infection, hemorrhage, anemai, anastomosis, and PE
What are the treatment field beams used for stomach cancer
AP/PA and it extends from diaphragm to L3 including the duodenal loop and regional lymph nodes
What is the curative dose for stomach cancer?
What is the palliative dose for stomach cancer?
What dose do you use if the gastric lymphnodes are involved?
4000 cGy and this is a curative dose because they are so radiosensitive
What is the patient position for stomach cancer
supine with arms over head (similar to esophagus)
What are the side effects for Stomach cancer radiation
ulcers, fistula, decreased blood counts, bowel obstruction, and transverse myelitis (sever cord)
What critical structures do you have to worry about when doing radiation treatment for stomach cancer?
- spinal cord
small intestines are the most sensitive and is where we get most of our nutrients but we typically do not treat the small intestines because it is a moving target.
The small intestine can take a dose of up to
Where are small instestine tumors located?
usually in the duodenum or first jejunal loops
What % of small intestine lesions are generally adenocarcinoma
- lymphoma, cartinoids, and sarcomas make up the rest
What are disorders of small intestinal cancers
- Chron disease
- Gardner syndrome
What are symptoms of small instestine cancer?
- rectal bleeding,
- weight loss,
- abdominal pain,
- fever, or
- change in bowel habits
how are tumors in the small intestine usually discovered?
via upper Gi and small bowel follow through or endoscopy
How can small intestinal cancer spread
via direct extension, lymph, blood stream to #1 liver, lungs, and bone.
where is the #1 blood spread of small intestinal cancer
What are the treatment options for small intestinal cancer
- chemo using 5 FUwe do not really treat this with radiation due to bowel sensitivity and motion of the organ
What is the 5 year survival rate of small intestinal cancer
Rectal CA/large intestine is ranked _____ in the US or men and women in incidence and ____ for overall death
What is the peak age to get rectal ca/large intestine
50 or older
What are some symptoms for rectal CA
- blood in stool #1
- rectal bleeding (hematochezia)
- change in bowel habits
- pencil stools
- tenesmus (rectal spazma)
How is rectal CA cancer detected
- via physical exam
- radiographic (have to use contrast)
What determines the size, mobility, location from the anal verge (where the anus exits the body), and rectal wall involvement?
- digital exam (finger exam)
What is doe to evaluate metastatic disease from rectal CA?
- Chest xray
- lab studies
If _____ antigen rises, then there is a good chance that you have rectal CA
- carcinoembryonic antigen (tumor marker)
What % of all rectal ca lesions are adenocarcinoma
How is staging done for rectal CA
TNM or the dukes classification which is ABC
What are the staging classifications of rectal ca telling you?
they are explaining the penetrations of the tumor through the layers of the bowel wall.
Rectal CA does not skip around like esophagus, how does it spread?
- direct extension (penetrates bowel wall, not longitudinally)
- lymphatic (if tumor has penetrated the submucosal layer)
- Hematogenous (liver, lung, bone, ovaries, adrenal)
- Peritoneal seeding (very bad, this is when the tumor breaks all the rectal layers and goes into the abdomial cavity)
Where is the #1 site of blood spread
What are the treatment options for rectal CA
In rectal CA, which chemo drug do you use?
- 5 FU and gemcitabine and possibly
- 5 fu, leucovorin, folfox, folfirir, erbitux
What is the 5 year survival rate for rectal CA
sometimes you would give radiation before surgery in conjuction with chemo for what reason?
to shrink the tumor first and you would use around 4500 cGy
A 3 field or 4 field technique can be used to treat rectal CA. which ones are used?
What are you covering to treat AP/PA used in treating rectal CA
- Top-L4-L5 interspace
- Bottom- bottom of obturator foramina or 3-5 cm below gross tumor
- Lateral-2cm lateral to pelvic brim and inlet (inside hole of pelvis)
What are you covering to treat Rt-LT laterals in treating rectal CA
- Top- L4-L5 interpace
- Bottom- bottom of obturator formina or 3-5 cm below gross tumor
- Anterior- Anterior edge of femoral head
- Posterior- 2cm behind the bony sacrum
How do you postition a patient for rectal CA radiation treatment
- Supine or prone
- prone allows gluteal fold to decrease
- Full bladder (can save the bowel if bladder is full because the bladder can take more Cgy)
- empty bladder
- Women have a vaginal marker
- contrast for bowels
- wire scar and anal verge (you can put a radiation wire to mark this so we can try to save the sphincter)
What radiation dose do you give for rectal CA via external beam
- 4500 cGy
- 540-1440 cGy to boost
What radiation dose do you give for rectal CA via intraoperative radiation?
- 1000-2000 cGy of electrons in single fraction
- this is while you are open for surgery, we can blast it with radiation but only major hospitals like John Hopkins do this technique
What are the acute side effects of rectal CA treatment
- Small bowel toxicities (<4500cGy)
- abdominal cramps and bloating
- proctitis (hemroids)
- bloody or mucus discharge
- leukopenia (decreased white blood count)
- thrombocytopenia( decreased platelets)
- moist desquamation
What are the chronic side effects of rectal CA (3-6mos later)
- persistent diarrhea
- increased bowel frequency
- urinary incontinence
- bladder atrophy
- obstructions of small bowel
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