Gastrointestinal tract cancer

Description of the clinical and anatomic morphology of nonepithelial gastrointestinal tract cancer; description of surgical methods and evaluation of surgical treatment results for non-epithelial gastrointestinal tract cancer.

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Colorectal cancer (CRC) represents a common malignancy in gastrointestinal tract. Iodine-125 (125I) seed implantation is an emerging treatment technology for unresectable tumors. This study investigated the mechanism of 125I seed in the function of CRC cells.

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ADH1 and ADH4 are the major alcohol dehydrogenases (ADH) in ethanol and retinol oxidation. ADH activity and protein expression were investigated in rat gastrointestinal tissuehomogenates by enzymatic andWesternblot analyses. In addition, sections of adult rat gastrointestinal tract were examined byin situ hybridization and immunohistochem-istry.ADH1andADH4weredetectedalong thewhole tract, changing their localization and relative content as a function of the area studied.

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There are 20 subtypes of cytokeratin (CK) intermediate filaments with different molecular weights and differential expression in various cell types and cancers. Monoclonal antibodies to specific CK subtypes have been used to help classify tumors according to their site of origin; commonly used CK stains in CUP are CK7 and CK20. CK7 is found in tumors of the lung, ovary, endometrium, and breast and not in those of the lower gastrointestinal tract, whereas CK20 is normally expressed in the gastrointestinal epithelium, urothelium, and Merkel's cells.

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Bibliography ESOPHAGEAL CANCER Al-Sarraf M et al: Progress report of combined chemoradiotherapy versus radiotherapy alone in patients with esophageal cancer: An intergroup study. J Clin Oncol 15:277, 1997 [PMID: 8996153] Bedenne L et al: Chemoradiation followed by surgery compared with chemoradiation alone in squamous cancer of the esophagus: FFCD 9102.

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Cancers of the Anus Cancers of the anus account for 1–2% of the malignant tumors of the large bowel. Most such lesions arise in the anal canal, the anatomic area extending from the anorectal ring to a zone approximately halfway between the pectinate (or dentate) line and the anal verge. Carcinomas arising proximal to the pectinate line (i.e., in the transitional zone between the glandular mucosa of the rectum and the squamous epithelium of the distal anus) are known as basaloid, cuboidal, or cloacogenic tumors; about one-third of anal cancers have this histologic pattern.

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Lymphomas Lymphoma in the small bowel may be primary or secondary. A diagnosis of a primary intestinal lymphoma requires histologic confirmation in a clinical setting in which palpable adenopathy and hepatosplenomegaly are absent and no evidence of lymphoma is seen on chest radiograph, CT scan, or peripheral blood smear or on bone marrow aspiration and biopsy. Symptoms referable to the small bowel are present, usually accompanied by an anatomically discernible lesion.

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Tumors of the Small Intestine Small-bowel tumors comprise

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Radiation therapy to the pelvis is recommended for patients with rectal cancer because it reduces the 20–25% probability of regional recurrences following complete surgical resection of stage II or III tumors, especially if they have penetrated through the serosa.

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Most recurrences after a surgical resection of a large-bowel cancer occur within the first 4 years, making 5-year survival a fairly reliable indicator of cure. The likelihood for 5-year survival in patients with colorectal cancer is stagerelated (Fig. 87-3). That likelihood has improved during the past several decades when similar surgical stages have been compared. The most plausible explanation for this improvement is more thorough intraoperative and pathologic staging.

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Double-contrast air-barium enema revealing a sessile tumor of the cecum in a patient with iron-deficiency anemia and guaiac-positive stool. The lesion at surgery was a stage II adenocarcinoma. Since stool becomes more formed as it passes into the transverse and descending colon, tumors arising there tend to impede the passage of stool, resulting in the development of abdominal cramping, occasional obstruction, and even perforation. Radiographs of the abdomen often reveal characteristic annular, constricting lesions ("apple-core" or "napkin-ring") (Fig. 87-2).

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Hereditary Nonpolyposis Colon Cancer Hereditary nonpolyposis colon cancer (HNPCC), also known as Lynch syndrome, is another autosomal dominant trait. It is characterized by the presence of three or more relatives with histologically documented colorectal cancer, one of whom is a first-degree relative of the other two; one or more cases of colorectal cancer diagnosed before age 50 in the family; and colorectal cancer involving at least two generations. In contrast to polyposis coli, HNPCC is associated with an unusually high frequency of cancer arising in the proximal large bowel.

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Screening The rationale for colorectal cancer screening programs is that earlier detection of localized, superficial cancers in asymptomatic individuals will increase the surgical cure rate. Such screening programs are important for individuals having a family history of the disease in first-degree relatives. The relative risk for developing colorectal cancer increases to 1.75 in such individuals and may be even higher if the relative was afflicted before age 60.

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Table 87-5 Hereditable (Autosomal Dominant) Gastrointestinal Polyposis Syndromes Syndrom e Distribu Histolo nant Malig Associated Lesions tion of Polyps gic Type Potential Familial adenomatous polyposis Large intestine a Adenom on Comm None Gardner's Large Adenom Comm Osteomas, syndrome and intestines small a on fibromas, lipomas, epidermoid cysts, ampullary cancers, congenital hypertrophy retinal of pigment epithelium Turcot's syndrome Large intestine a Adenom on Comm tumors Brain Nonpoly Large Adenom on Comm al Endometri and ovarian posis syndrome int...

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Etiology and Risk Factors Risk factors for the development of colorectal cancer are listed in Table 874. Table 87-4 Risk Factors for the Development of Colorectal Cancer Diet: Animal fat Hereditary syndromes (autosomal dominant inheritance) Polyposis coli Nonpolyposis syndrome (Lynch syndrome) Inflammatory bowel disease Streptococcus bovis bacteremia Ureterosigmoidostomy ? Tobacco use Diet The etiology for most cases of large-bowel cancer appears to be related to environmental factors. The disease occurs more often in upper socioeconomic populations who live in urban areas.

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Gastric (Nonlymphoid) Sarcoma Leiomyosarcomas and GISTs make up 1–3% of gastric neoplasms. They most frequently involve the anterior and posterior walls of the gastric fundus and often ulcerate and bleed. Even those lesions that appear benign on histologic examination may behave in a malignant fashion. These tumors rarely invade adjacent viscera and characteristically do not metastasize to lymph nodes, but they may spread to the liver and lungs. The treatment of choice is surgical resection. Combination chemotherapy should be reserved for patients with metastatic disease.

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Gastric Adenocarcinoma: Treatment Complete surgical removal of the tumor with resection of adjacent lymph nodes offers the only chance for cure. However, this is possible in less than a third of patients. A subtotal gastrectomy is the treatment of choice for patients with distal carcinomas, while total or near-total gastrectomies are required for more proximal tumors. The inclusion of extended lymph node dissection in these procedures appears to confer an added risk for complications without enhancing survival.

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Several additional etiologic factors have been associated with gastric carcinoma. Gastric ulcers and adenomatous polyps have occasionally been linked, but data on a cause-and-effect relationship are unconvincing. The inadequate clinical distinction between benign gastric ulcers and small ulcerating carcinomas may, in part, account for this presumed association. The presence of extreme hypertrophy of gastric rugal folds (i.e.

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Tumors of the Stomach Gastric Adenocarcinoma Incidence and Epidemiology For unclear reasons, the incidence and mortality rates for gastric cancer have decreased markedly during the past 75 years. The mortality rate from gastric cancer in the United States has dropped in men from 28 to 5.8 per 100,000 persons, while in women the rate has decreased from 27 to 2.8 per 100,000. Nonetheless, 21,260 new cases of stomach cancer were diagnosed in the United States, and 11,210 Americans died of the disease in 2007.

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Harrison's Internal Medicine Chapter 87. Gastrointestinal Tract Cancer Gastrointestinal Tract Cancer: Introduction The gastrointestinal tract is the second most common noncutaneous site for cancer and the second major cause of cancer-related mortality in the United States. Esophageal Cancer Incidence and Etiology Cancer of the esophagus is a relatively uncommon but extremely lethal malignancy. The diagnosis was made in 15,560 Americans in 2007 and led to 13,940 deaths. Worldwide, the incidence of esophageal cancer varies strikingly. ...

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