Zaporizhzhya State Medical University

Chair of oncology

Anatoliy I. Shevchenko
lexandr M. Sidorenko
lexey P. Kolesnik

Cancer
of gastrointestinal tract
(Hand book for student of medical university)
 Zaporizhzhya, 2007

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A.I. Shevchenko, A.M. Sidorenko, A.P. Kolesnik Cancer of gastrointestinal tract:

Hand book for student of medical university. Zaporizhzhya: ------- ,ZSMU. 34 p.

This booklet conteius information about gastrointestinal cancer. The

epidemiology, etiology, clinical presentation, diagnostics and treatment of
esophagus, stomach, pancreas, liver, and colorectal cancer are regardet.
The cancer sourse book for foreign students medical univercity according to
oncology educational programme.

: . .., . ..
. .., . ..

: . . ., ..

3
ONTENTS

ESOPHAGEAL CANCER .. 6

Epidemiology, Risk Factors, Pathology Rules for classification .. 6

Definition of TNM, Stage grouping 7
Histopathologic type, Histopathologic grade, Clinical Presentation,
Diagnosis . 8
Treatment . 9
TEST 10

GASTRIC CANCER 13

Epidemiology, Risk Factors, Pathology, Ruls for classification . 13

Definition of TNM, Stage grouping 14
Histopathologic type, Histopathologic grade, Clinical Presentation,
Diagnosis,Treatment . 15

COLORECTAL CANCER .. 17

Epidemiology, Risk Factors, Pathology .. 17

Ruls for classification, Definition of TNM . 18
Stage grouping, Histopathologic type . 19
Histopathologic grade, Clinical Presentation, Diagnosis. 20
Treatment 21

TEST 23

CANCER OF THE PANCREAS 24

Epidemiology, Risk Factors, Pathology, Definition of TNM . 24

Stage grouping, Histopathologic type, Histopathologic grade, Clinical
Presentation . 25
Diagnosis, Treatment .. 26

CANCER OF THE LIVER 28

4
Epidemiology, Risk Factors, Pathology, Rules for classification,
Definition of TNM .. 28
Stage grouping, Histopathologic grade, Clinical Presentation .. 29
Diagnosis, Treatment 30

CANCER OF THE GALLBLADDER .. 31

Epidemiology, Risk Factors, Pathology, Rules for Classification, Definition

of TNM .. 31
Stage grouping, Histopathologic type, Histopathologic grade, Clinical
Presentation 32
Diagnosis, Treatment . 33

BIBLIOGRAPHY.. 34

5
 ESOPHAGEAL CANCER

Epidemiology

In the United States, the incidence of esophageal cancer is approximately 7

cases per 100000 people, in Ukraine 2.5 cases per 100000 people. The overall
prognosis for this disease is poor, with only 5% of patients surviving 5 years after
diagnosis. The bleak outlook is partly because most esophageal neoplasms have
spread beyond local control when they are diagnosed.
Esophageal cancer occurs most commonly in males over age 60. In addition,
esophageal cancer occurs more frequently in certain geographic areas of the world,
including Japan, China, Russia, Scotland, the Caspian region of Iran, and parts of
eastern and southern Africa.

Risk Factors

In most of the world, dietary and nutritional factors are the most common
etiologic agents. Alcohol ingestion is generally accepted as a potent risk factor, and
this risk is potentiated when combined with smoking. Chronic irritation caused by
a hiatal hernia and reflux esophagitis has also been implicated. Ingestion of lye or
other caustic agents may also be a contributing factor. Several dietary factors have
been suggested as risk factors, including heavy food seasoning, hot foods and
beverages, betel nut products, and deficiencies or excesses of trace metals and
vitamins.

Pathology

Approximately 90% of esophageal cancers are squamous cell (or

epidermoid) tumors. The remainder are adenocarcinomas; sarcomas, small-cell
cancers, and lymphomas rarely occur. Approximately 15% of these malignancies
occur in the upper third of the esophagus, 50% in the middle third, and 35% in the
lower third. The lymph nodes and mediastinum become involved early in the
disease, and frequently the tumors are locally advanced before producing
symptoms. Distant metastases are probably microscopically present at diagnosis,
but do not become clinically apparent until late in the disease or at autopsy. Most
commonly the liver, lungs, adrenals, bone, or kidneys are involved.

6
Rules for classification

Clinical staging depends on the anatomic extent of the primary tumor that
can be ascertained by examination before treatment. Such an examinationmay
include physical examination, medical history, biopsy, routine laboratory studies,
endoscopic examinations, and imaging. Endoscopic ultrasound and computed
tomography are useful for identifying tumor location, depth of invasion, and lymph
node metastasis. The location of the primary tumor should be recorded, because
prognosis will vary depending on its site of origin.

Definition of TNM
Primary Tumor (T)
TX: Primary tumor cannot be assessed
T0: No evidence of primary tumor
Tis: Carcinoma in situ
T1: Tumor invades lamina propria or submucosa
T2: Tumor invades muscularis propria
T3: Tumor invades adventitia
T4: Tumor invades adjacent structures
Regional Lymph Nodes (N)
NX: Regional lymph nodes cannot be assessed
N0: No regional lymph mode metastasis
N1: Regional lymph node metastasis
Distant Metastasis (M)
MX: Presence of distant metastasis cannot be assessed
M0: No distant metastasis
M1: Distant metastasis
Tumor of the lower thoracic esophagus
M1a: Metastasis in celiac lymph nodes
M1b: Other distant metastasis
Tumor of the midthoracic esophagus
M1a: Not applicable
M1b: Nonregional lymph nodes and/or other distant metastasis
Tumor of the upper thoracic esophagus
M1a: Metastasis in cervical nodes
M1b: Other distant metastasis

Stage grouping

Stage T N M
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage IIA T2 N0 M0
T3 N0 M0
Stage IIB T1 N1 M0
7
 T2 N1 M0
Stage III T3 N1 M0
T4 Any N M0
Stage IV Any T Any N M1
Stage IVA Any T Any N M1a
Stage IVB Any T Any N M1b

Histopathologic type
Epitelial:
Squamous cell carcinoma
Spindli cell carcinoma
Carcinosarcoma
Adenocarcinoma
Adenosquamous carcinoma
Mucoepidermoid carcinoma
Adenoid cystic carcinoma
Small cell carcinoma
Nonepitelial:
Leiomyoma
Leiomyosarcoma
Malignant melanoma
Rhabdomyoma
Rhabdomyosarcoma
Granular cell tumors
Malignant lymphoma

Histopathologic grade
Gx Grade cannot be assessed
G1 Well differentiated
G2 Moderately differentiated
G3 Poorly differentiated
G4 - Undifferentiated

Clinical Presentation

Patients usually present because of complaints of dysphagia. Early

symptoms of esophageal cancer are usually vague and rarely reported. Initial
symptoms include a sense of pressure, indigestion, and substemal distress. As the
disease progresses, dysphagia and weight loss are the most common complaints.
Patients may change their diet from solids to liquids to compensate for their
swallowing difficulty; eventually, even liquids may become difficult. Aspiration of
food or liquids leads to aspiration pneumonia. A tracheoesophageal fistula can
occur. Tumor can encroach into nerve systems, causing hoarseness, hiccups, or
paralysis of the arm or diaphragm.
8
Diagnosis

Barium esophagram and computerized tomography (CT) are often used to

delineate the gross appearance of the tumor. Tissue for cytologic and microscopic
examination is obtained by esophagoscopy. Laryngoscopy and bronchoscopy may
also be performed to evaluate the extent of tumor spread into the tracheobronchial
tree.

Treatment

Because surgery alone has proven inadequate in the management of

esophageal cancer, aggressive, combined modality therapy is being used in an
attempt to improve treatment results. Surgery is often combined with radiation or
chemotherapy to decrease the extent of surgical resection, treat areas that are not
easily resectable, or reduce the chance of distant metastases from residual micros-
copic disease following surgery.
Patients who are candidates for curative treatment should be free of
accompanying cardiac, renal, and pulmonary diseases; nutritionally stable; and
have a localized tumor that is not fixed to adjacent structures.
Surgery: The surgical approach to lesions of the cervical esophagus, or
upper third, usually includes resection of the entire larynx, thyroid, and a portion of
the proximal esophagus. A unilateral radical neck dissection may also be
performed if cervical lymph nodes are clinically involved. Usually, the stomach is
pulled up and anastomosed to the posterior pharynx. The severe cosmetic defect
resulting from surgery usually necessitates reconstructive procedures.
Reconstruction may include the use of full-thickness skin grafts, formation of a
gastric tube from the greater curvature of the stomach, or (less commonly)
interposition of a segment of the colon.
Esophagectomy is recommended for lesions of the thoracic esophagus, or
middle and lower third. The lower two-thirds of the esophagus and proximal
stomach are removed, because many lesions extend into the stomach. The
remaining stomach is then pulled up and anastomosed to the cervical esophagus.
Causes of morbidity following esophageal resection include anastomotic leaks,
fistulae, strictures, pulmonary emboli, respiratory insufficiency, congestive heart
failure, and wound infections or dehiscence. Preoperative conditions, such as poor
nutritional status, can also contribute to operative morbidity.
Radiation therapy: Patients who are not candidates for aggressive,
combined modality treatment, such as those with inadequate cardiopulmonary
function, may be treated with radiation therapy. The treatment period is prolonged,
lasting 6 to 8 weeks. Treatment-induced esophagitis can be severe, requiring
systemic analgesics, parenteral nutrition, and antifungal medications,
More frequently, radiation therapy is used in conjunction with surgery to
improve treatment results. Preoperative radiotherapy has been used successfully to
reduce tumor bulk, thereby decreasing the extent of the surgical resection and
9
lessening the accompanying surgical risk. Postoperative irradiation is used most
commonly to treat residual macroscopic or microscopic disease in unresected
portions of the esophagus or at the margins of the resection. It can also be used
palliatively in patients found to have unresectable disease during surgery.
Chemotherapy: Combination drug regimens administered in addition to
radiotherapy and surgery are currently being evaluated. Agents that have shown
some activity against esophageal cancer include methotrexate, cisplatin, 5-
fluorouracil (5-FU), mitomycin C, lomustine (CCNU), doxorubicin,
cyclophosphamide, and bleomycin.
Palliation: Patients with advanced or unresectable esophageal cancer may
be treated to palliate pain and dysphagia and to maintain esophageal patency for
food passage.
Both radiation and surgery may be used to relieve impending obstruction
caused by tumor growth. In addition to using these traditional therapies, some
institutions are currently using endoscopic laser therapy as local treatment for
esophageal obstruction. This therapy provides short-term local control by
vaporizing tumor tissue. Complications of this technique include perforation of the
esophagus, bleeding, and fistula formation. Following any procedure to establish
lumen patency, the esophagus must be dilated repeatedly to maintain patency.
To provide adequate nutrition when esophageal continuity is interrupted, a
feeding gastrostomy tube can be surgically inserted. This procedure may assure
adequate caloric intake, but does not treat the patient's inability to handle oral
secretions. Also, a number of synthetic endoesophageal tubes have been designed
to maintain a patent passage for swallowing. These are used primarily in patients
who are very debilitated or have T-E fistulae or invasion of surrounding structures.

TEST
1. Patient has a voming with dirt of blood and grume in vomiting mass. To
diagnosis is?
*. Acute ulceration of stomach, complicated by bleeding
. Acute erosive gastritis, complicated by bleeding
. Bleeding from varicose extended esophagus veins
D. Esophageal cancer, esophageal bleeding
. Syndrome of Melory-Veisa

2. Patient, 46 years old, has obtuse pain behind sternum. Pain become stronger
during a meal. Furthermore worry feeling passing hard food on esophagus,
periodical regurgitation undigested food, loos weight. On X-ray of esophageal is
define S-shaped flexure and widening of esophagus, relief of mucosis is smooth
without peristalsis, in cardiac area has contraction. To diagnosis is?
. Hernia diaphragms outcome
. Esophagospasm
*. Esophageal cancer
D. Diverticulosis of esophagus
. Sclerodermia
10
3. Patient has feeling burn in epigastric area, that attend of pain. Pain spreading in
back, become stronger than patien lies and lies on left side. Pain was stopt after
receiving alkaline water. Not rarely observe air regurgitation. Listing complaints
worred during last two years, after hernia diaphragms outcome operations. To
diagnosis is?
. Achalasia of cardia
. Esophageal cancer
*. Reflux-esophagitis
D. Diverticulum of esophagus
. Hernia diaphragms outcome

4. Patient, 32 years old, has abnormality passing food on esophagus and pain
behind of sternum after meal, nausea, sometimes voming. X-ray: moderate
widening of esophagus, contraction it distal part like a mouses tail brief delay
barium in lower part of esophagus. To diagnosis is?
. Burn of esophagus, stricture
*. Achalasia of cardia
. Esophageal cancer
D. Diverticulum of esophagus
. Cancer of antrum

5. Patient, 55 years old, after checkuping in oncology center has diagnosis cancer
of lower thoracal part of esophagus. Its necessary surgycal treathment. What is
operation is need?
. Torecs operation
. Gastroenterostomia
*. Operation of Lewes
D. Dukens operation
. Operatin of Garloc

6. Patient, 60 years old has a diphagia. It prograssion fast during last two weeks. Is
determine loss weight, anemia. To diagnosis is?
A.*Esophageal cancer
B. Diverticulum of esophagus
C. Hernia diaphragms outcome
D.Achalasia of cardia
E. Foreing body of esophagus

7. What is basic to choice surgical metod of treathment esofageal cancer?

A. Stage of desiase
B. Localisation of tumor
C. General condition
D. Heavy concominant diseases
*E. All factors
11
8. What is basic of diagnostic for operable cancer of lower part esofagus?
A. Computer tomography
B. Ultrasonography
C. X-ray
D. Laparotomy

9. Patient, 70 years old, has tumor in lower part of esophgus stage IIIb, ulcerous
form. Is appear disphagia, sometimes poor pass fluid food. What treathment youll
reguire to patient?
A. Simptomatical treathment
B. Beam therapy
C. Chemotherapy
*D. Gastrostomia + Beam therapy
E. Gastrostomia + Chemotherapy

12
 GASTRIC CANCER

Epidemiology:

Gastric cancer is the second leading cause of cancer-specific mortality

worldwide. There is a trend of declining incidence through out the world. Japan
and Chile, however, continue to have a very high incidence of this disease. These
differences in geographic distribution remain unexplained but are generally
considered to be related to the environment. In the United States and western
Europe, stomach cancer occurs more frequently in lower socioeconomic groups.
The incidence rate of gastric cancer in the United States is 8.4/100000, in
Europe 18.9/100000, in Ukraine 16.9/100000.

Risk Factors

Dietary factors may increase the risk of developing gastric cancer: a higher
incidence of this disease is noted with increased consumption of smoked and salted
foods, and foods contaminated with aflatoxin. Helicobactor pylori infection,
Heredity and race. Previous gastric resection.
Gastric metaplasia and dysplasia have also been associated with the development
of gastric carcinoma. However, a history of gastric ulcers contributes little to the
risk of this type of cancer.

Pathology

Approximately 95% of stomach cancers are epithelial tumors,

predominantely adenocarcinomas. Approximately 50% of stomach cancers are
located in the antrum and pyloric region. Disease spreads by extension along the
stomach wall, through the lymphatics or the blood stream, or by direct extension to
adjacent structures. The most common sites of metastasis are the liver, peritoneum,
pancreas, lung, and bone.

Ruls for classification

Clinical Staging. Designated as cTNM, clinical staging on evidence acquired

before definitive treatment is instituted. It includes physical examination, imaging,
endoscopy, biopsy, and other findings. All cases must be confirmed histologically.
Pathologic Staging. Pathologic staging depends on data acquired clinically along
with results of surgical exploration and examination of the regional lymph nodes
13
entails removal of nodes adequate to validate the absence of metastasis and to
evaluate the highest pN category. Metastatic nodules in the fat adjacent to the
gastric carcinoma, without evidence of residual lymph node metastases. If there is
doubt concerning the correct T, N, or M assignment, the lower (less advanced)
category should be selected. This guideline also applies to the stage grouping.

Definition of TNM
Primary tumor (T)
TX: Primary tumor cannot be assessed
T0: No evidence of primary tumor
Tis: Carcinoma in situ: intraepithelial tumor without invasion of the lamina
propria
T1: Tumor invades lamina propria or submucosa
T2a: Tumor invades the muscularis propria
T2b: Tumor invades the subserosa
T3: Tumor penetrates the serosa (visceral peritoneum) without invading adjacent
structures,
T4: Tumor invades adjacent structures
Regional lymph nodes (N)
The regional lymph nodes are the perigastric nodes, found along the lesser and
greater curvatures, and the nodes located along the left gastric, common hepatic,
splenic, and celiac arteries. For pN, a regional lymphadenectomy specimen will
ordinarily contain at least 15 lymph nodes. Involvement of other intra-abdominal
lymph nodes, such as the hepatoduodenal, retropancreatic, mesenteric, and para-
aortic, is classified as distant metastasis.
NX: Regional lymph node(s) cannot be assessed
N0: No regional lymph node metastasis
N1: Metastasis in 1 to 6 regional lymph nodes
N2: Metastasis in 7 to 15 regional lymph nodes
N3: Metastasis in more than 15 regional lymph nodes
Distant metastasis (M)
MX: Distant metastasis cannot be assessed
M0: No distant metastasis
M1: Distant metastasis
Stage grouping
Stage T N M
Stage 0 Tis N0 M0
Stage IA T1 N0 M0
Stage IB T1 N1 M0
T2a, T2b N0 M0
Stage II T1 N2 M0
T2a, T2b N1 M0
T3 N0 M0
Stage III A T2a, T2b N2 M0

14
 T3 N1 M0
T4 N0 M0
Stage III B T3 N2 M0
Stage IV T4 N1-3 M0
T1-3 N3 M0
Any T Any N M1
Histopathologic type
-Adenocarcinoma
-Papillary adenocarcinoma
-tubular adenocarcinoma
-mucinous adenocarcinoma
-signet ring cell carcinoma
-adenosquamous carcinoma
-squamous cell carcinoma
-small cell carcinoma
-undifferentiated carcinoma

Histopathologic grade
Gx Grade cannot be assessed
G1 Well differentiated
G2 Moderately differentiated
G3 Poorly differentiated
G4 - Undifferentiated

Clinical Presentation

Clinical Presentation of castric cancer depends on the stage of desiase and

localization tumor in stomach. Vague complaints of anorexia, early satiety, weight
loss, bloating, nausea, and pain are the presenting features in most cases of gastric
cancer. Dysphagia occur predominantly among patients with proximal cancer
localization. Nausea end voming are more common among patients with
nonproximal cancer. Often, patients use home remedies and self-medication to
successfully treat these symptoms for a period of time. Only symptoms of
advanced disease, such as progressive weight loss, weakness, and anemia, may
prompt patients to seek medical intervention. A palpable abdominal mass is usually
a late physical finding. Patients may also present with ulcer-like symptoms, hemor-
rhage, obstruction, or symptoms related to metastatic disease.

Diagnosis

Initial screening usually involves a barium upper gastrointestinal series to

evaluate the stomach for evidence of a mass. Endoscopy is then routinely done to
better visualize the lesion and obtain tissue for cytologic examination. Levels of
tumor markers such as car-cinoembryonic antigen (CEA) and alpha fetoprotein

15
(AFP) are of limited value in the diagnosis and follow-up of gastric cancer,
because these values may be elevated in other benign and malignant diseases.

Treatment

The treatment for gastric cancer depends on the stage of disease and may
incorporate a combined modality approach. Localized gastric cancers are usually
treated with surgical resection, sometimes in combination with chemotherapy
and/or radiotherapy.
Surgery: The extent of surgery depends on the location of the cancer within the
stomach. Tumors located in the upper proximal portion of the stomach may be
resected by a subtotal esophagogastrectomy. This operation consists of removal of
the lower portion of the esophagus and resection of the cardia, fundus, and the
body of the stomach. In addition, the supporting circulatory and lymphatic
structures and the greater and lesser omenta are removed. The remaining
esophagus is sutured to the duodenum or jejunum.
A total gastrectomy is usually performed for lesions located in the mid-portion of
the stomach. The esophagus is then anastomosed to the jejunum. Lesions located in
the antrum, or lower portion of the stomach, are treated by subtotal gastrectomy,
using either a Bilroth I or Bilroth II procedure.
Immediate postoperative concerns include prevention of respiratory complications,
infection, hemorrhage, and anastomotic leak.
Symptomatic surgery include the bypass procures or metal stents.
Radiation therapy: Gastric and intestinal mucous membranes tolerate the effects
of irradiation poorly. Nausea, esophagitis, and diarrhea are frequently observed
following intestinal radiation. As a result, radiotherapy is rarely used as the sole
treatment modality because of the difficulty in administering curative doses
without unacceptable gastrointestinal toxicity.
More commonly, radiation therapy is combined with surgery or chemotherapy for
patients with unresectable, partially unresectable, or recurrent disease. When
combined with surgery, radiation may be given preoperatively, intraoperatively, or
postoperatively. The sequencing of these two modalities remains controversial.
Radiotherapy administered with 5-FG has been shown to be more effective than
either radiotherapy or chemotherapy alone in prolonging survival.
Chemotherapy: The use of chemotherapy in the treatment of gastric cancer is
primarily limited to patients with unresectable or metastatic disease, although
adjuvant chemotherapy following surgical resection is eing evaluated for its role in
improving survival. Combination chemotherapy regimens appear to be more
successful than single agents. When 5-FU is combined with doxorubicin and
mitomycin C or with the nitrosoureas, survival time is slightly increased.
Palliative care: In advanced gastric cancer, nutritional maintenance becomes a
serious problem. The resulting malnutrition and weight loss decrease the patient's
ability to withstand the rigors of therapy, resist infection, and perform self-care
activities. Patients with unresectable obstructing gastric cancer can obtain
palliative nutrition through double lumen tubes placed by endoscopy. One lumen
16
allows the obstructed gastric fluid to drain; the second is placed in the jejunum for
tube feedings.

COLORECTAL CANCER

Epidemiology

Cancer of the colon and rectum, often called colorectal cancer, is one of the
most common malignancies. It affects both sexes equally and occurs
approximately as often in blacks as in whites. Colorectal cancer, which is second
only to lung cancer in mortality, causes an estimated 61,000 deaths in the United
States each year.
Five-year survival for both colon and rectal cancers has improved in the past
20 years, but remains just over 50% for all stages of disease combined. When their
disease is detected in an early, localized state, 87% of colon cancer patients and
79% of rectal cancer patients survive 5 years or more, compared with 58% and
46%, respectively, of patients with locally advanced or metastatic disease. The
statistics support the need for screening and early detection programs.

RISK FACTORS

Advanced age is strongly associated with the development of colorectal

cancer: the incidence increases after age 40, and more than 94% of all cases occur
after age 50. Individuals at greater risk of developing colorectal cancer include
those with a history of familial polyposis, familial cancer syndromes, inflammatory
bowel disease, or villous adenomatous polyps.
Research indicates that diet may play a role in the development of this
cancer, possibly affecting the interaction of carcinogens with the intestinal mucosa.
Increased intake of dietary fats has been linked to greater incidence of colorectal
cancer. High-fiber diets on the other hand, may work in several ways to decrease
cancer risk-perhaps by protecting the intestinal mucosa from carcinogens that pass
through the bowel.

PATHOLOGY

Tumor configuration may be divided into fungating (exophytic), ulcerating,

stenosing, or constricting (annular, circumferential). Approximately two thirds of
all tumors are ulcerating and one third are fungating. These configurations do not
represent different kinds of tumors but different phases of an orderly progression.
Most malignant bowel tumors start out as a small polyloid lesions. These lesions
17
may grow into the lumen, or into the bowel wall itself. As they grow laterally or
circumferentially, they are termed infiltrating. Right-sided cancer, usually
fungating in nature, tend to grow more into the lumen and extend along ane wall,
especially in the capacious cecum. Left-sided cancers tend to grow more into the
bowel wall and circumferentially, having a typical napkin ring configuration on
barium enema examination. These cancers are thought to start as sessile masses
that gradually span the circumferential lymphatics mayaccasionally leading to
necrosis, ulceration, and perforation. Approximately 95% of the malignant
colorectal tumors are adenocarcinomas.

Ruls for classification

Clinical Staging. Clinical assessment is based on medical history, physical

examination, routine and special roentgenograms, including barium enema,
sigmoidoscopy, colonoscopy with biopsy, and special examinations used to
demonstrate the presence of extracolonic metastasis, for example, chest film, liver
function tests, and liver scans.
Pathologic staging. Colorectal cancer are usually staged after pathologic
examination of the resected specimen and surgical exploration of the abdomen

Definition of TNM

Primary tumor (T)

TX: Primary tumor cannot be assessed
T0: No evidence of primary tumor
Tis: carcinoma in situ (intramucosal, intraepithelial);
T1: tumor confined to mucosa or submucosa
T2: tumor involves muscularis propria but not beyond
T3: Tumor through the muscularis propria into the subserosa, or into
nonperitonealized or perirectal tissues
T4: tumor directly invadesother organs or structures, and/or perforates the visceral
peritoneum. External iliac or common iliac metastatic lymph nodes are considered
M1.

Regional lymph nodes (N)

NX: Regional lymph node(s) cannot be assessed
N0: No regional lymph node metastasis
N1: 1 to 3 metastatic regional lymph nodes
N2: 4 or more metastatic regional lymph nodes

Distant metastasis (M)

MX: Distant metastasis cannot be assessed
M0: No distant metastasis
M1: Distant metastasis

18
b
A limited to the bowel wall;
B extends through the bowel wall;
C involvement of regional limph nodes.
c
A limited to the mucosa;
B1 involving the muscularis propria but not beyond;
B2 through the muscularis propria;
B3 invasion into adjacent organs;
C1/C2/C3 similar to B1/B2/B3 expect regional lymph nodes involved;
D distant metastases.

Stage grouping

Colorectal cancer stage classification

Modified
AJCC (2002)a Dukesb
Astler-Collerc
Stage 0
TisN0M0
Stage I
T1N0M0 A A
T2N0M0 A B1
Stage II
Stage IIA
T3N0M0 B B2
Stage IIB
T4N0M0 B B3
Stage III
Stage IIIA
T1-2N1M0 C C1
Stage IIIB
T3-4N1M0 C C2/C3
Stage IIIC
Any TN2M0 C C1/C2/C3
Stage IV
Any T, any N, M1 D

Histopathologic type
Adenocarcinoma
Well differenciated
Moderately well differenciated
Poorly differenciated
Mucinous carcinoma
Signed ring cell-type
Medullary

19
Adenosquamous carcinoma
Carcinoid
Lymphoma
Melanoma
Sarcoma/Malignant gastrointestinal stromal tumor
Small-cell carcinoma
Squamous cell carcinoma
Undifferenciated carcinoma
Macroscopically, colorectal tumors can be described as ulcerative, polypoid,
annular or infiltrative.

Histopathologic grade
Gx Grade cannot be assessed
G1 Well differentiated
G2 Moderately differentiated
G3 Poorly differentiated
G4 - Undifferentiated

Clinical Presentation

Illustrates the relative distribution of cancers within the colon and rectum.
Symptoms vary according to the location of the tumor. The most common
symptoms are rectal bleeding, a change in bowel habits, abdominal pain or
cramping, and unexplained weight loss or anemia. The American Cancer Society
recommends reporting any of these symptoms to a physician, as well as the
following procedures for asymptomatic individuals: annual digital rectal exams
beginning at age 40, annual testing of stool for occult blood beginning at age 50,
and sigmoidoscopy every 3 to 5 years on the advice of a physician starting at age
50.

Diagnosis

The stool guaiac, or hemoccult, test is inexpensive and can be done either at
the doctor's office or at home. This test is not specific for cancer, and therefore
should be performed in conjunction with the annual rectal examination and
sigmoidoscopy.
Sigmoidoscopy permits inspection and biopsy of suspicious tissues of the
rectum and left side of the colon. There are two types of sigmoidoscopes: rigid and
flexible. If an experienced physician performs a colonoscopy, another colon
examination procedure, the entire colon can be visualized. The sigmoidoscope and
colonoscope can also be used to remove suspicious polyps.
A barium enema is often indicated to evaluate an unexplained abdominal
mass, iron-deficiency anemia (with occult blood in stools), or overt rectal bleeding
without an obvious site of active bleeding in the rectum or anus.

20
 Carcinoembryonic antigen (CEA) is a tumor marker measured in a blood
sample that may indicate the presence of colorectal cancer. Because CEA is not
specific for colorectal cancers, it is more commonly used to evaluate response to
treatment or disease recurrence.
Evaluation of the extent of disease may also require a chest film, liver scan,
computerized axial tomography (CT) scan of the abdomen and pelvis, and
laparotomy. Pretreatment evaluation will also include obtaining a history of polyps,
colorectal cancer, and other cancers.

TREATMENT
Surgery
Historically, surgery has been the primary treatment for colorectal cancers.
The basic surgical principles are removal of the major vascular pedicle feeding the
tumor along with its lymphatics, obtaining a tumor-free margin, and en bloc
resection of any organs or structures attached to the tumor.

Fig. 1. Schem of resection (left and right gemecolectomy)

For rectal cancer adecuate is total mesorectumectomy (TME). TME consist

of sharp dissection of the plane between the endopelvic fasciaand the mesorectum,
with removal of the mesorectum with its intact fascia propria and with preservation
of the pelvic fascia and the autonomic nerve plexus.
Adequate lymph node resection is imperative for adecuate staging and
selection of patients for adjuvant treatment. A minimum of 12 negative lymph node
should be examined to accurately define node negative disease.
Ostomies: A permanent colostomy is seldom needed for cancers of the colon
or upper one-third of the rectum, because improved surgical techniques permit
end-to-end anastomosis of the remaining intestine at a lower level than previously
possible. In some cases, the physician will create a temporary colostomy during
surgery to divert fecal flow until the anastomosis site has adequately healed.
21
Patients and families often have grave concerns about the possibility of a
colostomy. They need to know that the majority of colorectal cancers can be
treated without an ostomy.
Surgical Complications: The most common complication of bowel surgery
is infection. For this reason, thorough preoperative evacuation of stool and
prophylactic administration of antibiotics pre and postoperatively are important to
prevent infection.
Obstruction and perforation are serious complications of colo-rectal cancer.
These can occur as a manifestation of initial or recurring disease or as a result of
adhesions from surgery. In addition, certain surgical procedures involving pelvic
structures can cause sexual dysfunction. For example, partial to complete sexual
dysfunction in males is commonplace after abdominal perineal resection. The wide
dissection necessary involves the nerves governing sexual function. Retrograde
ejaculation occurs after pelvic surgery. In females, dysfunction after surgery is less
common but may occur from post-surgical scarring or contractures. The health care
team should discuss possible complications with patients before surgery.
Radiation Therapy
The disease site may be externally irradiated before, during, or after surgery,
depending on the extent of disease. The sequencing of surgery and radiation in
combination therapy remains controversial. Preoperatively, radiotherapy may
reduce the size of the tumor and improve resectability. Theorectically, preoperative
administration also reduces the number of cancer cells that can spread locally or to
distant sites during surgery.
The major advantage of postoperative radiotherapy is that surgical staging
can be incorporated into treatment planning. After surgery, the tumor bed and
involved lymph nodes or the whole abdomen is irradiated to decrease local
recurrences from residual microscopic disease.
Patients with locally advanced rectal cancers or recurrent disease may receive
intra-operative radiotherapy. This technique permits delivery of a larger dose
(sometimes referred to as a boost) directly to the tumor bed while minimizing the
dose to normal tissues. Radiotherapy is often the primary modality for cases in
which surgery poses an unsuitable risk or is refused. Radiation may also be
employed palliatively to relieve pain, obstruction, and hemorrhage
Chemotherapy
Chemotherapy is generally reserved for patients with advanced inoperable or
recurrent disease, but adjuvant chemotherapy may be used for patients with
resectable tumors who are at risk for recurrent disease. This approach has
improved disease-free survival in several large studies. Researchers are also
studying perioperative portal-vein infusion of chemotherapy because of the high
risk of disseminating tumor cells into the hepatic circulation during surgery.
Another investigational approach used in the management of metastatic disease is
intra-arterial chemotherapy administration to patients with liver metastases.
Follow-up
The detection of asymptomatic recurrence is an important aspect of patient
follow-up. The preferences of the individual physician guide the extent and
22
frequency of follow-up, but a reasonable approach would include a history and
physical examination, fecal occult stool, and sigmoidoscopy every 3 to 4 months
for 3 years and then every 6 months for 2 years. New primary colorectal cancers
can occur in about 5% of patients; patients who have had colorectal cancer may
also be at greater risk for the development of certain other cancers, including
ovarian, cervical, or breast cancer in females. When providing information to
patients after surgery, the nurse should emphasize the value of close follow-up for
the detection of asymptomatic recurrence

TEST
Risk factors for colorectal cancer include:
A. High alcohol intake
B. History of constipation
C. Abdominal bowel habits
D. *Conbination of factors, including diet, genetics, and predisposing factors
such as bowel disorders

2. Reduced dietary fiber promotes carcinogenic changes by:

*A. Increasing the contact time of carcinogenic substances with the colonic
mucosa
B. Promoting growth of polyps
C. Promoting constipation concerns
D. Reabsorbing fluids

3. Recomendation for colon cancer screening include:

A. Digital ractal examination every year
B. Proctosigmoidoscopy every year for patients over age 50
C. Need for persons at high risk to increase screening at an earlier age than the
normal population
D. *Colonoscopy examinations for every rectal bleeding episode

4. The primary location for presentation of colotectal cancer is the:

A. *Rectum
B. Descending colon
C. Transverse colon
D. Ascending colon

5. Late symptoms of colorectal cancer include:

A. Change in bowel habits
B. Blood in the stool
C. *Weight loss
D. Anorexia

23
 CANCER OF THE PANCREAS

Epidemiology

Cancer of the pancreas accounts for 2-3% of all cancers, but is the fourth
most frequent cause of cancer deaths. Pancreatic cancer is more common among
males than females, with the peak incidence occurring at age 60.

Risk Factors

The etiology of the disease remains unclear. Cigarette smoking has been
associated with an increased incidence of pancreatic cancer. Long-term exposure to
certain chemical carcinogens, such as dry cleaning chemicals, or gasoline or
metallurgic fumes, also appears to increase the risk of this cancer. Research has
yielded conflicting data on the causative roles of alcohol and coffee. Although an
increased incidence is observed in patients with chronic pancreatitis and diabetes
mellitus, it has been suggested that the onset of pancreatic insufficiency may occur
months before the cancer becomes clinically apparent.

Pathology

Almost all malignant neoplasms of pancreatic origin (95%) arise from the exocrine
portion of the gland and have light microscopic features consistent with those of
adenocarcinomas.

Definition of TNM

Primary tumor (T)

TX: Primary tumor cannot be assessed
T0: No evidence of primary tumor
Tis: Carcinoma in situ
T1: Tumor limited to pancreasand 2 cm in greatest dimension
T2: Tumor limited to pancreasand >2 cm in greatest dimension
T3: Tumor extends beyond the pancreas but without involvement of the celiac axis
or the superior mesenteric artery
24
T4: Tumor involves the celeac axis or the superior mesenteric artery (unresectable
primary tumor)

Regional lymph nodes (N)

NX: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis
N1: Regional lymph node metastasis

Distant metastasis (M)

MX: Distant metastasis cannot be assessed
M0: No distant metastasis
M1: Distant metastasis

Stage grouping

Stage T N M
Stage 0 Tis N0 M0
Stage IA T1 N0 M0
Stage IB T2 N0 M0
Stage IIA T3 N0 M0
Stage IIB T1-3 N1 M0
Stage III T4 N0-1 M0
Stage IV T1-4 N0-1 M1

Histopathologic type
Duct cell carcinoma
Pleomorphic giant cell catcinoma
Giant cell carcinoma, osteoclastoid type
Adenocarcinoma
Adenosquamous carcinoma
Mucinous (colloid) carcinoma
Cystadenocarcinoma
Acinar cell carcinoma
Papillary carcinoma
Small cell (oat cell) carcinoma
Mixed cell types
Carcinoma, NOS
Undifferentiated carcinoma

Histopathologic grade
Gx Grade cannot be assessed
G1 Well differentiated
G2 Moderately differentiated
G3 Poorly differentiated

25
G4 - Undifferentiated

Clinical Presentation

There are few early signs and symptoms of pancreatic cancer, and this
complicates diagnosis. Many patients wait until symptoms become worse before
visiting a physician. By the time the diagnosis is made, the cancer has spread;
almost half of pancreatic cancer patients have metastatic disease when diagnosed.
Seventy percent of all pancreatic cancers appear in the head of the gland. Early
diagnosis of a tumor in the head of the pancreas is sometimes possible because of
jaundice and pruritus that result from biliary obstruction.
Pain is usually the complaint that motivates patients to seek a physician's
care. Pain may occur well before other signs and symptoms. Almost all patients
with pancreatic cancer will have pain at some point in their disease, caused by
pressure from the tumor or by infiltration of the splenic nerves. Patients with
cancer in the body or tail of the pancreas frequently experience back or abdominal
pain. This pain may lessen after meals or when patients assume the fetal position.
Other symptoms of pancreatic cancer include anorexia, weight loss, abdominal
distention, diarrhea, and nausea.

Diagnosis

Diagnosis is made by physical and radiologic examination. Patients may

exhibit obstructive jaundice. Physical exam will frequently reveal an enlarged
liver, palpable gallbladder, and a mass in the upper abdomen. Computerized
tomography (CT) scan and ultrasound are used to determine the extent of tumor
invasion. Endo-scope retrograde cholangiopancreatogram (ERCP) is used to
localize the tumor or document blockage of pancreatic ducts. In patients with
metastatic or unresectable disease who are not candidates for surgery, a CT-guided
needle biopsy of the pancreas may be performed to confirm the malignancy.

Treatment:
Surgical resection is performed only when disease is localized and the
potential for cure exists. Most commonly, a Whipple procedure
(pancreatoduodenectomy) will be performed.

26
 Fig. 2 Pancreatoduodenectomy

Surgery is not done if disease has spread beyond the pancreas. Palliative
bypasses (such as cholecystqjejunostomy) are performed when obstruction is
present and cure is not possible.
Patients who have had curative surgery must take supplemental pancreatic
enzymes orally before eating for the remainder of their lives. Total pancreatectomy
will render the patient an insulin-dependent diabetic. Patients need instruction
about enzyme use and diabetic care.
Radiation can be used postoperatively to eradicate remaining disease or for
palliation. Radioactive implants and intraoperative radiation may also be used to
deliver higher doses of radiation directly to the tumor. Depending on the dose and
extent of the field involved, gastrointestinal distress frequently accompanies
radiation.
Inoperable carcinomas can sometimes be temporarily palliated with
combined radiotherapy and chemotherapyusually 5-fluorou-racil (5-FCI) and
mitomycin or doxorubicin and streptozocin. Combination chemotherapy has
produced better results than single-agent therapy, although the 5-year survival rate
for patients with extensive disease is less than 9%. Many patients with adenocarci-
noma of the pancreas die within a year of diagnosis.
An islet cell neoplasm is a rare form of cancer that arises from the endocrine
parenchyma. These neoplasms, which can occur in any portion of the pancreas, are
usually small, well circumscribed, and rarely extend beyond the pancreas. Surgical
resection followed by adjuvant chemotherapy is the standard treatment regimen for
islet cell carcinomas.
27
 CANCER OF THE LIVER

Epidemiology

Cancer of the liver is a rare malignancy in most countries, but in parts of

Asia and Africa it is one of the most common malignancies.
There is a strong association between chronic hepatitis infection and the
development of hepatocellular carcinoma. People with cirrhosis also have an
increased risk of liver cancer. Other possible hepatocarcinogens include aflatoxin,
nitrosamines, oral estrogen compounds, and numerous other chemicals.

Risk Factors

Chronic HBV infection has been established as a risk factor for development
of HHC. HCV infection increases risk of HCC is well established, but the
underlying mechanissm is unclear. Cirrhosis from nonviral causes is associated
with elevated HCC risk. Consumption of food cantaminated with aflatoxins, toxic
metabolites of some species of Aspergillus fungi, is associated both with human
28
hepatocellular carcinoma. Foods susceptible to Aspergillus infection include
peanuts, corn, oil, soi products increased rates of HCC. Some studies seen that
steroid hormones, smoking, hemohromatosis increased rates of HCC.

Pathology

The staging system applies to all primary carcinomas of the liver. These
include hepatomas or hepatocellular carcinomas and intrahepatic bile duct
carcinomas or cholangiocarcinomas and mixed types.

Rules for classification

T categories are based on the numer of tumor nodules, the size of the largest
nodule (2 cm is the discrinating limit), and the presence of vascular invasion. the
staging system does not consider etiologic mechanisms such as whether multiple
nodules represent multiple, independent primary hepatic carcinoma.
Because of tendency for vascular invasion, imaging of the liver is important for
staging primary hepatocellular carcinomas, unless distant metastasis is present at
the time of diagnosis.

Definition of TNM

Primary tumor (T)

TX: Primary tumor cannot be assessed
T0: No evidence of primary tumor
T1: Solitary tumor 2 cm or less in greatest dimension without vascular invasion
T2: Solitary tumor 2 cm or less in greatest dimension with vascular invasion, or
Multiple tumors limited to one lobe, none more than 2 cm in greatesd dimension
without vascular invasion, or A solitary tumor more than 2 cm in greatest
dimension without vascular invasion
T3: Solitary tumor more than 2 cm in greatest dimension whith vascular invasion,
or Multiple tumors limited to one lobe, none more than 2 cm in greatest dimension,
with vascular invasion, or Multiple tumors limited to one lobe, any more than 2
cm in greatest dimension, with or without vascular invasion
T4: Multipli tumors in more than one lobe, or tumor(s) involve(s) a major branch
of portal or hepatic vein(s)

Regional lymph nodes (N)

NX: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis
N1: Regional lymph node metastasis

Distant metastasis (M)

MX: Distant metastasis cannot be assessed
M0: No distant metastasis
29
M1: Distant metastasis

Stage grouping

Stage T N M
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage IIIA T3 N0 M0
Stage IIIB T1-3 N1 M0
Stage IVA T4 Any N M0
Stage IVB Any T Any N M1

Histopathologic grade
Gx Grade cannot be assessed
G1 Well differentiated
G2 Moderately differentiated
G3 Poorly differentiated
G4 Undifferentiated

Clinical Presentation

Signs of liver cancer include weakness, anorexia, fever of unknown origin,

abdominal fullness or bloating, and dull upper quadrant abdominal pain. The
clinical presentation will vary depending on the presence or absence of cirrhosis.
Patients with cirrhosis exhibit rapid onset of symptoms; in the absence of cirrhosis,
signs are much more subtle. As the tumor grows, pain may radiate to the back.
Patients must be assessed carefully, as weight loss is often obscured by ascites. The
liver is generally tender to palpation, and jaundice and portal hypertension may be
present.

Diagnosis

Diagnosis is made using radioisotope scans, CT scans, or hepatic

arteriography. Many patients will have advanced disease at diagnosis. Cancer of
the liver spreads throughout the organ and invades the portal vein and lymphatics.
The most common sites of distant metastases are the lungs and brain.

Treatment:

Surgical resection is attempted if no nodal involvement or distant spread is

found. Even with resection, recurrence of liver cancer is common, and 5-year
survival is rare. Patients may be treated with chemotherapy infused directly into
the hepatic circulation. With this type of treatment, a catheter is surgically placed
in the hepatic artery and the chemotherapeutic agent is continuously infused. The
most commonly used agents are 5-FU, doxo-rubicin, and methotrexate. Side
30
effects of this technique include toxic hepatitis (which subsides after
discontinuation of therapy), and catheter displacement or occlusion.
Radioimmunotherapy is an experimental form of treatment used for some
types of liver cancer. A radioactive isotope is attached to a radiolabeled antibody
against ferritin, a specific protein found in human liver tumors. The isotope is
given intravenously and concentrates in the liver, where it radiates the tumor
internally. No immediate treatment side effects have been noted, but thrombo-
cytopenia and neutropenia occur 4 to 6 weeks after treatment.
The prognosis for liver carcinoma patients is poor. Untreated patients
usually die in 3 to 4 months; treated patients may live 6 to 18 months if they
respond to therapy. Long-term survival is seen occasionally after successful
subtotal hepatectomy for noninvasive carcinoma. Because the normal metabolic
and storage functions of the liver are impaired, patients are at risk for nutritional
and bleeding complications.

CANCER OF THE GALLBLADDER

Epidemiology

Carcinoma of the gallbladder accounts for 0.2 to 0.4% of all malignancies. It

is seen more frequently in women than in men, with the incidence increasing in
those over age 55. Because the disease is usually advanced at diagnosis, the
prognosis is poor, with 5-year survival rates of less than 5%.

Risk Factors

Cholelithiasis has been linked to the development of cancer of the

gallbladder. Approximately 60 to 90% of these patients have a history of biliary
calculi.

Pathology

31
 The staging system does not apply to carcinoid tumors or to sarcomas.
Adenocarcinomas are the most common type (85%). Pure squamous cancer or
mixed carcinomas with glandular and squamous elements in 10%/ About 5% of the
cases have neither squamous nor glandular differentiation and by light microscopy
are found to be true sarcomas.

Rules for Classification

The staging classification depends on the depth of tumor penetration into the
wall of the gallbladder, the extent of invasion into the liver, and the number of
adjacent organs involved with regional spread of the tumor.

Definition of TNM

Primary tumor (T)

TX: Primary tumor cannot be assessed
T0: No evidence of primary tumor
T1a: Tumor invades mucosa
T1b: Tumor invades muscle
T2: Tumor invades perimuscular connective tissue, no extension beyond serosa or
into liver
T3: Tumor invades beyond serosa or into one adjacent organ or both (extension <2
cm into liver)
T4: Tumor extends >2 cm into liver and/or into two or more adjacent organs
(stomach, duodenum, colon, pancreas, omentum, extrahepatic bile ducts).

Regional lymph nodes (N)

NX: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis
N1: Regional lymph node metastasis
N1a: Metastasis in cystic duct, pericholedochal, and/or gastrohepatic lymph nodes
N1b: Metastasis in peripancreatic, periduodenal, periportal, caliac, and/or superior
mesenteric artery lymph nodes.

Distant metastasis (M)

MX: Distant metastasis cannot be assessed
M0: No distant metastasis
M1: Distant metastasis

Stage grouping

Stage T N M
Stage I T1a-b N0 M0
Stage II T2 N0 M0
Stage III T1-3 N1 M0
32
Stage IV Any T Any N M1

Histopathologic type
Carcinoma in situ
Adenocarcinoma
Papillary adenocarcinoma
Adenocarcinoma, intestinal type
Mucinous adenocarcinoma
Clear cell adenocarcinoma
Signet-ring cell carcinoma
Adenosquamous carcinoma
Squamous cell carcinoma
Small cell (oat cell) carcinoma
Undifferentiated carcinoma

Histopathologic grade
Gx Grade cannot be assessed
G1 Well differentiated
G2 Moderately differentiated
G3 Poorly differentiated
G4 Undifferentiated

Clinical Presentation

Symptoms of the disease mimic acute and chronic cholecystitis, with right
quadrant abdominal pain, anorexia, weight loss, nausea, vomiting, and fever as the
chief complaints. About 50% of patients exhibit jaundice and gallbladder
enlargement.

Diagnosis

Because radiologic and laboratory tests lack specificity, the diagnosis is

generally confirmed by laparotomy. Direct extension to the liver is common; other
metastatic sites include the lymph nodes, lungs, bone, and the adrenal glands.

Treatment:

Treatment for cancer of the gallbladder includes cholecystectomy with

subtotal hepatectomy if distant metastases are absent. Most patients have local
recurrences. Radiation and/ or chemotherapy may be used for local control, but
palliation of obstructive jaundice remains the primary treatment goal.

33
BIBLIOGRAPHY

1. Rubin Ph. Clinical Oncology. A Multidisciplinary approach for physicians

and students. 7th Edition // W.B. Saunders company. 1993. P.791
2. Alberts S.R., Cervantes A., van de Velde J.H. Gastric cancer: epidemiology,
pathology and treatment // Annals of Oncology. 2003. 14. P.31-36
3. Manual for staging of cancer / American joint committee on cancer $
sponsoring organization, American Cancer Society ... [et al.]; edited by
Oliver H. Beahrs ... [et al.]. 4th ed.
4. Vincent T DeVita, Samuel Hellman, Steven A. Rosenberg Cancer, principles
and practice of oncology // 3rd edition. 2490 p.

34