esophageal tumors cengiz pata gastroenterology, yeditepe university, istanbul
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Esophageal TumorsEsophageal Tumors
Cengiz PataCengiz Pata
Gastroenterology, Yeditepe Gastroenterology, Yeditepe University, IstanbulUniversity, Istanbul
Bening esophagial tumorsBening esophagial tumors LeiomyomaLeiomyoma HemangiomaHemangioma Granuller cell tumorGranuller cell tumor Congenital cell tumorCongenital cell tumor Fibrovasculer polypFibrovasculer polyp Bronchogenic cystBronchogenic cyst Eosinophilic granulomaEosinophilic granuloma LymphangiomaLymphangioma Squamose cell papillomaSquamose cell papilloma lipomalipoma
epidemiologyepidemiology
60-70 years60-70 years4/1 towards to men4/1 towards to men5-10/100.0005-10/100.0007. ca mortality in men7. ca mortality in menSquamose cell carcinoma(80%), Squamose cell carcinoma(80%),
adenocarsinoma, sarcomas, lymphoma, adenocarsinoma, sarcomas, lymphoma, malignt melanomemalignt melanome
etiologyetiologySquamose CaSquamose Ca Alchol, tabaccoAlchol, tabacco NitrosemanineNitrosemanine RadiationRadiation AchalasiaAchalasia TylosisTylosis Plummer Winson syndromePlummer Winson syndrome RadiationRadiation HPVHPVAdenocaAdenoca Baret’s (5% malignancy)Baret’s (5% malignancy) GERD (85% baret’s)GERD (85% baret’s) ObesityObesity SclerodermaScleroderma
Clinacal presentationClinacal presentation 1/3 upper esophagus 15%, middle 50%1/3 upper esophagus 15%, middle 50% Progressive dysphagia (firstly solid)Progressive dysphagia (firstly solid) OdynofagiaOdynofagia Back painBack pain AnorexiaAnorexia Weight lossWeight loss RegurgitaionRegurgitaion Voice changeVoice change Aspritaion/pnomoniaAspritaion/pnomonia hematemesishematemesis
prognosisprognosis
>5 cm involvement>5 cm involvementLymph node metastas (5 year survival Lymph node metastas (5 year survival
%20)%20)Small cell, malign melanomaSmall cell, malign melanoma
diagnosisdiagnosis
EndoscopyEndoscopyBarium graphyBarium graphyChest radiogramChest radiogramCTCTEUSGEUSG
treatmenttreatment
Surgery (only %40)Surgery (only %40) RadiationRadiation CheomoradiationCheomoradiation DilataionDilataion AblationAblation Photodynamic thrapyPhotodynamic thrapy EMR (<3cm)EMR (<3cm) StentsStents
Tumors of StomachTumors of Stomach
Cengiz Pata, M.DCengiz Pata, M.DGastroenterology Department, Yeditepe UniversityGastroenterology Department, Yeditepe University
IstanbulIstanbul
HISTOLOGYHISTOLOGY
95% 95% AdenocarcinomaAdenocarcinoma- papiller- papiller
- tubular- tubular
- mucinous- mucinous
4%4% Adeno-squamousAdeno-squamous
< 1%< 1% SquamousSquamous
< 1%< 1% undifferentiatedundifferentiated
Stomach CarcinomaStomach Carcinoma
EpidemiologyEpidemiologyChronic A-GastritisChronic A-GastritisChronic B-Gastritis (HP)Chronic B-Gastritis (HP)BI, BII resectionBI, BII resectionPolyposisPolyposisChr. Ulcer VentriculiChr. Ulcer VentriculiM, MenetrierM, MenetrierBlood Group ABlood Group AMen > WomenMen > Women
MacroscopicMacroscopic(Borrmann Classification)(Borrmann Classification)
I.I. PolypousformPolypousform
II.II. UlceratedUlcerated
III.III. Ulcerated-infiltrativeUlcerated-infiltrative
IV.IV. Diffuse-infiltrativeDiffuse-infiltrative
Early Cancer JapanEarly Cancer Japan
I.I. ProtrusionProtrusion
II. Surface (II. Surface (, , , , ))
III. ExcavatedIII. Excavated
TherapyTherapy
Radical Tumour ResectionRadical Tumour ResectionSt. OpSt. Op : : GastrectomyGastrectomy
LymphadenectomyLymphadenectomyOmentum major +Omentum major +
minorminorSplenectomySplenectomy
Antrum CaAntrum Ca : partial resection ? : partial resection ?Primary inoperable neoplasmPrimary inoperable neoplasm
chemotherapychemotherapyradiationradiation
PrognosisPrognosis
5 year rate5 year rate
Carcinoma in citu 100 %Carcinoma in citu 100 %
Early Ca : 90 %Early Ca : 90 %
Small intestine tumorsSmall intestine tumors
Cengiz Pata, M.DCengiz Pata, M.DGastroenterology Department, Yeditepe UniversityGastroenterology Department, Yeditepe University
IstanbulIstanbul
clasificationclasification Adenoca %35-50, proximalAdenoca %35-50, proximal Carcinoid TM %20-40 apendix, ileumCarcinoid TM %20-40 apendix, ileum Lymphoma %14Lymphoma %14-MALTOMA-MALTOMA-IPSID-IPSID-EATCL (after the gluten enteropathy %7-10)-EATCL (after the gluten enteropathy %7-10)-multiple Lymphoid Poliposis-multiple Lymphoid Poliposis-Periferal Nodal lenfoma-Periferal Nodal lenfoma FibrosarkomFibrosarkom AngiosarkomAngiosarkom LiposarkomLiposarkom LeiyomyosarkomLeiyomyosarkom
Bening (41%)Bening (41%)
AdenomaAdenomaGISTGISTHamartomaHamartomaAngiomaAngiomaPseudotumor (brunner gland hyperplasia, Pseudotumor (brunner gland hyperplasia,
pancreatic rest,endometrioma, pancreatic rest,endometrioma, hyperplastic polypshyperplastic polyps
Malign (51%)Malign (51%)
Carcinoids tumors (25-45%)Carcinoids tumors (25-45%)GIST (15-25%)GIST (15-25%)Adenocarcinoma (30-40%)Adenocarcinoma (30-40%)Lymphoma (4-10% )Lymphoma (4-10% )Metastatic carcinomaMetastatic carcinomaMalign melanomaMalign melanoma
NETNET
APUD (Amine precursor uptake and APUD (Amine precursor uptake and decarboxylation) celldecarboxylation) cell
IntroductionIntroduction
İntestine and pancreas İntestine and pancreas İncidance 1/ İncidance 1/ 100,000100,000Carcinoid %Carcinoid %5050
ClinicsClinics
tumor syndrome hormone localisation
Carcinoid Carcinoid syndrome Serotonin, taşikinin, bradikinin, histamin
Mmidintest ne
VIPoma Diorhea, achloirdi (WDHA)
Vazoaktif intestinal peptid (VIP)
pancreas alung
Glukagonoma Glucogonoma a
Glukagon Pankreas, duodenum
Gastrinoma Zollinger-Ellison sendromu
Gastrin Pankreas, duodenum
Insülinoma ghypoglycemia Insülin Pankreas
Zollinger Ellison SyndromeZollinger Ellison Syndrome
Severe peptic ulcer diathesis + gastric Severe peptic ulcer diathesis + gastric acid hypersecretion due to acid hypersecretion due to -cell -cell endocrine tumor endocrine tumor
0.1-1% of PUD patients 0.1-1% of PUD patients
Sporadic, or associated with MEN type I Sporadic, or associated with MEN type I (25%)(25%)
Zollinger Ellison SyndromeZollinger Ellison Syndrome
>80% Localized to gastrinoma triangle:>80% Localized to gastrinoma triangle:cystic & common bile ducts, duodenum, cystic & common bile ducts, duodenum, junction head and body of pancreas. junction head and body of pancreas.
60 % malignant, up to 50% with metastasis60 % malignant, up to 50% with metastasis
Clinical: PUD >90%Clinical: PUD >90% (recurrent, multiple, refractory, complicated) (recurrent, multiple, refractory, complicated)
Clinical features of Zollinger-Clinical features of Zollinger-Ellison syndromeEllison syndrome
MEN I MEN I Autosomal Dominant:Autosomal Dominant:
Parathyroid (~90%), Pancreas (40-80%)Parathyroid (~90%), Pancreas (40-80%)Pituitary (30-60%)Pituitary (30-60%)
Contributory effect of Contributory effect of hyperparathyroidism, hypercalcemia hyperparathyroidism, hypercalcemia hypergastrinemia hypergastrinemia acid secretion acid secretion
Higher incidence of carcinoids Higher incidence of carcinoids
Smaller and multiple duodenal Smaller and multiple duodenal gastrinomas gastrinomas
Diagnosis of Gastrinoma Diagnosis of Gastrinoma
Combination of clinical signs Combination of clinical signs Fasting gastrin levels (> 150 pg/ml) Fasting gastrin levels (> 150 pg/ml) Avoid confounding factorsAvoid confounding factors
(hypochlorhydria, PPIs, outlet obstruction, (hypochlorhydria, PPIs, outlet obstruction, renal failure) renal failure)
Assess acid secretion (if low- excludes)Assess acid secretion (if low- excludes)Provocative tests (calcium, secretin)Provocative tests (calcium, secretin)
Treatment Treatment
Localization (EUS, Oct scan, MRI, CT)Localization (EUS, Oct scan, MRI, CT)
Exclusion of metastasisExclusion of metastasis
If positive – symptomatic cureIf positive – symptomatic cure
If negative attempt surgical resection If negative attempt surgical resection ( less likely in MEN I ~ 6%) ( less likely in MEN I ~ 6%)
NETNET Diagnosis Diagnosis
ClinicsClinicsHistopaHistopathologythologyHormon levelHormon levelStimStimulating testulating testRadyologyRadyology
NET treatmentNET treatment
Image courtesy of Dr. L. Anthony.
SurgerySurgery(total excision difficult(total excision difficult))Stopping tumor growthStopping tumor growth AndAndBetter life Better life
SurgerySurgery(total excision difficult(total excision difficult))Stopping tumor growthStopping tumor growth AndAndBetter life Better life
NETNET, medical treatment, medical treatment
SomatostatinSomatostatinee
iinterferonnterferonee
CheomothreapyCheomothreapy
Carcinoid tumore Carcinoid tumore syndromesyndrome
Carcinoid tumorCarcinoid tumor
GIGIS system end respiratory systemS system end respiratory system İncidance İncidance 100,000100,000 1/2 1/2 ApeApenndectomdectomyy and diag and diagnnose !ose !
Carcinoid tumor Carcinoid tumor
Asymptomatic (up to liver metastase )Asymptomatic (up to liver metastase )– dyspepsiadyspepsia
– misdiagnosismisdiagnosis
Carcinoid syndromeCarcinoid syndrome ( (diseasedisease) )
%10%10LLarge, metastatic poor survivearge, metastatic poor survive
Carcinoid syndromeCarcinoid syndrome
serotonineserotonine
Carcinoid sendrom Carcinoid sendrom –– symptomssymptoms
Artriis(%7)Artriis(%7)
Dermatitis(%5)Dermatitis(%5)
Diarrhea(%68–84)Diarrhea(%68–84)
cyanose(%18)cyanose(%18)
Heart disease(%14–41)Heart disease(%14–41)
flushing(%63–94)flushing(%63–94)
Telanjektzy(%25)Telanjektzy(%25)
Bronkokonstriksiyon(%3–19)Bronkokonstriksiyon(%3–19)
Abdominal pain(%10–55)Abdominal pain(%10–55)
Attack of CarcinoidAttack of Carcinoid
4040
5-HIAA 5-HIAA Carcinoid tumor Carcinoid tumor
5-HIAA5-HIAA,, serotoninineserotoninineUrinary expression of Urinary expression of 5-HIAA5-HIAA
DiagnosisDiagnosis
Pathology(Pathology( arg argininooffil il andand argentaffin argentaffin ))Biochemical (Biochemical (5-HIAA, 5-HIAA, chchromogranin A)romogranin A) OctreoScanOctreoScan®*®*,,CT, MRCT, MRBBronronchoscopychoscopy, gastros, gastroscopy, copy,
colonoscopycolonoscopy
survivesurvive
Vinik A, et al. Dig Dis Sci. 1989; 34(suppl): 14S–27S.
treatmenttreatment
Carcinoid disease treatmentCarcinoid disease treatment
Carcinoid tumor follow upCarcinoid tumor follow up
Every year• 5-HIAA• Chromogranin A• Pre-operative marker• Abdominal CT (6-12
mounths)
Every year• 5-HIAA• Chromogranin A• Pre-operative marker• Abdominal CT (6-12
mounths)
Every 4 - 6 mounths• 5-HIAA• Chromogranin A• Follow up high marker
Every 6 - 12 muonths• Abdominal CT• Echocardiography
Every 4 - 6 mounths• 5-HIAA• Chromogranin A• Follow up high marker
Every 6 - 12 muonths• Abdominal CT• Echocardiography
• OctreoScan®• OctreoScan®
AsymtomaticAsymtomatic SymtpmaticSymtpmatic
Treatment, Treatment, Sandostatin Sandostatin
Long activation (every mounths)Long activation (every mounths)Binding Sst-2/sst-5 receptorBinding Sst-2/sst-5 receptor%70 and %80%70 and %80Activation of these receptorActivation of these receptor
SandostatinSandostatinSandostatinSandostatin
Adapted from Lancranjan I, et al. Metabolism. 1995;44(suppl 1):18–26.
• Theropatic level:7 - 11 day
• One mounths
• Theropatic level:7 - 11 day
• One mounths
Effect of 5 IHAA Effect of 5 IHAA
Supress to 50%Supress to 50%
*L
1. Rubin J, Ajani J, Schirmer W, et al. J Clin Oncol. 1999;17:600–6.
2. The Medical Network. Healthcarenews. http://www.themedicalnetwork.org/full_magazine/june2003-p28–40.pdf.
defecation flushingdefecation flushing
SCN = screening (tarama); BASE = baseline (başlangıç).Rubin J, et al. J Clin Oncol. 1999;17:600–6.
diarheadiarhea
diarheadiarhea
1. Rubin J, Ajani J, Schirmer W, et al. J Clin Oncol. 1999;17:600–6.
2. The Medical Network. Healthcarenews. http://www.themedicalnetwork.org/full_magazine/june2003-p28–40.pdf.
SurviveSurvive before afterbefore after
Anthony LB, et al. Digestion. 1996;57(suppl 1):50–3.
adenocarcinomaadenocarcinoma
High animal fat and protein, bile acid, High animal fat and protein, bile acid, polyposis syndrome, crohn disease, celiac polyposis syndrome, crohn disease, celiac diseasedisease
Crampy periumblical pain, bloating, nausea,Crampy periumblical pain, bloating, nausea,
Bleeding, obstruction, intussiception, Bleeding, obstruction, intussiception, volvulus, weight lessionsvolvulus, weight lessions
5 year survive %20-355 year survive %20-35
Cheomotherapy, surgeryCheomotherapy, surgery
lymphomalymphoma T cell lyphoma (celiac)T cell lyphoma (celiac) MALTomaMALToma Multiple lymphoid polyposisMultiple lymphoid polyposis Difuse large cellDifuse large cell Small noncleaved lymphomaSmall noncleaved lymphoma
(malabsorbtion: T cell, others: obstruction, pain, (malabsorbtion: T cell, others: obstruction, pain, mass unless bacterial overgrowth)mass unless bacterial overgrowth)
IPSIDIPSID
IPSIDIPSID
alfa chain disease (west type lymphoma )alfa chain disease (west type lymphoma ) beningn or low grade lymphomabeningn or low grade lymphoma IgAIgA 15-25 year15-25 year severe diarhea, abdominal pain, weight loss, feversevere diarhea, abdominal pain, weight loss, fever Double bloon endoscopy,band alfa2 or beta in Double bloon endoscopy,band alfa2 or beta in
electrophoresis, electrophoresis, Early stage antibiotics (tetracyline plus Early stage antibiotics (tetracyline plus
metranidazole 6-12 mounts)metranidazole 6-12 mounts) Malignant chance occurs: cheomathrapyMalignant chance occurs: cheomathrapy
GISTGIST Nonepithelial neoplasmsNonepithelial neoplasms Primitive mesencymal cellsPrimitive mesencymal cells Leiomyoma, schwanoma,leiyomyosarcoma Leiomyoma, schwanoma,leiyomyosarcoma
(70%), leiomyoblastoma, myofibroblastic tumor(70%), leiomyoblastoma, myofibroblastic tumor All segments of GIS, 60% stomach, 30% intestineAll segments of GIS, 60% stomach, 30% intestine Prognose: size>5cm, mitotic count 1-5 per 10 Prognose: size>5cm, mitotic count 1-5 per 10
high power, presence of c kit genehigh power, presence of c kit gene bleedingbleeding 5 year survive 25-30%5 year survive 25-30% Radiotion, cheomotherapy (tyrosinase kinaseRadiotion, cheomotherapy (tyrosinase kinaseİnhibitor –St1-571)`, surgeryİnhibitor –St1-571)`, surgery