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Radha Tamerisa, MD, Gastroenterology Fellow,
Division of Gastroenterology, University of Texas Medical
Branch, Galveston, TX
Manoop S. Bhutani,MD,FACG,FACP, Director, Center for Endoscopic
Ultrasound, Co-Director, CERTAIN(Center for Endoscopic Research,
Training and Innovation), University of Texas Medical Branch,
Galveston, TX
ESOPHAGEAL CANCER (CARCINOMA)
1. What is the esophagus?
The esophagus is a tube that connects the mouth and throat
with the stomach ("food pipe"). When a person swallows, the
muscular wall of the esophagus contracts to help push food
down to the stomach. There are two main types of cancer that
can occur in the esophagus. Squamous cell carcinoma occurs
more commonly in the upper or middle part of the esophagus.
Adenocarcinoma occurs in the lower part of the esophagus.
2. Who gets esophageal cancer?
Studies show that esophageal cancer is more commonly diagnosed
in people over the age of 55 years. Men are affected twice
as commonly as women. Squamous cell esophageal cancer is more
common in African Americans than Caucasians. On the other
hand, adenocarcinoma appears to be more common in middle-aged
Caucasian men.
The exact cause is unknown; however there are well-recognized
risk factors. In the US, alcohol, smoking and obesity are
the major risk factors. Stopping drinking and smoking may
reduce the chance of getting esophageal cancer as well as
other types of cancers. Sometimes adenocarcinoma of the esophagus
runs in families.
The risk of cancer of the esophagus is also increased by
irritation of the lining of the esophagus. In patients with
acid reflux, where contents from the stomach back up into
the esophagus, the cells that line the esophagus can change
and begin to resemble the cells of the intestine. This condition
is knows as Barrett's esophagus. Those with Barrett's esophagus
have a higher risk of developing esophageal cancer.
Less common causes of irritation can also increase the chance
of developing esophageal cancer. For example, people who have
swallowed caustic substances like lye can have damage to the
esophagus that increases the risk of developing esophageal
cancer.
3. What are the symptoms of esophageal
cancer?
Very small tumors at an early stage do not generally cause
symptoms. Patients commonly experience difficulty swallowing
as the tumor gets larger and the width of the esophagus becomes
narrowed. At first, most have trouble swallowing solid foods
such as meats, breads or raw vegetables. As the tumor grows,
the esophagus becomes more narrowed causing difficulty in
swallowing even liquids. Cancer of the esophagus can also
cause symptoms of indigestion, heartburn, vomiting and choking.
Patients may also have coughing and hoarseness of the voice.
Involuntary weight loss is also common.
4. How is esophageal cancer diagnosed?
The doctor will generally start by taking a complete history
and performing a physical examination. An esophagram, also
called a barium swallow, is a series of x-rays of the esophagus.
The patient is asked to drink a barium solution, which coats
the inside of the esophagus. Multiple x-rays are then taken
to look for changes in the shape of the esophagus.
Most patients undergo a test called endoscopy where a thin
flexible lighted instrument with a camera at the end is passed
through the mouth into the esophagus. This scope allows the
doctor to see the inner layer of the esophagus. Biopsies can
be taken during this procedure if needed and submitted to
the pathologist for examination under a microscope to detect
cancer cells.
A CT scan of the neck, chest and abdomen may help to identify
if there is any spread of the cancer to other organs in the
body so that the doctor can determine appropriate management.
Endoscopic ultrasound is a newer technique that can be used
to provide detailed assessment of the depth of the tumor and
involvement of adjacent lymph nodes. This instrument is similar
to the endoscope above except there is ultrasound embedded
at the tip of the scope.
5. What is the treatment for esophageal
cancer?
Depending on the stage of esophageal cancer the patient may
undergo surgery, radiation and/or chemotherapy. Other measures
that may improve symptoms include stretching or dilation,
tube prosthesis (stent) and radiation or laser treatment to
reduce the size of the cancer.
Doctors are actively looking at new ways of combining various
types of treatment to see if they may have a better effect
on treating esophageal cancer. Many patients with esophageal
cancer undergo some form of combination therapy with surgery,
radiation and chemotherapy.
STOMACH CANCER (GASTRIC
CANCER)
1. What is the stomach?
The stomach is part of the digestive system and connects
the esophagus to the small intestine. Once food enters the
stomach the muscles in the stomach help to mix and mash the
food using a motion called peristalsis.
2. Stomach cancer
Stomach cancer can develop in any part of the stomach and
can spread throughout the stomach and to other organs such
as the small intestines, lymph nodes, liver, pancreas and
colon.
3. Who gets stomach cancer?
No one knows the exact reason why a person gets stomach cancer.
Researchers have learned that there are certain risk factors
associated with the development of stomach cancer. Those over
the age of 55 years are more likely to get stomach cancer.
Men are affected twice as often as women and African Americans
are affected more commonly than Caucasians.
Stomach cancer is more common in some parts of the world
such as Japan, Korea, parts of Eastern Europe and Latin America.
Some studies do suggest that a type of bacteria known as Helicobacter
pylori, which can cause inflammation and ulcers in the stomach,
can be an important risk factor for developing gastric cancer.
Studies show that people who have had stomach surgery or
have a condition such as pernicious anemia, or gastric atrophy
(which result in lower than normal production of digestive
juices) can be associated with an increased risk of developing
gastric cancer.
There is also some evidence that smoking increases the risk
of developing gastric cancer.
4. What are the symptoms of gastric cancer?
Patients may not have any symptoms in the early stages and
often the diagnosis is made after the cancer has spread. The
most common symptoms include:
- Pain or discomfort in the abdomen
- Nausea and vomiting
- Loss of appetite
- Fatigue or weakness
- Bleeding (vomiting blood or passing blood in stools)
- Weight loss
- Early satiety (cannot eat a complete meal because of a
“full feeling”)
5. How is gastric cancer diagnosed?
In addition to taking a complete history and performing a
physical exam, your doctor may do one or more of the following
tests:
Upper GI series- The patient is asked to drink a barium
solution. Subsequently x-rays of the stomach are taken. The
barium outlines the inside of the stomach helping to reveal
any abnormal areas that may be involved with cancer. This
test is used less often than it used to be, and patients now
often undergo endoscopy (see below) first.
Endoscopy- A lighted, flexible tube with a camera,
called an endoscope, is inserted through the mouth into the
esophagus and then into the stomach. Sedation is given prior
to insertion of the endoscope. If an abnormal area is found,
biopsies (tissue samples) can be taken and examined under
a microscope to look for cancer cells.
If cancer is found, the doctor may schedule additional staging
tests to determine if the cancer has spread. A CT scan may
be used to determine if cancer has spread to the liver, pancreas,
lungs or other organs near the stomach.
Staging of gastric cancer may also be performed by using
endoscopic ultrasound. Endoscopic ultrasound can help to determine
the depth of spread of the tumor into the wall of the stomach
and involvement of adjacent structures as well as assess for
any enlarged lymph nodes that may be invaded with cancer cells.
6. What is the treatment for stomach
cancer?
Treatment plans may vary depending on the size, location,
extent of tumor and the patient's overall health. Treatments
include surgery, chemotherapy and /or radiation therapy.
Surgery is the most common treatment. The surgeon can remove
part of the stomach (gastrectomy) or the entire stomach. Lymph
nodes near the tumor are generally removed during surgery
so that they can be checked for cancer cells.
Researchers are exploring the use of chemotherapy before
surgery to help shrink the tumor and after surgery to help
kill residual tumor cells. Chemotherapy is given in cycles
with intervals of several weeks depending on the drugs used.
Radiation therapy is the use of high-energy rays to damage
cancer cells and stop them from growing. Radiation destroys
the cancer cells only in the treated area.
Doctors are looking at the combination of surgery, chemotherapy
and radiation therapy to see what combination would have the
most beneficial effect.
LIVER CANCER (HEPATOCELLULAR
CARCINOMA)
1. What is the liver?
The liver is one of the largest organs in the body, located
in the upper right portion of the abdomen. The liver has many
important functions, including clearing toxins from the blood,
metabolizing drugs, making blood proteins, and making bile
which assists digestion.
2. What is hepatocellular carcinoma (HCC)?
Hepatocellular carcinoma is a cancer that arises in the liver.
It is also known as hepatoma or primary liver cancer.
3. How common is liver cancer?
HCC is the fifth most common cancer in the world. Recent
data shows that HCC is becoming more common in the US. This
rise is thought to be because of chronic hepatitis C, an infection
that can cause HCC.
4. Who gets HCC?
It is well established that individuals with the hepatitis
B and/or hepatitis C virus infection are at increased risk
of developing HCC. Alcohol related liver disease is also a
risk factor for the development of HCC.
There are certain chemicals that are associated with liver
cancer-aflatoxin B1, vinyl chloride and thorotrast. Aflatoxin
is the product of a mold called Aspergillus flavus and is
found in foods such as peanuts, rice, soybeans, corn and wheat.
Also thorotrast is no longer used for radiologic tests, and
vinyl chloride, is a compound found in plastics.
Hemochromatosis, a condition in which there is abnormal iron
metabolism, is strongly associated with liver cancer.
Individuals with cirrhosis from any cause such as the hepatitis
virus, hemochromatosis and alpha-1-antitrypsin deficiency
are at increased risk of developing HCC.
5. What are the symptoms of HCC?
Abdominal pain is the most common symptom of HCC and usually
is present when the tumor is very large or has spread. Unexplained
weight loss or unexplained fevers are warning signs in patients
with cirrhosis. Sudden appearance of abdominal swelling (ascites),
yellow discoloration of the eyes and skin (jaundice), or muscle
wasting suggests the possibility of HCC.
6. How is HCC diagnosed?
The diagnosis of HCC cannot be made by routine blood tests.
Screening by a blood test for the tumor marker, alpha- fetoprotein
(AFP), and radiological imaging must be performed. Some doctors
advocate measurement of AFP and imaging every 6- 12 months
in patients with cirrhosis in an effort to detect small HCC.
Sixty percent of patients with HCC will have an elevated AFP
level and the remainder may have normal AFP. Therefore, a
normal AFP level does not exclude HCC.
Radiological imaging studies are very important and may include
one or more of the following-ultrasound, CT scan (MRI magnetic
resonance imaging) and angiography.
Ultrasound examination of the liver is frequently
the initial study if HCC is suspected.
CT scan is a very common study used in the USA for
the workup of liver tumors. The ideal study is multi-phase
CT scan with the use of oral and IV contrast.
MRI can provide sectional views of the body in different
planes. MRI can actually reconstruct images of the biliary
tree and the arteries and veins of the liver.
Angiography is a study where contrast material is injected
into a large artery in the groin. X-ray pictures are then
taken to evaluate the arterial blood supply to the liver.
If the patient has HCC, a characteristic pattern is seen because
of the newly formed abnormal small blood vessels that feed
the tumor.
Biopsy may not be needed in patients with a risk factor for
HCC and elevated AFP. Biopsy can be performed if there is
some question as to the diagnosis of HCC or if the doctor
feels the management may be changed by the biopsy results.
7. What is the prognosis of people with
HCC?
The prognosis depends on the stage of the tumor and the severity
of the associated liver disease. There are some factors that
predict poor outcome. These include:
- Demographics: male gender, older age, alcohol consumption
- Symptoms: weight loss, decreased appetite
- Signs of impaired liver function: jaundice, ascites or
mental confusion related to liver disease (encephalopathy)
- Blood tests: elevated liver tests, low albumin, high
AFP, low sodium, high blood urea nitrogen
- Staging of tumor: tumor over 3 cm, multiple tumors, tumor
invasion of local blood vessels, tumor spread outside of
liver.
8. What are the treatment options for
HCC?
Chemotherapy:
This may include injection of anti-cancer chemicals into
the body through a vein or through chemoembolization.
The technique of chemoembolization is a procedure where chemotherapeutic
drugs are given directly into the blood vessels that supply
the tumor and small blood vessels are blocked so that the
drug stays within the area of the tumor. Chemotherapy can
provide some relief of symptoms and possibly decrease tumor
size (in 50% of patients) but it is not curative.
Ablation:
Ablation (tissue destruction) therapy in the form of using
radiofrequency waves, alcohol injection into the tumor or
proton beam radiation to the tumor site are other options
for treatment. There is no data to indicate that any one of
these treatment is better than another.
Surgery:
Surgery is only available to patients with excellent liver
function who have tumors less than 3-5 cm that are confined
to the liver. If the patient is able to undergo surgery successfully,
the five year survival is 30-40%. Many patients may have recurrence
of HCC in another part of the liver.
Liver transplantation is a treatment option for patients
with end-stage liver disease and small HCC. There is however
a severe shortage of donors in the USA.
9. Is liver cancer always HCC?
Actually, in the United States most cancers that are found
in the liver are ones that spread or metastasize from other
organs. These cancers are not HCC, as HCC cancers begin in
the cells of the liver. Cancers that commonly metastasize
to the liver include colon, pancreatic, lung and breast cancer.
PANCREATIC CANCER
1. What is the pancreas?
The pancreas makes pancreatic juices, which help digest food
in the small intestines, and hormones, including insulin.
It is located behind the stomach in the back of the abdomen.
The duct of the pancreatic gland opens into the first portion
of the small intestine (called the duodenum) through a nipple
like opening called the ampulla.
2. What causes pancreatic cancer?
It is not known exactly why certain people get pancreatic
cancer. Research shows that there are certain risk factors
that increase the chance of getting pancreatic cancer. Smoking
is a major risk factor. Alcohol consumption, a diet rich in
animal fat and chronic pancreatitis may also be risk factors.
People with a condition called hereditary pancreatitis are
also at increased risk for getting pancreatic cancer.
3. What are the symptoms of pancreatic
cancer?
Early pancreatic cancer usually does not cause symptoms and
is therefore known as the "silent" disease. As the tumor gets
larger, the patient may have one or more of the following:
- Jaundice- If the tumor blocks the bile
ducts (the major bile duct passes through the pancreas),
the patient may develop jaundice, a condition where the
skin and eyes may become yellow and the urine may become
dark in color.
- Abdominal pain- As the cancer grows,
the patient may have pain in the abdomen which may radiate
to the back. Pain may increase with eating or lying down.
- Nausea
- Decreased appetite
- Weight loss
4. How is cancer of the pancreas diagnosed?
In addition to taking a complete history and performing a
physical examination, the doctor may perform certain endoscopic
and radiologic tests such as a CT scan or ultrasound. Endoscopic
ultrasound may also be performed. This test may help in finding
small tumors that may be less than 2-3 cms (one inch). A biopsy
of an abnormal area of the pancreas may be performed in certain
cases by inserting a needle into the pancreas under ultrasonic
guidance.
ERCP (endoscopic retrograde cholangiopancreatogram), a special
x-ray study of the pancreatic duct and the common bile duct
may also be used to make the diagnosis. For this test, a flexible
tube with a light and a camera at the end is passed through
the mouth into the stomach and then the small intestines.
Sedation is given. A dye is then injected into the pancreatic
duct and the bile duct to look for abnormal filling or obstruction
of these ducts by the tumor. During this procedure, biopsies
can be taken using a brush that is inserted into the bile
duct. The biopsy specimens are then examined under a microscope
to look for cancer cells.
5. What is the treatment for cancer of
the pancreas?
Cancer of the pancreas is really only curable if it is found
in the early stages. Surgery, radiation and chemotherapy are
possible treatment options. Surgery may be done to remove
all or part of the pancreas and surrounding tissues if needed.
Radiation therapy can be used to damage the cancer cells and
prevent them from growing. Radiation maybe used in certain
trials after surgery to help kill any remaining cancer cells.
Chemotherapy will not cure pancreatic cancer but may have
some effect on slowing the rate of progression of the tumor
or to improve the patient's quality of life. Many new drugs
are being investigated for chemotherapy of pancreatic cancer
and patients with this disease may have an opportunity to
participate in one of the research trials for chemotherapeutic
treatment of pancreatic cancer.
Pain control may be a difficult problem in patients with
pancreatic cancer. Oral pain medication may be used, or patients
may be referred for a nerve block which is performed by injecting
alcohol into the bundle of nerves (celiac plexus) near the
pancreas to decrease pain signals from the pancreatic cancer
to the brain.
GASTROINTESTINAL TRACT IMAGE:
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