Upper GI Malignancy - Tutor

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in
Éirinn
Case Based Teaching - Upper GI
Upper GI Malignancy
Prepared by : Prof Nuha Birido

Learning Outcomes
CBT 05 Oesophageal cancer
 Demonstrate the ability to take and present a history of

a patient with dysphagia
 Describe the relevant findings on physical examination
 Define the common presentation of a patient with
oesophageal cancer
 Outline the medical, surgical and endoscopic treatment
of oesophageal cancer including palliation
Learning Outcomes
CBT 06 Gastric cancer
 Demonstrate the ability to take and present a history of a

patient with suspected gastric cancer
 Describe the relevant findings on physical examination
 Define the common presentation of a patient with gastric
cancer
 Outline the medical, surgical and endoscopic treatment of
gastric cancer and define the role of the multidisciplinary
approach
CASE 1
History
• A 79-year-old man is admitted from the endoscopy unit after an

oesophagogastroscopy.
• He initially presented to his GP with increasing difficulty in
swallowing. Over the preceding months he has required a soft
diet and is now only able to tolerate thin fluids.
• These symptoms have been associated with a weight loss of 1
stone over the past month.
• He is a heavy smoker and enjoys a half bottle of wine each
evening. He has no other relevant past medical history.
CASE 1
History
• A 79-year-old man is admitted from the endoscopy unit after an

oesophagogastroscopy.
• He initially presented to his GP with increasing difficulty in
swallowing. Over the preceding months he has required a soft
diet and is now only able to tolerate thin fluids.
• These symptoms have been associated with a weight loss of 1
stone over the past month.
• He is a heavy smoker and enjoys a half bottle of wine each
evening. He has no other relevant past medical history.
CASE 1
Examination
Patient is cachectic
Figures demonstrates the

endoscopic findings
CASE 1
Questions
• What is the likely diagnosis?

• What are the risk factors?
• How should the patient be assessed for surgery?
• What are the other therapeutic options?
CASE 1
What is the likely diagnosis?
This patient has an oesophageal carcinoma.
Worldwide, squamous cell carcinomas account - 90 per cent

UK and USA over half of new presentations are adenocarcinomas
Dysphagia is the most common presenting symptom and is often associated

with weight loss.
Patients can also present with bleeding or with respiratory symptoms due to
aspiration or fistulation of the tumour into the respiratory tract.
CASE 1
• What are the risk factors?
• Alcohol and smoking

• Nitrosamines and aflatoxins
• Deficiency of vitamins A and C
• Achalasia
• Coeliac disease
• Tylosis
• Barrett’s oesophagus: adenocarcinoma

CASE 1
How should the patient be
assessed for surgery?
• CT of the chest, abdomen

and pelvis
• Positron emission
tomography (PET).
If there is metastatic disease,

then no further assessment for
operability is required.
PET scan showing coeliac node
involvement
CASE 1
How should the patient be
assessed for surgery?
• If the patient is fit for

surgery, the tumour depth
and lymph node
involvement is assessed by
endoscopic ultrasound.
• Approximately 40 per cent

of patients are suitable for EUS demonstrating T4 tumour
surgical resection. with loss of fat plane between
oesophagus and aorta
CASE 1
What are the therapeutic
options?
Multidisciplinary Decision
Making
Is the patient for curative or

palliative treatment
CASE 1
What are the therapeutic options?
Curative
Chemotherapy +/- radiation can be given prior to

surgery (neoadjuvant) to downsize the tumour
Surgery – Oesophagectomy and lymphadenectomy

CASE 1
What are the therapeutic options?
Palliative - For patients with unresectable tumours, the

aim is to relieve dysphagia with minimal risks.
• Chemotherapy
• Radiotherapy - can also reduce pain and improve
swallowing difficulties.
• Endoscopic/radiological stenting
CASE 1
Endoscopic/radiological
stenting
Complications :
• Oesophageal perforation
• Migration
• Blockage from ingrowth by
the tumour.
Discuss
• Barrett’s Oesophagus
• The intestinal metaplasia can progress to

dysplasia and adenocarcinoma.
• The risk of cancer is increased by up to

30 times.
• Patients should be started on lifelong

acid suppression.
• Endoscopic surveillance to detect

dysplasia before progression to
carcinoma.
CASE 2
History
• A GP has referred a 56-year-old man for an

oesophagogastroduodenoscopy.
• The patient presented to the GP 2 months previously with epigastric
discomfort and bloating.
• He was prescribed a proton pump inhibitor, which failed to improve his
symptoms.
• He has no history of gastro-oesophageal reflux or gallstones and is not on
any other regular medication.
• He smokes 20 cigarettes a day.
• The GP also sent some blood tests, shown below.
CASE 2
Normal
• Haemoglobin 9.0 g/dL 11.5–16.0 g/dL
• Mean cell volume 69 fL 76–96 fL
• White cell count 10.2 × 109/L 4.0–11.0 × 109/L
• Platelets 252 × 109/L 150–400 × 109/L
• Sodium 137 mmol/L 135–145 mmol/L
• Potassium 3.9 mmol/L 3.5–5.0 mmol/L
• Urea 5.0 mmol/L 2.5–6.7 mmol/L
• Creatinine 59 μmol/L 44–80 μmol/L
• Amylase 78 IU/dL 0–100 IU/dL
• AST 30 IU/dL 5–35 IU/L
• GGT 23 IU/dL 11–51 IU/L
• Albumin 45 g/L 35–50 g/L
• Bilirubin 12 mmol/L 3–17 mmol/L
• Glucose 5.0 mmol/L 3.5–5.5 mmol
CASE 2
The image across

demonstrates the findings on
endoscopy
What do the
investigations show?
CASE 2
Questions
• What are the risk factors for this diagnosis?

• Describe other clinical presentations of this condition?
• How should the patient be staged?
• What are the treatment options?
CASE 2
What are the risk factors for this diagnosis?
• Diet -Diets rich in pickled vegetables, salted fish and smoked

meats
• H. pylori infection
These factors contribute to a premature atrophic gastritis, a
precursor state to malignant transformation.
• Vitamin C deficiency
• Hypogammaglobulinaemia
• Pernicious anaemia
• Family History
• Post-gastrectomy
CASE 2
Describe other clinical presentations of this condition?
• Unintended weight loss
• Bleeding
• Anemia
• Dysphagia
• Odynophagia
• Hematemesis
• A palpable abdominal mass or lymphadenopathy
• Persistent vomiting
• Unexplained iron deficiency anemia
• Family history of upper gastrointestinal cancer
• Previous gastric surgery
• Jaundice
CASE 2
How should the patient be staged?
• Clinical – Examination may reveal supraclavicular

lymphadenopathy or hepatic enlargement
• Imaging –
– CT – assessment of nodal spread and extent of metastatic disease.
– Endoscopic ultrasound - assessment of tumour depth and nodal
involvement.
– PET scan
– Endoscopic ultrasound
• Laparoscopy - is useful to identify any peritoneal seedlings
that are not detected on conventional imaging.
CASE 1
What are the therapeutic
options?
Gastric cancer typically presents

late and is associated with a poor
prognosis.
Multidisciplinary Decision Making

CASE 2
What are the treatment options?
Antral tumours may be
suitable for a
sub-total gastrectomy.
If the tumour is less than 5cm from

the gastro-oesophageal junction, the
patient will require a
total gastrectomy.
CASE 2
Further Treatment
• Combined Adjuvant chemo-radiotherapy have shown a

survival advantage in recent trials
• Trials with neo-adjuvant (before resection) chemotherapy or

chemo-radiotherapy are still pending
CASE 2
Palliative – e.g. Patients with distant metastasis, inoperable
patients, carcinomatosis, invasion of other organs
Radiotherapy – can provide relief from bleeding, and pain

Surgical by-pass – allows oral intake of food
Chemotherapy
Stents – relieve gastric outlet obstruction and allow intake of
food
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RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in

Case Based Teaching - Upper GI

Prepared by : Prof Nuha Birido

CBT 05 Oesophageal cancer

 Demonstrate the ability to take and present a history of

CBT 06 Gastric cancer

 Demonstrate the ability to take and present a history of a

• A 79-year-old man is admitted from the endoscopy unit after an

• A 79-year-old man is admitted from the endoscopy unit after an

Figures demonstrates the

• What is the likely diagnosis?

This patient has an oesophageal carcinoma.

Worldwide, squamous cell carcinomas account - 90 per cent

Dysphagia is the most common presenting symptom and is often associated

• What are the risk factors?

• Alcohol and smoking

• Barrett’s oesophagus: adenocarcinoma

• CT of the chest, abdomen

If there is metastatic disease,

• If the patient is fit for

• Approximately 40 per cent

Is the patient for curative or

What are the therapeutic options?

Chemotherapy +/- radiation can be given prior to

Surgery – Oesophagectomy and lymphadenectomy

What are the therapeutic options?

Palliative - For patients with unresectable tumours, the

• The intestinal metaplasia can progress to

• The risk of cancer is increased by up to

• Patients should be started on lifelong

• Endoscopic surveillance to detect

• A GP has referred a 56-year-old man for an

The image across

• What are the risk factors for this diagnosis?

• Diet -Diets rich in pickled vegetables, salted fish and smoked

• Clinical – Examination may reveal supraclavicular

Gastric cancer typically presents

Multidisciplinary Decision Making

If the tumour is less than 5cm from

• Combined Adjuvant chemo-radiotherapy have shown a

• Trials with neo-adjuvant (before resection) chemotherapy or

Radiotherapy – can provide relief from bleeding, and pain

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