CANCER: PART I
From the 30th Annual San Diego Postgraduate Assembly in Surgery, sponsored by the University of California, San Diego,
School of Medicine, Department of Surgery
| CANCER OF THE GASTROESOPHAGEAL JUNCTION —Alex G. Little, MD, Professor and Elizabeth Berry Gray
Chair, Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH
|
| Epidemiology: in Eastern countries, still disease of squamous cell cancer; in United States, almost exclusively adenocarcinoma;
more common in men; incidence increasing in West but still far less than in East; adenocarcinoma found in people
who have moved from East to West; not racial, ethnic, or genetic issue, but environmental issue (depends on diet
consumed and frequency of consumption); Barrett’s epithelium—premalignant; intestinal-type epithelium with goblet
cells only type of columnar epithelium associated with cancer risk; length of abnormal epithelium not factor, but rather,
presence of goblet cells
|
| Barrett’s esophagus: suggestion that stopping acid reflux and chronic irritation of epithelium might stabilize epithelium
and even result in reversal to nondysplasia (from dysplasia) far from conclusive; treatment remains based on symptoms;
previously thought that 10% of individuals with Barrett’s esophagus develop cancer (actually ≈1/150-200 patient-
years); gastroenterologists now recommend follow-up endoscopy every 2 yr; presence of dysplasia indicates need to determine
potential for development of cancer; patients need either close follow-up or endoluminal therapy; from previous
data (3-4 yr ago), ≈40% of patients with dysplasia, when operated on, had invasive cancer (more recent data show 20%);
reasonable to give endoluminal therapy and perform endoscopic ultrasonography (US) for analysis to ensure no obvious
cancer present
|
| Adenocarcinoma of gastroesophageal junction (GEJ): only reason for surgery is to contribute to possibility of
cure; need for palliative operation uncommon; presently, several methods for palliation (eg, stents, laser therapy, chemotherapy,
radiation therapy); no indication for surgery if unable to provide patient with reasonable chance for long-term
cure; stage of tumor most likely correlates with likelihood of cure; make decision based on clinical (not pathologic) staging;
stages 1 and 2 (and perhaps 3b) have better prognosis; if metastasis, local invasion, and lymphatic involvement
present, cure unlikely
|
| Tests: computed tomography (CT)—helpful but not accurate for staging; endoscopic US—gold standard; shows how far
tumor has invaded esophageal wall, enables accurate staging of tumor, and shows extent of lymph node involvement; in
conjunction with CT, provides most information about local and regional nodal disease; positron emission tomography
(PET)—not advocated by speaker; obtaining good history and physical examination still best way to look for metastatic
disease; every patient should have endoscopic US and, with clinical staging information, make decision about surgery; better
ways to palliate dysphagia than surgery; assess ability of patient to undergo surgery; neoadjuvant therapy—weak evidence
of efficacy; those who respond to neoadjuvant component of therapy do better
|
| Surgery: considerations for surgery—3 approaches to surgery; regardless of surgical approach, question of what degree
of regional lymphadenectomy necessary; 1) surgery performed completely or partially using minimally invasive techniques,
2) trans-hiatal type of surgery, or 3) variations of Ivor Lewis procedure (most commonly used); minimally invasive
techniques—may become standard; better for patients; visibility good (divide azygos vein for access to esophagus); obtain
access to regional lymph nodes (eg, subcarinal nodes, periesophageal nodes) and mobilize esophagus; in abdomen,
same procedure (dissection of nodes and division of stomach) as when performed open; video-assisted thoracic
approach—mobilizes esophagus; challenging to perform in obese patients but of benefit; trans-hiatal approach—more
viable for adenocarcinoma of GEJ (than for squamous cell carcinoma in body of esophagus); lymph nodes of interest include
those in upper abdomen, left gastric artery, and celiac axis; less morbidity than with thoracotomy; results similar to
those obtained with other approaches; Ivor Lewis approach—several variations; abdominal incision and thoracotomy, either
without repositioning patient (midline laparotomy and anterior thoracotomy) or closed laparotomy and posterolateral
thoracotomy; incision in neck and anastomosis in neck or upper chest another variation; argument for approach based on
fact that since esophagus has no serosa, failure to remove tissue around esophagus may leave cancer; therefore, removing
rim of diaphragm and all tissue en bloc with esophagus recommended (argued that this approach most likely to remove all
regional lymph nodes and any cancer that penetrated through esophagus); extent of dissection—several variations of therapy;
goal to perform D2 lymphadenectomy (dissection of level 2 [regional] lymph nodes); in abdomen, with tumor of GEJ,
necessary to remove greater omentum outside of epiploic vessels, subpyloric lymph nodes, and nodes along celiac axis in
left gastric artery; if chest accessible (not so with transhiatal operation), remove periesophageal nodes, nodes in pulmonary
ligament, and those in subcarinal area (ensures everything reasonable and necessary for staging and, potentially, for cure
has been done); speaker believes more extensive dissection (eg, nodes along left recurrent nerve, bilateral neck dissection)
does not necessarily contribute to cure; tubularizing stomach beneficial (functions better; better quality of life [QOL]);
procedure to improve gastric emptying—questionable whether necessary (≈20% experience problems if not done);
speaker performs short pyloromyotomy (closed transversally); either myotomy or short (3-5 stitches) pyloroplasty; opening
must be small to avoid dumping problems; anastomosis in neck or chest—with current technology, leak rate should
be so low that irrelevant whether performed in neck or chest; most importantly, anastomosis must be high (if low [below
azygos vein], significant reflux results); good results if performed at apex of chest and/or through neck; operative
mortality—presently, 5% realistic (should not be >10%); factors include patient selection, appropriateness (palliation vs
cure), and morbidity (anastomotic leaks); clinically significant anastomotic leak should be uncommon; nutritional depletion
less of issue than previously; survival—correlates with stage; patients now presenting at earlier stages (possibly due
to follow-up for Barrett’s esophagus); current 5-yr survival rate, 25% to 40%; palliation—rarely should be rationale for
surgery; most patients should be nearly completely relieved of dysphagia; dilation necessary on occasion; ≈70% of patients
can eat normal diet
|
| PALLIATION OF PERIAMPULLARY TUMORS —Larry C. Carey, MD, Professor of Surgery, University of South Florida
College of Medicine, and Associate Chief of Staff for Education, James A. Haley Veterans’ Hospital, Tampa, FL
|
| Introduction: most periampullary tumors not resectable; especially true for pancreatic cancer; signs of unresectability—
presence of metastasis on CT; back pain (ominous sign in cancer of head of pancreas); patient nonjaundiced, with tumor
in head of gland; vascular invasion or intrusion; tumor extending to left of midline on CT; ability to determine unresectability
before surgery significant advantage to patient whose life expectancy measured in months; important to minimize
time in hospital; periampullary tumors—within 1 to 2 cm of papilla of Vater
|
| Role of physician in providing palliation: first objective to relieve symptoms (without intent to cure); when palliation
warranted—tumor determined nonresectable and not curable; patient cannot tolerate surgery for cure (even if resectable);
symptoms present or anticipated; symptoms include jaundice, pain (nonspecific upper abdominal), dyspepsia,
weight loss, anorexia, and possibly gastric dysfunction; almost never see steatorrhea (patients generally constipated);
esophagogastroduodenoscopy (EGD)—ampullary and duodenal tumors visible; effective when combined with US to
clarify possible resectability of tumor; can be overutilized; plastic stent vs Wallstent placed endoscopically—if patient’s
life expectancy ≤4 mo, plastic stent used; if life expectancy >4 mo, Wallstent used; in jaundiced patient, magnetic resonance
cholangiopancreatography (MRCP) tool of future; trans-hepatic endoscopic alternatives to relieve jaundice (stent
placed trans-hepatically); leakage of bile problematic if unable to establish internal drainage; surgical relief of
jaundice—cholecystojejunostomy previously gold standard; current standard, choledochojejunostomy or choledochoduodenostomy;
cholecystojejunostomy—worst alternative for recurrent jaundice; acceptable alternative if done laparoscopically,
provided cystic duct not involved in malignant process; if life expectancy ≤6 mo, stent preferable method for
treating jaundice; if ≥6 mo, surgery; if not necessary to perform surgery on patient (tumor unresectable and jaundice
treated endoscopically), speaker prefers laparotomy to changing stent every 3 to 4 mo; speaker avoids surgery for palliation
|
| Narcotics: pain worsens as disease progresses; start with oral narcotics, progressing to more potent agents as necessary;
transdermal delivery (skin patches) with fentanyl useful alternative to oral antibiotics (more convenient for patient); for
injectable narcotics, spend time teaching patient’s caregiver how to give injection; start with oxycodone 5 mg and acetaminophen
325 mg q4h; can give ≤4 g acetaminophen before reaching toxic level (use caution); if pain control poor, increase
from mildly to moderately potent narcotics, increasing by 25% to 50% per alteration until pain under control; for
moderate to severe pain, may need to increase potency of dosage by 50% to 100%; relief of pain often neglected by physicians;
small frequent doses better than large infrequent doses; switch to long-acting drugs, eg, oxycontin; make no
changes in program until after 24 to 48 hr to determine whether changes effective; constipation —start prophylaxis
when narcotic started; bisacodyl and senna effective laxative agents; objective for patient to have bowel movement every
other day (avoid fecal impaction); respiratory failure—rare, unless patient narcotic naive; short-acting agents in small
doses provide pain control without concern of respiratory compromise; objective to minimize length of hospitalization
and keep patient comfortable and functional; subcutaneous and intravenous (IV) narcotics equivalent in activity (no need
to resort to IV narcotics if patient unable to take oral agents or if transdermal delivery not appropriate); avoid pumps, and
give subcutaneous injection if parenteral treatment required; controlled-release morphine—boon to treatment of cancer
pain; given q8-12h, not bid or qid; wait 48 hr to achieve steady state before adjusting dose; fentanyl patch—requires 18
hr for steady state; can increase dose ≈q24h; disadvantage cost; dilaudid—used infrequently; given in 1- to 8-mg doses
q4h; fewer side effects than morphine; disadvantage cost; nerve blocks—possible if operating on patient and find unresectable
tumor; celiac ganglionectomy; blocking celiac axis at time of surgery shown effective (absolute alcohol injected
on either side of celiac axis in periaortic region); few instances of associated paraplegia; sympathectomy—useful; performed
surgically, laparoscopically, or thorascopically; splanchnicectomy—most effective when done through chest
with scope, resecting lower sympathetic chain and dividing greater splanchnic nerves; intraoperative or percutaneous
blocks—performed mostly by pain specialists or anesthesiologists under CT or US control; effective way to diminish
pain and narcotic requirements; risk for paraplegia minimal but possible (inform patient); celiac blocks—shown in randomized
controlled trials to provide modest pain control or to be of no benefit; little convincing evidence of improved
QOL or duration of life
|
| Relief of symptoms: anorexia—generally associated with malabsorption or gastric dysfunction (not rare);
dexamethasone—useful in treatment of anorexia; relatively few of side effects associated with prednisone; 4- to 8-mg
dose every morning; side effects not serious; less mineralocorticoid effect than with prednisone; avoid nighttime dosing
due to gastroesophageal reflux symptoms; should be used more extensively; total parenteral nutrition—decreases survival
and response to chemotherapy; increases rate of infection; no redeeming qualities; nausea—haloperidol; alcohol in
small amounts (if acceptable to patient); small frequent meals; sweets often important in adding nutrition; attention to detail,
spending time with patient and family, and discussion of alternatives often make enormous difference in comfort of
patients; dexamethasone requires few days to take effect; gastrojejunostomy at time of laparotomy and discovery of unresectable
periampullary cancer—ongoing debate about utility; only 10% to 15% of patients with unresectable cancers in
this area develop gastric outlet obstruction before death; speaker reserves gastrojejunostomy for patients with apparent gastric
outlet obstruction or when gastric outlet obstruction likely (sufficient tumor invasion in duodenal area); laparoscopic
gastrojejunostomy associated with lower morbidity and shorter length of hospital stay; also associated with ≈10% delay in
function and ≈5% mortality in patients who have 9-mo survival rate; in patients whose cancer is unresectable, jaundice
should be relieved by most noninvasive mechanism possible; gastric bypass reserved for those with evidence of gastric
dysfunction; for those with known unresectable tumors, endoscopic biliary drainage preferable
|
| CYSTIC TUMORS OF THE PANCREAS —Dr. Carey
|
| Introduction: rare; patients usually women and >50 yr of age
|
| Types of tumors: 2 major types (based on secretion); serous—watery secretion, absent mucus; subtypes include microcystic
tumors (with cut surfaces that resemble sponge and cysts varying in size [rarely >2-3 mm]) and oligocystic tumors
with larger cysts; rarely malignant; mucinous—propensity to be premalignant or frankly malignant; usually bigger than
serous tumors; tend to be unilocular or oligocystic; intraductal papillary mucinous neoplasms (IPMNs)—recently described;
uncommon; islet cell tumors or neuroendocine tumors—occasionally cystic; large tumors with few symptoms;
oligocystic serous tumors occur in mid portion of gland, with main duct dilated proximally; in mucinous tumors, main
duct dilated distally; no practical significance; preoperatively, impossible to distinguish serous from mucinous tumors
with any reliability
|
| Distinguishing tumors: study—series in Gastroenterology 2004; determined accuracy of differentiating serous from
mucinous tumors using US and fine needle aspiration (FNA) and examination for mucin; in 112 of 341 tumors resected,
US accurate in 51% and cytology in 69%; measurement of carcinoembryonic antigen (CEA) in fluid content of tumor accurate
in ≈80%; CEA >200 ng/mL reasonably accurate for distinguishing serous from mucinous tumors; exercise care
when interpreting analysis by radiologist; septations, solid components, and abnormal ducts more likely associated with
mucin-producing tumor (malignant potential); Singaporean study—showed that presence of symptoms not significantly
useful in decision making; speaker’s experience that majority of microcystic tumors (serous cystadenomas) centrally located,
≤2 cm, and symptomatic; limited ability to distinguish malignancy preoperatively
|
| Intraductal papillary mucinous neoplasms: gastric type more common and less malignant; intestinal type tends to
produce pancreatic atrophy and fibrosis; surgical intervention—performed on younger patients (more likely mucinous
tumors), larger (>5 cm) tumors, and when symptoms reasonably attributable to tumor; enlarging tumor should be resected;
presence of mucin on aspiration useful, as is presence of elevated CEA; resection needed when pancreatitis recurrent,
due to mucin obstructing pancreatic duct; speaker has occasionally performed cystgastrostomy in large symptomatic
mucin-producing cancer to relieve pressure and improve gastric function; IPMNs unusual tumors; mostly safe for observation,
except in young patients, presence of symptoms, enlargement, and identified mucin production
|
Suggested Reading
Beer AJ et al: Adenocarcinomas of esophagogastric junction: multi-detector row CT to evaluate early response to neoadjuvant
chemotherapy. Radiology 239:472, 2006; Bizekis C et al: Initial experience with minimally invasive Ivor
Lewis esophagectomy. Ann Thorac Surg 82:402, 2006; Fountoulakis A et al: Effect of surveillance of Barrett's oesophagus
on the clinical outcome of oesophageal cancer. Br J Surg 91:997, 2004; Hardacre JM et al: An aggressive
surgical approach is warranted in the management of cystic pancreatic neoplasms. Am J Surg 193:374, 2007; House MG
et al: Palliative therapy for pancreatic/biliary cancer. Surg Clin North Am 85:359, 2005; Lim SJ et al: Preoperative
evaluation of pancreatic cystic lesions: cost-benefit analysis and proposed management algorithm. Surgery 138:672, 2005;
Nieveen van Dijkum EJ et al: Quality of life after curative or palliative surgical treatment of pancreatic and periampullary
carcinoma. Br J Surg 92:471, 2005; Preston SR et al: Effect of endoscopic ultrasonography on the management
of 100 consecutive patients with oesophageal and junctional carcinoma. Br J Surg 90:1220, 2003; Sharma P: Barrett
esophagus: will effective treatment prevent the risk of progression to esophageal adenocarcinoma? Am J Med 117 Suppl
5A:79S, 2004; Sheehan MK et al: Spectrum of cystic neoplasms of the pancreas and their surgical management. Arch
Surg 138:657, 2003; Sohn TA et al: Intraductal papillary mucinous neoplasms of the pancreas: an updated experience.
Ann Surg 239:788, 2004; Spinelli KS et al: Cystic pancreatic neoplasms: observe or operate. Ann Surg 239:651, 2004;
Van Heek NT et al: The need for a prophylactic gastrojejunostomy for unresectable periampullary cancer: a prospective
randomized multicenter trial with special focus on assessment of quality of life. Ann Surg 238:894, 2003; Walsh RM
et al: Prospective preoperative determination of mucinous pancreatic cystic neoplasms. Surgery 132:628, 2002.
Educational Objectives
| The goal of this program is to improve management of cancer of the gastroesophageal junction (GEJ) and cystic tumors of
the pancreas. After hearing and assimilating this program, the clinician will be better able to:
|
 | 1. Determine which test is most useful in staging adenocarcinoma of the GEJ.
|
| 2. Describe the various surgical approaches appropriate for cancer of the GEJ.
|
| 3. Discuss methods of palliation for periampullary tumors.
|
| 4. Utilize narcotics appropriately for palliation.
|
| 5. Recognize when surgery is necessary for pancreatic cystic tumors.
|
Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified
conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business
or commercial interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Drs. Little and Carey were recorded at 30th Annual San Diego Postgraduate Assembly in Surgery, held February 26 to
March 2, 2007, in San Diego, CA, and sponsored by the University of California, San Diego, School of Medicine, Department
of Surgery. The Audio-Digest Foundation thanks the speakers and the sponsor for their cooperation in the production
of this program.
|
