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Cancers of the gastrointestinal tract 

Cancers of the gastrointestinal tract

Chapter:
Cancers of the gastrointestinal tract
Author(s):

J.A. Bridgewater

and S.P. Pereira

DOI:
10.1093/med/9780199204854.003.1516_update_002

Update:

Oesophageal cancer—discussion of options after failure of first line palliative chemotherapy.

Biliary tract cancers—new section added.

Updated on 28 Nov 2013. The previous version of this content can be found here.
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date: 27 March 2017

Cancers of the gastrointestinal tract are one of the most rewarding interfaces in translational medicine—particularly on colorectal cancer—leading to greater understanding of the genetic mechanisms leading to cancer and the development of novel targeted therapies.

Diagnosis of gastrointestinal tract cancers is usually made or suspected at endoscopy, confirmed by biopsy.

Oesophageal cancer

A common cancer, usually of squamous cell histology, that is particularly prevalent in China (male incidence 28/100 000), southern and eastern Africa, and Japan. Typical presentation is with dysphagia, initially to solids and then to liquids. Staging investigations include contrast-enhanced CT, 2-[18F] fluoro-2-deoxy-d-glucose positron emission tomography (FDG-PET scan), and endoscopic ultrasonography. In patients who are fit and suitable for surgery, neoadjuvant chemotherapy is commonly given, but most patients are elderly with comorbid disease and unsuitable for curative surgery, and many others present with advanced disease such that palliation with or without systemic therapy is the only option. For locally advanced inoperable patients, chemoradiation in preference to radiation alone may confer a survival benefit. Specific palliation for dysphagia can include laser, brachytherapy, external beam therapy or stenting. Overall survival is less than 40% at 2 years.

Stomach cancer

A common cancer, usually adenocarcinoma, that is particularly prevalent in eastern Asia (male incidence 46/100 000), eastern Europe, Polynesia and South America. Predisposing factors include deprivation, Helicobacter pylori infection, tobacco, alcohol, and diet. Dysphagia, early satiety, and anaemia are common presenting features, with weight loss being an indication of advanced disease. Tumour staging is by CT and, in some centres, endoscopic ultrasonography. Best treatment, when appropriate and when possible, is by surgery with extensive nodal resection with postoperative chemoradiation, neoadjuvant chemotherapy or adjuvant chemotherapy. Palliation in advanced disease is as for oesophageal cancer. Overall survival is 30 to 40% at 5 years.

Colorectal cancer

A common cancer, predisposed to by a Westernized diet (male incidence in the United Kingdom is 56/100 000). It arises in many cases by transformation of adenoma to carcinoma by sequential inherited and acquired mutations: some cases are associated with well-characterized polyposis syndromes (e.g. familial adenomatous polyposis, hereditary nonpolyposis colorectal cancer). Typical presentation of left sided tumours is with alteration of bowel habit, obstruction or overt bleeding, and of right sided tumours is with iron-deficiency anaemia. Staged by Dukes’ classification: stage A, confined to the bowel wall; stage B, full thickness involvement of the bowel wall with extension through to the serosa; stage C, spread to lymph nodes; stage D, distant spread, usually to the liver. Surgical resection is the primary treatment and potentially curative in all except Dukes’ stage D, with adjuvant fluoropyrimidine and oxaliplatin providing benefit. Fluoropyrimidine, in combination with both oxaliplatin and irinotecan and the monoclonal antibodies bevacizumab and cetuximab, can improve survival in patients with advanced disease. Colonic stenting is an effective technique for symptoms from bowel obstruction. Overall survival is 83% at 5 years for Dukes’ stage A, declining to 3% for Dukes’ stage D.

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