-
The ____ is a straight collapsable tube about 25cm (10inches) long that functions as a passageway through the thorax.
esophagus
-
the esophagus begins at the base of the pharynx at the level of ____ and descends behind the _____, passing through the mediastinum.
-
THe esophagus penetrates the diaphragm through an opening called the _____ _____, and it is comtinous with the stomach on the abdominal side of the diaphragm.
esophageal hiatus
-
The esophagus is inclose proximity of the ____ and the trachea and can be divided into various areas.
aorta
-
The cervical esophagus is about 5cm long and extends from the level of ___ to the level of ____.
C6 & T1
-
Below the cervical esophagus is the ____ esophagus
thoracic
-
In addition to the cervical & thoracic divisions, the esophagus can also be broken arbitrarily into an ____ third, a ____ third, and a ____ third.
-
Cancers are the least common in the ____ third and most common in the ___ or ___ third of the esophagus.
- least common = upper
- most common= middle or lower third
-
The lymphatic drainage of the esophagus is unpredictable and there are a large number of widely seperated collections of lymph nodes. Drainage does not always follow a contiguous pattern; a distance of as much as 8cm of normal esophagus may be interposed between the site of gross tumor and lymphatic metastases.
-
When you start trying to measure where the espohageal tumor is - start counting at the ______.
incisiors
-
Esophageal cancer is ____% of all cancer
Esophageal cancer is ____% of all cancer deaths in the US
1%
2%
-
Men are __ to __ times more affected than women.
3 to 4
-
African Americans are ___% more likely to get esophageal cancer than whites
50%
-
The most common age of diagnosis of esophageal cancer is ___ - ___.
55 to 85
-
Esophageal cancer is greater in frequency in Northern ____, northern ____ and South _____.
- northern china
- northern iran
- south africa
-
Incidence & Etiology (Causes of Esophageal Cancer)
- Alcohol & Tobacco use
- Chemical Exposure
- Barrett's esophagus
- Achalasia
- Plummer-Vision Syndrome
-
Esophageal
What do people commonly complain of upon clinical presentaion?
- Dysphagia
- Chest pain
- Regurgitation & aspiration
- Odynophagia
- Hematemesis
- Coughing
- Hemoptysis
- Hoarseness
-
Define Dysphagia
difficulting swallowing
-
Define Odynophagia:
painful swallowing
-
Define Hematemesis
vomitting up blood
-
Define hemoptysis
spitting up blood
-
What are some different teset used to detect esophageal tumors
- Chest x-ray
- barium swallow
- Pet/Ct
- Esophagoscopy
-
Esophageal Tumor Locations:
___ - ___ are located in the middle third
___ - ___ are located in the lower third
___ - ___ are located in the upper third
-
With esophageal cancer what is the most common pathology (in upper & middle)
squamous cell
At the beginning of the esophagus it is squamous cell once you pass the gastroesophageal it becomes adenocarcinomas until you reach the anus
-
What does it mean when staging is based on extension outward
it is staged by how many layers it has invaded.`
-
What are the routes of spread of esophageal cancers?
- Lymphatic (submuscosal spread)
- Local invasion
- Distant Metastasis
-
What is the primary site of metastasis of esophageal cancer?
Liver
-
what are the main sites of metastasis of esophageal cancer?
Liver, lung, bone, adrenals & brain
-
What are adrenals?
Adrenals are littel glands that sit atop the kidneys
-
What are treatment techhniques of esophageal cancer?
- surgery - if possible.
- radiation therapy
- chemotherapy
-
When is surgery for esophageal cancer appropriate?
- when the tumor is in the middle & lower third only.
- Usually reserved for small and non-metastatic lesions
-
What are some complications of surgery for esophageal cancers?
- anastomotic leaks
- PE (Pulmonary Emblem blood clot)
- myocardial infarction
- strictures
- GE reflux
-
What are the 2 most common chemotherapy drugs used for esophageal cancer?
-
Remember because it has submuscosal spread the fields are large
-
Esophageal Radaitoin Therapy:
All lesions have a ___cm margin superior and inferior and __-__cm laterally
-
Lesions of the ___ third are treated with a field that begins at the level of the thyroid cartilage and end at the level of the ____ to include any scv nodes, low anterior cervical and mediastinal nodes.
-
Lesions of the ____ third are treated with fields that include the mediastial nodes and the celiac axis
lower
-
Lesions in ___ third include ther periesophageal and medistinal nodes
mid
-
In esophageal radiation therapy _____ fields are used to treat the initial large fields followed by shrinking fields.
AP/PA
-
Boost fields can be done with a 3 field technique (____ and 2 posterior obliques), Obliques, Laterals or ____)
-
What is the patient positioning during esophageal radiation therapy?
- supine with arms by side or over head
- or
- prone with arms above head
-
What is the esophageal radiation alone dose?
6500 cGy with offcord at 3600 - 4500 cGy
-
What is the esophageal radiation doses with chemotherapy?
5040 cGy with off cord at 3600 - 4500 cGy
-
What are the critcal structures involved when givinig radiation to the esophagus?
Lungs, heart, and spinal cord
-
What are side effects of radiation to the esophagus?
- esophagitis
- ulceration of the esophagus
- decreased blood counts
- radiation pneumonitis
- pericarditis
- perforation of the esophageal-treachea wall
- strictures
- transverse myelitis
-
what is the #1 side effect of radiation to esophagus?
esophagitis
-
what is pericarditis
inflammation of heart muscles
-
what is transverse myelitis
severed spinal cord
-
What is the most important digestive enzyme?
pepsin
-
There are greater incidence in ____, ____, & ____ of stomach cancer than inthe United States
-
Stomach cancer:
Incidence is higher in _______ americans and _____ americans
african & native
-
Stomach cancer is 2:1 more common in _____
men
-
What is the peak age of stomach cancer diagnosis?
50 - 70
-
Stomach cancer is ___% adenocarcinoma.
the other 10% include lymphoma, squamous cell and leimomyosarcoma (smooth muscle)
90
-
In stomach cancer ____% of lesions are found in the distal portion
___% in the cardiac region
___% in the greater curvature, and
__ - ___% in the entire stomach
-
If the entire stomach is involved it will be a ______ not an adenocarcinoma
lymphema
-
What are some risk factors (etiology) for stomach cancer?
- Diet (red meat)
- Coal mining
- Blood type (A)
- Rubber working
- Asbestos exposure
- Gastric ulcers/polyps
- Alcohol/tobacco
- Poor nutrition
- Inadequate sanitation of consumable
- H. pylori (bacteria than live in the stomach acid)
-
What are some symtoms of stomach cancer?
- persistent indigestion
- epigastric distress or pain
- loss of appetite
- weight loss
- nausea & vomitting
- Dysphasia
- jaundice
- abdominal mass or bloating
-
stomach tumors are diagnoised on physical exam, upper gi series, ct & endoscopy
-
what does the work up for stomach cancer consist of?
- CBC (most have anemia)
- Guaiac stool test
- Upper GI
- Endoscopy with biopsy
- CT scan of chest and abdomen
- Laparoscopy
-
What is the staging system of stomach cancer?
TNM
-
_______ have distanct mets at diagnosis
1/3
-
what does anastomosis mean?
leaks
-
what is the 5 year survival rate of stomach cancer?
10%
-
Spread patterns of stomach cancer:
Lymphatics -
greater & lesser curvature, splenic, celiac, and haptic nodes
-
Spread patterns of stomach cancer:
Direct -
Bowel, omenta, pancreas, colon, regional nodes
-
spread patterns of stomach cancers:
Blood -
Liver & Lung
-
When is surgery possible for treating stomach cancer?
when no mets is present
-
what are some complications of surgery for stomach cancer?
- infection
- hemorrhage
- anemia
- anastomosis
- PE
-
Radiatioon therapy for stomach cancer:
AP/PA - Fields extends from diaphragm to L3 including duodenal loop and regional lymph nodes
-
What is the curative dose for stomach cancer?
5000-5500 cGy
-
What is the Pallative dose for stomach cancer?
3500-4000 cGy
-
What is the dose for Gastric Lymphomas?
4000 cGy
-
What are side effects of radiation therpay when treating stomach ca?
- ulcers
- fistula
- decreased blood counts
- bowel obstruction
- and transverse myelitis
-
what are the critcial structures to be concerned with when giving radiation therapy to the stomach ca?
- kidneys
- liver
- bowels
- spinal cord
-
What position should the patient be in for rad. therapy of the stomach?
supine with arms over head
-
In the small intestine cancers are rarely ______
carcinoma
-
In the small intestine tumors are usually located in the _____ or first few jujunal lesions.
duodenum
-
___% of all small intestine lesions are adenocarcinomas
Lymphoma, carcinoids and sarcomas make up the rest
50%
-
You do not treat the small intestine with radiation because the small bowel is constantly moving
-
Once cancer of the small intestine moves into the blood stream it normally goes straight to the ____
liver
-
What are some symtoms of small intestine cancer?
- Obstruction
- rectal bleeding
- weight loss
- weakness
- bloating
- abbdominal pain
- N & V
- fever
- change in bowel habits
-
Small Intestine disease can spread by direct extension, ____ or blood system to _____, lungs and bone
lymph
liver
-
_____ ______ disorders include polyposis, Crohn disease, and Gardner's syndrome
small intestine
-
What are treatment options for small intestine disease?
- Surgery
- Chemotherapy ( 5 FU )
with no role for radiation therapy due to the bowel sensitivity and motion of the organ
-
what is the 5 year survival rate for small intestine?
less than 20%
-
Large intestine cancer is ranked ____ in the US for men & women in incidence and ____ for overall death rates
3rd
2nd
-
peak age for large intestine diagnosis is ____ or older
50
-
_______ lesions are most common in large intestine cancer
rectal
-
causes of large intestine cancer are:
- diets high in fat
- diets low in fiber
- obesity
- smoking
- alcohol
- minimal physical activity
- familial polyposis
- chronic ulcerative colitis
-
What is the # 1 symptom of large intestine cancer?
blood in stool
-
Define tenesmus. (large Intestine)
ractal spasms
-
define hematochezia
rectal bleeding
-
What are some symptoms of Large Intestine Cancer?
- Blood in stool
- rectal bleeding (hematochezia)
- Change in bowel habits
- Pencil stools
- tenesmus (rectal spasms)
- N & V
- Obstruction
-
How is large intestine cancer detected & diagnosed?
- physical exam
- radiographic & endoscopic studies
-
How is staging done for Large Intestine Cancer?
TNM classification or the Dukes classification (A, B,C)
-
All staging classifications are explaining the penetration of the tumor through the layers of the bowel wall
(Large Intestine)
-
What are some of the routes of spread in Large Intestine Cancer?
Direct extension (penetrates bowel wall, not longitudinally like esophagus)
- Lymphatic (if tumor has penetrated the submucosal layer)
- This will be in an orderly fashion starting with the
- perirectal nodes, internal iliacs, common iliacs,
- paraaortic, and scv.
Hematogenous: Liver, lung, bone, ovaries, & adrenals
Peritoneal seeding
-
What does hematogenous mean?
blood spread
-
What does peritoneal seeding mean?
when a tumor breaks through the rectal wall & you have little tumors floating around everywhere in the abdominal wall
-
What is the anal verge?
the actual anal opening
-
What is an Abdominoperineal resection?
When everything is sewed back together and the person will have a colostomy bag for the rest of their life
-
What are the treament options for large Intestine Cancer?
Surgery it the treatment of choice
- Chemotherapy (5-FU and gemcitabine)
- Chemo is used with radiation therapy in pre & post op
Radiation Therapy
-
What is the 5 year survival rate for Large Intestine Cancer?
25%
-
How is Radiation Therapy use for Large Intestine:
Can be used pre or post op.
Fields are designed to encompass the primary tumor volume and pelvic lymph nodes, shrinking to treat primary tumor to a higher dose.
- A 3-field or 4-field technique is used.
- AP, PA, RT adn LT lateral
-
Large Intestine Field Designs ( CLASSIC FIELD )
AP/PA
Top - L4-L5 interspace
Bottom - Bottom of obturator foramina or 3-5cm
below the gross tumor
Lateral - 2 cm. lateral to pelvic brim & inlet
- Rt-Lt Laterals
- Top & bottom - same as AP/PA
-
- Anterior - Anterior edge of femoral head
Posterior - 2 cm behind the bony sacrum
-
What is proper simulation for a patient with large intestine cancer?
Supine or Prone
Prone allows the gluteal fold to decrease
- Full or empty bladder ( full bladder pushes the small
- bowel up out of the way)
Women have a vaginal marker
Contrast for bowels
-
What is the radiation dose for large intestine cancer?
External Beam
Intraoperative Radiation Therapy (IORT)
Extenal beam: 4500 cGy to large field, 540-1440 cGy boost
IORT - 1000-2000 cGy of electrons in a single fraction
-
What are the acute side effects of Large Intestine Cancer
- Small bowel toxicities ( less than 4500 cGy)
- Diarrhea
- Abdonimal cramps and bloating
- Proctitis
- Bloody or mucus discharge
- Dysuria
Leukopenia and thrombocytopenia
Moist desquamation
-
What is procitis
painful rectum ---somewhat like hemmoroids
-
what is dysuria
painful urination
-
what is leukopenia
decreased white blood cells
-
what is thrombocytopenia
decreased platelet counts
-
what is moist desquamation
when skin starts to break down and sloft off
-
what happens with bladder atrophy
the bladder shrinks
-
what is enteritis
Inflammation of the bowel
-
What are some chronic side effects of Large Intestine Cancer?
- Persistant diarrhea
- Increased bowel frequency
- Procitis
- Urinary Incontinence
- Bladder atrophy
- Enteritis, adhesions and obstructions of the small bowel
-
Anal cancer occurs more frequently in what gender?
female
-
what percentage of large bowel cancers are anal cancers?
1 -2 %
-
what is the median age of diagnosis of anal cancer?
60
-
There is an increase of anal cancer in men greater than ___ years old.
This is attributed to male homosexuality and anal intercourse
45
-
what are some etiologic factors of anal cancer
- genital warts
- genital infections
- and HPV
-
In anal anatomy the ______ is where the cells change and it makes the change in histology.
It goes from adenocarcinoma to squamous cell
denate line
-
Clincal presentation of anal cancer is:
- rectal bleeding
- pain
- change in bowel habits
- sensation of a mass
- rectal discharge
-
how do you diagnosis anal cancer
- physical exam
- anoscopy and/or proctoscopic exam
- PET/CT
- MRI
- chest x-ray to evulate extent of disease
-
The pathology of anal cancer ___% are _______and next is basaloid, adenocarcinoma, mucoepidermoid, and melanoma.
-
What is the most common pathology in anal cancer?
squamous cell
-
With anal cancer staging is done with teh TNM system and is based on
the size of the tumor and the depth of invasion
-
in anal cancer if tumor spread above the dentate line it spreads to what lymph nodes?
Internal iliac nodes
-
in anal cancer if the tumor spreads below the dentate line it spreads to what lymph nodes?
inguinal nodes
-
A shrinking field is also known as
a boost dose
-
what are the treatment techinques for anal cancer
a combination of radiation therapy and chemotherapy
-
what is the most common chemotherapy for anal cancer
5-fu and mitomycin C
-
what is the treatment field for anal cancer
- AP/PA or
- 4 field technique with electrons to the inguinal nodes
-
Dose RT alone for anal cancer is _________cGy with shirinking fields of _______cGy
6000-6500 cGy
4500 cGy
-
Dose chemorads for anal cancer is ______ cGy with shrinking fields to ______ cGy
4500
5940-6940
-
what is the most painful side effect of anal cancer radistion therapy
moist desquamation
-
what are some side effects of anal cancer
- moist desquamation
- N&V
- Diarrhea
- Bone marrow suppression
-
usually by the ___ week their skin is slothing off
(anal cnacer radaition)
3rd week
-
Bone marrow suppression leads to _______
blood counts dropping
-
the organs at risk when you are treating anal cancer is
- bladder
- small bowel
- femoral heads
-
bladder can take ____cGy
small bowel can take ____-cGy
femoral heads can take _____cGy
Some doctors will treat patients with a full bladder so it will push the small intestine up & out of the way.
6000
4000
5000
-
pancreatic cancer has a _____ mortality rate
high
-
____% of all all GI cancers inthe US are pancreatic cancers
2%
-
what gender is diagnosised with pancreatic cancer more?
male
-
2/3 of all pancreatic cancer cases occur in the ____ of the pancreas
head
-
Pancreatic cancer is rare in people less than ___ years old; and most common in the ___-___ age group
40
50-80
-
smokers have a __-__ times higher risk of developing pancreatic cancer
2-3
-
what are some common causes of pancreatic cancer
- chronic pancreatitis
- exposure to benzidine or other industrial chemicals
- obesity
- diets high in fats
- diabetes
-
Anatomy of pancreas:
level of ___
head, body, and ____
regional nodes: superior & ____ pancreaticoduodenal, portahepatis, suprapancreatic, para-aorta, and splenic hilar nodes
L1-L2
tail
inferior
-
the portahepatis is where
the vessels and everything come in & go out of the liver
-
what are the clinical presentations/symtoms of a patient with pancreatic cancer
- jaundice
- abdominal pain
- anorexia
- weight loss
- alceration of bowel
- bloating
-
what doees alceration of the bowel mean
the tumor has grown out of the pancreas & into the bowel
-
What procedures are used to detect & diagnosis pancreatic cancer
- history & physical
- Ct & Pet/Ct
- ERCP (endoscopic retrograde cholangio-pancreatography
- ultasound
-
how is a ERCP done?
a tube goes down the throat, simular to a colonscopy
-
What % of pancreatic cancers are adenocarcinoma
80%
other pathologys include islet cell tumors, acinar cell carcinomas, and cystadenocarcinomas
-
what form of staging is done when measuring pancreatic cancer
TNM
-
In pancreatic cancer
T1 - T3 is confined to the pancreas and considered resectable
-
More than ___% of patients have pancreatic mets at diagnosis
50%
surgury is not an option for distant mets; pallative treatment only
-
what are the routes of spread of pancreatic cancer?
Direct entension (stomach, duuodenum, and colon)
- Lymph nodes
- superior and inferior pncreatico-duodenal
- portahepatis
- suprapancreatic
- para-aortic
- splenic hilar nodes
- celiac axis nodes
- Hematogenous
- Liver #1
- Lung
peritoneal seeding
-
What are treatment options for pancreatic cancer
- Surgury (Whipple) is the treatment of choice.
- Contraindications include: liver mets, extrapancreatic
- extension, and adherence to major vessels
- Chemoradiation
- Gemcitabine, 5 Fu, and Cisplatin
- External beam dose 4500-5000 cGy
- IORT - 1000-2000 cGy in single fraction
-
What is the 5 year survival rate for pancreatic rate
less than 10%
-
What is the proper simulation for pancreatic cancer treatment?
Supine
Arms over head with mold
Contrast for bowel and kkidney enhancement
-
what is IORT?
Intra operative radiation therapy
when is apatient is opened up for surgery they will go ahead and give a blast of radation then close up and start conventional treatments
-
what are treatment fields for pancreatic treatment
AP/PA - t10, t11 to l1, width should include duodenal loop and cross midline
Laterals - 2cm anterior to gross disease and posteriorly 1.5 cm behind anterior vertebral body
IMRT
see pg 797
-
what are the following critcal organ doses
kidneys
liver
small bowel
spinal cord
stomach
- kidneys 1800-2300 cGy
- liver 2500-3500 cGy
- small bowel 4500 cGy
- spinal cord 4500 cGy
- stomach 5000 cGy
-
what are some side effects of pancreatic cancer
- N & V
- Leukopenia and thrombocytopenia
- Diarrhea
- Stomatitis
- Renal failure
-
what is aflaxtoxin associated with
peanut butter
-
when liver cancer is the primary tumor it is called
hepatocellular carcinoma (HCC)
-
hepatobillary tumors are linked to hepatitis B & C, ____ ___, aflatoxin ingestion
liver cirrhosis
-
Hepatocellular carcinoma (HCC) is increasing in incidence in the US as results of _______
hepatitis C
-
what are some clinical presentations of liver cancers
- jaundice
- abdominal pain
- weight loss
- fatigue
- fever
- night sweats
-
What is the #1 met. site for liver ca?
and then ?
#1 is the lung then the brain
-
regional lymph nodes of the liver are:
- portahapatic
- celiac
- cystic
- ppericholeductal
- hilar nodes
-
what does the work up include for liver ca?
- history & physical
- CBC with chemistry, liver function
- CA 19-9
- AFB
- CEA
- Ultrasound
- CT abdomen and pelvis
- Cholangiography
-
what is the treatment for liver ca
- surgery is the mainstay
- liver transplant for cirrhosis
- chemotherapy
- radiation therapy
- doses 36-60 Gy
- critical structures include bowel, kidneys & cord
-
Liver cancer is ____ in the US, but more commono in Africa and Asia due to inadequate soil and water
rare
-
Liver cancer is more common in what gender
men
-
what is the age range that liver ca is diagnosised
60-70 years old
-
Liver cancer is closely linked to
- cirrhosis
- hepatitis B
- oral steroids
- exposure to toxins and vinyl chloride
-
What are some symtoms of liver cancer
- weakness
- loss of appetite
- bloating and dull pain
- weight loss
- cities
- fever
- anorexia
- nausea jaundice
-
what is the 5 year liver cancer survival rate?
1%
-
What is the liver tolerance dose
30 Gy
-
What are treatment options of liver cancer
- surgery
- chemotherapy (Adriamycin)
- radiosurgery
-
Distant mets occurs in ___% of patients at diagnosised
50%
-
where does liver cancer spread
- regional nodes
- lungs
- bone
- brain
-
what is the hisptogy of liver ca
- hepatocellular carcinoma
- or
- cholangiocarcinomas (adenocarcinoma)
-
what is the histology of gallbaldder cancer
adenocarcinoma
-
What does the gallbladder do?
stores & concentrates bile
-
Gallbladder cancer is more common in what gender?
It is associated with _________?
female (4 to 1)
gallstones
-
what is the age range of diagnosis of gallbladder ca?
60-70 years of age
-
what are some common symtoms of gallbladder ca?
- n&v
- fever
- itching
- jaundice
- RUQ pain
- weight loss
-
what is the treatment of choice for gallbladder cancer
surgery
invasion of the liver is early so partial removal of the liver is often necessary
-
what is the histology of gallbladder ca?
adenocarcinoma, squamous cell or sarcoma
-
what is the 5 year survival rate of gallbladder ca?
10-30%
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