Upper digestive system and accessory organ cancers

Upper Digestive System and Accessory Organ body diagram

Cancer of the oesophagus

Facts and figures

Cancer of the oesophagus is the 13th most common cancer in the UK. Higher incidence in men, male to female ratio is approximately 2:1. Age related with approximately 83% of cases arising in the 60+ years age group.

Risk factors include tobacco use, a diet lacking in fruit and vegetables, being overweight, obesity and alcohol. Also, a pre-existing condition of Barrett’s oesophagus increases risk.

Tumours arise in the interior layer of the oesophagus and spread by growing beyond the oesophageal wall. Those arising in the upper third and middle third are mainly squamous cell carcinomas and those in the lower third mainly adenocarcinomas.

Cancer of the oesophagus is often detected late as symptoms can be vague.

Symptoms may include:

  • Pain and/or difficulty when swallowing (sometimes patients refer to a feeling of food being stuck).
  • Weight loss.
  • Tiredness.

Diagnosis

Investigations may include:

  • Physical examination.
  • Endoscopy- tissue samples may be taken to biopsy any abnormal looking cells.
  • CT scan.
  • PET-CT scan.
  • MRI scan.
  • Barium swallow (not often used now).
  • Laparoscopy.

Treatment

Depends on several factors:

  • The type of tumour.
  • The position of the tumour (upper third, middle or lower third).
  • The stage of disease.
  • General health.
  • Treatment aim may be to cure the disease or control it and relieve symptoms.

Surgery

In early stage, surgery will normally be used to remove the affected part of the oesophagus (oesophagectomy). However, surgery may also be used in more advanced disease to place self-expanding stents in the oesophagus to hold the oesophagus open and improve swallowing.

Chemotherapy

Chemotherapy is frequently given before surgery to shrink the tumour but may be given on its own.

In tumours of the lower third, chemotherapy is often prescribed before and after surgery. If the tumour is difficult to remove or the patient is not fit or refuses surgery, chemoradiation may be offered.

Radiotherapy

External beam radiotherapy is usually given in combination with chemotherapy (chemoradiation). This is sometimes given before surgery to shrink the tumour or radiotherapy may be prescribed after surgery to reduce the risk of recurrence.

In advanced cases, radiotherapy and/or chemotherapy may be used to help control and improve symptoms. Brachytherapy is not used very often. This involves a radioactive source being placed in the oesophagus for a set time to enable a very high dose of radiation to be delivered directly to the tumour.

Targeted therapy

Research is being conducted in the use of drugs that block the effects of the proteins that encourage the growth of cancer cells in oesophageal cancers

Stomach cancer

Facts and figures

Stomach cancer is the 15th most common cancer in the UK. Higher incidence in men, male to female ratio approximately 19:10. Age related, rising sharply from around 60 years with an average of 51% diagnosed in those aged 75+ years.

Risk factors include smoking, a diet high in salty food, processed meats, red meat and possibly a large intake of pickled foods. Also, the presence of helicobater pylon bacteria and an inflammatory condition called severe chronic atrophic gastritis (SCAG) and those working in the rubber production industry.

Tumours usually arise in the interior layer of the five layer stomach and spread by growing beyond the stomach wall.

Stomach cancer is often detected late as the symptoms can be vague. 95% of tumours are adenocarcinomas, others include lymphomas and leiomyosarcomas.

Symptoms may include:

  • Indigestion and burping.
  • Acidity and heartburn.
  • Nausea and vomiting.
  • Discomfort or pain when swallowing.
  • Feeling bloated, loss of appetite and weight loss.
  • Pain and/or swelling of the abdomen.
  • Anaemia, due to bleeding into the stomach.

Diagnosis

Investigations may include:

  • Physical examination.
  • Chest X-ray.
  • Endoscopy- tissue samples may be taken for biopsy.
  • Barium meal (not often used now).
  • CT scan.
  • Endoscopic ultrasound.
  • MRI scan.
  • PET- CT scan.
  • Liver ultrasound scan.
  • Laparoscopy- tissue samples may be taken for biopsy.

Treatment

Depends on several factors:

  • The stage of the cancer
  • General health

Surgery

Surgery is the main treatment for stomach cancer, part or all of the stomach may be removed (gastrectomy) as well as surrounding lymph nodes. This may be done via traditional open surgery or keyhole surgery.

Chemotherapy

If the tumour size is considered large or has spread into the blood or lymph vessels nearby, chemotherapy may be recommended. Chemotherapy is used at different stages of treatment, and can be used in combination to make other treatments more effective:

Neo-adjuvant: to shrink the tumour(s) before surgery in order to get a better outcome following the operation.

Adjuvant: to destroy any microscopic cancer cells that may remain after the cancer is removed by surgery and reduce the possibility of the cancer returning. Palliative – to relieve symptoms and slow the spread of the cancer, if a cure is not possible. In stage 4 (advanced) cancer, symptoms can be controlled and the spread of the cancer can be slowed using a combination of surgery, chemotherapy and or radiotherapy 

Radiotherapy

Radiotherapy is not usually used to treat cancer of the stomach but it may also be used as an adjuvant to chemotherapy and/or surgery. Radiotherapy may be used to try and shrink the tumour. It can also help to control pain or bleeding in late stage disease.

Pancreatic cancer

Facts and figures

Pancreatic cancer is the 10th most common cancer in the UK. The incidence in men and women is approximately the same, giving a male to female ratio of 1:1. Age related with approximately 96% of cases being diagnosed in those aged 50+ years and approximately 50% of all cases in the 75+ years age group.

Risk factors are not well known but about 30% may be linked to tobacco smoking. Some medical conditions such as hereditary pancreatitis, stomach ulcers, helicobacter pylon infection and diabetes increase the risk. 95% of tumours are adenocarcinomas arising from the exocrine pancreas; the others arise in the endocrine pancreas but are very rare.

Pancreatic cancer is often diagnosed late as symptoms can be vague. Symptoms may include: Pain and/or swelling of the abdomen Back pain Jaundice Tiredness Weight loss

Diagnosis

Investigations may include:

  • Physical examination.
  • Blood tests.
  • Ultrasound scan of pancreas and liver.
  • CT scan.
  • Endoscopic ultrasound- tissue samples may be taken for biopsy.
  • MRI scan.
  • Laparoscopy- tissue samples may be taken for biopsy.

Treatment

Depends on several factors:

  • The size of the tumour.
  • The position of the tumour within the pancreas.
  • The stage of the cancer.
  • General health.

Surgery

Surgery may be used in early stage disease to remove part or all of the pancreas and possibly other organs such as the gall bladder, duodenum and part of the stomach. This may cure the disease but it is long and complicated surgery and only feasible for those fit enough for surgery with small localised tumours. In some more advanced cases bypass surgery may be performed to relieve symptoms such as jaundice and sickness caused by a blockage of the bile duct or duodenum.

Chemotherapy

Chemotherapy may be prescribed after surgery to reduce the risk of recurrence. In cases of locally advanced (unresectable) disease, it may be used to shrink the tumour, control the disease and relieve symptoms.

Occasionally chemotherapy and radiotherapy are used in combination (chemoradiation) for this purpose.

Radiotherapy

Radiotherapy is not used very often in pancreatic cancer. It can be used to shrink the tumour to help relieve symptoms, possibly in combination with chemotherapy.

Radiotherapy, pain killers and nerve blocks may be used on their own or in combination to control any pain.

Liver cancer

Facts and figures

Liver cancer is the 18th most common cancer in the UK. Primary liver cancer accounts for 1% of all cancers in the UK. Higher incidence in men with a male to female ratio of approximately 18:10. Age related with approximately 81% of cases diagnosed in those 65+ years.

Liver cancer incidence has increased since the mid 1970s and risks include heavy alcohol consumption, Hepatitis B and Hepatitis C infection. The majority of liver cell cancers are hepatocellular carcinomas. Many cases of liver cancer are metastatic or secondary tumours that have spread from primary tumours in other parts of the body such as colon, rectum, stomach or oesophagus.

Only a small number of primary liver tumours are diagnosed early.

Symptoms may include:

  • Jaundice.
  • Pain and/or swollen abdomen.
  • Weight loss.
  • Night sweats and/or fever.

Diagnosis

Investigations may include:

  • Physical examination.
  • Blood tests.
  • Ultrasound scan.
  • CT scan.
  • MRI scan.
  • Needle biopsy – local anaesthetic is used, tissue sample is acquired by putting needle through the skin into the liver using ultrasound to guide the needle.
  • Laparoscopy – tissue samples may be taken for biopsy.

Treatment

Depends on several factors:

  • The type of liver cancer.
  • The position of the tumour in the liver.
  • The stage of the cancer.
  • Liver function.
  • General health.

Surgery

Surgery may be used in early stage. This can either be by removing the liver and proceeding with a liver transplant or removing the affected part of the liver (resection). Surgery is only considered if the cancer is contained within the liver.

Radiofrequency ablation (RFA)

This uses radio waves to heat up the cancer cells until they are destroyed. Under local or general anaesthetic, a needle is put through the skin (guided by ultrasound or CT scan) and then radio waves are sent down the needle to the tumour site. Only appropriate for small tumours that are not close to major blood vessels.

Microwave ablation

This is a newer treatment to RFA, using the same technique but using slightly different energy waves i.e. microwaves. May not be an option if tumour is too close to another organ.

Percutaneous ethanol injection

This involves injecting alcohol through the skin directly into the liver tumour during an ultrasound scan. The alcohol destroys the tumour by dehydrating the tissue and stopping its blood supply.

Chemoembolisation (trans arterial chemoembolisation TACE)

Chemotherapy is administered directly into the liver using tiny plastic beads (microspheres) that give off a chemotherapy drug or through a catheter directly into the artery and then plugging up the artery. These block the blood vessels to the tumour site in the liver, reducing the supply of oxygen and nutrients to the tumour and may make it shrink.

It can be used in conjunction with other treatments such as surgery of RFA. This may help to control the disease but it is unlikely to cure.

Radioembolisation

A new treatment that is now being used, similar to TACE, but using radioactive isotopes instead of chemotherapy.

Chemotherapy

Chemotherapy is rarely used in liver cancer but may be suggested for advanced disease to help control the symptoms and slow the growth of the tumour. There are limited benefits for hepatocellular cancer (HCC) and a risk of more severe side effects in patients with cirrhosis.

Radiotherapy

Radiotherapy is not routinely used in liver cancer as it can damage healthy liver cells. However, if the disease has spread, it may be used to control symptoms such as pain. Clinical trials are researching the use of radiotherapy in primary liver cancer.

Gall bladder cancer

Facts and figures

Gall bladder cancer is very rare; only around 800 new cases are diagnosed in the UK each year. It is the 5th most common gastrointestinal cancer. Higher incidence in women, male to female ratio is approximately 1:2. Age related, most common in those 70+ years.

Risks factors include smoking, obesity and possibly an unhealthy diet. Medical conditions such as gall stones, cholecystitis and diabetes increase the risk as does having a first degree relative diagnosed with gall bladder cancer. 80% of cases are adenocarcinomas arising from the lining of the gall bladder. Most tumours are detected at a late stage, often during surgery to remove gall stones.

Symptoms may include:

  • Abdominal pain/swelling.
  • Nausea.
  • Jaundice.
  • Weight loss.
  • Night sweats and/or fever.
  • Tiredness.

Diagnosis

Investigations may include:

  • Physical examination.
  • Blood tests.
  • Ultrasound scan.
  • CT scan.
  • MRI scan.
  • Endoscopy - tissue samples may be taken for biopsy.
  • Angiogram (this is to assess any involvement of surrounding blood vessels).
  • Fine needle aspiration (FNA) - under CT scan or ultrasound a very fine needle is passed through the skin into the liver and gall bladder to enable tissue samples to be collected for biopsy.
  • Laparoscopy- tissue samples may be taken for biopsy.

Treatment

Depends on several factors:

  • The type of gall bladder cancer.
  • The stage of the cancer.
  • General health.

Surgery

In early disease, different operations may be required depending on position of the tumour and findings at surgery. The main option will be to remove the gall bladder (cholecystectomy).

During this procedure, lymph nodes from the surrounding tissue will be removed and sent for analysis. If they are found to contain cancer cells, a further operation may be required to remove lymph nodes and surrounding tissues. This helps reduce the risk of recurrence.

Radiotherapy

Radiotherapy is most likely to be given in combination with other treatments. It may be used after surgery with the intention of destroying any remaining cancer cells (adjuvant radiotherapy), but it is a rare cancer and it has been difficult to undertake large enough clinical trials to provide evidence that this reduces recurrence.

It may be used in advanced cases to shrink the tumour and relieve symptoms. If the disease has spread significantly outside of the gall bladder, surgery is very unlikely, therefore a combination of radiotherapy and/or chemotherapy may be used.

Chemotherapy

Chemotherapy may be prescribed if the disease has recurred after surgery or it has spread beyond the gall bladder. It may be used to relieve symptoms and try and slow the growth of the cancer cells.

Bile duct cancer (cholangiocarcinoma)

Facts and figures

Bile duct cancer is very rare; less than 2000 new cases are diagnosed each year in the UK. The incidence in men and women is approximately the same, giving a male to female ratio of 1:1. Age related with approximately 66% arising in those 65+ years.

Causes are unknown but medical conditions such as primary sclerosing cholangitis, ulcerative colitis, choledochal cysts and bile duct stones can increase the risks. Other possible factors include liver cirrhosis, tobacco smoking, obesity, diabetes, hepatitis C infection and HIV. Most of the tumours are adenocarcinomas.

The majority of the tumours develop in bile ducts outside of the liver (extrahepatic) in the perihilar and distal regions with around 20% of them arising in the bile ducts inside the liver (intrahepatic). It is often diagnosed late as symptoms are vague.

Symptoms may include:

  • Nausea and loss of appetite.
  • Abdominal pain.
  • Weight loss.
  • Jaundice.
  • High temperatures and shivering.

Diagnosis

Investigations may include:

  • Physical examination.
  • Blood tests.
  • Ultrasound scan.
  • Ultrasound from inside the body (EUS) –tissue samples may be taken for biopsy.
  • CT scan.
  • MRI scan.
  • Endoscopy – tissue samples may be taken for biopsy.
  • Fine needle aspiration- under CT scan or ultrasound a very fine needle is passed through the skin into the bile duct to enable tissue samples to be collected for biopsy.
  • Percutaneous transhepatic cholangiography (PTC) - tissue samples may be taken for biopsy.
  • PET-CT scan.
  • Laparoscopy- tissue samples may be taken for biopsy.

Treatment

Depends on several factors:

  • Position of the tumour.
  • The stage of the cancer.

Surgery

In early stage, surgery is the main treatment. This involves removing the bile duct and other adjacent structures which is long and complicated surgery. In the less common intrahepatic cancers, part of the liver will also be removed (hepectomy), sometimes a lobe of liver will be removed with the bile duct (lobectomy).

Liver cells can regenerate and function normally again after surgery. Surgery for perihilar and distal cancers is more difficult; perihilar cancers will require removing part of the liver, gall bladder, local lymph nodes and possibly part of the pancreas and small bowel. Distal tumours will involve removing bile ducts, part of the pancreas and part of the small bowel.

The tumours are often advanced at diagnosis and this surgery is not appropriate but insertion of a stent to open the bile duct to allow the bile to drain and relieve the jaundice may be required.

Radiotherapy

Radiotherapy may be prescribed after surgery possibly with chemotherapy to reduce the risk of recurrence. If surgery is not an option, radiotherapy may be used to relieve symptoms and slow the growth of the cancer cells.

Chemotherapy

After surgery, chemotherapy may be used in conjunction with radiotherapy to reduce the risk of recurrence or used to relieve symptoms and slow the growth of cancer cells in inoperable cases.

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