Information about Approach to the patients of GI malignancy by Dr Dhaval Mangukiya. Details of GI malignancy, HPB malignancy, Liver, Pancreas, Biliary, https://drdhavalmangukiya.com/ http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat https://gastrosurgerysurat.blogspot.com/

1. Approach to the patients of GI
malignancy
DR DHAVAL MANGUKIYA
HPB & GI SURGEON

2. G I MALIGNANCY
• HPB
– LIVER
– CBD
– GALL BLADDER
– PANCREAS
• LUMINAL
– ESOPHAGUS
– STOMACH
– SMALL BOWEL
– COLON
– RECTUM
– ANAL CANAL
• CARCINOIDS LYMPHOMA
• NEURO ENDOCRINE TUMORS GIST
• RETRO PERITONEAL TUMORS NEURO FIBROMA

3. HPB MALIGNANCY

4. LIVER
• HCC
• FNH
• ADENOMA
• HAMENGIOMA / ATYPICAL HAMENGIOMA
• HEPATOBLASTOMA
• METASTASIS
• FLC
• INTRA HEPATIC CHOLANGIO CARCINOMA

5. LIVER
• Important tips
– Biopsy is not needed
– One good imaging modality (triphasic scan- plain +
arterial + equilibrium + venous + delayed phase)
– If not sufficient than MRI with contrast (triphasic)
– If still not conclusive only than biopsy (after
consulting liver surgeon)
– If in doubt get all tumor markers i.e.  CEA, CA
19-9, AFP

6. • ADENOMA – can be observed, avoid o.c.pills
• HAMENGIOMA – Can be observed,
Surgery only
– If in left lobe and diameter more than 7-8 cm with
hanging variety or
– If the diameter more than 15 cm in right lobe
– Or with high reticulocyt count with persistant
anemia and weakness + growth retardation
– Relative indication  palpable mass

7. • HCC  primary treatment is surgery / transplant
according to UCSF/MILLAN’S criteria
• Liver resection can be done up to 70% of the
normal liver paranchyma in absence of jaundice
• In Cirrhosis its usually CPT SCORE, MELD SCORE
and the resection volume should not be more
than 40%
• Negative AFP (nearly 30%) does not rule out
presence of HCC

8. • Hepatoblastoma  most common in pediatric
age group
– Staging is totally different than conventional TNM
– Irrespective of size if its resectable than its stage 1
– Primary treatment of any of this is surgery
– If unresectable only than neoadjuvant
chemotharapy followed by surgery followed by
chemo
– Overall prognosis is better than HCC

9. • METASTASIS
– From colorectal tumors – primary treatment is
surgery second line chemotherapy
– If unresactable  chemo  surgery
– Even unresectable  TACE (trans arterial chemo
emboization)
• (Both the hepatic arteries and portal veins needs to be
patient on d same side)
– RFA
• Limitation – cant be done near vessel,surface, more than
5cm in size.

10. • Intra hepatic cholangio carcinoma
– Look for jaundice
– Volume of tumor and residual liver volume
– Liver resection can never be done if the jaundice
level is more than 2mg/dl
– Best way to reduce billirubin is B/L PTBD
– Same side portal or hepatic artery involvement is
not contraindication.
– Porto portal reconstruction is very routine
procedure.

11. PANCREAS
• ADENO CA
– HEAD
– UNCINATE
– BODY
– TAIL
• CYSTIC
– Serous cyst adenoma
– Mucinous cyst adenoma
– IPMN (Intraductal papillary
mucinous neoplasm)
– Mucinous cyst
adenocarcinoma
– Solid pseudopapillary
tumor
• NET
• INSULINOMA
• GLUCAGONOMA , SOMATOSTATINOMA,GASTRINOMA
• NON FUNCTIONAL TUMORS

12. PANCREAS
• ADENOCARCINOMA OF HEAD & UNCINATE
– Biopsy is not needed and even FNAC also not
needed (only 40% positive)
– CA 19.9 is not reliable in presence of infection /
jaundice except the values exceeds >1000
– Borderline resectabllity  portal vein involvement
< 180 degree upto 1.5 cm in length
– SMA involvement full of challenges and no long
term data available (trials on going)

13. – IVC involvement in uncinate mass  borderline
resectable
– WHEN ERCP
Presence of Jaundice is not indication for ERCP
Every ERC also not an indication for Stenting
Stenting should never be done before cross
sectional imaging (CECT)
It should be only done in presence of cholangitis
or s. bilirubin more than 15-20mg/dl

14. • Whipples’ pancreatico duodenectomy (WPD)
– What is best
– classical , PPD, PPPD, Machado modification
– Use of octreotide
– FJ
– ORAL DIET
– Predictors of leak

15. • Adeno carcinoma of body / tail
– Distal pancreatico splenectomy is choice of
surgery – RAMPS
 Issues
– biopsy??  Not mandatory unless diagnostic
dilemma on imaging
– Distal stump management
– Pancreatic fistula
– Use of pancreatic enzymes / octride

16. Serous cyst adenoma (SCN)
– NO SURGERY Only observation
MCN
always surgery
IPMN
surgery with frozen section
SPT
Radical surgery – excellent prognosis

17. • Pancreatic NET
– DIAGNOSIS  Insulin level, C Peptide level,
IMAGING, s. gastrin
– Enucleation of tumor if possible
– Otherwise radical resection
– Metastasis  debulking of liver mets if functional
– therapeutic DOTATOC/DOTANOC scan and sos long
acting octreotide treatment.

18. Biliary
• CARCINOMA GB
• MID CBD CHOLANGIO CA
• HILAR CHOLANGIO CA
• LOWER END CHOLANGIO CA

19. • CA GB
– INCIDENTAL  Post cholecystectomy biopsy
detected
– Further management depends on exact T stage
and location
– T1a (lamina propria)  std cholecystectomy is the
treatment
– If more than T1a  as early as possible re-
evaluation , with CECT Whole abdomen

20. – Tumor markers
– Assessment of L.N. status
– If operable completion radical cholecystectomy
– IAC & Cystic duct margin for frozen
– IF IAC positive closure
– if cystic duct margin positive EHBDE & RYHJ

21. • CA GB With Jaundice / MID CBD Cholangio ca
– PTBD VS ERC STENTING
– Surgery needs to be avoided till the bilirubin level
is less than 2mg/dl
– If there is Rt sided vessel involvement  extended
Rt hepatectomy or modified extended rt
hepatectomy

22. • Hilar cholangio carcinoma
– Staging is most important
– CECT Triphasic with liver volumetry + MRCP
– PTBD B/L always better than ERC If we r planning
resection
– No surgery till jaundice less than 2 mg/dl
– If volumetry is low than portal vein embolization is
best option

23. – Extended rt hepatectomy is most commonly
performed surgery.
– Ipsilateral involvement of vessel is not
contraindication
– Main PV involvement can also be reconstructed
– Lymphadenectomy is must

24. THANK YOU

33. Ca esophagus
• Stage and location, HPE, Medical condition
• So diagnosis is must and classification
according to WHO criteria is mandatory
• Staging is better done with CECT chest and
upper abdomen
• PET may be helpful in detection of distant
mets (2b)

34. • Lap must in lower and middle one third of
tumors
• Celiac nodes is considers as N not M
• Squamous cell  sx only in T1 &T2
• Adenocarcinoma 
• For palliation also chemo + radio
• No role of one therapy alone

35. • Upper end
– Generally squamous cell ca
– Primary treatment is radiotherapy
–
• Middle one third and lower one third
– Now since last one decade trend is changing
towards ADENO Ca

37. Ca stomach