1. Gastro-intestinal Tumours:
Aetiology, Diagnosis and
Management
School of Medicine
7th Year Students Lecture
Prof. BFK ODIMBA
MD MTD-EPI MSC MPH SDGS Ph. D
FFAS FCS-ECSA FWACS MFAcS IASGOFM FM FACAF
2. Outline
• Introduction
• Aetiology and factors
• Histological types
• Clinical presentations and diagnosis
• Treatment techniques
• Indications
• Prognosis and perspectives
• References
3. Introdution
• GIT:
– Factory To Human Body
– Highly Vulnerable
• Lack of Food: Atrophy
• Swallowing: mouth, hypopharynx oesophagus
• Digestion/Absorption: stomach, bowel
• Evacuation: bowel, colon, rectum, anus
• Primary GI Tumours
– Arising from GI wall(stromach in let anus outlet)
– Excluded: metastatic deposits, compression or evasion,
oesophagus tumours
4. Introduction (cont)
GI tumours’ concerns
•Involved at all levels of GIT vulnerability
•Late diagnosis
• Tx: Surgery+++ or association
• ?Benign or malignant tumour
Benign or malignant GI tumours
Macroscopy
? Benign: regular, slow growth, well delimitated, not evading surrounding structure
? Malignant: irregularity, rapid extention, evasion of surrounding structure
Histology ultimately +++ because of
•border-line tumours : carcinoid tumours
•possible change from benign to malignant (malignant degenerescence)
5. Aetiology
• Not any cause known as 100% responsible
of GI tumour
• Factors leading to GI range as follows
– Genetic factors
– Environmental factors+++
– Pre-existing condition+++
7. Aetiology
Environmental factors +++
Difference from one country to another: low risk in Japan
Alimentary factors: high rate of protein and animal calories protects against
ca of the stomach
Means of foods keeping or storage : use of nitrites is a high risk
Nutrition and alcohol : poor nutrition, excess alcohol: high risk.
Pre-existing condition +++
Atrophic gastritis;
Giant hypertrophic gastritis of Ménétrier;
Common chronic gastritis;
Some polyadenomas;
Benign gastric ulcer;
Gastric stump after gastrectomy
8. GI tumours groups: Histology++++
• A/ Benign
– Arising from epthithelium
– Arising from connective tissue
– Dysgenetic tumours
– Inflammatory pseudotumours
• B/ Malignant
– Stomach
– Duodenum
– Small bowel
– Large Bowel and Rectum
– Anus
10. Benign GI tumours from connective tissue
Types comprise :
Nerve
muscle,
fat,
stromal tissue
vessel
Description:
origin,
level,
site,
number
colour,
size
shape,
degeneration and association
11. Benign GI tumours from dysgenetic tissue
Comprise
Heterotopia
Cysts
teratoma
Main origins:
pancreas,
duodenum,
organoid and enteroid
Characteristics:
level,
number
colour,
size
Shape
, degeneration, association
12. GI benign Inflammatory pseudotumours
Comprise
Each Granuloma
Eosinophil granulomas
Characteristics:
level,
number
colour,
size
shape,
degeneration, association
13. Gastric malignant tumours: types
• From epithelial surface :
– Carcinoma
– carcinoïd
• From non epithelial surface
– sarcomas: lympho or
pseudolymphosarcoma
– and from stromal tissues
• Many subdivisions in each entity
14. Gastric malignant tumours: classification
• WHO : papillary ; tubular ; mucinous
and signet_ring
• Lauren :
– intestinal adenocarcinoma of the stomach
– diffuse carcinoma of the stomach : poor
prognosis
• Three modes of spread : lymphatic,
bloodstream and transperitoneal
15. Gastric malignant tumours: epidemiology
and prognosis
• Epidemiology
– Precursor lesions and pre-existing lesions
– Environmenatal impact and nutrition
• Prognosis factors
– histological type
– early detection : endoscopy
– early accurate surgery
• Overall poor prognosis : 20% survive after 5
years if curative treatment
• Ideal Tx: radical surgery
16. Duodenal malignant tumours
• Frequency: rare (In contrast with the stomach)
• The most common:
– From epithelial surcface: :adenocarcinomas (87%): or from
Lieberküln (cylindric cells) : squirhous tumour ; or from
Brunner,s cells (spheric cells)
– From non-epithelial tumour: : lymphosarcomas and
leiomyosarcomas
• Benign tumours are : carcinoid tumours and
duodenal insulinomas leading to Zolliger Ellison
syndrome
• Close connexion with pancreas and bile duct
• Classifications : pre, peri and post papillary tumours
17. Small bowel malignant tumours
• From epithelial surface Carcinoma 40%
– < than those of duodenum and of large bowell.
– often associated with adenomas
– Diagnosis difficult ? : endoscopy and biopsy
– carcinoid tumours not rare and is often
secreting
• From non epithelial tumours: lymphoma and
smooth/muscle tumours
• For classifications: as for colorectal cancers
18. Colo-rectal cancers: Types and grades
• Carcinoma:
– the highest and most typical here
– the second visceral cancer in USA
• Grading: three grades according to
the arrangement of cells
– Grade I : low grade or well differenteiated(15%) ;
– grade II : average grade : moderately
differentiated(60 to 70%) ;
– grade III : poorly differentiated : 15 to 20%)
19. Colorectal cancers staging
Dukes (esp. rectum)
• Stage A: limited to the wall of the rectum
• Stage B : Extension to extrarectal tissues, but
no metastases to regional lymph nodes
• Stage C : metastases in regional lymp nodes
• Modifications of stage III (1935) : C1 :
Metastases to regional lymph nodes; C2 :
Metastases to lymp nodes at the point of
mesenteric blood vessel ligature
20. Colo-rectal cancers staging: Astler-Coller
classification for colorectal carcinoma
• Stage A : Lesion limited to the mucosa
• Stage B1 : Lesion involves muscularis propria but
does not penetrate through it
• Stage B2 : Lesion penetrates through the muscularis
propria without LN envolvement
• Stage C1 : Metastatic tumour in lymph nodes, but the
tumour itself is still confined to the bowel wall
• Stage C2 : metastatic tumour in lymph nodes and
tumour itself has penetrated through the entire bowel
wall
21. AJCC AND UICC staging for colorectal cancer
• Stage 0 : T0 ; N0 ; M0
• Stage I : T1, N0 M0 or T2, No, M0
• StageII : T3, N0, M0 or T4, N0, M0
• StageIII : Tany, N1, M0 or Tany, N2,
N3, M0
• Stage IV : T any, N any, M1
22. Malignant tumours of the anus
• Squamous cell tumours are common
• Radiotherapy (brachyradiotherapy) may
work in some cases
• Some pediculated tumours may be
resected endoscopically
23. GIT Tumours Clinical Presentation
and Diagnosis
• Latent tumours : imaging, surgery or autopsy
• Abdomen pain mainly chronic epigastric pain
• GIT bleeding : repeated melena ( frank or
microscopic : occult)++++, haematemesis
• Intestinal obstruction periods (subacute,
acute)
• Peritonitis (rare)
• Decline of general condition : loss of appetite, loss of
weight,
• Manifestation from metastatic deposit
24. GIT Tumours Clinical Presentations and
Diagnosis 2
Particulars of certain tumours
• Big tumours felt by patient : schwanomas, lipomas, fibromas .
• Tumours with mechanical obstruction : acute or chronic
voluvlus, pyloric obstruction+++, cardial obstruction, left colon
acute intestinal obstruction
• Severe anaemia : Polypoid adenomas, with hyperchromic
megaloblastic (Biermer)
• Perioficial pigmentation and diffuse polyposis : PeutzJeghers
Touraine
• Cutaneous angiomas or multiple teleangiectasis : angiomatosis
of Rendu Osler
• Endocrine syndrome : severe peptic ulcers de Zolliger Ellison ;
Flush syndrome carcinod tumours
25. Physical Examination
• Always complete abdominal
examination +++
• Systemic review
• May be normal or without
significant signs of findings
• Allows to plan investigations
26. Investigations
• Standard Lab
• Blood : FBC, ESR, HB
• Stools : blood (red cells)…..
• Standard Imaging
• Plain Abdomen Xrays, Chest Xrays
• Opacifications : Ba swallow ; Ba meal ; Ba enema
• Endoscopy+ biopsy+++
• Upper GIT endoscopy,
• Proctoscopy, rectosigmoidoscopy, colonoscopy
• Angiogram
27. Investigations 2
• Extension or special assessment and
staging
– US/
– CT Scan/
– NMR
• CEA
• Open biopsy,
• Exploratory laparotomy
28. Differential diagnosis
• If biopsy has not been done or before it
is done
• They are mainly
– Acute or chronic ulcers
– Foreign bodies
• Benign or malignant : clinical,
radiological and endoscopic criteria
29. GIT Tumours: Principes of Treatment
• Surgical Methods
– Surgical excision of the tumour+++
• Endoscopic polypectomy
• Surgical excision of the tumour
• Surgical excsision of segment of
gastrointestinal tube
– Carcinologic resection to remove the tumour
– Palliative surgery for advanced malignant
tumours
– Laparoscopic surgery for GIT tumours
30. Other methods of threatment of GIT
malignant tumours
• Radiotherpy
• Chemotherapy
• Hormonotherapy
• Immunotherapy
• Rarely isolated
• More often combined to surgery as
adjuvant or neoadjuvant
32. General Information About Gastrointestinal Carcinoid Tumors
• Gastrointestinal carcinoid tumors form in the lining of the gastrointestinal tract, most often in the
appendix, small intestine, or rectum.
• Health history can affect the risk of gastrointestinal carcinoid tumors.
• Some gastrointestinal carcinoid tumors have no signs or symptoms in the early
stages like in the stomach
• Elsewhere they may have symptoms
– Duodenum:: abdoman pain. constipation ,diarrhea, change in color , jaundice
Heartburn, nausea
– Jejunum, ileum: abdominal pain, weight loss for no known reason, feeling very
tired, feeling bloated, diarrhea, nausea, vomiting
– Colon: abdominal pain and weight loss for no knownnd reason.
– Rectum: Blood in the stool.Pain in the rectum.Constipation
• They might some times spread (small intestine)
• The carcinoid syndrome due to secreted hormone a(if it is not destroyed by the
liver enzymes) : redness or a feeling of warmth in the face and neck.,abdominal pain, .feeling
bloated , diarrhea, wheezing or other troubl breathing and fast heartbeat
33. Diagnosis
Imaging studies and tests that examine the blood and urine are used to detect (find) and
diagnose gastrointestinal carcinoid tumors.
History and physical examination: checking for signs of disease. history of the
patient’s health habits and past illnesses and treatments will also be taken.
Blood chemistry studies: a blood sample is checked to measure the amounts of certain
substances, such as hormones, released into the blood by organs . An unusual (higher or
lower than normal) amount of a substance can be a sign of disease. The blood sample is
checked to see if it contains a hormone produced by carcinoid tumors. This test is used to
help the diagnosis of carcinoid syndrome.
Tumor marker test: A procedure in which a sample of blood, urine, or tissue is checked
to measure the amounts of certain substances, such as chromogranin A made by organs,
tissues, or tumor cells in the body. Chromogranin A is a tumor marker. It has been linked to
neuroendocrine tumorswhen found in increased levels in the body.
Twenty-four-hour urine test: A test in which urine is collected for 24 hours to measure
the amounts of certain substances, such as 5-HIAA or serotonin (hormone). An unusual
(higher or lower than normal) amount of a substance can be a sign of disease in the organ
or tissue that makes it. This test is used to help diagnose carcinoid syndrome.
34. •MIBG scan : A procedure used to find neuroendocrine tumors, such as carcinoid tumors. A very small amount of
radioactive material called MIBG (metaiodobenzylguanidine) is injected into a vein and travels through the
bloodstream. Carcinoid tumors take up the radioactive material and are detected by a device that measures radiation.
•CT scanCAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from
different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein
or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography,
computerized tomography, or computerized axial tomography.
•MRI(magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series
of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging
•PET scan(positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small
amount of radioactive glucose(sugar) is injected into a vein. The PET scanner rotates around the body and makes a
picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because
they are more active and take up more glucose than normal cells.
35. •ultrasound(EUS): A procedure in which an endoscope is
inserted into the body, usually through the mouth or rectum. An
endoscope is a thin, tube-like instrument with a light and a lens
for viewing. A probe at the end of the endoscope is used to
bounce high-energy sound waves (ultrasound) off internal tissues
or organs, such as the stomach, small intestine, colon, or rectum,
and make echoes. The echoes form a picture of body tissues
called a sonogram This procedure is also called endosonography.
•Upper endoscopy
An endoscope is inserted through the mouth and passed
through the esophagus into the stomach. Sometimes the
endoscope also is passed from the stomach into the small
intestine. It may also have a tool to remove tissue or lymph
nodesamples, which are checked under a microscopefor signs of
disease.
36. •Colonoscopy: A procedure to look inside the rectum and colon
for polyps, abnormal areas, or cancer. A colonoscope is inserted
through the rectum into the colon. A colonoscope is a thin, tube-
like instrument with a light and a lens for viewing. It may also
have a tool to remove polyps or tissue samples, which are
checked under a microscope for signs of cancer.
•Capsule endoscopy: A procedure used to see all of the small
intestine. The patient swallows a capsule that contains a tiny
camera. As the capsule moves through the gastrointestinal tract,
the camera takes pictures and sends them to a receiver worn on
the outside of the body.
Biopsy : The removal of cells or tissues so they can be viewed
under a microscope to check for signs of cancer. Tissue samples
may be taken during endoscopy and colonoscopy
37. Gastro-intestinal Stromal Tumors (GIST), Practice Essentials
Background, Pathophysiology
<
less than 1% of gastrointestinal tumors,
the most common mesenchymal neoplasms of the
gastrointestinal tract
usually found in the stomach or small intestine
can occur anywhere along the gastrointestinal
may rarely have extra-GI involvement.
38. Up to 75% of GISTs : discovered when less than 4 cm in diameter
are either asymptomatic or associated with nonspecific symptoms.
frequently diagnosed incidentally
during radiologic studies
or during endoscopic or surgical procedures performed to investigate
the GI tract disease
or to treat an emergent condition such as hemorrhage, obstruction, or
perforated viscus.
Clinical manifestations of GISTs are
vague, nonspecific abdominal pain or discomfort (most common)
early satiety or a sensation of abdominal fullness
abdominal mass (rare)
dyspnea with significant blood loss
focal or widespread signs of peritonitis (with perforation)
obstructive signs site-specific, as follows:
dysphagia with an esophageal GIST
constipation and a distended, tender abdomen : colorectal
GIST
obstructive jaundice with a duodenal GIST
39. Diagnosis
No specific laboratory test can specific (complete blood cell
count, coagulation profile , serum chemistry studies , blood urea
nitrogen (BUN) and creatinine levels, LFTs, amylase and lipase
measurements, type, screen, and crossmatch , Serum albumin
levels
Imaging studies
plain abdominal radiography: non specificli
Ba study: only limited information if GISTs has grown
CTSCan usefull: description, size, number and grading
Large GISTs (>10 cm) are as follows [3] : irregular margins,
Heterogeneous densities , locally aggressive behavior , distant
and peritoneal metastases
high-grade histology and increased mortality if : tumor larger
than 11.1 cm, irregular surface contours , indistinct margins ,
adjacent organ invasion, heterogeneous enhancement , hepatic
or peritoneal metastasis
40. MRI: like Ctscan but less performing
Positron emission tomography (PET) scanning with 2-
[F-18]-fluoro-2-deoxy-D-glucose (FDG) has the
following uses: detection of metastatic disease and
monitoring of response to adjuvant therapy
Endoscopy
Specially if bleeding, abdominal pain, or GI
obstructive symptoms from GISTs
May give suggestion of a smooth submucosal
mass displacing the overlying mucosa
Problematic for biopsy specimen collection
Obtaining a repeat biopsy in the same site as a
prior biopsy may increase the diagnostic yield
41. Endoscopy ultrasonography (EUS)
localization of lesions and their characterization
fine-needle aspiration biopsy specimens may be
obtained under sonographic guidance
more accurate than CT scanning in differentiating
benign from malignant lesions
EUS characteristics of malignant GISTs include the
following [9] : size larger than 4 cm, heterogeneous
echogenicity , internal cystic areas, irregular borders on
the extraluminal surfaces
EUS features that may help differentiate gastric GISTs
from leiomyomas are as follows : inhomogenicity ,
hyperechogenic spots , a marginal halo and higher
echogenicity than the surro nding muscle layer
42. Management
Surgery is the definitive therapy for patients with GISTs, as
follows:
Radical and complete surgical extirpation offers the only chance
for cure
Surgery is also indicated in symptomatic patients with locally
advanced or metastatic disease
Debulking large lesions is helpful when adjuvant therapy is
contemplated
Laparoscopic resection has improved and is a more frequently
considered option
44. Imatinib mesylate is used in GIST as follows:
adjuvant therapy post complete surgical resection in
patients with high-risk tumors
neoadjuvant therapy with the goal of tumor shrinkage prior
to surgical resection
Other tyrosine kinase inhibitors are used when imatinib is not
tolerated or is not effective are as follows:
Sunitinib: Less specific than imatinib; approved as a
second-line agent for advanced GIST
Sorafenib: Investigational second-generation agent
Dasatinib: Investigational second-generation agent
Nilotinib: Investigational second-generation agent
45. Thank you
• Bibliography
– News and Perspectives Medscape online: GI stromal tumours
– Nishida T, Kitagawa Y, Kang YK,- The standard diagnosis, treatment,
and follow-up of gastrointestinal stromal tumors based on
guidelines, Published online August 2015
– National Cancer Institude (online 2016): **-General Information About
Gastrointestinal Carcinoid Tumors
