Less Common Cancers Series: Upper GI Cancers
MR KRISHNA EPARI
Introduction
Mr Krishna Epari Upper GI and HPB Surgeon
Fiona Stanley Hospital SJOG Murdoch - www.uppergiwest.com.au
ANZGOSA Board Member Lead Clinician WACPCN Upper GI Tumour
Collaborative
Cancer incidence and mortality in Western Australia, 2014
http://www.health.wa.gov.au/wacr/statistics/stats_full.cfm
Cancer incidence and mortality in Western Australia, 2014
http://www.health.wa.gov.au/wacr/statistics/stats_full.cfm
Current Status – Upper GI Cancer Surgery
8th June 2016
Current Status – Upper GI Cancer Surgery
FSH* SCGH* RPH
Oesophagus ✔ ️ ✔ ️
Stomach ✔ ️ ✔ ️
Pancreas ✔ ️ ✔ ️
Liver ✔ ️ ✔ ️ ✔ ️
* Comprehensive Cancer Centres
Optimal Care Pathways
https://www.cancer.org.au/ocp
Optimal Care Pathways
https://www.cancer.org.au/ocp
Resources
https://www.cancerwa.asn.au
Patient Resources
https://www.cancerwa.asn.au/resources/publications/patients/
Pancreatic Cancer
Pancreatic Ductal Adenocarcinoma 4th highest cause of cancer deaths in WA 6% overall 5 year survival 80% metastatic/inoperable at presentation 20% are surgically resectable 20-25% 5 year survival post resection
Histopathology – Pancreatic Tumours
Primary Pancreatic Ductal Adenocarcinoma Cholangiocarcinoma Ampullary Adenocarcinomas Duodenal Adenocarcinomas Pancreatic Neuroendocrine Tumours (NETs) Pancreatic Cystic Tumours Intraductal Papillary Mucinous Neoplasms (IPMN) Other rare tumours
Secondary Renal Cell Carcinoma
Risk Factors
Smoking Age Dietary factors Environmental factors Alcohol Chronic Pancreatitis Genetic factors IPMN (Main duct > mixed > side branch type)
Familial Syndromes
Breast Cancer (BRCA2) Peutz-Jeghers Syndrome Familial Atypical Mole Melanoma (FAMMM) Hereditary Non-Polyposis Colorectal Cancer (HNPCC) Familial Adenomatous Polyposis (FAP) Hereditary Pancreatitis
These only account for a small percentage of cases. Most pancreatic cancers are sporadic cases.
Diagnosis - Symptoms
High index of suspicion
OBSTRUCTIVE JAUNDICE Unexplained abdominal pain Loss of Appetite Loss of Weight New onset diabetes Pancreatitis
Diagnosis – Primary Investigations
Blood Tests U&E, FBE, LFTs, Coags, Amylase, Lipase CA19-9, CEA (Tumour Markers)
Imaging Abdominal Ultrasound Triple Phase CT scan*
Refer to Specialist
Referral – Suspected Upper GI/HPB Cancers
Central Referral Service
Upper GI Cancer Nurse Specialist Briony McBride (Full Time @ FSH) Mobile 0434 679 679 Email [email protected]
Private Rooms
Pancreatic Surgeon
2 years post fellowship subspecialty training in Upper GI/HPB surgery (ANZHPBA)
Roles Confirm diagnosis Staging the tumour Assess fitness for surgery Present cases to Multidisciplinary Team Perform Pancreatic surgery Palliate biliary & duodenal obstruction
Pancreatic Surgery
High risk, complex, low volume procedures Difficult to manage complications
Pancreatic leak/fistula Sepsis/Collections Haemorrhage Delayed gastric emptying
~3% mortality >50% morbidity
Pancreatic Surgery Centres
Centralisation Better outcomes with higher volume surgeons and
higher volume institutions Availability of resources required for peri-operative
management and complications
WA Health has mandated that all Pancreatic Surgery must now be performed at the 2 metro comprehensive cancer centres (FSH, SCGH)
Assessment
Fitness for Surgery/Treatment Cardiac Disease Respiratory Disease Renal Disease
Tips
Cease Clopidogrel Cease Smoking Nutrition
Staging Investigations
US CT MRI/MRCP PET ERCP/PTC Endoscopic Ultrasound Laparoscopy / Laparoscopic Ultrasound
Pancreatic Surgery
Surgical candidates Fit for surgery No metastatic disease No vascular invasion*
Cystic, neuroendocrine, ampullary, duodenal
tumours have a better prognosis compared with adenocarcinoma
Pancreatic Surgery
Whipple’s Procedure (Pancreatico-duodenectomy)
Distal Pancreatectomy / Splenectomy Total Pancreatectomy Enucleation
Pancreatic Surgery
Whipples Surgery takes 6-8 hours Average LOS 10-14 days 6-12 months to recover QOL Pancreatic Exocrine Insufficiency
Very common Pancreatic Enzyme Supplementation (‘Creon’) Nutritional Support
Diabetes (~10%)
Pancreatic Surgery - Whats New?
Borderline resectable cases Extended resection/vascular reconstruction
Better Chemotherapy regimens Neoadjuvant therapies Minimally invasive surgery
Laparoscopic assisted Whipples
Enhanced recovery after surgery (ERAS)
Enhanced Recovery After Surgery
Palliative Treatment
Avoid resection with palliative intent Palliative Chemotherapy &/or Radiotherapy Median Survival usually > 12 months Palliation of Obstruction
ERCP / PTC / Biliary Stents Endoscopy / Duodenal Stents Surgical Bypass
Laparoscopic Open
Biliary Stents
Incidental Pancreatic cyst
Benign Pseudocyst Serous Cystadenoma
Malignant Potential Mucinous Cystadenoma Intraductal Papillary
Mucinous Neoplasm (IPMN)
Investigations Tumour Marker
CA 19-9 Fine Cut Triple Phase CT
Pancreas MRI/MRCP Endoscopic Ultrasound
+/- FNA/Biopsy
Incidental Pancreatic cyst
Must consider risk of pancreatic surgery versus risk of malignancy
Low risk lesion – Observation with serial imaging and tumour markers (CA 19-9)
High risk lesion – Consider surgical resection
Various International Guidelines based on low levels of evidence
Oesophageal Cancer
Western Countries Incidence 5-10/100,1000 Male>Females Increasing age Mostly Adenocarcinoma Mostly lower third / GOJ
Asian countries More common Mostly Squamous Cell Carcinomas
Oesophageal Cancer
Presentation Dysphagia Reflux Weight loss
Risk factors Smoking, alcohol Barrett’s Oesophagus (Reflux Oesophagitis, Obesity) Achalasia Caustic/Corrosive injury
Barrett’s Oesophagus
Barretts Oesophagus
Journal of Gastroenterology and Hepatology 30 (2015) 804–820
Oesophageal Cancer
Curative Treatment options Surgery (Oesophagectomy) Endoscopic mucosal resection (EMR)
Barretts/HGD (Tis) Early tumours confined to mucosal layer (T1m)
Chemoradiotherapy Not fit for surgery Proximal tumours SCC > Adeno
HALO Ablation
Oesophagectomy
Minimally Invasive Oesophagectomy
Oesophageal Cancer
Neoadjuvant therapy (Improves survival) Pre-operative chemotherapy Pre-operative chemoradiotherapy
Outcomes Most patients Stage 3 (T3N1) 20-25% 5 year survival
Oesophageal Cancer
Palliative therapy Chemotherapy (Systemic disease) Chemoradiotherapy (Locally advanced disease) Endoscopic Stent Supportive care
Gastric Cancer
2nd Commonest cause of cancer deaths worldwide
High incidence in Eastern countries (Japan, China), South America
Western countries Less common Shift towards more proximal tumours
Gastric Cancer
Presentation Epigastric Pain Dyspepsia Nausea, Vomiting Bleeding Early satiety
Risk factors Smoking, alcohol Dietary (high salt, smoked foods) Helicobacter Pylori
Gastric Cancer
Pathology Adenocarcinoma
Intestinal type Diffuse type (Linitus plastica)
Carcinoid (Neuroendocrine tumour) Lymphoma Gastrointestinal Stromal Tumour (GIST)
Gastric Cancer
Curative Treatment options Surgery (Gastrectomy)
Total or Subtotal Radical lymphadenectomy (D2) Reconstruction
Endoscopic mucosal resection (EMR)
Early tumours confined to mucosal layer (T1m)
Gastrectomy Reconstruction
Bilroth II Roux-en-Y
Gastric Cancer
Post-Gastrectomy problems B12 and Iron deficiency Diarrhoea Dumping
Early Late
Bile Reflux
Gastric Cancer
Peri-operative chemotherapy MAGIC trial demonstrated survival advantage with
chemo before and after surgery 36% vs 23% 5 year survival
Post-operative chemoradiotherapy
Intergroup trial Benefit for node positive disease
Gastric Cancer
Palliative treatment Chemotherapy Chemoradiotherapy Radiotherapy Endoscopic Stent Supportive care
Liver Lesions
Benign Cyst(s) Haemangioma Focal Nodular
Hyperplasia (FNH) Hepatic Adenoma Focal fatty sparing Abscess Hydatid Cyst
Malignant Primary
Hepatocellular Carcinoma (HCC)
Cholangiocarcinoma
Secondary COLORECTAL LIVER
METASTASES Neuroendocrine Tumours Melanoma Others
Colorectal Liver Metastases
50% of colorectal cancers develop liver metastases
40% liver only site of initial progression 20% liver only site at death 10-20% resectable
20-60% 5 Year Survival
Curative Surgery Fit for Surgery Liver Tumour(s) all resectable with clear margins No Unresectable Metastatic Disease Adequate Functional Remnant Liver Volume (FRLV)
>25% Healthy Liver >40% Cirrhosis/NASH/Post Chemo
Preserve portal venous inflow, hepatic arterial inflow and hepatic venous outflow
Thank You
MR KRISHNA EPARI Upper GI / HPB Surgeon
Fremantle Hospital SJOG Murdoch / Mount www.uppergiwest.com.au