Gastrointestinal System Neoplasms (PEARLS)

The NCCPA™ Gastroenterology and Nutrition PANCE Content Blueprint gastrointestinal system neoplasms (PEARLS)

Esophageal Neoplasms	Patient will present as → a 62-year-old man with a history of alcoholism who complains of difficulty swallowing solids that has progressed to difficulty swallowing liquids. He has smoked 1-2 packs of cigarettes per day for the past 38 years. In addition, he reports occasional bouts of hematemesis and hoarseness, along with progressive weight loss and weakness. Progressive dysphagia to solid foods along with weight loss, reflux, and hematemesis Squamous cell m/c worldwide and adenocarcinoma common in the US Adenocarcinoma: A complication of Barrett's esophagus (screen Barrett's patients every 3-5 years with endoscopy), affects distal (lower) 1/3rd of the esophagus Squamous cell: Associated with smoking and alcohol use Affects the proximal (upper) 2/3rds of the esophagus Progressive dysphagia, weight loss, hoarseness DX: endoscopy + biopsy TX: Resection Endoscopic image of a patient with esophageal adenocarcinoma seen at the gastroesophageal junction.
Gastric Neoplasms	Patient will present as → a 58-year-old male chef with a history of smoking and chronic gastritis presents with a four-month history of progressive epigastric pain, occasional vomiting, and a 15-pound weight loss. He reports the pain worsens after eating, especially with spicy foods. Recently, he noticed decreased appetite and early satiety. He has no family history of gastrointestinal cancers. Physical examination reveals mild epigastric tenderness without palpable masses. You are surprised to discover a firm, enlarged, painless lymph node above the patient’s left clavicle. Laboratory tests show Guiac-positive stool and iron deficiency anemia. An upper endoscopy reveals a 3 cm ulcerated lesion in the antrum of the stomach, and a biopsy confirms adenocarcinoma. Abdominal pain and unexplained weight loss are the most common symptoms, along with reduced appetite, anorexia, dyspepsia, early satiety, nausea and vomiting, anemia, melena, and guaiac-positive stool Gastric adenocarcinoma in most cases worldwide Virchow's node (Supraclavicular) (view image) Sister Mary Joseph's node (Umbilical) (view image) DX: Upper endoscopy with biopsy Linitis plastica is a finding that refers to the diffuse thickening of the stomach wall due to cancer infiltration (worst type) Treatment: Gastrectomy, radiotherapy, chemotherapy; poor prognosis Upper endoscopy (stomach cancer)
Liver neoplasms (ReelDx)	ReelDx Virtual Rounds (Liver neoplasms) Liver neoplasms You are called to see a 43-year-old with right-side abdominal pain Patient Gender: Female Age: 43 years Weight: 136.7 lb/62 kg Height: 63 in/160 cm Vitals Temperature: 98 F/36.7 C Blood Pressure: 135/84 Heart Rate: 96 Respiratory Rate: 18 Pulse Oximetry: 98% RA Signs and Symptoms RUQ and RLQ abdominal pain Click here to work through this patient case simulation. Patient will present as → a 52-year-old female with a history of cirrhosis secondary to long-standing alcohol abuse visits your office to discuss a 15-pound weight loss over the last 6 months. She reports early satiety, jaundice, and vague abdominal discomfort. Her ascites, generally stable and small, has worsened in the last 3 weeks. Abdominal pain, weight loss, right upper quadrant mass Etiology: cirrhosis, Hepatitis B, Hepatitis C, Hepatitis D, aflatoxin from aspergillus Tumor Marker: ↑ alpha-fetoprotein and abnormal liver imaging DX: ↑ Alpha-fetoprotein - a rise in serum AFP in a patient with cirrhosis or hepatitis B should raise concern that HCC has developed HCC can be diagnosed on contrast-enhanced CT, MRI, or US If there are radiologic hallmarks of HCC a diagnosis of HCC is made. If the radiologic hallmarks of HCC are not seen, a biopsy should be obtained and assessed by an expert pathologist Incidental liver lesions may be detected on imaging studies performed for an unrelated reason Lesion characteristics and size guide further management Image lesions with MRI or CT to look for imaging features of HCC. If negative, obtain follow-up ultrasounds every three months TX: Resection, transplant - poor prognosis Non-contrast and contrast CT of hepatocellular carcinoma.
Pancreatic neoplasms (ReelDx)	ReelDx Virtual Rounds (Pancreatic neoplasms) Pancreatic neoplasms You are called to see a 72-year-old male with decreased appetite, weight loss, fatigue, dark urine, and jaundice Patient Gender: Male Age: 72 years Signs and Symptoms Decreased appetite; weight loss; fatigue; dark urine; jaundice. Click here to work through this patient case simulation. Patient will present as → a 68-year-old smoker with a 25 lb weight loss over the last three months that is associated with a burning pain deep in the epigastrium after eating, diarrhea, and jaundice. Physical exam reveals a palpable, non-tender gallbladder and clay-colored stool. Labs show a total bilirubin of 8, alkaline phosphatase of 450, and an ALT of 150. Painless jaundice is pathognomonic! Most commonly ductal adenocarcinoma located at the pancreatic head Presentation: Jaundice and palpable non-tender gallbladder (Courvoisier’s sign) Trousseau sign of malignancy - migratory phlebitis Virchow's node (or signal node) is a lymph node in the left supraclavicular fossa (the area above the left clavicle) that is associated with pancreatic cancer DX: Diagnose with abdominal CT scan - 75% show tumor at the head of the pancreas, 25% at the tail Tumor Marker: CA 19-9 Treatment: Whipple procedure: remove the antrum of the stomach, part of the duodenum, head of the pancreas, gallbladder The Whipple procedure involves removing the antrum of the stomach, part of the duodenum, the head of the pancreas, and gallbladder CT with IV contrast showing pancreatic adenocarcinoma at the head of the pancreas.
Colon cancer	Patient will present as → a 65-year-old male with several months of weight loss, vague right upper quadrant pain, and thin-caliber stools. His medical history is notable for 50-pack-years of smoking and obesity. On exam, he appears chronically ill and has firm hepatomegaly. His labs reveal a hemoglobin of 10.7 g/dL and mildly elevated ALT and AST. Painless rectal bleeding and a change in bowel habits in a patient 50-80 years of age Apple core lesion on barium enema, adenoma most common type Screening begins at 45 and continues until 75 y/o Recommended intervals for colorectal cancer screening tests include High-sensitivity gFOBT or FIT every year sDNA-FIT every 1 to 3 years CT colonography every 5 years Flexible sigmoidoscopy every 5 years Flexible sigmoidoscopy every 10 years + FIT every year Colonoscopy screening every 10 years Selectively screen adults aged 76 to 85 years for colorectal cancer: Discuss together with patients the decision to screen, taking into consideration the patient’s overall health status (life expectancy, comorbid conditions), prior screening history, and preferences. USPSTF colorectal cancer screening guidelines DX: Definitive diagnosis is with colonoscopy and biopsy. Barium enema will classically show an "apple core lesion" More likely to be malignant: sessile, > 1 cm, villous Less likely to be malignant: pedunculated, < 1 cm, tubular Increased tumor Marker CEA and CBC may show anemia Treatment: Resect tumors and adjuvant chemotherapy An 'apple core' lesion of the colon shown on contrast enema Image by Alzaraa et al. License: CC BY 3.0
Anorectal cancer	Patient will present as → a 69-year-old male who complains of rectal pruritus, bleeding with defecation, and a sensation of incomplete evacuation. A palpable mass is noted on digital rectal examination. Rectal bleeding + tenesmus (a feeling of incomplete emptying after a bowel movement), the most common anorectal cancer is adenocarcinoma Primarily adenocarcinomas DX: Typically, colonoscopy is done whenever rectal bleeding occurs, even in patients with obvious hemorrhoids or known diverticular disease. Coexisting cancer must be ruled out TX: Treated with wide local surgical excision, radiation with chemotherapy for large tumors with metastases Carcinoma of the anal canal