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Esophageal Tumors Cengiz Pata Gastroenterology, Yeditepe University, Istanbul.

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Presentation on theme: "Esophageal Tumors Cengiz Pata Gastroenterology, Yeditepe University, Istanbul."— Presentation transcript:

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2 Esophageal Tumors Cengiz Pata Gastroenterology, Yeditepe University, Istanbul

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4 Bening esophagial tumors Leiomyoma Leiomyoma Hemangioma Hemangioma Granuller cell tumor Granuller cell tumor Congenital cell tumor Congenital cell tumor Fibrovasculer polyp Fibrovasculer polyp Bronchogenic cyst Bronchogenic cyst Eosinophilic granuloma Eosinophilic granuloma Lymphangioma Lymphangioma Squamose cell papilloma Squamose cell papilloma lipoma lipoma

5 epidemiology years years 4/1 towards to men 4/1 towards to men 5-10/ / ca mortality in men 7. ca mortality in men Squamose cell carcinoma(80%), adenocarsinoma, sarcomas, lymphoma, malignt melanome Squamose cell carcinoma(80%), adenocarsinoma, sarcomas, lymphoma, malignt melanome

6 etiology Squamose Ca Alchol, tabacco Alchol, tabacco Nitrosemanine Nitrosemanine Radiation Radiation Achalasia Achalasia Tylosis Tylosis Plummer Winson syndrome Plummer Winson syndrome Radiation Radiation HPV HPVAdenoca Baret’s (5% malignancy) Baret’s (5% malignancy) GERD (85% baret’s) GERD (85% baret’s) Obesity Obesity Scleroderma Scleroderma

7 Clinacal presentation 1/3 upper esophagus 15%, middle 50% 1/3 upper esophagus 15%, middle 50% Progressive dysphagia (firstly solid) Progressive dysphagia (firstly solid) Odynofagia Odynofagia Back pain Back pain Anorexia Anorexia Weight loss Weight loss Regurgitaion Regurgitaion Voice change Voice change Aspritaion/pnomonia Aspritaion/pnomonia hematemesis hematemesis

8 prognosis >5 cm involvement >5 cm involvement Lymph node metastas (5 year survival %20) Lymph node metastas (5 year survival %20) Small cell, malign melanoma Small cell, malign melanoma

9 diagnosis Endoscopy Endoscopy Barium graphy Barium graphy Chest radiogram Chest radiogram CT CT EUSG EUSG

10 treatment Surgery (only %40) Surgery (only %40) Radiation Radiation Cheomoradiation Cheomoradiation Dilataion Dilataion Ablation Ablation Photodynamic thrapy Photodynamic thrapy EMR (<3cm) EMR (<3cm) Stents Stents

11 Tumors of Stomach Cengiz Pata, M.D Gastroenterology Department, Yeditepe University Istanbul

12 HISTOLOGY 95% Adenocarcinoma - papiller - tubular - mucinous 4%Adeno-squamous < 1%Squamous < 1%undifferentiated

13 Stomach Carcinoma Epidemiology Chronic A-Gastritis Chronic A-Gastritis Chronic B-Gastritis (HP) Chronic B-Gastritis (HP) BI, BII resection BI, BII resection Polyposis Polyposis Chr. Ulcer Ventriculi Chr. Ulcer Ventriculi M, Menetrier M, Menetrier Blood Group A Blood Group A Men > Women Men > Women

14 Macroscopic (Borrmann Classification) I. Polypousform II. Ulcerated III. Ulcerated-infiltrative IV. Diffuse-infiltrative

15 Early Cancer Japan I.Protrusion II. Surface ( ,,  ) III. Excavated

16 Therapy Radical Tumour Resection St. Op :Gastrectomy Lymphadenectomy Omentum major + minorSplenectomy Antrum Ca : partial resection ? Primary inoperable neoplasm chemotherapyradiation

17 Prognosis 5 year rate Carcinoma in citu 100 % Carcinoma in citu 100 % Early Ca : 90 % Early Ca : 90 %

18 Small intestine tumors Cengiz Pata, M.D Gastroenterology Department, Yeditepe University Istanbul

19 clasification Adenoca %35-50, proximal Adenoca %35-50, proximal Carcinoid TM %20-40 apendix, ileum Carcinoid TM %20-40 apendix, ileum Lymphoma %14 Lymphoma %14-MALTOMA-IPSID -EATCL (after the gluten enteropathy %7-10) -multiple Lymphoid Poliposis -Periferal Nodal lenfoma Fibrosarkom Fibrosarkom Angiosarkom Angiosarkom Liposarkom Liposarkom Leiyomyosarkom Leiyomyosarkom

20 Bening (41%) Adenoma Adenoma GIST GIST Hamartoma Hamartoma Angioma Angioma Pseudotumor (brunner gland hyperplasia, pancreatic rest,endometrioma, hyperplastic polyps Pseudotumor (brunner gland hyperplasia, pancreatic rest,endometrioma, hyperplastic polyps

21 Malign (51%) Carcinoids tumors (25-45%) Carcinoids tumors (25-45%) GIST (15-25%) GIST (15-25%) Adenocarcinoma (30-40%) Adenocarcinoma (30-40%) Lymphoma (4-10% ) Lymphoma (4-10% ) Metastatic carcinoma Metastatic carcinoma Malign melanoma Malign melanoma

22 NET APUD (Amine precursor uptake and decarboxylation) cell APUD (Amine precursor uptake and decarboxylation) cell

23 Introduction İntestine and pancreas İntestine and pancreas İncidance 1/ 100,000 İncidance 1/ 100,000 Carcinoid %50 Carcinoid %50

24 Clinics

25 Zollinger Ellison Syndrome Severe peptic ulcer diathesis + gastric acid hypersecretion due to  -cell endocrine tumor Severe peptic ulcer diathesis + gastric acid hypersecretion due to  -cell endocrine tumor 0.1-1% of PUD patients 0.1-1% of PUD patients Sporadic, or associated with MEN type I (25%) Sporadic, or associated with MEN type I (25%)

26 Zollinger Ellison Syndrome >80% Localized to gastrinoma triangle: cystic & common bile ducts, duodenum, junction head and body of pancreas. >80% Localized to gastrinoma triangle: cystic & common bile ducts, duodenum, junction head and body of pancreas. 60 % malignant, up to 50% with metastasis 60 % malignant, up to 50% with metastasis Clinical: PUD >90% (recurrent, multiple, refractory, complicated) Clinical: PUD >90% (recurrent, multiple, refractory, complicated)

27 Clinical features of Zollinger- Ellison syndrome

28 MEN I Autosomal Dominant: Parathyroid (~90%), Pancreas (40-80%) Pituitary (30-60%) Autosomal Dominant: Parathyroid (~90%), Pancreas (40-80%) Pituitary (30-60%) Contributory effect of hyperparathyroidism, hypercalcemia  hypergastrinemia  acid secretion Contributory effect of hyperparathyroidism, hypercalcemia  hypergastrinemia  acid secretion Higher incidence of carcinoids Higher incidence of carcinoids Smaller and multiple duodenal gastrinomas Smaller and multiple duodenal gastrinomas

29 Diagnosis of Gastrinoma Combination of clinical signs Combination of clinical signs Fasting gastrin levels (> 150 pg/ml) Fasting gastrin levels (> 150 pg/ml) Avoid confounding factors (hypochlorhydria, PPIs, outlet obstruction, renal failure) Avoid confounding factors (hypochlorhydria, PPIs, outlet obstruction, renal failure) Assess acid secretion (if low- excludes) Assess acid secretion (if low- excludes) Provocative tests (calcium, secretin) Provocative tests (calcium, secretin)

30 Treatment Localization (EUS, Oct scan, MRI, CT) Localization (EUS, Oct scan, MRI, CT) Exclusion of metastasis Exclusion of metastasis If positive – symptomatic cure If positive – symptomatic cure If negative attempt surgical resection ( less likely in MEN I ~ 6%) If negative attempt surgical resection ( less likely in MEN I ~ 6%)

31 NET Diagnosis Clinics Clinics Histopathology Histopathology Hormon level Hormon level Stimulating test Stimulating test Radyology Radyology

32 NET treatment Image courtesy of Dr. L. Anthony. Surgery Surgery (total excision difficult) Stopping tumor growth Stopping tumor growthAnd Better life Surgery Surgery (total excision difficult) Stopping tumor growth Stopping tumor growthAnd Better life

33 NET, medical treatment Somatostatine Somatostatine interferone interferone Cheomothreapy Cheomothreapy

34 Carcinoid tumore syndrome

35 Carcinoid tumor GIS system end respiratory system GIS system end respiratory system İncidance 100,000 1/2 İncidance 100,000 1/2 Apendectomy and diagnose ! Apendectomy and diagnose !

36 Carcinoid tumor Carcinoid tumor Asymptomatic (up to liver metastase ) Asymptomatic (up to liver metastase ) – dyspepsia – misdiagnosis

37 Carcinoid syndrome (disease) %10 %10 Large, metastatic poor survive Large, metastatic poor survive

38 Carcinoid syndrome serotonine serotonine

39 Carcinoid sendrom – symptoms Artriis (%7) Artriis (%7) Dermatitis (%5) Dermatitis (%5) Diarrhea (%68–84) Diarrhea (%68–84) cyanose (%18) cyanose (%18) Heart disease (%14–41) Heart disease (%14–41) flushing (%63–94) flushing (%63–94) Telanjektzy (%25) Telanjektzy (%25) Bronkokonstriksiyon (%3–19) Bronkokonstriksiyon (%3–19) Abdominal pain (%10–55) Abdominal pain (%10–55)

40 Attack of Carcinoid

41 40 5-HIAA Carcinoid tumor 5-HIAA, serotoninine 5-HIAA, serotoninine Urinary expression of 5-HIAA Urinary expression of 5-HIAA

42 Diagnosis Pathology( arginofil and argentaffin ) Pathology( arginofil and argentaffin ) Biochemical (5-HIAA, chromogranin A) Biochemical (5-HIAA, chromogranin A) OctreoScan ®*,CT, MR OctreoScan ®*,CT, MR Bronchoscopy, gastroscopy, colonoscopy Bronchoscopy, gastroscopy, colonoscopy

43 survive Vinik A, et al. Dig Dis Sci. 1989; 34(suppl): 14S–27S.

44 treatment

45 Carcinoid disease treatment

46 Carcinoid tumor follow up Every year 5-HIAA Chromogranin A Pre-operative marker Abdominal CT (6-12 mounths) Every year 5-HIAA Chromogranin A Pre-operative marker Abdominal CT (6-12 mounths) Every mounths 5-HIAA Chromogranin A Follow up high marker Every muonths Abdominal CT Echocardiography Every mounths 5-HIAA Chromogranin A Follow up high marker Every muonths Abdominal CT Echocardiography OctreoScan ® Asymtomatic Symtpmatic

47 Treatment, Sandostatin Long activation (every mounths) Long activation (every mounths) Binding Sst-2/sst-5 receptor Binding Sst-2/sst-5 receptor %70 and %80 %70 and %80 Activation of these receptor Activation of these receptor

48 SandostatinSandostatin Adapted from Lancranjan I, et al. Metabolism. 1995;44(suppl 1):18–26. Theropatic level: day One mounths Theropatic level: day One mounths

49 Effect of 5 IHAA Supress to 50% *L 1. Rubin J, Ajani J, Schirmer W, et al. J Clin Oncol. 1999;17:600–6. 2. The Medical Network. Healthcarenews.

50 defecation flushing SCN = screening (tarama); BASE = baseline (başlangıç). Rubin J, et al. J Clin Oncol. 1999;17:600–6.

51 diarhea diarhea 1. Rubin J, Ajani J, Schirmer W, et al. J Clin Oncol. 1999;17:600–6. 2. The Medical Network. Healthcarenews.

52 Survive before after Anthony LB, et al. Digestion. 1996;57(suppl 1):50–3.

53 adenocarcinoma High animal fat and protein, bile acid, polyposis syndrome, crohn disease, celiac disease Crampy periumblical pain, bloating, nausea, Bleeding, obstruction, intussiception, volvulus, weight lessions 5 year survive %20-35 Cheomotherapy, surgery

54 lymphoma T cell lyphoma (celiac) T cell lyphoma (celiac) MALToma MALToma Multiple lymphoid polyposis Multiple lymphoid polyposis Difuse large cell Difuse large cell Small noncleaved lymphoma Small noncleaved lymphoma (malabsorbtion: T cell, others: obstruction, pain, mass unless bacterial overgrowth) IPSID IPSID

55 IPSID alfa chain disease (west type lymphoma ) alfa chain disease (west type lymphoma ) beningn or low grade lymphoma beningn or low grade lymphoma IgA IgA year year severe diarhea, abdominal pain, weight loss, fever severe diarhea, abdominal pain, weight loss, fever Double bloon endoscopy,band alfa2 or beta in electrophoresis, Double bloon endoscopy,band alfa2 or beta in electrophoresis, Early stage antibiotics (tetracyline plus metranidazole 6-12 mounts) Early stage antibiotics (tetracyline plus metranidazole 6-12 mounts) Malignant chance occurs: cheomathrapy Malignant chance occurs: cheomathrapy

56 GIST Nonepithelial neoplasms Nonepithelial neoplasms Primitive mesencymal cells Primitive mesencymal cells Leiomyoma, schwanoma,leiyomyosarcoma (70%), leiomyoblastoma, myofibroblastic tumor Leiomyoma, schwanoma,leiyomyosarcoma (70%), leiomyoblastoma, myofibroblastic tumor All segments of GIS, 60% stomach, 30% intestine All segments of GIS, 60% stomach, 30% intestine Prognose: size>5cm, mitotic count 1-5 per 10 high power, presence of c kit gene Prognose: size>5cm, mitotic count 1-5 per 10 high power, presence of c kit gene bleeding bleeding 5 year survive 25-30% 5 year survive 25-30% Radiotion, cheomotherapy (tyrosinase kinase Radiotion, cheomotherapy (tyrosinase kinase İnhibitor –St1-571)`, surgery

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