Hepatic Arterial Chemoembolization

Hepatic artery occlusion has been used alone or in combination with intra-arterial chemotherapy. Hepatic artery occlusion may be permanent, accomplished with surgical ligation or inert particle embolization, or it may be intermittent, accomplished with balloon occlusion or chemoem-bolization with degradable microspheres. Attempts have been made to increase the activity of locoregionally administered treatments by prolonging the duration of contact between tumor tissue and the chemotherapeutic...

Info

Abbreviations HAC, hepatic artery chemotherapy 5-FU, 5-tluorouracil FUDR, tloxuridine NS, not significant. * Patients with positive portal lymph nodes excluded. Modified with permission from Vauthey et al (1996b). Abbreviations HAC, hepatic artery chemotherapy 5-FU, 5-tluorouracil FUDR, tloxuridine NS, not significant. * Patients with positive portal lymph nodes excluded. Modified with permission from Vauthey et al (1996b). significant in only 3 studies (8-16 months vs 13-22 months,...

Ishaan S Kalha and Frank A Sinicrope

Chapter Diagnosis and Histopathology Epidemiology Pathogenesis Surveillance of Barrett's Esophagus Dysplasia and Cancer Molecular Proliferative Management Medical and Surgical Endoscopic Ablative Techniques Endoscopic Thermal Endoscopic Mucosal Resection Photodynamic Combined Endoscopic Mucosal Resection and Photodynamic Key Practice Points Suggested Barrett's esophagus is an acquired condition in which specialized metaplastic intestinal epithelium with goblet cells replaces the normal...

Chapter Overview

This chapter addresses concepts used as a foundation for bowel management in patients with cancer. Because cancer treatment can be very noxious and disrupt bowel function, a preventive approach is an important part of bowel management for patients with cancer. The 6 steps to good bowel management are assessment and diagnosis of bowel dysfunction, normalization of the bowel, establishment of expectations for bowel-movement frequency, development of a bowel management program, assessment of...

N

National Cancer Institute, 292 National Comprehensive Cancer Network, 92 colorectal cancer screening guidelines of, 88, 89-90 National Polyp Study, 91,138 National Surgical Adjuvant Breast and Bowel Project, 143-144, 144f Nausea gastric cancer-related, 221 intestinal obstruction-related, 302 Neuroendocrine tumors as diarrhea cause, 341 gastropancreatic, endoscopic Neurolysis, of the celiac plexus, 53 Neuropathy, sensory, oxaliplatin- related, 130-131 Nonsteroidal anti-inflammatory drugs as...

T3 T4 T3 T4 T13

TX Primary tumor cannot be assessed TO No evidence of primary tumor Tis Carcinoma in situ intraepithelial tumor without invasion of the lamina propria T1 Tumor invades lamina propria or submucosa T2 Tumor invades muscularis propria or subserosa* T2a Tumor invades muscularis propria T3 Tumor penetrates serosa (visceral peritoneum) without invasion of adjacent structures**' *** T4 Tumor invades adjacent structures**' *** * Note A tumor may penetrate the muscularis propria with extension into the...

Introduction

Barrett's esophagus is an acquired condition in which specialized metaplastic intestinal columnar epithelium with goblet cells replaces the normal stratified squamous epithelium anywhere in the esophagus. This intestinal metaplasia occurs in the tubular esophagus and is distinct from intestinal metaplasia of the gastric cardia. At endoscopy, Barrett's-type mucosa appears orange to red compared to the pearly-white appearance of the normal squamous mucosa of the esophagus. Barrett's esophagus is...

Key Practice Points

Colon cancer is highly preventable if appropriate screening with colonoscopy is performed. Patients with carcinoma in situ or small T1 tumors can be cured with simple polypectomy. However, all T2 or more extensive tumors require treatment with hemicolectomy and lymph node dissection. After surgical resection, the standard treatment for patients with stage II disease remains observation, but it is important to discuss with patients the potential benefits of adjuvant treatment. All patients with...

Genetic Alterations of Colorectal Cancer

The molecular genetic alterations in colorectal carcinoma are among the best understood in human cancer and involve abnormalities in multiple dominant-acting oncogenes and tumor-suppressor genes (Kinzler and Vogelstein, 1996 Fearon and Dang, 1999). Various pathways of colorectal carcinogenesis are evident in sporadic, familial, and inflammatory bowel disease-associated neoplasms. The somatic alterations in sporadic colo- Table 2-2. Immunophenotype of Various Adenocarcinomas Table 2-2....

Portal Vein Embolization

Preoperative portal vein embolization (PVE) prior to extended liver resection is an option in selected patients if there is concern regarding possible postoperative liver failure or complications due to a small liver remnant volume. The rationale for this technique is to induce hypertrophy of the future liver remnant (FLR). The first clinical report demonstrating this technique was by Kinoshita et al in 1986. In this study, 21 patients with a diagnosis of hepatocellular carcinoma underwent...

Asif Rashid

Chapter Histopathologic Features of Gastrointestinal Cancers 15 Metastatic Carcinoma of Unknown Primary Origin 18 Genetic Alterations of Colorectal Cancer Histopathologic Features of Colorectal Cancers with MSI 20 Prognostic Significance of Chromosome 18q Loss and MSI 21 Chromosome 18q Loss and MSI Assay in Surgical Pathology Practice Immunohistochemistry for Mismatch Repair Genes 22 Indications for MSI Therapeutic Importance of Overexpression of Epidermal Growth Factor Receptor and Related...

Suggested Readings

Aaltonen LA, Salovaara R, Kristo P, et al. Incidence of hereditary nonpolyposis colorectal cancer and the feasibility of molecular screening for the disease. N Engl J Med 1998 338 1481-1487. Ahlquist DA, Skoletsky JE, Boynton KA, et al. Colorectal cancer screening by detection of altered human DNA in stool feasibility of a multitarget assay panel. Gastroenterology 2000 119 1219-1227. Atkin WS, Morson BC, Cuzick J. Long-term risk of colorectal cancer after excision of rectosigmoid adenomas. N...

Endoscopy in the

Management of Gastrointestinal Malignancies Chapter Basic Endoscopic Procedures Esophageal Stricture Percutaneous Endoscopic Advanced Endoscopic Procedures Endoscopic Retrograde Procedures in Patients with Acute Cholangitis 48 Endoscopic Esophageal Gastric Cancers Pancreatic Cystic Neoplasms of the Celiac Plexus Gastropancreatic Neuroendocrine Tumors 54 Rectal Tumors Indeterminate Mediastinal, Upper Abdominal, and Pararectal Masses Esophageal and Enteral Stent Key Practice Points Suggested...

Patrick M Lynch

Chapter Principles of Screening Current Screening Recommendations and Limitations 88 Fecal Occult Blood Testing Flexible Barium Colonoscopy Investigational Measures for Colorectal Cancer Screening 94 Colon Cancer Groups at High Risk for Colorectal Cancer as Targets for Chemoprevention COX-2 Inhibition in Patients with Sporadic Colorectal Adenoma The Key Practice Points Suggested Colorectal cancer is one of the most common and serious cancers. The predictable adenoma-to-carcinoma sequence and...

Immunohistochemistry for EGFR and Related Receptors

Overexpression of EGFR and related receptors can be assessed by immunohistochemical analysis using formalin-fixed, paraffin-embedded tissue (Figure 2-2). At M. D. Anderson, EGFR expression is assayed using mouse monoclonal antibody 31G7 (Zymed Laboratories, San Francisco, CA), and ErbB2 expression is assayed using AD8 monoclonal antibody (NeoMarkers, Lab Vision Corporation, Fremont, CA). The intensity of EGFR reactivity is scored as follows 0, no reactivity or cytoplasmic staining of neoplastic...

Components of an Effective Bowel Management Program

Any bowel management program should include fluid, fiber, food, and medication (Figure 19-1). This is verified in recent literature by Rao (2003) and Lembo and Camilleri (2003). Additionally, patients must understand Figure 19-1. Four essential elements of any bowel management program. Figure 19-1. Four essential elements of any bowel management program. the need to balance these 4 components this is the most fundamental concept in managing their bowels. A balanced scale, with 2 components in...

RFA of Primary Liver Tumors

RFA has recently been used to treat primary liver tumors in patients at M. D. Anderson and the G. Pascale National Cancer Institute in Naples, Italy (Curley et al, 2000). The HCCs treated with RFA in this patient population ranged from 1 to 7 cm in greatest dimension. As the size of the tumor increased, the number of deployments of the multiple-array needle electrode and the total time of applying RF energy increased. Primary liver tumors tend to be highly vascular, so a vascular heat sink...

Mo Mo Mo Mo Mo Mo Mo Mo M1

TX Primary tumor cannot be assessed TO No evidence of primary tumor lis Carcinoma in situ* T1 Tumor limited to the pancreas, 2cm or less in greatest dimension T2 Tumor limited to the pancreas, more than 2 cm in greatest dimension T3 Tumor extends beyond the pancreas but without involvement of the celiac axis or the superior mesenteric artery T4 Tumor involves the celiac axis or the superior mesenteric artery (unresectable primary tumor) NX Regional lymph nodes cannot be assessed NO No regional...

Repeat Hepatectomy for Recurrent Malignant Tumors

The long-term disease-free survival rates for patients undergoing surgical resection of primary liver tumors are usually below 40 in the most optimistic reports and may be below 20 in others. Clearly, most patients develop recurrent malignant disease after hepatic resection. In a subset of these patients, the only recurrence will be new tumor deposits in the liver. A further subset of these patients may have undergone significant hepatic regeneration and have tumors in locations amenable to...

Basic Endoscopic Procedures

Because of our patient mix, the usual indications for EGD and colonoscopy in our endoscopy unit are cancer diagnosis, follow-up, or management of complications of cancer therapy. Patients with primary luminal gas trointestinal cancers undergo appropriate endoscopic procedures to document the extent of tumor involvement and undergo biopsies. EGD or colonoscopy is also performed to look for gastrointestinal involvement by extragastrointestinal cancers such as lymphoma and leukemia. Patients who...

Hypermethylation and Colorectal Cancer

Tumor suppressor genes, such as p 6 and hMLHl, are inactivated in colorectal cancers by mutation, deletion, or methylation (Kane et al, 1997). Abnormal patterns of DNA methylation are common molecular changes in human neoplasms, including colorectal cancer. p16 methylation is closely associated with K-ras mutations (Guan et al, 1999). Also, aberrant methylation is associated with the microsatellite instability (MSI) pheno-type in colorectal cancer. Recent studies showed that hypermethylation of...

Magnetic Resonance Imaging

The advantages of MRI include the lack of ionizing radiation and the ability to scan without an iodinated contrast agent. Inherent tissue contrast on T1- and T2-weighted images and the use of proper imaging pulse sequences often allow lesion detection and characterization without the use of contrast agent. However, gadolinium chelates and new tissue-specific contrast agents further improve lesion detection and characterization (Semelka and Helmberger, 2001). The major limitations of abdominal...

Regional Intraarterial Chemotherapy

In patients with HCC, uncontrolled tumor in the liver is the most significant cause of morbidity and mortality, although extrahepatic metastases are apparent in up to 25 of patients at the time of diagnosis and up to 90 on autopsy. Thus, effective local chemotherapy would have a significant clinical effect. Administration of the drug into the hepatic artery could theoretically increase local drug delivery to the tumor tissue and possibly lower systemic toxicity. An ideal pharmacologic profile...

Treatment of Early Stage Stage I Esophageal Cancer

One of the problems with esophageal cancer has traditionally been the inability to accurately assess the stage preoperatively. Endoscopic ultrasonography, however, has revolutionized our ability to assess depth of penetration and involvement of regional lymph nodes. Additionally, the combination of CT and PET has allowed a more accurate determination of metastatic spread. These noninvasive modalities have allowed us to more accurately stage esophageal cancers before treatment is initiated. They...

Identifying Epidemiologic and Genetic Risk Factors for Colorectal Cancer

Most epidemiologic studies cannot be designed as controlled experiments. Therefore, epidemiologic studies identify associations between risk factors and disease outcomes. Associations can be useful for classifying individuals into risk sets, whether or not a causal relationship between the disease and its correlate can be established. Typical measures of risk include the absolute risk, relative risk, and odds ratio. Here we briefly describe the main risk measures much more detail can be found...

Colon Cancer Chemoprevention

Chemoprevention of colorectal cancer has come to imply the use of orally administered agents, whether dietary or strictly pharmacologic, to reduce the risk of developing adenocarcinoma. Epidemiologic data strongly point to geographic differences in colo-rectal cancer incidence. Rates have been highest in northwestern Europe, North America, Oceania, and Argentina and lowest in sub-Sahara Africa. As such differences were explored in greater detail, specific factors in the diet came to be...

Investigational Measures for Colorectal Cancer Screening

Two new methodologies, virtual colonoscopy (also known as computed tomography colonography) and stool-based testing for mutated DNA, are exciting and of considerable interest. Virtual colonoscopy entails the use of spiral computed tomography with very thin cuts (otherwise, small lesions would be missed) and new computer techniques for 3-dimensional reconstruction. Currently, standard bowel preparations are required and elimination of all effluent is important. Efforts are under way to develop...

Advanced Endoscopic Procedures

The advanced endoscopic procedures performed at M. D. Anderson include ERCP, EUS with or without FNA, and placement of esophageal and enteral stents. Endoscopic Retrograde Cholangiopancreatography Most patients who present to M. D. Anderson with pancreatic and biliary malignancies have undergone ERCP prior to presentation. Some patients present after an unsuccessful attempt at ERCP at another hospital. ERCP is also performed to rule out pancreatobiliary disease in a small group of patients...

Current Screening Recommendations and Limitations

Several measures are currently recommended for colorectal cancer screening, and no single test can be considered ideal (Rex et al, 2000 Smith et al, 2001 Winawer et al, 2003). The options include FOBT (Mandel et al, 1993) flexible sigmoidoscopy (Selby et al, 1992), used alone or in combination with other tests (Lieberman et al, 2001) double-contrast barium enema, often used in combination with flexible sigmoidoscopy and a more recently discussed approach, primary colonoscopy. Firm...

Other Palliative Therapies

The role of surgical palliation for advanced gastric cancer is limited because patients with metastatic disease have relatively short survival durations. The operative morbidity and mortality rates are also higher for patients who undergo palliative surgery than for those who undergo curative surgery. Surgery is especially difficult in patients with peritoneal carcinomatosis. Thus, gastrectomy should be considered for intractable bleeding or in cases in which the patient has a dramatic systemic...

Background and Basics of Radiofrequency Tissue Ablation

In general, thermal injury to cells begins at 42 C, with the time of exposure to low-level hyperthermia needed to achieve cell death ranging from 3 to 50 hours, depending on the tissue type and conditions. As the temperature increases above 42 C, the exposure time necessary to kill cells decreases exponentially. For example, at 46 C only 8 minutes is needed to kill malignant cells, and 51 C can be lethal after only 2 minutes. At temperatures above 60 C, intracellular proteins become denatured,...

Colorectal Cancer

Colorectal adenocarcinoma is the second most common cause of cancer death in the United States, and patients with colon and rectal cancer form the largest single group of GI cancer patients seen at M. D. Anderson. Presenting complaints in patients with colorectal cancer may include rectal bleeding, fatigue related to anemia, change in bowel habits, or the development of abdominal pain. A significant number of patients referred to M. D. Anderson are asymptomatic but have positive findings on a...

And Charles Cleeland

Chapter Principles of Palliative Therapy Clinical Presentations Requiring Palliative Management 301 Pelvic Anemia or Obstructive Symptoms Pain Treatment Gastroesophageal Tumors Small Bowel Pancreatic Tumors Ulceration of Skin and Subcutaneous Tissues 311 Key Practice Points Suggested More than 70 of all cancer patients develop symptoms from either their primary tumor or metastatic disease. Approximately half of patients diagnosed with cancer will develop metastatic disease. Controlling symptoms...

A A B B C C C

Stage IIA Stage IIB Stage IIIA Stage IIIB Stage IIIC Stage IV * Dukes B is a composite of better (T3 N0 M0) and worse (T4 N0 M0) prognostic groups, as is Dukes C (Any T N1 M0 and Any T N2 M0). TX Primary tumor cannot be assessed T0 No evidence of primary tumor lis Carcinoma in situ intraepithelial or invasion of lamina propria* T1 Tumor invades submucosa T2 Tumor invades muscularis propria T3 Tumor invades through the muscularis propria into the subserosa, or into non- peritonealized pericolic...

Barry W Feig

Chapter Palliation Therapeutic Tumor Implantation Key Practice Points Suggested The introduction of laparoscopy into the armamentarium of the general surgeon in the late 1980s resulted in a revolution of new technology and procedures. Despite this meteoric application in general surgery, there has been only a slow and cautious application of laparoscopic procedures in surgical oncology. This has been due in large part to concerns about peritoneal dissemination and port-site implantation raised...

Gist290

Preoperative and Postoperative Adjuvant Imatinib for Primary Key Practice Points Suggested Over the past 60 years, basic scientists, pathologists, and clinical investigators have studied gastrointestinal stromal tumors (GISTs), with no major advances in patient care. Recent discoveries have led to an understanding of the biological role of Kit in GISTs and the development of one of the most exciting examples of targeted therapy to date. The success of the Kit tyrosine kinase inhibitor imatinib...

Histopathologic Features of Gastrointestinal Cancers

Malignancies of the gastrointestinal tract can be classified histopathologi-cally as epithelial tumors, endocrine or mesenchymal tumors, or lymphomas (Table 2-1 Hamilton and Aaltonen, 2001). Epithelial tumors can be subclassified as adenocarcinoma, squamous cell carcinoma, adeno-squamous carcinoma, small cell carcinoma, carcinoid tumor, or other. Table 2-1. Histopathologic Classification of Primary Malignant Neoplasms of the Esophagus, Stomach, and Colon and Rectum Histopathologic Subtype by...

Hepatobiliary Malignancies

Physicians and physician assistants in the GI Tumor Center at M. D. Anderson evaluated more than 900 new patients with primary or metastatic hepatobiliary tumors in 2002. Patients with primary liver cancer include those with hepatocellular carcinoma (HCC), gallbladder cancer, and intrahepatic or extrahepatic cholangiocarcinoma. Patients with liver metastases from other organ sites, most commonly colorectal adenocarci-noma, and with disease confined to the liver may be considered for surgery,...

Gastrointestinal Cancer

Abbruzzese, MD, and Raphael E. Pollock, MD, PhD Jaffer A. Ajani, MD Department of Gastrointestinal Medical Oncology Patrick M. Lynch, MD, JD Department of Gastrointestinal Medicine and Nutrition The University of Texas M. D. Anderson Cancer Center Houston, TX 77030-4009 USA Oncology The University of Texas M. D. Anderson Cancer Center Houston, TX 77030-4009 USA Cover illustration Peter Siu Images.com. Nora A. Janjan, MD Department of Radiation Oncology The University of...

Irox

Regimen with Irinotecan and Oxaliplatin Irinotecan 80-100 mg IV over 90 minutes Oxaliplatin 85-125 mg IV over 30 minutes Repeat cycle every 21 days Neutropenia, 36 Diarrhea, 24 Vomiting, 22 Paresthesia, 7 Regimens with Capecitabine and Irinotecan Capecitabine (X) 1000 mg m2 day by mouth days 1-14 (total dose 2000 mg m2 day) Irinotecan 200-250 mg IV day lu Or Irinotecan 80 mg IV on day 1 and day 82 Repeat cycle every 21 days Capecitabine (X) 1000 mg m2 day by mouth days 1-14 (total dose 2000 mg...

M1

TX Primary tumor cannot be assessed TO No evidence of primary tumor Tis Carcinoma in situ T1 Tumor invades lamina propria or muscle layer T1a Tumor invades lamina propria T1b Tumor invades muscle layer T2 Tumor invades perimuscular connective tissue no extension beyond serosa or into liver T3 Tumor perforates the serosa (visceral peritoneum) and or directly invades the liver and or one other adjacent organ or structure, such as the stomach, duodenum, colon, or pancreas, omentum or extrahepatic...

Management

Once Barrett's esophagus is diagnosed, the goals of therapy include the control of symptoms of GERD and the maintenance of healed esophageal mucosa. Other treatment objectives include the regression or removal of Barrett's-type tissue and the secondary prevention of adenocarcinoma in patients with known Barrett's esophagus. A critical question is whether regression of Barrett's esophagus occurs in response to medical or surgical therapy. The natural history of Barrett's esophagus can be altered...

O

As Barrett's esophagus risk factor, 351 as colorectal cancer risk factor, 72 Octreotide, 160, 302, 341 Odynophagia, gastrointestinal stromal tumor-associated, 274 Online Mendelian Inheritance in Man database, 138 Opioid analgesics as constipation cause, 265-266, 325-326, 331-332 as intestinal colic treatment, 302 use in bowel management, 159, 265-266 Ornithine decarboxylase 98 Ovarian cancer colorectal cancer associated with, 138 114-115,127 hereditary nonpolyposis colorectal cancer-associated,...

Mo Mo Mo Mo Mo Mo Mo Mo M1 Mo

TX Primary tumor cannot be assessed TO No evidence of primary tumor Tis Carcinoma in situ T1 Tumor confined to the bile duct histologically T2 Tumor invades beyond the wall of the bile duct T3 Tumor invades the liver, gallbladder, pancreas, and or unilateral branches of the portal vein (right or left) or hepatic artery (right or left) T4 Tumor invades any of the following main portal vein or its branches bilaterally, common hepatic artery, or other adjacent structures, such as the colon,...

Radiation Therapy

The addition of radiation therapy to chemotherapy in patients with locally advanced disease has been studied in a number of trials, which have shown that concurrent 5-fluorouracil-based chemotherapy and radiation therapy at a dose of 35 to 50 Gy is feasible. Chemoradiation therapy provides a survival advantage similar to that seen with chemotherapy alone. At M. D. Anderson, we have found concurrent 5-fluorouracil, paclitaxel, and radiation therapy at a dose of 45 to 50 Gy to be feasible (Table...

Prognostic Significance of Chromosome 18q Loss and MSI

Chromosome 18q loss (Jen et al, 1994) and MSI (Gryfe et al, 2000) are prognostic factors for sporadic colorectal cancer. In a study of 319 patients with stage III colon cancer, chromosome 18q loss was associated with a worse prognosis after chemotherapy (Watanabe et al, 2001). Patients with tumors that retained chromosome 18q had a 5-year overall survival rate of 69 , compared with 50 for patients with loss of heterozygosity at chromosome 18q. Similarly, patients with sporadic MSI-positive...

Principles of Palliative Therapy

The goal of palliative therapy is the prompt and cost-effective relief of symptoms with little treatment-related morbidity. Control of cancer-related pain with the use of analgesics is imperative to allow patient comfort during therapeutic interventions and while the patient awaits response to such interventions. Pain represents a sensitive measure of disease activity. Symptoms that recur or worsen most commonly result from localized regrowth of tumor. Patients should be followed up closely...

Principles of Screening

A successful screening test should be inexpensive, safe, easy to perform, well accepted by consumers and providers, sensitive (identify persons with the disease in question), and specific (exclude persons lacking disease). Screening for colorectal cancer and precancerous polyps must be carried out with knowledge of the costs, benefits, risks, and limitations. For those who would actually order or perform any of the available tests, a basic understanding of technique is helpful as well. Several...

Treatment of Patients with Locoregional Disease Surgery

Surgery remains the cornerstone of therapy for patients with locoregional gastric cancer. Tremendous variations exist in the type of surgery performed for gastric cancer. For nonproximal gastric cancer, a subtotal gastrectomy should be considered if negative margins of at least 5 cm can be obtained both proximally and distally. Total gastrectomy should be performed if adequate margins cannot be otherwise obtained. For proximal gastric cancer, options include total gastrectomy and...

Tumor Implantation

As mentioned previously, the widespread application of laparoscopic techniques to oncologic procedures has been significantly slowed by concern about tumor implantation at the trocar insertion sites (port sites). The first reported port-site recurrence after a laparoscopic procedure was described in 1978, in a patient with malignant ascites who developed detectable disease at a trocar site 2 weeks after laparoscopy. Subsequent reports surfaced that described port-site recurrences in patients...

Indications for Resection

The indications for resection of HCC have recently been reevaluated. Studies from the 1980s and early 1990s suggested that cirrhosis and mul tiple tumor nodes were harbingers of poor outcome after resection of HCC. However, these studies were performed when operative mortality rates in cirrhotic HCC patients were 6 to 15 and the need for intraoperative and postoperative blood transfusion was common. Current studies that have compared the outcome of patients undergoing surgery utilizing modern...

Computed Tomography

The effect of helical CT and the recently developed multidetector helical CT on abdominal and pelvic imaging has been substantial. The advantage of helical CT over conventional CT is the speed at which imaging can be acquired. The organs in the upper abdomen, including the liver, spleen, and pancreas, can be imaged within a single breath-hold, and therefore, respiratory misregistration and motion artifacts can be minimized. The speed at which images are acquired also allows multiphasic imaging...

Pancreatic Cancer

Cancer of the pancreas is the fifth leading cause of cancer death in the United States. Almost 30,000 new patients will be diagnosed with pancreatic cancer in 2003, and at least 28,000 of these individuals will die of the disease. Because there are no proven or standardized laboratory or radiologic diagnostic tests for pancreatic carcinoma, most patients present with locally advanced or metastatic disease. The patients with the highest probability of long-term survival are those who present...

Diagnosis and Staging

The development of high-speed helical computed tomography (CT) and organ-specific scanning protocols has markedly improved preoperative CT staging of liver tumors. Three-dimensional reconstruction and arterial and venous imaging without invasive arterial angiography can be accomplished with currently available equipment and software programs. For hepatocellular carcinoma (HCC), the helical CT detection rate for small tumors (40 to 60 ) is less than that for hepatic metastases, owing to the...

Ci 5fu

300 mg m2 5 days wk during pelvic XRT ' Abbreviations XRT, radiation therapy CTX, chemotherapy CI, continuous infusion 5-FU, tluorouracil NR, not reported. Reprinted with permission from Janjan NA, Delclos ME, Ballo MT, Crane CH. Hie colon and rectum. In Cox JD, Ang KK, eds. Radiation Oncology Rationale, Technique, Results. 8th ed. St. Louis, MO Mosby 2003 497-536. infusion 5-FU during preoperative chemoradiation. With lower total doses of preoperative radiation (45 Gy) and continuous infusion...

Conclusions

The most important determinants of colorectal cancer risk are age and family history. In addition, environmental factors--such as a diet rich in saturated fats, high in red meats, and low in fiber or fruits and vegetables appear to increase the risk for colorectal cancer. NSAID use is associated with a decreased risk for colorectal cancer in observational studies. NSAIDs decrease COX-2 levels. Clinical trials in individuals with FAP documented decreased development of adenomas from...

Histopathologic Features of Colorectal Cancers with MSI

MSI-high colorectal cancers have a distinct clinicopathologic phenotype (Kim et al, 1994 Jass et al, 1998 Alexander et al, 2001). MSI-high colorectal cancers are more frequent in younger patients. Most are right-sided (proximal to the splenic flexure), bulky (large) tumors, with an exophytic growth pattern are poorly differentiated, with signet-ring-cell, mucinous, medullary, or variegated (mixed) histologic subtypes have an intense lym-phocytic response with Crohn's-like lymphoid reaction...

Metastatic Carcinoma of Unknown Primary Origin

In most patients, the site of origin of a metastatic carcinoma of unknown primary origin cannot be reliably determined by light microscopy (Hammar, 1998). Almost 60 of metastatic carcinomas of unknown primary origin are adenocarcinomas. Some metastatic adenocarcinomas (e.g., colonic adenocarcinomas) have distinctive histologic features that allow for determination of their site of origin. For most other metastatic adenocarcinomas of unknown primary origin, immunohistochemical analysis can help...

Cec

1 to 3 small (< 3.0 cm in diameter) tumors located in the periphery of the liver are considered for ultrasound-guided percutaneous RFA. Lesions located high in the dome of the liver near the diaphragm are not always accessible by a percutaneous approach. Furthermore, general anesthesia or monitored sedation is required for most patients treated percutaneously because of pain associated with the heating of tissue near the liver capsule. Patients treated percutaneously are usually discharged...

Gastric Cancer

Gastric adenocarcinoma is one of the most common human solid tumors worldwide. In the United States, approximately 25,000 people are diagnosed annually with gastric adenocarcinoma. We see approximately 300 patients with newly diagnosed gastric cancer yearly at M. D. Anderson. The symptoms related to gastric cancer are typically vague and longstanding in many patients. Thus, advanced-stage disease is diagnosed in a significant proportion of patients. Esophagogastroduodenoscopy is considered the...

Constipation

Low Lying Transverse Colon

Definitions of constipation vary from one reference to another. At M. D. Anderson, we define constipation as the condition in which stool is hard and difficult to eliminate. Even if the frequency of bowel movements decreases, as long as the stool remains soft and formed, the patient is not constipated. Never Underestimate How Much Stool the Intestines Can Hold The average length of the colon is 4 to 5 feet, and the colon is 2 inches in diameter, which makes possible a large fecal-mass...

Dmi

Barium, as fecal impaction cause, 319, 343 screening, 114 Barium swallow for esophageal cancer diagnosis, 234, 243 for gastrointestinal stromal tumor diagnosis, 274, 275 Barrett's esophagus, 346-373 biomarkers of, 358-361 biopsy of, 348-350, 355 definition of, 346, 348-349 diagnosis of, 349-351 epidemiology of, 351-352 as esophageal adenocarcinoma cause, 348, 350, 351-352, 353, 353 , 355-356, 357 esophageal dysplasia associated with, 347, 348, 349, 356-358, 359 histopathology of, 347, 349-351...

Nora A Janjan John M Skibber Miguel A Rodriguez Bigas Christopher Crane Marc E Delclos Edward H Lin and Jaffer A Ajani

Chapter Overview Epidemiology Anatomy and Patterns of Disease Spread Pathology Clinical Presentation Staging Prognostic Factors Combined-Modality Therapy Regimens with Radiation plus 5-Fluorouracil and Mitomycin C Regimens with Radiation plus 5-Fluorouracil and Cisplatin Other Issues Special Treatment Issues Posttreatment Biopsy Treatment of the Elderly and Patients with Comorbid Conditions Treatment of HIV-Positive Patients Anal Margin Definitive Chemoradiation The M. D. Anderson Technique...

Clinical Presentations Requiring Palliative Management

There are many types of clinical presentation that necessitate palliative management for tumors involving the gastrointestinal region. Among the most common are symptoms caused by recurrent rectal cancer and biliary obstruction caused by pancreatic cancer. Nausea and vomiting due to gastrointestinal obstruction may require surgical decompression. Metastases from gastrointestinal malignancies can occur in any location, become symptomatic, and necessitate palliative care. Pelvic tumors that cause...

Requirements for Adequate Bowel Function

Adequate bowel function requires GI motility, mucosal transport, defecation reflexes, and intact anal sphincter muscles. GI motility requires muscle contraction secretions supplied by the salivary glands, stomach, biliary system, pancreas, and small intestine an adequate central nervous system and adequate nutrition and hydration. Mucosal transport promotes the absorption of nutrients, water, and electrolytes in the small bowel, leaving water resorption to take place in the large bowel. If the...

Laxatives

Patients who are undergoing treatment for cancer need particular attention given to the type of laxative used for constipation. It is important to provide immediate relief in the most gentle way, even if an aggressive approach is needed to relieve severe constipation and prevent more severe problems. The patient's total physical condition and the presence of bulky disease in the abdomen must be considered, as addressed in the following paragraphs. Patients undergoing chemotherapy that may cause...

Annette K Bisanz

Chapter Overview Introduction Steps to Effective Bowel Management Assessment and Diagnosis of Bowel Dysfunction 316 Normalization of the Bowel Establishment of Expectations for Bowel-Movement Frequency Development of a Bowel Management Program 318 Assessment of Outcomes Adjustment of Bowel Management Program to Achieve the Desired Outcome Requirements for Adequate Bowel Function 318 Components of an Effective Bowel Management Program 319 Fluid Fiber Food Medications to Offset Bowel Side Effects...

Christopher I Amos Carol H Bosken Amr S Soliman and Marsha L Frazier

Chapter Identifying Epidemiologic and Genetic Risk Factors for Colorectal Cancer Cohort Studies Assessing Familiality and Segregation Analysis 70 Factors Associated with Risk for Colorectal Cancer 71 Inflammatory Bowel Disease Factors Related to a Western Calcium and Folate Supplementation Cigarette Smoking Nonsteroidal Anti-inflammatory Hormone Replacement Therapy Genetic Factors Hypermethylation and Colorectal Cancer Gene-Gene Environmental Factors Related to Hereditary and Familial...

Steps to Effective Bowel Management

There are 6 steps to good bowel management assessment and diagnosis of bowel dysfunction, normalization of the bowel, establishment of expectations for bowel-movement frequency, development of a bowel management program, assessment of outcomes, and adjustment of the bowel management program through problem-solving. Assessment and Diagnosis of Bowel Dysfunction Thoroughly assessing bowel function and obtaining a bowel history together constitute the most important step in bowel management....

Edward H Lin and Henry Q Xiong

Chapter Epidemiology Clinical Presentations Diagnosis and Tenets of Management Fluorouracil Targeted Bevacizumab Cetuximab Celecoxib Management of Colon Cancer by Stage Carcinoma In Situ Stage I Colon Stage II Colon Cancer Stage III Colon Stage IV Colon Management of Side Effects Diarrhea Hand-Foot Syndrome Neuropathy Surveillance after Treatment Future Key Practice Points Suggested For decades, 5-fluorouracil was the only chemotherapy agent known to be active against colorectal cancer. In...

Environmental Factors Related to Hereditary and Familial Colorectal Cancer

Familial colorectal cancer may reflect the influence of multiple genetic factors along with environmental cofactors. Fuchs et al (2002) found that women with high folate intake who had a first-degree relative with colo-rectal cancer were not at increased risk for colorectal cancer. However, women with low folate intake who had a relative with colorectal cancer had about a 2.5-fold increased relative risk for colorectal cancer compared with women with low folate intake and no family history of...