Pictorial lesson in GI Pictorial lesson in GI CancersCancers

Oesophageal CancerOesophageal Cancer

Staging of Oesophageal CancerStaging of Oesophageal Cancer

Incidence in USA by pathologyIncidence in USA by pathology

Squamous cell carcinomaSquamous cell carcinoma

Endoscopic Endoscopic view of the view of the oesophagus oesophagus shows a tiny, shows a tiny, early ulcer early ulcer which proved which proved on biopsy to on biopsy to be malignant.be malignant.

Squamous cell carcinoma Squamous cell carcinoma

An established, An established, infiltrating, well-infiltrating, well-differentiated differentiated lesion exhibits lesion exhibits islands of islands of malignant malignant epithelium epithelium invading deep invading deep into oesophageal into oesophageal muscle.muscle.

Squamous cell carcinomaSquamous cell carcinoma Endoscopic Endoscopic

view shows view shows circumferential circumferential involvement of involvement of the the oesophagus oesophagus with friable with friable tumour. tumour.

Note the Note the narrowed narrowed lumen.lumen.

CASE: Squamous cell carcinomaCASE: Squamous cell carcinoma

A 62-year-old man with A 62-year-old man with progressive dysphagia and progressive dysphagia and marked weight loss was marked weight loss was found on endoscopy to found on endoscopy to have a poorly have a poorly differentiated tumour of differentiated tumour of the middle third of the the middle third of the oesophagus. oesophagus.

Barium swallow film shows Barium swallow film shows narrowing of the narrowing of the oesophagus with mucosal oesophagus with mucosal destruction, consistent destruction, consistent with oesophageal cancer with oesophageal cancer

CaseCase CT scan reveals CT scan reveals

regional regional metastases and a metastases and a large primary large primary mass obstructing mass obstructing the oesophagus. the oesophagus.

Complete clinical Complete clinical remission was remission was achieved in 3 achieved in 3 months after months after combination combination chemotherapy chemotherapy plus radiotherapy. plus radiotherapy.

Unfortunately, Unfortunately, liver metastases liver metastases subsequently subsequently occurred.occurred.

Squamous cell carcinomaSquamous cell carcinoma This sagittal section through the This sagittal section through the

larynx, trachea and anterior wall larynx, trachea and anterior wall of the Oesophagus obtained at of the Oesophagus obtained at autopsy of a 57-year-old man who autopsy of a 57-year-old man who presented with a short history of presented with a short history of dysphagia. dysphagia.

A barium swallow revealed A barium swallow revealed neoplastic obstruction of the neoplastic obstruction of the oesophagus; the patient died soon oesophagus; the patient died soon afterward from afterward from bronchopneumonia. bronchopneumonia.

A solid, raised, pale tumour (6 x 2 A solid, raised, pale tumour (6 x 2 x 2 cm), arising in the x 2 cm), arising in the oesophagus, has infiltrated the oesophagus, has infiltrated the posterior wall of the trachea, posterior wall of the trachea, forming a nodular projection into forming a nodular projection into the tracheal lumen. the tracheal lumen.

CaseCase Adenocarcinoma. Weight loss Adenocarcinoma. Weight loss

and right upper abdominal and right upper abdominal pain, with minimal dysphagia, pain, with minimal dysphagia, developed in a 58-year-old developed in a 58-year-old man. man.

Upper GI endoscopy showed a Upper GI endoscopy showed a constricting, poorly constricting, poorly differentiated lesion of the differentiated lesion of the lower third of the oesophagus. lower third of the oesophagus. Barium swallow film defines Barium swallow film defines the extent of the lesion the extent of the lesion (arrows). (arrows).

On CT scan, a large liver On CT scan, a large liver metastasis metastasis

TreatmentTreatment

Depends on stage, but includes Depends on stage, but includes surgery, radiotherapy, chemotherapy surgery, radiotherapy, chemotherapy and laser treatmentand laser treatment

Gastric CancerGastric Cancer

Gastric CancerGastric Cancer

Barium swallow Barium swallow study shows a study shows a large fundal large fundal carcinoma carcinoma

Malignant gastric ulcerMalignant gastric ulcer

This antral This antral lesion lesion exhibits exhibits heaped-up heaped-up nodular nodular margins, margins, particularly particularly suggestive suggestive of of malignancy malignancy

Adenocarcinoma.Adenocarcinoma.

This This intestinal-intestinal-type tumour type tumour exhibits well-exhibits well-formed formed malignant malignant glandular glandular elements elements

AdenocarcinomaAdenocarcinoma

Barium swallow Barium swallow study reveals a study reveals a large polypoid large polypoid lesion in the body lesion in the body of the stomach, of the stomach, causing a filling causing a filling defect.defect.

Diffuse adenocarcinoma - linitis Diffuse adenocarcinoma - linitis plasticaplastica

Barium study shows the Barium study shows the typical appearance of an typical appearance of an extensive linitis plastica extensive linitis plastica involving the entire involving the entire stomach, which appears stomach, which appears fixed and narrowed. fixed and narrowed.

No peristalsis was observed No peristalsis was observed and barium flowed out of and barium flowed out of the stomach quickly. the stomach quickly.

The mucosal edge is only The mucosal edge is only slightly irregular; ulceration slightly irregular; ulceration of the mucosa may be of the mucosa may be minimal or absent in this minimal or absent in this type of carcinoma. type of carcinoma.

(Arrow indicates the gastric (Arrow indicates the gastric fundus.)fundus.)

CaseCase Diffuse adenocarcinoma (linitis Diffuse adenocarcinoma (linitis

plastica). plastica).

This gastrectomy specimen, This gastrectomy specimen, opened anteriorly, is from a 64-opened anteriorly, is from a 64-year-old man who had a 3-year year-old man who had a 3-year history of dyspepsia. Barium history of dyspepsia. Barium swallow and endoscopy revealed swallow and endoscopy revealed a gastric carcinoma. a gastric carcinoma.

There is diffuse infiltration of the There is diffuse infiltration of the pylorus and body of the stomach pylorus and body of the stomach by pale tumour, as well as marked by pale tumour, as well as marked luminal narrowing, although the luminal narrowing, although the tumour has no exophytic tumour has no exophytic component. component.

Note the irregular infiltration of Note the irregular infiltration of the muscle coat.the muscle coat.

Pancreatic CancerPancreatic Cancer

Staging of pancreatic carcinoma Staging of pancreatic carcinoma

Pancreatic carcinomaPancreatic carcinoma

Barium study Barium study shows a tumour shows a tumour mass in the mass in the head of the head of the pancreas pancreas invading the invading the duodenal loop duodenal loop and producing and producing changes in the changes in the fold pattern.fold pattern.

Pancreatic carcinomaPancreatic carcinoma Abdominal Abdominal

CT scan CT scan shows a shows a large focal large focal mass in the mass in the tail of the tail of the

pancreaspancreas

Hepatic TumoursHepatic Tumours

Staging of hepatocellular Staging of hepatocellular carcinoma (including intrahepatic carcinoma (including intrahepatic

bile ducts) bile ducts)

Multifocal hepatocellular carcinoma Multifocal hepatocellular carcinoma in haemochromatosisin haemochromatosis

A 61-year-old man with A 61-year-old man with haemochromatosis and a 12-haemochromatosis and a 12-year history of hepatomegaly year history of hepatomegaly and diabetes mellitus died and diabetes mellitus died after developing liver failure after developing liver failure with ascites.with ascites.

Section through the right lobe Section through the right lobe of the liver shows an ill-of the liver shows an ill-defined micronodular defined micronodular cirrhosis, associated with cirrhosis, associated with deep brick-red parenchymal deep brick-red parenchymal pigmentation. pigmentation.

Scattered throughout the Scattered throughout the posterior region are many posterior region are many pale nodules of carcinoma. pale nodules of carcinoma.

Primary hepatic angiosarcomaPrimary hepatic angiosarcoma Typically, these tumours Typically, these tumours

may appear as (a) a may appear as (a) a surface vascular tumour or surface vascular tumour or as a hemorrhagic tumour as a hemorrhagic tumour mass. mass.

They are associated with They are associated with industrial exposure to vinyl industrial exposure to vinyl chloride and the chloride and the radiographic contrast radiographic contrast agent Thorotrast and agent Thorotrast and usually comprise usually comprise multicentric hemorrhagic multicentric hemorrhagic nodules. nodules.

Lung metastasesLung metastases Chest film of a 19-year-old Chest film of a 19-year-old

Asian man who presented Asian man who presented with hepatocellular with hepatocellular carcinoma shows the well-carcinoma shows the well-defined pulmonary nodules defined pulmonary nodules characteristic of metastatic characteristic of metastatic deposits. Rapid disease deposits. Rapid disease progression occurred progression occurred within 2 months. within 2 months.

Metastases are unusual Metastases are unusual with hepatoma but do with hepatoma but do occur to the bones, lung occur to the bones, lung and brain.and brain.

Bowel CancerBowel Cancer

Familial adenomatous polyposisFamilial adenomatous polyposis

FAP is a genetic FAP is a genetic disorder greatly disorder greatly increasing the risk of increasing the risk of bowel cancer.bowel cancer.

Barium enema study Barium enema study demonstrates demonstrates multiple, small polyps multiple, small polyps throughout the colon.throughout the colon.

Familial adenomatous polyposisFamilial adenomatous polyposis

Innumerable Innumerable adenomatous adenomatous polyps, increasing polyps, increasing in size and density in size and density from proximal from proximal (upper left) to (upper left) to distal (lower right) distal (lower right)

Carcinoma in ulcerative colitisCarcinoma in ulcerative colitis Malignancies Malignancies

developing in developing in ulcerative colitis may ulcerative colitis may present as an present as an infiltrative plaque, or a infiltrative plaque, or a polypoid mass polypoid mass

The cumulative risk of The cumulative risk of cancer increases cancer increases dramatically with the dramatically with the duration of ulcerative duration of ulcerative colitis. After 20 years, colitis. After 20 years, there is a 15% there is a 15% incidence of colon incidence of colon cancer, which cancer, which increases to 50% after increases to 50% after 40 years.40 years.

Carcinoma in ulcerative colitisCarcinoma in ulcerative colitis

They may also They may also develop as a develop as a stricture. stricture.

Modified Dukes' staging Modified Dukes' staging classification of colorectal cancer. classification of colorectal cancer.

StagingStaging

Stages B3 and C3 (not shown) signify Stages B3 and C3 (not shown) signify perforation or invasion of contiguous perforation or invasion of contiguous organs or structures (T4).organs or structures (T4).

The TNM classification provides a more The TNM classification provides a more

accurate staging system: Dukes B is a accurate staging system: Dukes B is a composite of better (T2N0) and worse composite of better (T2N0) and worse (T3N0, T4N0) prognostic groups as is (T3N0, T4N0) prognostic groups as is Dukes C (TxN1 or TxN2).Dukes C (TxN1 or TxN2).

Survival by StageSurvival by Stage

Adenocarcinoma of caecumAdenocarcinoma of caecum Intestinal obstruction Intestinal obstruction

occurs late in the course of occurs late in the course of the disease. the disease.

Although this lesion Although this lesion (arrows) is relatively large, (arrows) is relatively large, there was no obstruction to there was no obstruction to retrograde filling of the retrograde filling of the ileum and no dilatation of ileum and no dilatation of the small intestine. the small intestine.

Symptoms may include Symptoms may include anaemia or dyspepsia and anaemia or dyspepsia and weight loss reminiscent of weight loss reminiscent of a benign or malignant a benign or malignant gastric ulcer.gastric ulcer.

Adenocarcinoma of caecumAdenocarcinoma of caecum

Large, fungating Large, fungating tumours, as tumours, as seen here, are a seen here, are a less common less common presentation of presentation of colorectal colorectal tumours; they tumours; they predominate in predominate in the caecum.the caecum.

AdenocarcinomaAdenocarcinoma Moderately Moderately

differentiated differentiated tumours are tumours are marked by gland marked by gland (acinar) (acinar) formation by formation by malignant malignant epithelium; epithelium; there is there is considerable considerable nuclear nuclear pleomorphism pleomorphism within individual within individual cells cells

Adenocarcinoma of sigmoid colonAdenocarcinoma of sigmoid colon

Barium Barium enema shows enema shows an annular an annular stenosing stenosing lesion of the lesion of the distal sigmoid, distal sigmoid, producing a producing a characteristic characteristic 'apple core' 'apple core' appearance appearance

Adenocarcinoma of colon.Adenocarcinoma of colon.

This specimen exhibits This specimen exhibits an annular, stenosing an annular, stenosing lesion with dilatation lesion with dilatation of the colon proximal of the colon proximal to it. to it.

This appearance may This appearance may be seen at any site be seen at any site and is facilitated by and is facilitated by circumferential spread circumferential spread of the tumour through of the tumour through submucosal (or submucosal (or serosal) lymphatic serosal) lymphatic channels channels

TreatmentTreatment

Surgical, even if palliative to relieve Surgical, even if palliative to relieve obstructionobstruction

Adjuvant chemotherapy if node Adjuvant chemotherapy if node positive or at increased risk of positive or at increased risk of metastasesmetastases

Adenocarcinoma of rectumAdenocarcinoma of rectum This lower rectal This lower rectal

lesion lesion demonstrates demonstrates the most the most common common macroscopic macroscopic appearance of appearance of colorectal colorectal cancers as well-cancers as well-circumscribed circumscribed lesions with lesions with raised edges raised edges and an and an ulcerated ulcerated centre.centre.

TreatmentTreatment

Combination of surgery, radiotherapy Combination of surgery, radiotherapy and chemotherapy, depending on and chemotherapy, depending on extent of diseaseextent of disease

Anal CancerAnal Cancer

Staging of Anal CancerStaging of Anal Cancer

Anatomy of the lower rectum and Anatomy of the lower rectum and anal canal. anal canal.

The anal canal The anal canal extends from extends from the anorectal the anorectal ring to an area ring to an area about halfway about halfway between the between the dentate dentate (pectinate) (pectinate) line and the line and the anal verge. anal verge.

The anal The anal margin margin consists of the consists of the area distal to area distal to the anal canal, the anal canal, including the including the perianal skinperianal skin

Squamous cell carcinoma of anal Squamous cell carcinoma of anal marginmargin

Squamous cancers of the Squamous cancers of the anus are divided into tumours anus are divided into tumours arising in the anal canal (most arising in the anal canal (most often above the dentate line) often above the dentate line) and those arising in the skin and those arising in the skin at the anal margin, as shown at the anal margin, as shown here. here.

This lesion measures 1cm This lesion measures 1cm across. Neoplasms at this site across. Neoplasms at this site tend to be slow growing and tend to be slow growing and metastasize to inguinal lymph metastasize to inguinal lymph nodes.nodes.

They have a 5-year survival They have a 5-year survival rate of approximately 70%.rate of approximately 70%.

Anal CancerAnal Cancer

Treatment is potentially curative with Treatment is potentially curative with combined chemo radiotherapycombined chemo radiotherapy

These tumours are often HPV related These tumours are often HPV related and associated with immuno-and associated with immuno-supression.supression.

Malignant melanoma of anal canalMalignant melanoma of anal canal This specimen is from a 74-year-old This specimen is from a 74-year-old

woman who presented with a brief woman who presented with a brief history of episodic rectal bleeding. history of episodic rectal bleeding.

A hard mass was palpable in the A hard mass was palpable in the lateral wall of the anal canal and an lateral wall of the anal canal and an abdominoperineal resection was abdominoperineal resection was performed. performed.

The anal canal has been opened to The anal canal has been opened to show a flattened, ovoid nodule (2 cm show a flattened, ovoid nodule (2 cm in diameter) arising at about the level in diameter) arising at about the level of the dentate line. The edge of the of the dentate line. The edge of the tumour shows obvious melanotic tumour shows obvious melanotic pigmentation and an irregular streak pigmentation and an irregular streak of pigment extends from the nodule to of pigment extends from the nodule to the anal margin. the anal margin.

Anorectal melanoma is rare, Anorectal melanoma is rare, accounting for about 1% of anal accounting for about 1% of anal cancers.cancers.