Neoplasms of the Gastrointestinal Tract

Laura W. Lamps, M.D.

 Esophagus
 Squamous cell carcinoma
 80-85% of esophageal cancers
 USA: adults >50, men > women; 6/100,000/yr,
non-caucasian > caucasian
 Asia: women > men; 100/100,000/yr
 Esophagus-SCC
 Clinical presentation
 insidious onset, asymptomatic early
 gradual and late onset of dysphagia and obstruction
 spread by local extension and lymphatic routes
 5% alive at 5 years
 Esophagus-SCC (cont’d)
 Risk Factors
chronic esophagitis
tobacco use
alcohol, especially hard liquor
nitrosamines
genetic factors: abnormal p53 in 50% of
esophageal cancers
Infiltrating nests of keratinizing esophageal squamous cell carcinoma
 Esophagus-adenocarcinoma
 15-20% of esophageal carcinoma, but greater than
50% in distal third of esophagus
 Barrett’s esophagus and Barrett’s with dysplasia
are recognized precursor lesions
 Clinically, usually through the esophageal wall
and in lymph nodes at time of diagnosis
 Ulcerated esophageal adenocarcinoma

Gastric
mucosa Esophageal
mucosa
 Gastric tumors-polyps
 Uncommon; 0.4% of adults at autopsy as
compared to colon polyps in 25-50% of adults at
autopsy
 Hyperplastic- response to damage
 Fundic gland-small hamartoma
 hyperplastic andfundic gland polyps are not believed
to have malignant potential
 Adenomatous-malignant potential!
Pedunculated gastric
adenoma
 Gastric Carcinoma
 Classification
 Diffuse type
 no well defined risk factor
 Intestinal type
 Prognosis-invasion is most important factor
 early: limited to mucosa and submucosa; 90-95%
survival at 5 years
 late: beyond submucosa; less than 10% survival at 5
years
 Gastric Carcinoma
 Intestinal
 patients greaterthan 50, male>female
 arises from metaplastic glands in chronic gastritis;
associated with H. pylori
 incidence decreasing in USA

 Diffuse (signet ring cell, linitis plastica)

 younger patients, no gender preference
 not associate with H. pylori
 incidence unchanged
 Gastric Carcinoma
 90-95% of stomach malignancies
 variable incidence: Asia, S. America > USA
 Location: lesser curvature of antropyloric region
is most common, BUT an ulcerated lesion of the
greater curvature is more likely to be malignant
Ulcerated gastric adenocarcinoma
Thickened “linitis plastica”
type adenocarcinoma infiltrating gastric wall
Intestinal type gastric
adenocarcinoma
Diffuse signet-ring cell adenocarcinoma
 Tumors of Small & Large Bowel
 Classification the same for small and large
intestines
 polyps; nonneoplastic
 epithelial neoplasm
 benign adenomatous polyps
 adenocarcinoma

 carcinoid

 mesenchymal neoplasms
 lymphoma

 Tumors of large bowel are more common

 Bowel: Nonneoplastic Polyps
 Hyperplastic  Hamartomatous
 asymptomatic  Peutz-Jegher (AD)
 less than 5 mm  multiple, throughout GI tract
 mucocutaneous
 single or multiple
pigmentation
 rectosigmoid  increased risk of GI and non-

 virtually no malignant GI cancers

potential  Juvenile:
 children < 5
 can be quite large

 rectum

 no malignant potential
Hyperplastic polyp
 Adenomatous Polyps
result of epithelial proliferation and dysplasia
 Three types: tubular, villous, mixed
 Risk of malignancy related to size, histologic
type, and severity of dysplasia
 May be asymptomatic; commonly present with
bleeding
 small or large, pedunculated or sessile, usually in
colon
 Since they are considered premalignant, all should
be removed
Large pedunculated adenomatous polyp from the colon
Hyperchromatic, test-tube shaped glands from adenomatous colon polyp
Hereditary Colon Cancer Syndromes
 Familial Adenomatous Polyposis
 autosomal dominant
 mutation in APC gene on 5q21
 100-2500 polyps throughout GI tract
 virtually 100% risk of carcinoma
 HNPCC (Lynch Syndrome)
 autosomal dominant
 increased risk of GI and non-GI cancers
Hundreds of polyps in a colon from a patient with
Familial Adenomatous Polyposis
 Colon Adenocarcinoma
 Right colon:
 increasing incidence, especially in elderly
 usually polypoid
 present with bleeding, anemia

 Left colon:
 annular,napkin ring lesions
 present with decreased stool caliber, obstruction

 Less than half of cancers are detectable by

protoscopic exam
 Colon Adenocarcinoma
 Risk Factors:
 increasing age
 inflammatory bowel disease
 hereditary syndromes
 dietary (low fiber, high fat)
Constricting “napkin ring” colon adenocarcinoma
Large fungating colonic
adenocarcinoma
Cribriformed, malignant glands in
photomicrograph of colonic adenocarcinoma
 Staging of Colon Adenocarcinoma:
most important prognostic factor
Astler-Coller Classification
 A: limited to mucosa 100%
 B1: into muscularis propria; negative nodes 67%
 B2: through muscularis propria; negative nodes 54%
 C1: into muscularis propria; involved nodes 43%
 C2: through muscularis propria; involved nodes 22%
 D: distant metastatic spread low

from Astler-Coller, Ann Surg. 139:846, 1954

Lymphatic space invasion by colonic
adenocarcinoma
 Carcinoid Tumors
 Tumors of dispersed neuroendocrine system
 Present throughout GI tract, often asymptomatic
 All are potentially malignant
 Behavior correlates with size, location, and depth of
penetration
 May secrete numerous bioactive hormones
 Most common sites: appendix>small
bowel>rectum>stomach>colon
 Carcinoid Tumors-pathology
 Solitary or multicentric firm, yellow-tan nodules
 Usually submucosal masses, sometimes with ulceration
 Cause striking desmoplastic response
 Form islands, trabeculae, glands, or sheets
 Monotonous, speckled nuclei and abundant pink
cytoplasm
 Contain cytoplasmic secretory dense-core granules
Carcinoid tumor of the appendix
Monomorphic nests of carcinoid
tumor cells within the appendix
Carcinoid tumor cells stain positively for
neuroendocrine markers including
synaptophysin and
chromogranin (dark brown staining).,
 Gastrointestinal Lymphoma
 Most common primary extranodal lymphoma
location
 Sporadic/Western type-most common in USA
 Thought to arise from Mucosal Associated
Lymphoid Tissues
 Controversial relationship with H. pylori
 T-cell lymphomas associated with celiac sprue
Fleshy small intestinal B-cell lymphoma producing obstructive lesion
Neoplastic follicle centers in intestinal B-cell lymphoma of follicular center
cell origin