Upper Gastrointestinal Malignancies

See Pancreatic Cancer for the presentation-focused summary of pancreatic malignancy — this page covers gastric/oesophageal cancer plus pancreatic cancer treatment detail.

Gastric and oesophageal cancer

Upper GI cancers are a significant cause of morbidity and mortality worldwide — the 2nd most frequently diagnosed cancer group globally, accounting for 9.9% of all new cancers and 12.1% of all cancer deaths. More than half of cases occur in China and Japan.

In Australia, gastric cancer is the 10th most common cancer (2.2% of new diagnoses, 3.3% of deaths); oesophageal cancer is about a tenth as common as CRC (1.3% of new cases). Mortality from these two upper GI cancers is greater than CRC, as disease is often advanced at diagnosis and treatment is often supportive rather than curative.

Risk factors: geographic differences aren’t fully understood, but are thought to relate to dietary factors (high salt, smoked foods, low fruit/vegetable intake). Other risk factors: age, male sex, H. pylori infection (gastric MALToma), smoking, pernicious anaemia, chronic atrophic gastritis, family history. Acid reflux, alcohol, and smoking add significant risk specifically for oesophageal cancer.

Presentation: dyspepsia is such a common symptom of benign gastric pathology that it’s easy to miss malignancy — be wary when coupled with red flags: new/recent symptoms with age >40; weight loss; dysphagia; early satiety/fullness; anaemia (iron deficiency); palpable epigastric or liver mass; inadequate response of dyspepsia to PPI treatment.

Diagnosis: in a person under 40 without red flag symptoms, it’s reasonable to treat GORD symptoms with an appropriate PPI and only investigate with endoscopy if there’s an inadequate response. H. pylori testing and clearance should also be attempted for gastritis/duodenitis, but pursue endoscopy if there’s no improvement. Any other red flag symptom coupled with dyspepsia should be investigated with endoscopy (the gold standard); CT and/or ultrasound have a higher yield for biliary or pancreatic disease.

Treatment: surgical resection is the mainstay for gastric carcinoma, followed by adjuvant pre- and post-operative chemotherapy and radiotherapy. Adjuvant therapy has debatable benefit in late-stage disease, but shows significant benefit at early stages (36% vs 23% survival). Post-operative care involves maintaining nutritional balance (B12, iron, calcium).

Palliative treatment (where curative resection isn’t possible) — management of local symptoms and complications becomes the primary goal: obstruction (symptomatic resection/dilation/radiotherapy/ palliative bypass); bleeding (selective arterial embolisation via angiography, or cautery); nausea (medications); pain (medications/resection/radiotherapy).

Pancreatic cancer

The 5th most common cause of cancer death in Australia. Little progress has been made in understanding its aetiology; most cases present at a late stage with metastases and are not amenable to surgical resection.

Assessment and diagnosis: ultrasound and CT are the mainstay investigations for patients presenting with obstructive jaundice. Most patients have red-flag cancer symptoms on a background of low-grade abdominal discomfort, pain, or vomiting (similar red flags to gastric cancer); some have no symptoms until jaundice occurs.

Management: only ~20% of cases can be surgically resected — the only potentially curative treatment. Surgical approach is Whipple resection (pancreaticoduodenectomy), involving resection of the gallbladder, bile duct, duodenum, pancreatic head and uncinate process, varying amounts of peripancreatic lymph nodes, and the stomach — mortality rate ~5%, morbidity ~40%. Common post-surgical complications include delayed gastric emptying and gut dysfunction from division of the enteric nerve supply during lymph node resection. Adjuvant chemo-radiotherapy is advocated, though there is little evidence to support it.

Palliative management of non-resectable disease depends on probable length of survival and symptoms — median survival is 6 months overall, but 11 months in patients without metastatic disease. Palliative therapies include endoscopic stenting, debulking surgery, chemotherapy, radiotherapy, interventional radiological techniques (ERCP), and pain and symptom management.