Tumori maligne ale tractului

digestiv
Bogdan Gafton
 Cuprins
• Cancerul colo-rectal
• Carcinomul hepatocelular
• Colangiocarcinomul
• Cancerul gastric
• Cancerul esofagian
• Cancerul pancreatic
• GIST
Cancerele colo-rectale
 Epidemiologie
• Cazuri noi: 447000 în Europa în 2012
• Decese: 215000 în Europa în 2012
• Al doilea cancer din lume
– 13,2% din totalul cancerelor la bărbați
– 12,7% din totalul cancerelor la femei
• 25% au boală metastatică la diagnostic
• 50% vor dezvolta metastaze după chirurgie +/-
terapie adjuvantă
• Supraviețuirea la 5 ani: 60%
E. Van Cutsem et all. Annals of Oncology 25 (Supplement 3):
iii1–iii9, 2014
 Semne și simptome
• S/S în stadiile incipiente: • S/S de boală avansată:
– Constipație
– Diaree – Fatigabilitate
– Modificarea culorii scaunelor
(acolice, negre, hemoragice)
– Pierdere ponderală
– Scaune creionate – Simptome de
– Hemoragii: rectoragii,
hematochezie
ocluzie/subocluzie
– Flatulență intestinală
– Crampe și dureri abdominale

• S/S de boală metastatică

(exemple):
– Icter mecanic
– Edeme
– Dispnee
– Cefalee
– Dureri osoase
 Diagnostic
• Simptome
• Anamneză: PAF, MUTYH, boli inflamatorii
intestinale, factori ai stilului de viață, istoric
familial
• Laborator: hemogramă, biochimie (teste
hepatice), ACE, CA 19-9
• Imagistică
• Biopsie
• Stadializare
 Tratamentul
• Abord multidisciplinar
– Chirurgia tumorii primare
• Rezecabilitatea metastazelor
– Radioterapie cancerelor de rect
– Agenți citotoxici
– Terapii biologice țintite
– Imunoterapie
MMR/MSI
 Cancerul de colon localizat
• Stadiul I – operație
• Stadiul II – operație, uneori chimioterapie
adjuvantă cu fluoropirimidine
Cancerul de colon metastatic
Cancerul de colon metastatic
Cancerul de rect localizat
Cancerul de rect localizat
Cancerele colo-rectale metastatice
Tumorile ficatului
• Maligne
– Carcinomul
hepatocelular
– Colangiocarcinomul
– Angiosarcoame și
hemangiosarcoame
– Hepatoblastom
– Metastaze hepatice
• Benigne
– Hemangioame
– Adenoame
– Hiperplazie nodulară
focală
 Carcinomul hepatocelular
• Factori de risc
– Hepatite virale: B, C
– Abuzul de alcool
– Steatohepatita non-etanolică
– Ciroza biliară primară
– Deficitul de α1-antitripsină
 Screening
• AFP
• US – 6 luni
• Tumoare
– <1cm
• CT, RMN, US – 3 luni
– >1cm
• CT, RMN
• Confirmare histologică
• Rezecabilitate vs. Operabilitate
• Rezecabilitatea
– Localizare tumorală
– Criteriile UNOS
• Operabilitatea
– Rezervă hepatică inadecvată
– Child-Pugh A,B
– Hipertensiune portală
• 1 T < 5cm
• 2-3 T < 3cm
• Fără implicare macrovasculară
• Controlul hepatitei virale/toxice
 Diagnostic HCC

Stadiul 0 Stadiul A-C Stadiul D

PS 0, Child-Pugh A, PS 0-2, Child-Pugh A-B PS>2, Child-Pugh C
Okuda 1 Okuda 1-2 Okuda 3

Stadiu foarte incipient

Stadiu incipient (A) Stadiu intermediar Stadiu avansat (C)
(0) Stadiul terminal
-Leziune unică sau 3 (B) - Invazie portală
-Leziune unică<2cm (D)
noduli <3cm, PS 0 -Multinodular, PS 0 - N1, M1, PS 1-2
-Carcinom in situ

Leziune
unică

Presiune Afecţiuni Invazie portală,

portală/Bilirubină DA NU N1, M1
crescute? asociate?
N N D D
U U A A
Transplant Terapie
Rezecţie PEI/RF TACE
hepatic sistemic[a
Potenţial curativ Supravieţuire mediană Simptomatic
(Supravieţuire la 5 ani: 40%-70%) 11-20 luni (<3 luni)
 STRIDE (T300+D) Regimen

• FDA and EMA approval as 1L treatment in unresectable/metastatic HCC

• NCCN recommendation in 1L systemic therapy: preferred regimen

1.FDA approves tremelimumab in combination with durvalumab for unresectable hepatocellular carcinoma | FDA . Accessed 18 November 2022. 2.ESMO guidelines:
https://www.esmo.org/guidelines/esmo-mcbs/esmo-mcbs-scorecards/scorecard-358-1 . Accessed 17 November 2022. 3.
https://www.astrazeneca.com/media-centre/press-releases/2023/imfinzi-plus-imjudo-approved-in-the-eu-for-patients-with-advanced-liver-and-non-small-cell-lung-cancers.html . Accessed February 22, 2023. 4. NCCN guidelines Version
2.2023; https://www.nccn.org/professionals/physician_gls/pdf/hepatobiliary, Accessed 6 October 2023
Colangiocarcinomul
Cancerul gastric și de jonctiune eso-gastrică
• Stomach cancer makes up around 1.5% of all new cancer cases
diagnosed annually in the United States.
• Risk factors:
– Age. Stomach cancer occurs most commonly in people older than 55. Most
people diagnosed with stomach cancer are in their 60s and 70s.
– Gender. Men are twice as likely to develop stomach cancer as women
– H. pylori
– Family history/genetics: hereditary diffuse gastric cancer, Lynch
syndrome, hereditary breast and ovarian cancer (HBOC), and familial
adenomatous polyposis (FAP)
• Diet.
• Previous surgery or health conditions.
• Tobacco and alcohol.
• Obesity.
• Occupational exposure.
 Cancerul gastric și de jonctiune eso-gastrică

• Adenocarcinomas
• Gastrointestinal stromal tumors
(GISTs)
• Primary gastric lymphoma
– mucosa-associated lymphoid
tissue (MALT) gastric lymphoma
– diffuse large B-cell lymphoma
(DLBCL) of the stomach
• Neuroendocrine tumors
(including carcinoids)
• Other cancers
– squamous cell carcinomas,
– small cell carcinomas, and
– leiomyosarcomas
Cancerul gastric și de jonctiune eso-gastrică
Cancerul gastric și de jonctiune eso-gastrică

• Stomach cancer trends over time

• The increased use of refrigeration for food
storage, which has led to people eating fewer
salted and smoked foods (known risk factors
for stomach cancer).
• The decline in the number of people infected
with the Helicobacter pylori (H pylori) bacteria,
which is thought to be a major cause of
stomach cancer.
Cancerul gastric și de jonctiune eso-gastrică
Cancerul gastric și de jonctiune eso-gastrică
Cancerul gastric și de jonctiune eso-gastrică
 Cancerul esofagian

• Squamous Cell Carcinoma

• Adenocarcinoma
– Mostly EGJ – treated like gastric adenocarcinoma
Cancerul esofagian
Cancerul esofagian
Cancerul esofagian
 Cancerul pancreatic
• Adenocarcinoma
– Resectable >>> proceed to surgery
– Unresectable
• Chemotherapy
• Chemoradiation
• Induction chemotherapy followed by radiotherapy
• Neuroendocrine tumors
Cancerul pancreatic
Cancerul pancreatic
Cancerul pancreatic
Cancerul pancreatic
 Tumorile stromale gastro-intestinale
• Interstitial Cajal cells cancers (called the “pacemakers” of the GI tract
because they signal the muscles in the GI tract to contract to move
food and liquid along)
• mesenchymal tumor of the gastrointestinal tract
• Immunohistochemistry - diffuse strong CD117 (c-kit) positivity (rare
cases are negative – difficult differential diagnosis)
• A rare form of GIST, called succinate dehydrogenase (SDH)-deficient
GIST, tends to occur in childhood or young adulthood and affects
females more commonly than males.
• SDH-deficient GIST have a high risk of developing other types of
tumors, particularly noncancerous tumors in the nervous system
called paragangliomas (Carney-Stratakis syndrome) and noncancerous
lung tumors called pulmonary chondromas (Carney triad).
 GIST – model of cancinogenesis
• KIT and PDGFRA genes control many important cellular processes,
such as cell growth and division (proliferation) and survival.
• Mutations in the KIT and PDGFRA genes lead to proteins that no longer
require ligand binding to be activated.
• The SDHA, SDHB, SDHC, and SDHD genes provide instructions for
making proteins that come together to form the succinate dehydrogenase
(SDH) enzyme involved in cellular pathways that are critical for
converting the energy from food into a form that cells can use.
• Succinate acts as an oxygen sensor in the cell and can help turn on
specific pathways that stimulate cells to grow in a low-oxygen
environment (hypoxia).
• Excess succinate triggers cell growth pathways in normal oxygen
conditions, which leads to abnormal cell growth and tumor
formation.
Tumorile stromale gastro-intestinale
Tumorile stromale gastro-intestinale
Extragastrointestinal Stromal Tumor(EGIST)

• EGISTs are extremely rare. They represent

only 5% of all GISTs, which comprises only
<0.05% of all GI tumors.
• High index of suspicion in patients with
nonspecific symptoms and the presence of an
abdominal mass is necessary.
• The preferred treatment is a complete surgical
resection in low-risk patients.
• More aggressive biological behavior than their
GI counterparts
Carcinomul anal
 Alte cancere
• Adenocarcinomul de ampula Vater
• Adenocarcinomul de intestin subțire
• Mezoteliomul peritoneal
• Limfoame
• Sarcoame
• Metastze hepatice cu punct de plecare neprecizat
• Melanoame de intestin subțire și perianale
• Tumori neuroendocrine