Managing gastrointestinal malignancies

Malignancies of the gastrointestinal tract can occur in all organs that are involved in the ingestion and digestion of nutrients. Cancers can also affect the organs responsible for the elimination of all residue not used for human nutrition and metabolism. 

These organs include the mouth, salivary glands, pharynx, esophagus, stomach, liver, pancreas, and small and large intestine, each of which is susceptible to develop benign or malignant neoplasms. 

However, the factors which determine when and what types of neoplasms will develop are unclear. Solid scientific evidence suggests multiple factors influence the development of cancer of the gastrointestinal tract. 

These factors cause cellular disruption at the molecular level producing mutations in the genes that regulate cell growth and proliferation. Hereditary factors play a role in a small percentage of cases, however, environmental, dietetic and behavioral components play significantly larger roles. 

There is a strong association between tobacco use, smoked or chewed, and cancers of the oropharynx, esophagus, stomach and other organs that do not form part of the gastrointestinal tract. A particularly risky combination for the development of gastrointestinal malignancy is the use of tobacco and consumption of alcoholic beverages. 

Other agents associated with cancer development include bacterial and viral infections. There is a strong association between gastric cancer and H. Pylori colonization of the gastric mucosa. Chronic viral Hepatitis B or C are common infections of the liver that lead to the development of cirrhosis and an increased risk to develop primary liver carcinoma. 

Chronic alcohol abuse and obesity can also lead to the development of cirrhosis and increased risk of developing hepatocellular carcinoma. Altered anatomy and physiology are strongly associated with the development of malignancies. Hiatal hernia and chronic gastroesophageal reflux are commonly present as a causative factor of cancer of the lower esophagus. 

Obesity is responsible for a fatty liver that leads to a chronic, non-alcoholic seato-hepatitis. This chronic inflammation of the liver cells infiltrated by fat will produce cirrhosis, which increases the risk of cancer development. 

Prevention and early detection are the best opportunity for intervention. Strong preventive measures include absolute abstinence from tobacco products, moderate alcohol consumption, weight control, and good nutrition. 

The most effective and commonly used tool for early detection and diagnosis is endoscopy. Esophagogastro-duodenoscopy and colonoscopy are widely available and safely performed. Other methods include imaging techniques such as ultrasonography, computed tomography and magnetic resonance imaging. 

The management of gastrointestinal malignancies varies based on the site of origin, stage of the disease and specific cell type. Early cancer can be effectively managed by surgical removal. For advanced cancer, multimodality treatments offer the best probability for cure or remission. 

The use of newer forms of molecular targeted therapy, in combination with surgery and radiation therapy, has improved rates of tumor control and survival. Traditional cytotoxic chemotherapy remains vital in cancer treatment. 

Surgery remains the most frequently used and most effective modality of treatment. The techniques for tumor resection vary widely and include endoscopic resection or destruction by energy ablation. Other methods include minimally invasive approaches for radical resections of intra-abdominal tumor using laparoscopy or robotic-assisted surgery. 

The use of robotic-assisted intra-abdominal surgery is an emerging technology that offers distinct advantages over traditional open abdomen surgery. The robotic-assisted surgical management of intra-abdominal tumors has expanded the capability to perform complex procedures. It has also decreased the rate of complications and is associated with enhanced recovery. 

Currently, a great majority of gastrointestinal intra-abdominal malignancies can be successfully treated with minimally invasive robotic techniques. Existing techniques to remove esophageal, gastric, hepatic, pancreatic and intestinal tumors are safe. Additionally, these procedures can be as radical as needed for complete eradication of cancers. 

Dr. Adrian Legaspi is medical director of the Center for Advanced Surgical Oncology at Palmetto General Hospital, Hialeah, Florida. He is one of the speakers at this week’s Conquering Cancer event. 

Dr. Legaspi
Dr. Legaspi