Gastrointestinal tumours

General

Cancers of the oesophagus and stomach when considered together account for over 15,000 new cases every year in the UK.  Historically the most common types of oesophago-gastric cancer were squamous cell cancer of the oesophagus, caused by damage to the lining of the upper oesophagus from exposure to carcinogens such as alcohol and cigarette smoke, and adenocarcinoma of the stomach, usually caused by chronic inflammation of the stomach by the bacterium Helicobacter pylori, or other causes such as pernicious anaemia.  However the last thirty years have seen a very rapid rise in the incidence of adenocarcinoma of the oesophago-gastric junction which now accounts for around 70% of all new diagnoses of oesophago-gastric cancer.  The reason for this is thought to be the development of abnormal glandular tissue where the oesophagus meets the stomach, probably related to reflux.  This is called Barrett’s oesophagus, and in a small proportion of cases (probably less than 1% per year) this condition can undergo malignant change leading to the development of cancer.  If detected early, Barrett’s oesophagus can often be effectively monitored, and treated with non-invasive therapy if it appears to be developing malignant characteristics.

Unfortunately most cases of Barrett’s oesophagus are asymptomatic, and therefore many people are unaware of the risk of cancer until they develop symptoms.  The most common symptoms of oesophago-gastric cancer are difficulty in swallowing and loss of weight, but patients may also develop anaemia because of chronic bleeding, or even acute haemorrhage.  Other common symptoms include recurrent or prolonged indigestion, trapped wind, feeling very full after eating and nausea.

Diagnosis

Investigation is usually with an upper gastrointestinal endoscopy, using a flexible fibreoptic telescope to examine the lining of the gullet and stomach,  and a biopsy.  If a cancer is confirmed, the next step is usually a CT scan to assess whether the tumour is potentially operable.  Other tests which may be necessary include endoscopic ultrasound and PET/CT scan.

All cases of oesophago-gastric cancer are discussed in a multidisciplinary team at Addenbrooke’s Hospital.  The MDT includes specialist surgeons, oncologists, radiologists, pathologists, specialist nurses and dieticians to ensure the best possible treatment plan is put in place. 

Treatment

Treatment for many patients will include chemotherapy, radiotherapy or surgery either alone or in combination.  It is also important to focus on relief of symptoms.  Nutritional support is particularly important for this condition.  For patients whose cancers are not operable, their swallowing can often be improved by the insertion of a tube (stent) into the gullet to relive the blockage and allow food to pass. 

Cambridge Oncology Partners offers a full range of oncological treatments for oesophageal cancer. Patients can access a full range of chemotherapy and targeted treatments including, where appropriate, drugs which target HER-2 amplification and angiogenesis (new blood vessel formation). Radiotherapy is undertaken at Addenbrooke’s Hospital with fully equipped state of the art linear accelerators. Concomitant chemoradiotherapy is available (chemotherapy and radiotherapy given together) as well as advanced radiotherapy technologies such as intensity modulated radiotherapy (IMRT) and image guided radiotherapy (IGRT).

Other useful links:
www.macmillan.org.uk/cancerinformation/cancertypes/oesophagusgullet/oesoph...
www.macmillan.org.uk/cancerinformation/cancertypes/stomach/stomachcancer.aspx
www.opa.org.uk
www.cancerresearchuk.org/about-cancer/type/oesophageal-cancer
www.cancerresearchuk.org/about-cancer/type/stomach-cancer

Colorectal cancer, also known as bowel cancer, is a common cancer with over 40,000 new cases diagnosed in the UK every year. Colon cancers normally arise through the development of polyps in the bowel, which, sometimes over a very long period of time, can then acquire further genetic mutations causing the polyp to become cancerous. A small number of colorectal cancers are caused by inherited genetic abnormalities such as hereditary non polyposis colon cancer (HNPCC) or familial adenomatous polyposis (FAP), but most of them occur by chance. Diets low in fibre and high in red meat may contribute to the development of colorectal cancer.

Colorectal cancer can occur anywhere in the large bowel, and the symptoms will depend on where it is. The possible symptoms are bleeding from the bowel, which can show up as blood in the bowel motions, or as anaemia on a blood test. Other symptoms can include change in bowel habit (diarrhoea or constipation), tenesmus (a recurrent or constant sensation of wanting to pass a bowel motion) or less specific symptoms such as tiredness or loss of weight.  Bigger cancers can obstruct the bowel leading to abdominal pain, swelling and vomiting.  However many cancers do not cause symptoms until they are quite large, and there is now a national screening programme for bowel cancer which tests for small amounts of blood in the bowel motions (Faecal occult blood). If bowel cancer is suspected, then the next step is usually a colonoscopy in which the bowel is examined with a flexible endoscope. If a polyp or a suspicious tumour is seen a biopsy is performed at the same sitting. If cancer is confirmed then A CT scan will normally be performed, and if possible the cancer will be removed surgically.

For cancers in the rectum (at the lower end of the bowel) it is necessary to do further tests with an MRI scan to assess whether or not the tumour is near to the edge of the planned surgery.  If so, then it may be that preoperative treatment with radiotherapy and/or chemotherapy will be required to shrink the cancer and give the best chance of a curative operation.

Cancers which have been successfully removed are categorised into different stages, (called the Dukes stage) from A to C, based on how advanced they were. More advanced tumours (Dukes C and some Dukes B) may need further treatment (adjuvant therapy) to minimise the risk of recurrence. This is normally a 6 month course of outpatient based chemotherapy.  Occasionally post-operative radiotherapy may also be recommended.

For cancers which have spread and are not operable, or which come back after primary surgery, an assessment is required as to whether any areas of spread can be removed, as this offers the only real prospect of long term cure. However if surgery is not possible, bowel cancer can often be controlled very well with chemotherapy, sometimes for long periods of time.  Recently more advanced biological treatments have been developed which target new blood vessel growth (angiogenesis) or a specific growth protein called EGFR, and further improve the outcomes of treatment. Sophisticated molecular diagnostic tests may be required to identify if patients are suitable for EGFR targeted drugs, and locally these are performed by the laboratories at Addenbrooke’s Hospital. Some patients in whom the disease has spread to affect the liver, but not to other sites, may be treated with selective internal radiotherapy (SIRT) in which small radioactive beads (Yttrium microspheres) injected directly into the artery supplying blood to the liver may be advised.

Cambridge Oncology Partners offers a full range of oncological treatments for colorectal cancer. Patients can access a full range of chemotherapy and targeted treatments including, where appropriate, drugs which target the epidermal growth factor receptor (EGFR) and angiogenesis (new blood vessel formation). All cases of colorectal cancer are discussed the specialist multidisciplinary teams at Addenbrooke’s hospital of which Dr Ford and Dr Wilson are key members, and where specialist opinions can be gained from colorectal, liver and chest surgeons, specialist radiologists and pathologists and specialist nurses. Radiotherapy is undertaken at Addenbrooke’s with fully equipped state of the art linear accelerators. Concomitant chemo-radiotherapy is available (chemotherapy and radiotherapy given together) as well as advanced radiotherapy technologies such as tomotherapy, intensity modulated radiotherapy (IMRT) and image guided radiotherapy (IGRT). Addenbrooke’s is the only hospital in the East of England offering SIRT treatment.

Useful links:
www.beatingbowelcancer.org
http://www.cancerresearchuk.org/about-cancer/type/bowel-cancer/
http://www.macmillan.org.uk/Cancerinformation/Cancertypes/Bowelcancer.aspx

 

General

Anal Cancer is a rare cancer affecting the final part of the large intestine. There are only about 1200 new cases in the UK per year and treatment is usually given in designated centres. Anal cancer is linked with infection from the human papilloma virus, the same virus that causes cervical cancer and may also be associated with a weakened immune system and smoking. It is slightly commoner in women.

It may present with bleeding, itching, small lumps around the anus, pain and incontinence. These symptoms are usually non-specific and similar to the common benign conditions such as haemorrhoids or anal fissure. Sometimes it may present with an enlarged gland in the groin.

Diagnosis

Diagnosis may be suspected at initial digital rectal examination but usually requires an inspection of the lower part of the bowel using an endoscope and a biopsy to confirm the diagnosis. Anal Cancers are usually Squamous cell carcinomas.

Further tests to determine its extent include a CT scan of the body, an MRI scan of the pelvis and blood tests including an HIV test. A PET-CT Scan is sometimes recommended.

Treatment

Anal squamous cell cancers are usually very responsive to treatment by radiotherapy combined with chemotherapy - (chemoradiotherapy) and outcomes are usually successful. 

This normally involves a five week course of short daily treatments with radiotherapy in combination with chemotherapy given on the first and fifth week only.

Surgery is usually reserved for very small tumours which can be simply removed or if the chemoradiotherapy has been unsuccessful. In the latter case, this would normally require a complete removal of the anus by an abdominoperineal resection with the formation of a permanent colostomy.

Cambridge Oncology Partners offers the full range of non surgical treatments for anal cancer. Advanced Technologies such as intensity modulated radiotherapy (IMRT) and imaged guided radiotherapy (IGRT) are particularly important in reducing the side effects to normal tissues whilst ensuring accurate targeted treatment to the cancer.

Useful Links:
www.nhs.uk/conditions/cancer-of-the-anus/
http://www.cancerresearchuk.org/about-cancer/type/anal-cancer/
http://www.macmillan.org.uk/Cancerinformation/Cancertypes/Anal/Analcancer.aspx