The Farber Center: For Radiation Oncology

Gastrointestinal cancer refers to malignant disease of the gastrointestinal tract. It includes cancers of the esophagus, stomach (also called gastric cancer), liver, biliary system, pancreas, colon, rectum, and anus.

TYPES OF GASTROINTESTINAL CANCERS

Pancreatic: The more common type of pancreatic cancer usually occurs in the exocrine cells (exocrine tumors). The less common type are endocrine tumors of the pancreas.
The American Cancer Society's most recent estimates for pancreatic cancer in the United States are for 2009:

• 42,470 new cases of pancreatic cancer
• 35,240 deaths from pancreatic cancer

The lifetime risk of having pancreatic cancer is about 1 in 72. It is about the same for both men and women. A person's risk may be changed by certain risk factors. The pancreas is a gland about 6 inches long that is shaped like a thin pear lying on its side. The wider end of the pancreas is called the head, the middle section is called the body, and the narrow end is called the tail. The pancreas lies behind the stomach and in front of the spine.

Gallbladder/Biliary System:
The American Cancer Society's most recent estimates for cancer of the gallbladder and bile ducts in the United States are for 2009:

• about 9,760 new cases will be diagnosed
• about 3,370 people will die of these cancers

Of new cases more than half (about 60% or around 6,000 cases) are gallbladder cancer. The number of deaths in the United States from gallbladder cancer has been dropping slightly over the last couple of decades. Gallbladder cancer is not usually found until it is more advanced and causes symptoms. Approximately 1 out of 5 gallbladder cancers is found in the early stages, where the cancer has not yet spread beyond the gallbladder.

Liver:
The American Cancer Society's most recent estimates for primary liver and bile duct cancers in the United States are for 2009:

• 22,620 new cases of primary liver cancer and bile duct cancer
• 18,160 deaths from these cancers

This cancer is more common in men than in women. An average man's lifetime risk of getting liver or bile duct cancer is about 1 in 100, while an average woman's risk is about 1 in 217. Liver cancer is much more common in developing countries in sub-Saharan Africa and Southeast Asia than in the US.

There are several signs and symptoms in patients found to have gastrointestinal cancer, which vary from person to person and depend on the anatomic location. Not all patients exhibit any or all symptoms, which may include:

• Jaundice: yellowing of the eyes and skin
• Abdominal or back pain: common in advanced pancreatic cancer
• Sudden weight loss
• Poor appetite
• Digestive problems: including nausea, vomiting, and pain that tend to be worse after eating
• Gallbladder enlargement: can be found by physician during a physical exam
• Blood clots or fatty tissue abnormalities
• Diabetes

Risk Factors

• Age (close to 90 percent of all pancreatic cancers are found in people age 55 and older)
• Obesity
• Smoking cigarettes
• Diabetes
• Chronic pancreatitis
• Cirrhosis of the liver
• Helicobacter pylori (H. pylori) infection

Computed tomography (CT, CAT) scan: This test uses a special x-ray machine that takes pictures from many angles. Before any pictures are taken, you may be asked to drink 1 to 2 pints of a liquid called oral contrast. This helps outline the intestine so that certain areas are not mistaken for tumors. You may also receive an IV (intravenous) line through which a different kind of contrast dye (IV contrast) is injected. This helps better outline structures in your body. A computer then combines these pictures into images of slices of the part of your body being studied. The CT scan can help show where stomach cancer is and where it has spread. CT scans can also be used to guide a biopsy needle into a place that might have cancer. The patient stays on the CT scanning table while a doctor moves a biopsy needle through the skin toward the tumor. A small piece of the tumor is removed and looked at under a microscope.

Magnetic resonance imaging (MRI): MRI scan (magnetic resonance imaging): MRI (magnetic resonance imaging): Provide detailed images of soft tissues in the body. They use radio waves and strong magnets instead of x-rays, which are absorbed and then released in a pattern formed as they penetrate through different types of body tissue and by certain diseases. A computer translates the pattern into a very detailed image of parts of the body.

PET scan (positron emission tomography): a special type of scanner that uses a form of sugar that contains a radioactive atom. Because cancer cells in the body are growing rapidly, they absorb large amounts of the radioactive sugar. This allows for cancer cells to show up brighter in the images because they absorb more sugar than normal cells. PET scans are also useful to check if the cancer may have spread elsewhere in the body. PET can reveal spread of cancer to the liver, bones, adrenal glands, or some other organs. Some machines are able to perform both a PET and CT scan at the same time (PET/CT scan)

Chest x-rays: may be done to see whether the cancer has spread to the lungs.

Ultrasonography (ultrasound or US): uses sound waves to produce images of internal organs such as the pancreas. For an abdominal ultrasound, a wand-shaped probe called a transducer is placed on the skin of the abdomen. It emits sound waves and detects the echoes as they bounce off internal organs. The pattern of echoes is processed by a computer to produce an image on a screen. The echoes made by most pancreatic tumors differ from those of normal pancreas tissue. Different echo patterns can help distinguish some types of pancreatic tumors from one another.

Endoscopic ultrasound: is more accurate than abdominal ultrasound and is probably one of the best way to diagnose pancreatic cancer. This test is done with an ultrasound probe that is attached to an endoscope- a thin, lighted, flexible, fiber optic tube that doctors use to look at the inside of the intestinal tract. Patients are first sedated and the probe is then passed through the mouth or nose, through the esophagus (the tube that connects the mouth to the stomach) and stomach, and into the first part of the small intestine. The probe can then be pointed toward the pancreas, which sits next to the small intestine. The probe is on the tip of the endoscope, so it can get very close to the area where the tumor is to take pictures. This is a very good way to look at the pancreas. If a tumor is seen, it can be biopsied during this procedure.

Endoscopic retrograde cholangiopancreatography (ERCP): an endoscope is passed down the patient's throat, through the esophagus and stomach, and into the first part of the small intestine. The doctor can see through the endoscope to find the ampulla of Vater (the place where the common bile duct is connected to the small intestine). The doctor guides a catheter (a very small tube) from the end of the endoscope into the common bile duct. A small amount of dye (contrast material) is then injected through the tube into the common bile duct and x-rays are taken. This dye helps outline the bile duct and pancreatic duct. The x-ray images can show narrowing or blockage of these ducts that might be due to pancreatic cancer. The doctor doing this test can also put a small brush through the tube to remove cells for a biopsy (to view under a microscope to see whether or not they look like cancer). This procedure is usually done while the patient is sedated ERCP can also be used to place a stent (small tube) into the bile duct to keep it open if a nearby tumor is pressing on it.

Angiography: This is an x-ray procedure for looking at blood vessels. A small amount of contrast material is injected into an artery to outline the blood vessels. After this, x-rays are taken. Angiography can show whether blood flow in a particular area is blocked or compressed by a tumor. It can also show any abnormal blood vessels (feeding the cancer) in the area. This test can be useful in finding out if a pancreatic cancer may have grown through the walls of certain blood vessels. Mainly, it helps surgeons decide whether the cancer can be completely removed without damaging vital blood vessels and helps them plan the operation. Angiography can also be used to look for pancreatic neuroendocrine tumors that are too small to be seen on other imaging tests. These tumors cause the body to make more blood vessels to "feed" the tumor. These extra blood vessels can be seen on angiography.

Somatostatin receptor scintigraphy (SRS): also known as OctreoScan, can be very helpful in the diagnosis of pancreatic neuroendocrine tumors. It uses a hormone-like substance called octreotide that has been bound to radioactive indium-111. Octreotide attaches to proteins on the tumor cells. A small amount of this substance is injected into a vein. It travels through the blood and is attracted to neuroendocrine tumors. About 4 hours after the injection, a special camera can be used to show where the radioactivity has collected in the body.

Blood tests: Several types of blood tests may be used to help diagnose pancreatic cancer or to help determine treatment options if it is found. Blood tests that look at levels of different kinds of bilirubin (a chemical made by the liver) are useful to decide whether a patient's jaundice is due to a disease of the liver or to blockage (by a gallstone, a tumor, or other disease) of bile flow. Elevated blood levels of the tumor markers CA 19-9 and carcinoembryonic antigen (CEA) may point to a diagnosis of exocrine pancreatic cancer.

Pancreatic neuroendocrine tumors

Blood tests: looking at the levels of certain pancreatic hormones can help diagnose pancreatic neuroendocrine tumors (NETs). For insulinomas, insulin, glucose, and C-peptide levels are measured while the patient is fasting (not eating or drinking). Other pancreatic hormones, such as gastrin, glucagon, somatostatin, pancreatic polypeptide, and VIP can all be measured in blood samples and can be used to diagnose pancreatic NETs. Measuring the level of a substance called chromogranin-A (CgA) can be very helpful. This level goes up in most cases of pancreatic NETs - even the non-functioning tumors.

Biopsy: removal of a small piece of tissue. There are several types of biopsies.

Fine Needle Aspiration (FNA): A thin needle attached to a syringe is inserted through the skin and into the pancreas. The doctor uses CT scan images or endoscopic ultrasonography to view the position of the needle and make sure that it is in the tumor. Cells are drawn out for review under a microscope.

Endoscopic ultrasound guided biopsy: an endoscopic ultrasound is used to place the needle directly through the wall of the duodenum into the tumor. Small tissue samples can be removed through the needle. The main advantages of the test are that the patient does not require general anesthesia (is not "asleep") during the test, and major side effects are rare.

Laparotomy: (a large incision through the skin into the wall of the abdomen to examine internal organs). Areas that look or feel abnormal can be sampled by removing a small portion of tissue with a scalpel or a needle. The main drawback of this type of biopsy is that the patient must have general anesthesia and remain in the hospital for a period of time to recover.

Laparoscopy: a way of looking at and taking a piece of the pancreas with a biopsy. Patients are typically sedated for this procedure. The surgeon makes several small incisions in the abdomen and inserts small telescope-like instruments into the abdominal cavity. One of these is usually connected to a video monitor. The surgeon can view the abdomen and see how big the tumor is and whether it has spread, and may take tissue samples as well.

Staging of Gastrointestinal Cancers
When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.

Pancreatic Cancer:
The following stages are used for pancreatic cancer:

Stage 0 (Carcinoma in Situ)

Stage I
In stage I, cancer has formed and is found in the pancreas only. Stage I is divided into stage IA and stage IB, based on the size of the tumor.

• Stage IA: The tumor is 2 centimeters or smaller.
• Stage IB: The tumor is larger than 2 centimeters.

Stage II
In stage II, cancer may have spread to nearby tissue and organs, and may have spread to lymph nodes near the pancreas. Stage II is divided into stage IIA and stage IIB, based on where the cancer has spread.

• Stage IIA: Cancer has spread to nearby tissue and organs but has not spread to nearby lymph nodes.
• Stage IIB: Cancer has spread to nearby lymph nodes and may have spread to nearby tissue and organs.

Stage III
In stage III, cancer has spread to the major blood vessels near the pancreas and may have spread to nearby lymph nodes.

Stage IV
In stage IV, cancer may be of any size and has spread to distant organs, such as the liver, lung, and peritoneal cavity. It may have also spread to organs and tissues near the pancreas or to lymph nodes.

The management of gastrointestinal cancer depends on the site of the tumor several factors. Depending on the stage of the disease and these other factors, such as type, size, location of tumor, and general health, the main treatment options for people with gastrointestinal cancers include:

• Surgery
• Radiation Therapy
• Chemotherapy
• Other local treatments
• Targeted Therapy

Pancreatic Cancer:

SURGERY
One of the following types of surgery may be used to take out the tumor:

• Whipple procedure: A surgical procedure in which the head of the pancreas, the gallbladder, part of the stomach, part of the small intestine, and the bile duct are removed. Enough of the pancreas is left to produce digestive juices and insulin.
• Total pancreatectomy: This operation removes the whole pancreas, part of the stomach, part of the small intestine, the common bile duct, the gallbladder, the spleen, and nearby lymph nodes.
• Distal pancreatectomy: The body and the tail of the pancreas and usually the spleen are removed.

If the cancer has spread and cannot be removed, the following types of palliative surgery may be done to relieve symptoms:

• Surgical biliary bypass: If cancer is blocking the small intestine and bile is building up in the gallbladder, a biliary bypass may be done. During this operation, the doctor will cut the gallbladder or bile duct and sew it to the small intestine to create a new pathway around the blocked area.
• Endoscopic stent placement: If the tumor is blocking the bile duct, surgery may be done to put in a stent (a thin tube) to drain bile that has built up in the area. The doctor may place the stent through a catheter that drains to the outside of the body or the stent may go around the blocked area and drain the bile into the small intestine.
• Gastric bypass: If the tumor is blocking the flow of food from the stomach, the stomach may be sewn directly to the small intestine so the patient can continue to eat normally.

RADIATION THERAPY
External beam radiation treatment is most often used in conjunction with surgery, but it can also be combined with chemotherapy as an alternative to surgery.

• Neoadjuvant therapy: radiotherapy (sometimes along with chemotherapy) delivered prior to surgery to shrink a tumor and make it more manageable
• Adjuvant therapy: radiotherapy (sometimes along with chemotherapy) given after surgery to kill any cancer cells that may have been left behind
• Primary therapy: radiotherapy given as the main treatment (sometimes along with chemotherapy) for more advanced cancers or for some people who are not deemed to be surgical candidates
• Concurrent (chemoradiation) therapy: radiotherapy given along with chemotherapy

There are several methods by which the radiation therapy treatments can be given: external beam radiation and brachytherapy (internal radiation therapy).

External beam radiation therapy involves focusing a beam of ionizing radiation to the tumor while sparing the surrounding tissue. It is delivered by a series of painless outpatient treatments over several weeks. Treatments are given Monday through Friday and last less than 30 minutes.

• 3-Dimensional Conformal Radiotherapy (3D-CRT) is a method of treatment delivery that combines multiple radiation treatment fields using 3-Dimensional computer planning to produce a high-dose area of radiation that conforms to the shape of the area to be treated. This technique allows the tailoring of delivery of precise doses of radiation to the targeted area while sparing surrounding normal healthy tissue.
• Intensity modulated radiation therapy (IMRT) is an advanced form of 3D-CRT that modifies the intensity or strength of each radiation beam. It utilizes a sophisticated system of treatment delivery that allows a precise adjustment of the radiation beam intensity to the tissue within the target area while minimizing effects on surrounding tissue. This may allow for a higher dose of radiation to be delivered to the tumor from multiple angles.
• IGRT or Image Guided Radiation Therapy is another technology that can also be used to ensure better targeting of daily radiation treatments. 
• Stereotactic body radiation therapy (SBRT) is a specialized form of 3D-CRT that delivers high doses of radiation over a period of five to ten days. Instead of giving small doses of radiation each day for several weeks, SBRT involves delivery of very focused beams of high-dose radiation. Several beams are aimed at the tumor from different angles. In order to precisely target the radiation, a specially designed body frame is used for each treatment. If it is delivered in a single fraction it is known as stereotactic body radiosurgery. Like other forms of external radiation, these treatments are painless. It can be used for some very early stage (small) lung cancers when surgery isn't an option usually for other medical reasons. There is emerging data that have demonstrated that this technique may provide an alternative first-line approach to surgery.

BRACHYTHERAPY (internal radiation therapy)
is used most often to shrink tumors to relieve symptoms caused by the cancer. In some cases it may be part of a larger treatment regimen trying to cure the cancer.

• High-dose-rate brachytherapy (HDR): a small source of radioactive material is placed directly into the cancer or into the airway next to the cancer. It involves placing thin plastic tubes (catheters) into the area to treat. These tubes are connected to a special HDR delivery machine. A small amount of radioactive material is computer-driven through these catheters allowing a high dose of radiation to be delivered to a small, precise area while sparing surrounding normal healthy tissue. The radiation and catheters are removed at the end of each treatment.

CHEMOTHERAPY
Is the use of anticancer drugs injected into a vein or taken by mouth to destroy certain types of tumors and is utilized in different stages of lung cancer. These drugs enter the bloodstream and go throughout the body, making this treatment useful for cancer that has spread (metastasized) to distant organs. Depending on the type and stage of lung cancer, chemotherapy may be used in different situations (see Radiation Therapy Section):

• Neoadjuvant therapy: chemotherapy (sometimes along with radiation therapy) delivered prior to surgery to shrink a tumor and make it more manageable
• Adjuvant therapy: chemotherapy (sometimes along with radiation therapy) given after surgery to kill any cancer cells that may have been left behind.
• Primary therapy: chemotherapy given as the main treatment (sometimes along with radiation therapy) for more advanced cancers or for some people who are not deemed to be surgical candidates.
• Concurrent (chemoradiation) therapy: radiotherapy given along with chemotherapy

Possible Treatment Side Effects
Dr. Farber, Dr. Spierer, and their staff at The Farber Center for Radiation Oncology will discuss potential side effects with you before, during, and after treatment, and ensure that your experience is personalized.