Gastrointestinal (GI) Neoplasms: Pre-cancers, and Cancers
There have been many recent advances in Prevention, Screening, Surveillance, and Management of Gastrointestinal Dysplastic (pre-cancerous) Lesions, GI Malignancies, and patients with strong risk factors for Esophageal Cancer, Gastric Cancer, Pancreatic Cancer, Liver and Bile Duct Cancer, and Colon Cancer. CTGI is at the forefront of these. We routinely provide the latest methodologies and are researching new potential future advances, as well. Further our patients have access to the full complement of Oncologic Treatments offered by the world renowned Memorial Sloan Kettering Cancer Center.
Colon Polyps and Colon Cancer
Of all cancers for which there is standard screening (Colon, Breast, Prostate, and Cervical) colonoscopy for colon cancer screening has provided the greatest yield. Mortality rates from colon cancer, the 3rd most common cancer and cancer killer in the US, have been markedly reduced by screening. The physicians at CTGI are leaders in the field of colonoscopy and colonoscopy cancer screening, annually performing approximately 35,000 and 12,500 such procedures, respectively. We take pride in the quality of our work. We average an Adenoma Detection Rate (ADR) of 35% and are able to examine the entire colon > 98% of the time, far above industry guidelines.
For your convenience we perform colon cancer screening at numerous locations throughout CT. We perform most at our Ambulatory Surgical Centers (ASC’s). For those who must have their procedures done in a hospital setting we utilize Bristol Hospital, Hartford Hospital, Manchester Hospital, The Hospital of Central Connecticut, Mid-State Medical Center, Sharon Hospital, Johnson Memorial Hospital, Lawrence and Memorial Hospital, Day Kimball Hospital, Backus Hospital, and Charlotte-Hungerford Hospital.
Finding pre-cancerous polyps is one thing but removing them is essential for cancer prevention. Most Gastroenterologists and Surgeons who perform colonoscopy are able to remove all but the very largest and flattest lesions during the examination. When polyps are found to be too large and/or too flat, however, all but very few practices across the country must then refer their patients to a surgeon for a formal operation. Unfortunately, surgical resection of polyps requires removal a segment of the colon, often a large segment, and this is typically associated with a 24 % complication rate. We are one of very few practices in the country, however, with expertise in both Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD). These techniques allow us to be able to resect difficult polyps for cure and without organ loss in > 75% of patients who would otherwise have been referred to surgery. Further, most patients either go home same day or spend 1 night in the hospital. Because EMR and ESD resections are performed through a colonoscope no external incisions are made and no pain is experienced. Further, ESD resections are not only able to remove precancerous polyps but to cure early cancers, as well.
Detection and Risk Factors
Esophageal Adenocarcinoma, the fastest rising cancer as regards incidence over the past 15 years, is largely the result of Gastroesophageal Reflux Disease (GERD). GERD predisposes to Barrett’s Esophagus, a pre-cancerous state which is found in approximately 10% of persons undergoing EGD (Upper Endoscopy) for reflux symptoms. While strong acid blocking medications are associated with improvement in many persons with Barrett’s some will have progression to Esophageal Dysplasia the next step in the potential development of Esophageal Adenocarcinoma. Affected persons found to have low grade dysplasia or high grade dysplasia (during EGD Barrett’s screening) have a risk of having concomitant Esophageal Adenocarcinoma in x and y% respectively and an X and Y % risk of developing cancer in the future. Esophageal Squamous Cell Cancer (SCCA) is less common than adenocarcinoma in the US. This type of cancer is not related to reflux. Most affected individuals usually have a history of both heavy cigarette and alcohol use. There is also a racial predilection in that it is more common in Black and Asian persons who have immigrated to the US less than 10 years earlier.
Radiofrequency Ablation (RFA) is one of the latest advances in management of Dysplastic Barrett’s. Our radiofrequency ablation providers are leaders in this treatment with some of the largest experiences in the country. They have additionally trained (and continue to train) many Gastroenterologists in CT and Western Massachusetts in this technique. RFA has excellent results for dysplasia but not for cancer. The newest techniques in esophageal cancer management are Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD). These are potentially curative endoscopic tumor resection techniques. In contrast to surgery which requires external incisions and removal of the esophagus to remove the cancer EMR and ESD techniques remove esophageal cancer through a patient’s mouth. There are no external incisions and the esophagus is not removed. Only the cancer is removed. As a result, even patients with large lesions are usually able to go home from hospital in 1 day, with no pain, and are able to take nutrition by mouth. CTGI has more experience in these techniques than anywhere else in CT. In fact, while ESD, largely performed in Japan and China, is not yet available in most of the United States we have performed over 60 of these endoscopic surgical operations to date.
Gastric Cancer is the 5th most common cancer worldwide (approximately 1 million cases annually). There are no formal guidelines for Gastric Cancer Screening in the US because the incidence here is relatively low. We believe screening makes good sense for those with high risk, however. Groups with increased risk include immigrants from Far East Asia, Russia, and South America. (Interestingly, this geographic risk appears to be disappear within 2 generations.) Other risk factors include H. pylori infection, the presence of Atrophic Gastritis, particularly with Incomplete (Colonic-Type) Intestinal Metaplasia, Family History of Gastric Cancer in at least one first-degree relative, prior Personal History of Gastric Cancer, and predisposing Genetic Syndromes. The latter includes Hereditary Diffuse Gastric Cancer, Peutz-Jegher’s Syndrome, Juvenile Polyposis Syndrome, Lynch syndrome, BRCA-1, BRCA-2, and Li-Fraumeni Syndrome. Especially in light of our experience with Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD), (see Endoscopic Therapy of Colon Polyps and Esophageal Cancer, above) we believe screening of high risk persons to be potentially lifesaving and organ sparing. Based upon available data we support the use of screening endoscopy in high risk individuals beginning no later than age 50, depending upon the particular risk factor(s). Repeat endoscopy is offered every 1-2 years for high risk persons with atrophic gastritis and intestinal metaplasia and for persons with the highest genetic risks.
Although there is evidence that Pancreatic Cancer requires over 20 years to develop the diagnosis of pancreatic cancer is usually made extremely late in the course of the disease (when it is no longer curable) because symptoms occur very late. Pancreatic Cancer Screening is not feasible for the general population due to the low incidence of the disease but is performed in persons with high risk of developing pancreatic cancer. There are a number of high risk conditions for which screening is recommended and actively performed by CTGI. These include genetic conditions such as Peutz-Jegher’s Syndrome, Hereditary Pancreatitis (PRSS1), Familial Multiple Mole Melanoma Syndrome (FAMMM), mutations in the ATM gene, BRCA-2, and BRCA-1 with a Family history of Pancreatic Cancer, as well as Familial Pancreatic Cancer (> 2 first degree relatives with pancreatic cancer), and certain Pancreatic Cysts. Endoscopic Ultrasound (EUS) is considered the best single test for pancreatic cancer screening in high risk individuals. CTGI is the busiest EUS center in CT performing almost 1000 EUS examinations annually. We are one of only 10 EUS centers in the country chosen to take part in what has to date been the largest retrospective study of DNA (genetic abnormalities) in pancreatic cyst fluid for its potential to predict future cancer risk.
Hepatocellular Carcinoma (Liver Cancer) and Cholangiocarcinoma (Bile Duct Cancer)
Liver Cancer is the sixth most common malignancy worldwide and amongst all cancers in the United States its incidence appears to be one of the most rapidly rising. The average survival is between 6 and 20 months. It is primarily associated with cirrhosis, a result of chronic hepatitis from a large number of different causes (see section on Liver Diseases), occurring at a rate of 3-5% per year, but is also associated with fatty liver disease in the absence of cirrhosis. Smoking cessation and treatment of the underlying liver disease can help prevent the development of Hepatocellular Carcinoma (HCC). Treatment selection is dependent upon tumor size, number, and location within the liver as well as liver function and overall patient health. These range from local/regional therapies (HCC ablation and embolization) to Liver Transplant. HCC is one of the most common indications for liver transplantation. We at CTGI have several fully dedicated, board certified Transplant Hepatologists as well as highly experienced Nurse Practitioners who work hand-in-hand with Radiologists, Interventional Radiologists, Oncologists, Hepatobiliary and Transplant Surgeons. We all meet as a group several times/month to develop the best management strategies for each individual patient. For those that do need liver transplantation our program is highly experienced and has recently performed its 500th liver transplant.
Bile Duct Cancer, as with liver cancer, is usually associated with an underlying chronic inflammatory condition. Of these the most common is Primary Sclerosing Cholangitis (PSC) but it can also be seen in the setting of certain types of bile duct cysts (choledochocoele) and with certain parasitic infections. Unfortunately, there are no good screening tests for this type of cancer and the diagnosis can be difficult to make. Endoscopic retrograde cholangiopancreatography (ERCP), Endoscopic ultrasound (EUS), Intra-ductal Ultrasound (IDUS), and Choledochoscopy are the best tools to make this diagnosis (see Advanced Procedures section). CTGI performs the largest volume of these procedures in the state of Connecticut.
Submucosal Tumors represent a variety of different tumors that reside within the submucosal (middle layer) of the wall of the gastrointestinal tract. Submucosal tumors can be benign, benign but pre-malignant, or malignant (cancerous). They can be symptomatic or asymptomatic. The most common benign submucosal GI tumors include Leiomyomas and Lipomas. Carcinoids are another type of submucosal tumor. They are Neuroendocrine in origin, which means they can secrete hormones. Most remain inactive but up to 25% can become metastatic like a true malignancy. Gastrointestinal Stromal Tumors (GISTs) are another tumor with malignant potential.
The treatment of a submucosal tumor is resection (removal) and this is generally reserved for malignant lesions and lesions with malignant potential. Even benign lesions without malignant potential warrant treatment if they are causing symptoms, however. Until recently most Submucosal GI Tumors could only be resected surgically. Recent advances in Endoscopic Surgery, variations of Endoscopic Submucosal Dissection (ESD), now allow submucosal tumors of the esophagus, stomach, duodenum and colon to be performed with an endoscope. As with ESD affected patients have not external incisions made. Instead, surgery is performed through the patient’s mouth for upper GI lesions and through the rectum for colonic lesions. These variations on ESD include Submucosal Tunneling Endoscopic Resection (STER) when the submucosal tumor involves the submucosal layer only and Endoscopic Full Thickness Wedge Resection (EFTR) when tumors involve the deep muscle layer as well as the submucosa. We are the only center in Connecticut and one of very few in the country that successfully perform STER and EFTR procedures. As with ESD, patients undergoing STER or EFTR procedures generally spend one night in hospital for observation and then go home the very next day without having experienced abdominal pain.