Health Articles

The liver is the most common site of metastasis from other cancers. Liver metastases arc found at autopsy in 30% to 50%> of patients with cancer.
Primary malignancy of the liver is rare in the USA and Western Europe but common in Africa and Asia. About 90% of primary adult hepatic cancers originate in the hepatocyle and are called hepatocellular carcinoma or hepatoma; 5% to 10% originate in the bile ducts as chol-angiocarcinoma or are a mixed type, cholangiohepatoma. Other primary liver cancers are exceedingly rare and include cystadenocarcinoma, angiosarcoma, and hepatoblastoma. Hepatic malignancies are more common in men than in women and occur between ages 50 and 70.
Hepatocellular carcinoma may be nodular, massive, or diffuse. The nodular type, which is the most common, consists of multiple discrete nodules. The massive type, which essentially accounts for the rest, develops as a large, often necrotic, hemorrhagic mass. The diffuse type is most often associated with cirrhosis and consislsof minule lesions scattered Ihroughout the liver. Predisposing factors include hepatitis B. hepatitis C, alcohol or tobacco use, cirrhosis, and aflatoxin exposure.
Symptoms and Signs
About 70% of patients present with right upper quadrant or epigastric pain and weight loss. With progressive liver dysfunction, menial status may deteriorate. Pulmonary symptoms and pathologic fractures may result from metastases. A rare lumor rupture with intra-abdominal hemorrhage and symptoms of an acute abdomen is life threatening.
Physical examination may reveal hepatomegaly, a right upper quadrant mass, or ascites. Splenomegaly is less common. Lymphadcnop-athy, especially in the right supraclavicular region, can occur. Gynecomastia is rare.
Paraneoplastic syndromes associaled with hepatocellular carcinoma include erythrocytosis. hypercalcemia, hypoglycemia, hyperlipemia, porphyria cutanea tarda, and dysfibrinoginemia.
Diagnosis
Liver function test results arc usually abnormal. Elevated serum alkaline phosphatase levels are common, but elevated serum aminotransferases and bilirubin levels are less so. Hepatitis B surface antigen and hepatitis C virus markers may be positive. Elevaled levels of α-fetoprotein are noted in 90% of patients with hepatocellular carcinoma.
20%. Metastasis is found in 75% of cases a! the lime of diagnosis. Workers in rubber and automotive plants have a particularly high risk of gallbladder cancer.
Gallstones are associated with the development of gallbladder carcinoma, and preventing such carcinoma may justify early cholecystectomy in patients with cholelithiasis.
Symptoms, Signs, and Diagnosis
Symptoms include intermittent pain and dyspepsia similar to that of chronic cholecystitis. In the late stages, weight loss and jaundice develop. Often a firm, tender mass is palpable in the right upper quadrant. Abdominal ultrasonography and CT scan provide visualization of the tumor. Endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography is useful for a complete evaluation of the biliary tree.
Treatment
Radical cholecystectomy is the treatment of choice for localized disease. Radiation therapy and chemotherapy are ineffective. The prognosis is dismal; the 5-yr survival rate is only 5%. Biliary stenting by endoscopic refrograde cholangiopancreatography or percutaneous transhepatic cholangiography may provide limited palliation of an obstruction.

Hemangioma, the most common benign neoplasm of the liver, is found in about 5% of adult aulopsies. Other benign tumors include hepatocellular adenoma and local nodular hyperplasia, which are most often associated with oral contraceplives and are not usually seen in elderly persons. Bile duct adenomas and cystadenomas and rare mesenchymal tumors have also been reported.
Symptoms and Signs
Usually, these tumors are asymptomatic and are found incidentally at laparotomy or when a CT scan, ultrasonography, or angiography is performed for unrelated symptoms. Rarely, patients with hemangiomas present with massive hemorrhage from rupture or consumptive coagulopathy (Kasabach-Merritt syndrome).
Diagnosis and Treatment
liver function lest results are normal or slightly abnormal. The diagnosis can be established by routine liver biopsy in nonvascular lesions, although laparoscopy or laparotomy is often necessary- Therapy for nonvascular tumors usually consists of segmental resection.

Benign neoplasms of the liver are usually asymptomatic. By far, the most common form of hepatic tumor is metastatic carcinoma.

Kndocrine tumors arise from the neuroendocrine cells of the pancreas predominantly in the islets of Ihe pancreatic body and tail. However, enterochromaffin cells and other neuroendocrine cells can arise anywhere in Ihe GI tract. Endocrine tumors are rare in older persons.
These tumors are indistinguishable microscopically without special immunochemical staining. Localization of tumors can be aided by CT scan, portal venous sampling, and intraoperative ultrasonography. They may be cither nonfunctioning or functioning (ie, hormone secreting).
Nonfunctioning tumors may cause obstruction of the biliary tract or duodenum, bleeding into the GI tract, or an abdominal mass. Functioning lumors produce various syndromes.
Insulinomas, which may be single or multiple, produce insulin and arc identified by episodes of hypoglycemia, which may progress to coma in severe cases. Insulinomas are rarely malignant. Removal of all tumor tissue results in complete cure.
Gastrinomas produce the Zollinger-RIHson syndrome, an extremely virulent ulcer diathesis with excessive gastric acid secretion and diarrhea. The lumors can occur near the ampulla of Vater or the antrum as well as in the pancreas and are malignant in about 90% of cases. If metastasis does not occur, complete excision of Ihe lumor is curative. If metastasis does occur, various therapeutic modalities may be used, including administration of large doses of Hb-receptor blockers or omeprazole and, if medical therapy fails, gastric surgery to reduce acid secretion.
Glucagonomas secrete glucagon and have a high potential for malignancy. They lead to mild diabetes mellilus and a severe dermatitis involving portions of the lower half of the body. Although complete removal may not be possible, debtilking the tumor may help relieve symptoms. Streplozocin can help treat Ihe residual (umor.
Vipomas produce vasoactive intestinal polypeptide, pancreatic polypeptide, and perhaps other hormones. Recause the primary characteristics are watery diarrhea, hypokalemia, and achlorhydria, the disease is also known as the WDHA syndrome. Half of the tumors are malignant. As much tumor as possible should be resected, and the residual tumor should be treated with streplozocin.
Somatostatinomas are rare tumors that secrete somaloslatin. Clinical findings include diabetes, steatorrhea, and achlorhydria.
These clinical conditions can sometimes present as multiple endocrine neoplasia syndromes, in which tumors or hyperplasia occurs in two or more endocrine glands. Usually, these conditions are associated with tumors or hyperplasia of the parathyroid, pituitary, thyroid, or adrenal glands.

The only significant benign exocrine pancrealic neoplasm is cystade-nqma, which usually occurs in the body and tail of the pancreas in middle-aged and elderly women. Surgical resection may be needed for diagnosis and relief of symptoms from a large mass.
Pancrealic cancer is the second most common dl cancer in the USA with about 28,000 new cases diagnosed annually. The incidence increases with age and is 10 times greater in men > 75 yr than in the general population. Risk factors include cigarelle smoking, diabetes mellitus, and a diel high in animal fat and alcohol.
Ductal cell adenocarcinoma accounts for 75% to %% of all cancers arising from the pancreas. Others include giant cell carcinoma, adeno-squamous carcinoma, cysladenocarcinoma, and lymphoma. Giant cell carcinoma, also called carcinosarcoma, is a highly malignant lesion with distant metastases occurring early. Adenosquamous carcinoma occurs predominantly in men. more often in patienls wilh a history of radiation therapy. Cystadenocarcinoma, a low-grade malignancy, has the best prognosis because only 20% have metastasized by the time of surgery. Lymphoma of the pancreas accounts for 2% of all non-Hodgkin’s lymphoma and may be of B-cell or T-cell origin.
Symptoms and Signs
The clinical features of pancreatic cancer often depend on the location of the lesions; 80% occur in the head of Ihe pancreas, and 20% in Ihe body and tail. Patients with lesions of the pancreatic head often present with painless jaundice and acholic stools from common duct obstruction or with nausea and vomiting from gastric outlet obstruction. Itching may accompany jaundice. The onset of symptoms in those with lesions of the body and tail is more insidious, amounting to little more than weight loss and vague abdominal or back pain. Symptoms precede diagnosis by about 3 to 6 mo. In 90% of patients with ductal eel I adenocarcinoma, metastases are present at diagnosis, so death Often occurs within 6 mo.
Findings associated with pancreatic cancer include depression, thromboembolic phenomena associated wilh Trousseau’s syndrome, GI bleeding from gastric varices secondary to splenic vein thrombosis, polyarthritis, diarrhea caused by exocrine pancreatic insufficiency, superior vena cava syndrome caused by mediastinal metastases, and Homer’s syndrome caused by thoracic outlet metastasis. The onset of diabetes mellilus or a worsening of preexisting diabetes warrants an evaluation for pancreatic cancer.
Early in the disease the physical examination is negative. Later, an epigastric mass, supraclavicular lymphadenopathy, hepatomegaly from biliary stasis or metastasis, or a large, palpable gallbladder may be noted. Painless jaundice and a palpable gallbladder (Courvoisier’s sign) combined with acholic stools are diagnostic. Silver-colored stools may be noted in cancer of the ampulla of Vater because of the combination of mild bleeding and acholic stools.
Diagnosis
F.arly diagnosis when the tumor is still resectable is rarely possible. It is possible only wiih cancer of the pancreatic head associated with jaundice and with cancer of the ampulla of Vatcr. which may cause early i;iundiee. Diagnosis may be suggested by upper abdominal sonography, although a CT scan of the abdomen can better visualize a pancreaiu muss. In up to 90% of cases, endoscopic retrograde cholangiopancreatography can detect the tumor with the characteristic findings of dm till irregularity and cutoff. Although tissue for diagnosis can usually be obtained by needle biopsy, exploratory laparotomy is often necessary Serologic tumor markers including CEA, CA19-9, and galaetosyltransfeiase isoenzyme II (Gl-ll) may be elevated in some cases but are rarel> useful clinically.
Treatment
Patients who have nonmetastatic, resectable lesions in the pancreatic head may be candidates for pancreatoduodenectomy (Whipple’s operation). Only 10% of patients with ductal cell carcinoma have localized tumors. In most patients, the only procedure that can be performed is a palliative bypass (eg, cholecystojejunostomy for distal hile duct obstruction or gastrojejunostomy for gastric outlet obstruction); however, surgery is usually not warranted, and obstructive jaundice can be managed with an endoscopically placed stent. In older persons with nonrescctable tumors, forgoing all attempts at cure is often besl.
Chemotherapy produces little response and no long-term benefit in patients with adenocarcinoma. Radiation therapy offers minimal benefit, except for palliation of retroperitoneal pain. Palliative treatment wilh a biliary stent (placed endoscopically or radiological]y using transhepatic cholangiography) may reduce jaundice and itching.
Generally, abdominal pain is treated with analgesics and oral narcotics. However, a celiac axis nerve block maybe needed for severe, unrelenting pain. Pruritus from jaundice may be relieved wilh antihistamines or cholestyramine 4 gin orally I to 4 times daily. Pancreatic insufficiency can be managed with pancreatic enzymes (lipase, protease, and amylase).
The overall prognosis is dismal for adenocarcinoma; the I-yr survival rate is < 10%, and the 5-yr survival rate is only 2%. Cystadenocarcinoma. which has a low incidence of metastasis at diagnosis, has a 5-yr survival rate of 65% with aggressive surgery. Lymphoma also has a good prognosis.

Neoplasms of the pancreas include both exocrine and endocrine tumors.

The most common tumor of !he appendix is a carcinoid tumor, which is found in about 1 in 1000 resected appendixes. Rarely malignant, carcinoid tumors are treated by appendectomy. If Ihey are > 2 cm in diameter or show evidence of lymphatic or lymph node involvement, a right colectomy should be performed.
Primary adenocarcinoma of the appendix is rare, even though the appendix is lined with colonic mucosa. This tumor may block the lumen, leading to acute appendicitis and perforation.
Mucoceles produce appendiceal distention and outlet obstruction because of the intraluminal accumulation of mucus. The symptoms suggest early appendicitis. A mucocele may be demonstrated by CT scan. Although mucoceles are usually benign and treatable by appendectomy, some are associated with low-grade adenocarcinoma; if these mucoceles perforate, a form of carcinomatosis known as pseudomyxoma peritonei results. Palients who have this indolent tumor present with increased abdominal girth and a doughy abdomen. They can survive for several years, but repeated accumulation of intraperitoneal mucus or intestinal obstruction occurs. Palliative surgery often prolongs life and makes the patient more comfortable.

Cancer may develop in the perianal skin, the anal canal, or Ihe lower rectum. Epidermoid carcinoma accounts for 2% of colorectal cancers and 90% of anal cancers. The histologic types of anal carcinoma include squamous cell, basal cell, basaloid squamous, and cloacogenic carcinomas. Other malignant neoplasms include Bowen’s disease (intraepithelial squamous cell carcinoma in situ), ex-tramammary Paget’s disease, carcinoid tumor, and malignant melanoma. Cloacogenic carcinoma is most prevalent in patients ages 60 to 70. Factors predisposing persons to anorectal cancer include infections from human papillomavirus types 16 and 18 or human immunodeficiency virus, leukoplakia, lymphogranuloma venereum, chronic fistula formation, irradiation of the anal skin, and organ transplantation.
Symptoms, Signs, and Diagnosis
Bleeding is the mosl common symptom. Other frequent complaints are anal discomfort, constipation, and diminished stool caliber. The presenting feature may be a mass on digital rectal examination, inguinal adenopathy, or perianal dermatitis. Cancer should be considered wilh all nonhealing ulcers or fistulas. Biopsy of all suspicious lesions is essential.
Treatment
The treatment of choice is local surgical excision preceded by a course of radiation therapy and chemotherapy to debul k a large tumor mass. Such radiation therapy and chemotherapy may obviate abdominoperineal resection in many patients. Kulguration with electrocautery and laser photocoagulation are palliative measures in selected cases.

Colorectal cancer is second only to lung cancer as the most common malignancy among US and Western European men and women. In the USA, about 150,0(10 new cases of and 60.000 deaths from (his disease occur annually.
The incidence of colorectal cancer begins rising at age 40 and doubles every 5 yr thereafter, peaking in the eighth decade. Adenocarcinoma constitutes 95% of all colorectal cancers. Rectal cancer is more common in men; colon cancer apparently occurs equally in men and women. Synchronous colon cancers appear in about 3.5% of patients followed for > 25 yr, and metachronous lesions appear in 5% of such patients. Colonoscopic polypectomy in these palients will undoubtedly reduce these percentages.
Colorectal carcinoma is more common in upper socioeconomic classes. High-risk populations consume a diet higher in animal fat and refined sugar and lower in fiber than that consumed by low-risk populations. Other predisposing factors include age > 40, a history of colonic adenomatous polyps or cancer of the colon without follow-up colonoscopy surveillance, cancer of Ihe breast or female genital tract, first-degree relative with colon cancer, inflammatory bowel disease (eg, ulcerative colitis. Crohn’s disease, or radiation proctocolitis), and certain chronic parasitic infections (eg, schistosomiasis). Hereditary disorders (eg, familial polyposis) also arc associated with a high incidence of colorectal carcinoma, but they arc rare in the elderly.
The extent of tumor spread is graded by a modified Dukes classification. Dukes A lesions involve the mucosa; \i lesions extend through the wall but do nol involve lymph nodes; C lesions involve lymph nodes; and D lesions have distant metastases. Many modifications of this staging system exist.
Other colorectal malignancies include lymphoma, leiomyosarcoma, and carcinoid tumors.
Symptoms and Signs
Because colon cancer is asymplomalic in its early stages, screening is performed using routine sigmoidoscope examination every 3 lo 5 yr and annual fecal occull blood testing.
The location of a tumor in the colon influences the symptoms. Right-colon lesions are usually large, fungating. bleeding masses that cause iron deficiency anemia, fatigue, and weakness, and the large-caliber, thin-walled right colon contains fluid-like feces. These tumors usually do nol cause obstruction but may grow large enough to be palpable on abdominal examination. Left-colon lesions are usually “napkin-ring.” obstructive tumors that cause rectal bleeding, crampy abdominal pain, or altered bowel habits because of the narrower caliber of the left colon and the semisolid consistency of the feces. Patients with rectal lesions generally present with stool streaked or mixed with blood. They may also complain of tenesmus or a sensation of incomplete evacuation. Palpable lymphadenopathy, hepatomegaly, or both occur only in the late stages and suggest a very poor prognosis.
Diagnosis
Diagnosis is made by x-ray or endoscopy. A rigid sigmoidoscope may not be able to detect colon cancer because the instrument may not even reach its 25-cm iength. The fiberoptic sigmoidoscope can detect lesions in the rectum, the sigmoid colon, and the distal descending colon, the region where > 50% of cancers occur. The more proximal segments of the colon are examined by barium enema x-ray or colonoscopy. Air-contrast barium enema is usually superior lo the single-contrast technique in detecting colon cancer. Colonoscopy provides visualization and tissue for diagnosis and also allows inspection of the entire colon for synchronous polyps or cancers.
Fecal occult blood testing helps detect colonic tumors. Screening of elderly patients wilh annual fecal occult blood testing using six guaiac-impregnated slides over 3 days and sigmoidoscopy every 3 to 5 yr aids detection of early stage colon cancer, which is potentially curable. Wilh both screening tests, the positive predictive value is better in persons > 60 yr. Screening wilh fecal occult blood testing can reduce the mortality rate of colorectal cancer.
Carcinoembryonic antigen (CEA) levels may be elevated in patients with cancer of the colon, pancreas, breast, lung, prostate, stomach, or bladder as well as in those wilh benign conditions and !hus are nonspecific. An elevated CEA level is especially insensitive for early stage cancers. However, if the CEA level is elevated before surgery and decreases after it. a subsequent rise may indicate a recurrence.
Treatment
Treatment of colorectal cancer consists primarily of anatomic surgical resection (see Ch. 62). Except with lymphoma, radiation therapy ami chemotherapy do not cure. In Dukes C colon cancer and in Dukes B2 and C rectal cancer, adjuvant chemotherapy with 5-fluorouracil and levamisole combined with radiation therapy improves survival.
In patients with adenocarcinoma, the 5-yr survival r;ile is about 90% for piilienls with Dukes A lesions, 50% to 80% for those with B lesions, 30% to 40% for those with C lesions, and < 5% for those with I) lesions. Primary Gl tract lymphoma has an overall 5-yr survival rate of > 50%.

Incidence figures vary from 7% to 75% of the population > 50 yr. increasing with age and peaking in the seventh decade. Most benign tumors are polyps (a clinical term without pathologic significance that refers to any mass of tissue arising from a mucosal surface and protruding into the lumen). The relationship of colonic polyps to age, diet, geographic distribution, family history, and prior neoplasms is similar to that of adenocarcinoma of the colon, which is discussed below. Hamartomas, juvenile polyps, and congenital lesions usually do not occur in Ihe elderly.
Adenomatous polyps, the most common colorectal neoplasms, are found in 50% to 60% of persons > 60 yr at autopsy. Although they may involve the entire colon, they arc more concentrated in the distal region. Lesions may be sessile or pedunculated. Synchronous lesions (more than one at the same time) occur in about 50% of cases and are classified histologically as tubular, tubulovillous, or villous adenomas, depending on the proportion of villous elements. These polyps are true neoplasms with malignant potential, which varies wilh the size, proportion of villous elements, and degree of dysplasia. The overall risk for malignant change within an adenomatous polyp is about 1% to 2%.
Hyperplastic polyps are common benign tumors of the colon. They are small, dome-shaped, sessile lesions. Often a person has several of these lesions. These polyps have no inherent malignant potential.
Inflammatory polyps usually occur in persons with no associated disease; however, those with inflammatory bowel disorders, ischemic co-lilis, specific infections (eg. amebiasis and tuberculosis), toxic reactions to mineral oil and barium, and colitis cystica profunda are especially prone to such polyps.
Lipomas, the second most common benign tumors of the colon, usually occur at or near the ileocecal valve. Incidence peaks in the seventh to eighth decades. Colonic hemangiomas are predominantly found wilh advancing age. Frequently, many lesions appear. They may be classified as capillary, cavernous, or mixed and are a common cause of hemorrhage and a rare cause of intussusception. The incidence of leiomyomas seems to peak in the sixth decade and decline sharply thereafter.
Cronkhite-Canada syndrome is the only multiple polyposis syndrome affecting the elderly. The average age at diagnosis is 60, and ihe lesions resemble juvenile polyps. The syndrome occurs in bolh men and women, but il runs a relentless course in women with death occurring in 6 lo 18 mo, whereas men lend to have spontaneous remissions.
Symptoms and Signs
Most polyps are asymptomatic and arc found incidentally during evaluation for another disorder. The usual symptom is rectal bleeding, which most commonly is occult and rarely is massive; however, massive bleeding is more common with hemangiomas. Rarely, large villous adenomas cause a severe mucoid rectal discharge and diarrhea, which may result in hypokalemia and hyponatremia. Even more unusual are constipation caused by large, bulky tumors and rectal prolapse caused by distal lesions. In patients wilh Cronkhite-Canada syndrome, diarrhea is progressive, leading to inanition and cachexia, especially in women.
Patients wilh submucosal tumors (eg, lipomas, hemangiomas, and leiomyomas) may present with an abdominal mass or abdominal pain from intussusception.
Diagnosis and Treatment
Polyps are usually detected by fecal occult blood testing, sigmoidoscopy, barium enema, or colonoscopy. Although air-contrast barium enema is far superior (o (he single-contrast technique, it can miss up to 50% of polyps. With colonoscopy, polypectomy can he performed, and tissue can be obtained for diagnosis. Colonoscopy is usually performed when an adenomatous polyp is found on sigmoidoscopy because of the high frequency of additional polyps. Surgical excision may be necessary for submucosal tumors or polyps that cannot be removed en-doscopically.
When welt-differentia led carcinoma is detected in a polyp and no vascular, lymphatic, or stalk invasion exists and a clear resection margin does exist, the only treatment usually needed is endoscopic polypectomy. If these conditions are not met. surgery may be considered, depending on the location of the adenoma and other factors.
For patients with adenomatous polyps, repeated examinations every 3 to 5 yr after polypectomy are needed because additional lesions develop.