Gastrointestinal Cancer

Gastrointestinal Cancer

As the leading provider of health services in Greece, Athens Medical Group (AMG) is the first choice and best hope for treating gastrointestinal cancer and offering quality of life by minimizing its effect.

AMG care team

At AMG our gastrointestinal cancer team takes a multidisciplinary approach to treating cancer, that includes the complete process, from diagnosis, to treatment and follow-up care. We draw on the collective expertise, knowledge and experience of physicians and other health experts from various disciplines that constitute the Multidisciplinary Tumor Board.

This is a team of leading medical scientists, such as gastroenterologists, general surgeons, oncologists, radiation oncologists, radiologists, and pathologists, all collaborating to produce the best medical outcome for each patient.

The Oncology Board may also include health experts from other areas, such as genetics and urologic surgery, as well as nurses specialised in working with cancer patients, dietitians, occupational therapists and psychotherapists.

At AMG our experts will work together, as your personal care team, to ensure you receive a fast and accurate diagnosis, a most effective therapy and comprehensive care. For this purpose, your personal care team will work closely with you to review your treatment options and recommend the best course of action for your case.

AMG’s hospitals offer a full range of treatments for patients with gastrointestinal cancer, such as chemotherapy and radiation therapy, immunotherapy, targeted therapy and an array of surgical operations, including minimally invasive surgery and robotic surgery.

 

Departments that treat this condition:

Gastroenterology
General Surgery
Medical Oncology
Radiation Oncology
Radiology

The earlier the diagnosis, the better the prognosis for all types of gastrointestinal cancer.

At Athens Medical Group we implement the most advanced diagnostic approaches for a quick and accurate diagnosis as well as a valid staging of the cancer.

Clinical examination

It involves the physical examination of the abdomen, as well as rectal examination.

Endoscopy

It involves the insertion of a fine lighted tube with a camera through the anus into the large intestine, allowing the inspection of the interior of the bowel for abnormal areas or growths, as well as the performance of biopsy and the removal of polyps. The most common endoscopic procedures are proctoscopy, sigmoidoscopy and colonoscopy.

Radiological investigation

  • CT colonography. It involves a CT scan of the abdomen and computer generated 3D images from the interior wall of the large intestine. This procedure is also called virtual colonoscopy. It is applied when colonoscopy is difficult, e.g. in the case of obstructive tumors.
  • Double contrast barium enema. It involves the introduction of barium sulphate and air into the colon via the anus, in order to visualize, on X-ray film, the outline of the interior wall of the colon.
  • MRI
  • PET scan

Laboratory investigations

  • Routine blood tests.
  • Tumour markers. These are factors produced by tumours and can be measured with a blood test, such as Carcinoembryonic antigen.

Histopathological examination

It involves the laboratory investigation of the biopsy or polyp obtained via endoscopy. In the case of surgery, a histopathological examination is performed not only on the tumour tissue, but also on resected lymph nodes and organs, as well as metastases.

Histopathological examination is a crucial part of staging, that is determining the stage of the colon cancer.

Rectal cancer

Rectal cancer should be distinguished from colon cancer as it has its own causes and risk factors, such as a high body mass index, fatness and diabetes type II. Also, chronic ulcerative colitis and Crohn’s disease, excessive consumption of red or processed meat as well as smoking and frequent alcohol use are blamed for increasing the risk of rectal cancer.

Digital rectal examination and endoscopy with biopsy for histopathological confirmation play an important role in diagnosing rectal cancer.

Flexible sigmoidoscopy is a kind of flexible endoscopy that enables the doctor to look at the inside of the large intestine from the rectum through the last part of the colon, called the sigmoid. The latter helps determine the location of the tumour with regards to its distance from the anal verge. Tumours with a distal extension to ≤ 10 cm from the anal verge are classified as rectal tumours, otherwise they are classified as colonic.

According to international guidelines, apart from a history and physical examination of the patient including digital rectal examination, further testing will be needed, including blood tests, liver and renal function tests, serum carcinoembryonic antigen, rigid proctoscopy and preoperative colonoscopy as well as pelvic magnetic resonance imaging (MRI) and computed tomography (CT) scan of thorax and abdomen in order to define the status of the tumour and determine whether the cancer has spread to other parts of the body.

Positron emission tomography (PET) provides additional information on whether the cancer has spread outside the pelvis.

Endoscopic rectal ultrasound (ERUS) helps with identifying and defining the treatment for the earliest tumours, but offers less value in locally advanced rectal cancer.

All tests are monitored by the MDT board, a specialised and dedicated multidisciplinary team of radiologists, surgeons, radiation oncologists, medical oncologists, pathologists and other medical and health experts that make the treatment decisions for each patient.

Gastric cancer is twice as frequent in men as in women. Other risk factors include helicobacter pylori infection, smoking, atrophic gastritis, partial gastrectomy, alcohol consumption, high-salt diet, processed meat and low fruit and vegetable intake, as well as obesity.

90% of gastric cancers are adenocarcinomas, and these are subdivided according to histological appearances into diffuse (undifferentiated) and intestinal (well-differentiated) types.

If there is a suspicion for gastric cancer, a gastroscopic biopsy should be carried out for the diagnosis. The results of these examinations should be reviewed by an experienced pathologist.

Endoscopic ultrasound (EUS) is helpful in determining the proximal and distal extent of the tumour and provides more accurate information than computed tomography (CT) for the diagnosis of malignant lymph node.

Positron emission tomography (PET)-CT imaging provides additional information that helps with staging by detecting involved lymph nodes or metastatic disease.

There are two main types of esophageal cancer, the esophageal squamous cell carcinoma and esophageal adenocarcinoma, the former accounting for more than 90% of cases of esophageal cancer worldwide.

Squamous cell carcinoma is associated with smoking and alcohol consumption, whereas adenocarcinoma mainly occurs in patients with chronic gastro-esophageal reflux and is associated with the risk factors for the latter, such as obesity.

In the case of symptoms, such as new dysphagia, gastrointestinal bleeding, recurrent aspiration or emesis, weight loss and/or loss of appetite, an upper intestinal endoscopy should be carried out.

According to international medical statistics, approximately three-quarters of all adenocarcinomas are found in the distal esophagus, whereas squamous cell carcinomas are developed more frequently in the proximal to middle esophagus.

Endoscopic biopsies should be taken from every area that is suspected for cancer.

A proper differentiation between adenocarcinomas and squamous cell carcinomas is very important for the prognosis. In the case of poorly differentiated or undifferentiated cancer, immunohistochemical staining is recommended.

A computed tomography (CT) scan of the neck, chest and abdomen as well as an ultrasound of the abdomen, provides information on possible metastases. Positron emission tomography (PET-CT) helps identify distant metastases that are difficult to detect.

A tracheobronchoscopy and a thorough examination by an ear, nose and throat specialist may also be carried out.

 

Monitoring – outcome

After initial treatment for gastrointestinal cancer, all patients should be closely monitored.

Post-operative control of patients with Follow Up includes:

  • Computed Tomography
  • Colonoscopy
  • Checking of cancer markers
  • Haematological testing
  • Clinical examination

Colorectal cancer appears to be more and more frequent nowadays and concerns a large part of the population.

The implementation of screening programs, early diagnosis and scientifically documented treatment have now led to a spectacular increase in the survival of colon cancer patients, improving their quality of life and in many cases, to its cure.

Colorectal cancer (cancer of the colon and rectum), or CRC, is the most common gastrointestinal (GI) cancer. The mainstay of treatment for CRC is surgery, and tremendous advances in surgical technique have been made over the last few decades. The “latest and greatest” of these advances has been the growing use of minimally invasive surgical techniques, including robotic surgery.

The advantages of robotic surgery for patients are numerous, including shorter hospital stays, less postoperative pain and quicker time to resumption of work and normal activities. In addition, patients who may need adjuvant therapy, MIS techniques may require less interval time between the index operation and adjuvant chemotherapy.

Minimally invasive laparoscopic resection of colon and rectal tumors has been proven safe and effective. In addition, robotic surgery overcomes limitations of laparoscopic surgery and is used to treat even the most difficult cases.

The robotic approach can facilitate visualisation in difficult locations such as the deep pelvis, allowing greater dexterity for more precise dissections and less blood loss. (This can translate to better patient outcomes in many situations, especially in allowing for “sphincter-preserving surgery”—avoiding the need for permanent “bags” or colostomies)

A large number of people are diagnosed with bile duct (cholangiocarcinoma) cancer each year. Since the bile duct lies deep within the abdomen, open surgery for this condition requires a very large abdominal incision. However, bile duct cancer can now be treated very effectively with minimally invasive surgical approaches, including robotic surgery.

The type of robotic procedure performed to treat bile duct cancer depends on the location of the tumor:

  • For tumors in the top portion of the bile duct, surgery can involve removing a segment of the bile duct at times with a part of the liver.
  • For tumors in the middle of the bile duct, we can often remove a segment of the bile duct alone, without any associated part of the liver or pancreas.
  • For tumours in the lower part of the bile duct, part of the pancreas may need to be removed as well in order to properly obtain clearance around the tumor.

In all of these cases, after removing the portion of the diseased bile duct, a piece of intestine is used to reestablish the flow of bile from the liver into the intestinal tract.

Minimally invasive approaches to these operations have been greatly facilitated by the addition of the Da Vinci Robot. As a result, many of these procedures, which in the past routinely required a large incision, can now be done with a few small incisions (less than one inch, on average).

AMG’s cancer specialists use the latest medical and surgical advances to treat gastointestinal cancer at the earliest possible stage. Therapy for gastrointestinal cancer is multidisciplinary. However, surgery is currently considered to be the only radical treatment and it involves the removal of the malignant tumor and surrounding tissue, as well as neighboring lymph nodes that might be affected.

Histopathological examination of the resected tumor and lymph nodes contributes to the valid and accurate staging of the cancer which, in turn, determines the treatment plan for each patient.

Treatment for gastrointestinal cancer involves a plethora of therapeutic approaches which may be applied depending on the case, such as radiotherapy, chemotherapy, and targeted therapies.

Surgical Oncology treatments with the Da Vinci Χi HD Robotic System (Single-site) and the most modern minimally invasive methods (MIS) are performed in the Group’s hospitals.

  • Hepatobilliary, Colorectal & Stomach surgery
  • Transanal total mesorectal excision (TaTME)
  • Endoscopic surgery TEMS
  • Endoscopic surgery of early malignant gastrointestinal tumors
  • Transanal Minimally Invasive Surgery (TAMIS)
  • Transanal rectal excision without colostomy with the Pull-through method
  • Robotic Pancreaticoduodenectomy – Whipple procedure
  • Hepatectomy ALPPS
  • HIPEC (Hyperthermic Intraperitoneal Chemotherapy)
  • PIPAC (Pressurized Intraperitoneal Aerosol Chemotherapy)
  • IRE (Irreversible Electroporation)

The introduction of laparoscopic and robotic surgery to treat patients with gastrointestinal cancer has dramatically improved the results. Robotic-assisted gastrointestinal cancer surgery provides many technical advantages for surgeons compared to conventional laparoscopy.

Both laparoscopic and robotic surgery provides:

  • Easier identification of noble elements due to the magnification of the surgical field
  • Less postoperative pain
  • Faster mobilization of the patient and return to his everyday life
  • Oncological results absolutely comparable to open surgery
  • Optimal aesthetic outcome

Robotic Surgery – The evolution of the technology

Robot-assisted surgery (RAS) was developed to:

  • Increase the dexterity and facility with which complex surgical dissections are performed
  • To enhance visualization by providing three-dimensional stable view to the surgeon
  • To overcome limitations of the standard laparoscopic approach such as ergonomics.

Another critical advantage of RAS is the shorter learning curve when compared to laparoscopy, while intra-operative blood loss and operative time are believed to decrease as a surgeon’s experience grows

Advances in technology and surgical technique have given rise to minimally invasive approaches for the treatment of certain types of tumors in the rectum, such as:

Transanal minimally invasive surgery (TAMIS)

Transanal minimally invasive surgery (TAMIS) is a minimally invasive procedure applied for the removal of benign polyps and some cancerous tumors within the rectum.

TAMIS is performed entirely through the body’s natural orifice, requiring no skin incisions to gain access to a polyp or tumor, allowing for a fast and scar-free recovery.

With TAMIS your surgeon will precisely remove the affected tissue, leaving the rest of the bowel intact to function normally, unlike traditional surgery where a major portion of the large intestine is usually removed.

 Transanal total mesorectal excision

Total mesorectal excision is the cornerstone treatment of rectal cancer. Traditionally, it is performed trans-abdominally.

An alternative new approach is called the Trans-anal Total Mesorectal Excision. This technique involves the introduction of a tube containing special surgical tools through the anus. It allows the surgeon to dissect the low vectrum.

If you have been diagnosed with a rectal tumor, it’s important to talk to your doctor about the treatment options and determine if Transanal Total Mesorectal Excision or another procedure is recommended for you.

Cancer of the esophagus is treated with the removal of the tumor.

In the transhiatal esophagectomy, the esophageal tumor is removed through an abdominal incision, without thoracotomy, and a left neck incision. The esophagogastric anastomosis is applied in the neck area. This procedure may also be considered “minimally invasive” as compared with the Ivor Lewis esophagectomy.

In the Ivor Lewis esophagectomy, the esophageal tumor is removed through an abdominal incision and a right thoracotomy (a surgical incision of the chest wall). The esophagogastric anastomosis (reconnection between the stomach and remaining esophagus) is located in the upper chest.

Part of the esophagus or stomach where the tumor is located needs to be surgically removed when it has not spread requires surgery to remove the. The aim of surgery is to remove all of the cancer and a margin of healthy tissue, when possible. Nearby lymph nodes are typically removed as well.

Some of the options include:

  • Subtotal gastrectomy: the removal of a portion of the stomach. During this procedure, the surgeon removes only the portion of the stomach affected by cancer.
  • Total gastrectomy: the removal of the entire stomach. During this procedure, the entire stomach and some surrounding tissue are removed. The esophagus is then connected to the small intestine so that food will move through your digestive system.

Athens Medical Group is one of the few healthcare institutions in Europe that performs this procedure.
A Whipple procedure (pancreaticoduodenectomy) is a complex operation to remove the head of the pancreas, the first part of the small intestine, the gallbladder and the bile duct.

It is used to treat the disorders, including tumors- of the pancreas, intestine and bile duct. It is considered the most often used surgery to treat cancer that is confined to the head of the pancreas. Following the procedure, the surgeon reconnects the remaining organs to allow you to digest food normally after surgery.

The aim of the Whipple procedure is to remove the tumor and prevent it from growing and spreading to other organs.

Operations used to treat liver cancer include:

  • Surgery to remove the tumor. In certain situations, an operation may be recommended by your doctor to remove the cancer as well as a small part of the healthy liver tissue that surrounds it if your tumor is small and your liver function is good.

This is an option that depends on the size of the cancer, its location in the liver as well as how well your liver functions.

  • Liver transplant surgery. During liver transplant surgery, your diseased liver is replaced with a healthy liver from a donor. This is an option for only a small percentage of people with early-stage liver cancer.

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from proliferating.

Chemotherapy may be administered:

  • Before surgery, to shrink the tumor and decrease the amount of tissue that needs to be removed.
  • After surgery, to destroy any remaining cancer cells and decrease the risk of recurrence.
  • To help relieve symptoms of metastatic cancer and extend survival time.

Hyperthermic Intraperitoneal Chemotherapy may be used in selected cases of colorectal cancer with low cancer burden.

Targeted drug therapy

Targeted therapy uses special drugs that target particular functions of the cancer cells that allow them to grow and survive. Often it is administered along with standard chemotherapy and is typically applied to patients with advanced colon cancer. Unlike chemotherapy, targeted therapy drugs cause little or no damage to healthy cells.

Immunotherapy

Immunotherapy involves the use of specially designed drugs that either limit the cancer cells’ ability to hide from the immune system or enable the latter to better recognize and attack the cancer cells.

Trials to explore the use of immunotherapy are under active investigation worldwide and will continue to contribute to benefit gastrointestinal cancer patients.

PIPAC

Pressurized intraperitoneal aerosol chemotherapy is a palliative method which offers better quality of life in patients and in some cases increases life expectancy.

 

Radiotherapy is the use of ionizing radiation (also called x-ray therapy) to kill tumors anywhere in the body. It is used to mostly treat cancers and rarely non-cancerous conditions.

Most types of radiotherapy use high energy photos that destroy the cancer cells in the area where it is given by damaging the DNA of these cells.

It is estimated that about half of patients with cancer will be treated with radiotherapy at some stage during the course of their disease and this means that 1 in 2 patients with cancer may benefit from radiation therapy during their illness.

Radiotherapy can be applied safely to a wide range of cancers and may be used alone or in conjunction with surgery, chemotherapy, immunotherapy and other treatments.

The treatment might be given for several reasons:

  • To try to destroy a tumor and cure the cancer (radical radiotherapy)
  • After surgery to lower the risk of the cancer relapse (adjuvant radiotherapy)
  • Before surgery to shrink the cancer, making its removal easier (neoadjuvant radiotherapy)
  • To shrink the cancer and help with symptoms (palliative radiotherapy)

Our Radiation Oncology Department has 2 main assests: our highly skilled and experienced medical professionals and the advanced technologies used to deliver safe and effective radiation treatment to our cancer patients with as few side effects as possible.

The radiotherapy department works as a multi-disciplinary team, including different health professionals that work together to share specialist knowledge and expertise to make sure that all patients have the best possible treatment and care available. Our radiotherapy team includes highly trained and certified Radiation Oncologists, Radiation Physicists, Radiographers and Oncology Nurses committed to continuously improving the services delivered to the patients.

Developments in radiotherapy allow us to target tumors with more accurate doses of radiation than ever before. Greater accuracy means that fewer healthy cells are damaged, which, in turn, means that higher doses can be given, making the treatment more effective. The technology we use is constantly improving, resulting in higher cancer control rates, fewer patient side effects, shorter treatment times and improved quality of life.  Our equipment includes:

  • 2 Elekta linear accelerators (Elekta Synergy and Elekta VERSA HD) fitted with the very latest technology including multileaf collimator and cone beam CT
  • Siemens multi slice CT scanner for treatment simulation
  • ONCENTRA MASTERPLAN and MONACO computer planning systems
  • Brachytherapy Unit

This state-of-the-art equipment enables us to deliver the most up-to-date treatments such as:

  • 3D Conformal Radiotherapy where the radiation beams are shaped to make sure that they are carefully directed to the cancer
  • Intensity-Modulated Radiation therapy (IMRT) where the shape and strength of the radiation beams are varied to closely fit the cancer area
  • Volumetric Arc Modulated Radiotherapy (VMAT), a very accurate technique to maximize the radiation dose to the tumor and minimize exposure of the surrounding healthy tissues by independently controlling the angle of the beam, the dose rate and the leaf speed
  • Image-Guided Radiation Therapy (IGRT) which is the use of CT scans before and during each treatment session to confirm the position of the patient and the tumor and target the radiotherapy beam more precisely
  • Stereotactic Body Radiation Therapy (SBRT) which is the use of multiple small beams directed at small cancers from several directions to deliver high dose radiation in few fractions

The Radiation Oncology Department covers all main tumor sites and is in close collaboration with the Medical Oncology and Surgical Oncology Units, Diagnostic Radiology, PET CT, Nuclear Medicine and Pathology departments. Active participation in the Multidisciplinary Team Meetings ensures patient-centered, safe, evidence-based, high-quality care for every patient. The continuous professional development of the radiotherapy staff through training and educational programs in combination with the continuous investment in new technologies are our primary goals in order to maintain our ISO accredited service for outstanding quality.

Some of the most frequent questions asked to our doctors include:

  • Where is the cancer located?
  • What is the stage of my gastrointestinal cancer?
  • Has my gastrointestinal cancer spread to other parts of my body?
  • What kind of tests will I need?
  • What options do I have to treat my gastrointestinal cancer?
  • Can my gastrointestinal cancer be cured and with which treatment?
  • What is the chance of cure for my gastrointestinal cancer?
  • How much does each treatment increase my chances for cure of my gastrointestinal cancer?
  • What are the potential side effects of each treatment?
  • How will each treatment affect my daily life?
  • Which treatment do you feel is best for me?
  • How soon must I decide about the type of my treatment?
  • Should I seek a second opinion?
  • Should I see a specialist? What will that cost, and will my insurance cover it?
  • Do my siblings or my children have an increased risk of gastrointestinal cancer?
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