GI Malignancy: Oesophagus, Stomach, Pancreas, Colorectal

Question 1

Esophageal cancer
Types
-epidemiology
-location
-prognosis
-risk factors

Answer 1

Adenocarcinoma (dysplasia => Barrets esophagus) - more common in West, UK/US

• most common in UK/US
• lower 1/3d
• better prognosis
• GORD, Barretts, smoking, achalasia, obesity, RT

Squamous cell cancer - more common in East, developing world

• upper 2/3d
• poorer prognosis
• smoking, alcohol. achalasia, nitrosamines

Older adults, increasing in incidence
Majority of risk factors are modifiable

Question 2

Esophageal cancer
Presentation
Investigations

Answer 2

Dysphagia
Anorexia, weight loss
Vomiting, regurgitation of food, indigestion
Cough
Hoarse voice
Melena

FIRST LINE - Upper GI endoscopy, biopsy

Staging CT of chest, abdo, pelvis for mets
Local USS for staging of non metastatic

Question 3

Esophageal cancer
Management
-if operable
-palliative

Answer 3

If operable - surgical resection
-NAC + esophagectomy + AC

Palliation => radio, chemo, stenting of esophagus

Question 4

Esophageal and stomach cancer

-2ww

Answer 4

Stomach and oesophageal cancer
Dysphagia OR
55+ AND weight loss and any of the following:
Upper abdo pain
Reflux
Dyspepsia

Stomach - LUQ mass

Question 5

Stomach cancer

• epidemiology
• risk factors

Answer 5

Less common than colorectal, esophageal
Older males
-Japan, China, FInland, Colombia

• HPylori - inflammation of mucosa => atrophy and metaplasia
• atrophic gastritis
• pernicious anemia
• diet - salt, salt preserved, nitrates
• smoking
• blood group

Question 6

Stomach cancer

• presentation
• investigations
• management

Answer 6

EG pain, indigestion
Weight loss, anorexia
N+V
Dysphagia
Hemoptysis
Virchow
Periumbilical nodule - Sister Mary Joseph

Diagnosis - endoscopy + biopsy
Staging - CT

Surgical - mucosal resection/gastrectomy
Chemo

Question 7

Pancreatic cancer

• epidemiology
• type
• risk factors (environmental, genetic)

Answer 7

Increased incidence in older adults but often caught too late

Adenocarcinoma most common

Lifestyle - smoking, diabetes, chronic pancreatitis
Genetics - Lynch, MEN1, BRCA2, KRAS

Question 8

Pancreatic cancer

• presentation
• investigations
• management

Answer 8

Painless jaundice + Courvoisier’s
-pale stool, dark urine, itch, cholestatic LFT
Anorexia, weight loss, EG/back pain
Loss of exocrine function => steatorrhoea
Loss of endocrine function => DM
Trousseau syndrome - migratory thrombophlebitis

Diagnosis - CT
Staging - CT CAP
Cancer marker - Ca19-9

Surgery - majority of cancers not suitable
-Whipple/pancreatodudenectomy if cancer in head + AC
Pallation - ERCP stent

Question 9

Pancreatic cancer

-exocrine malignancies

Answer 9

Secretory tumours more likely to be benign
Non secretory => asymptomatic, more likely to be malignant but good prognosis

Insulinoma - most common, MEN1
-hypoglycemia, weight gain, high insulin, C peptide
VIPoma - stimulates pancreatic, intestinal secretion, inhibits acid and pepsinogen secretion
-diarrhoea, dehydration, lowK,Cl => weight loss
Glucagonoma
-DM, VTE, red blistering rash

Question 10

Colorectal cancer

• epidemiology
• risk factors (environmental, genetic)
• protective factors
• most common locations

Answer 10

Majority of cancer - sporadic
Both of the following monitored with regular colonoscopy
-2nd most common - Lynch (HNPCC) - MSH, MLH => microsatellite instability
Amsterdam criteria
-3 family members
-2 gens
-1 diagnosis U50

• 3rd most common - FAP - APC
• total colectomy + ileoanal pouch if polyps found

KRAS, p53
UC

Modifiable risk factors

• Obesity - high sugar, alcohol
• Red/processed meat

Modifiable protective factors

• physical exercise
• Ca, garlic, fibre, non starchy veg/pulses

In order of prevalence - rectal, sigmoid, asc/cecum, transverse, desc

Question 11

Colorectal cancer

• presentation
• how symptoms may differ depending on the site
• diagnosis
• tumour markers

Answer 11

Bowel habit changes - constipation, diarrhea, increased freq, straining
Rectal bleed => Fe def anemia
Abdo pain - bowel obstruction
Weight loss
UC, PSC
Impact on other organs
-ureter obstruction => urinary retention
-fistula formation into bladder/stomach

Right - more liquid
-slow prolonged blood loss => Fe def anemia
-obstructive symptoms less common due to wider lumen
Left - more solid
-CHANGE IN BOWEL HABIT
-bowel obstruction => colicky pain from peristalsis against mass => straining, bloody stool, rectal mucous

Diagnosis - colonoscopy
Staging - CAP CT
-rectal cancer - mesorectal pelvic MRI
Tumour marker - CEA

Question 12

Colorectal cancer

• colorectal management
• rectal management

Answer 12

Surgery for colorectal- hemicolectomy + lymphatic resection
-reattach bowel/stoma

Surgery for rectal

• local resection
• total mesorectal + LN excision
• anterior resection => attach sigmoid colon to remainder of rectum (temp ileostomy)
• abdoperineal resection => permanent stoma

NACR + ACR to reduce recurrence risk
Regular surveillance

Monoclonal AB to EGFR
Immune checkpoint inhibitors

Question 13

Metastatic sites for GI cancers

Answer 13

Hematogenous spread is the most common
LIVER
LUNG
PERITONEUM