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GI malignancy Flashcards

1
Q

Where do cancers occur along GI tract?

A

Oral cavity/tongue
Oesophagus
Stomach
Pancreas
Liver
Gallbladder
Large intestine
Small intestine
Anal

(basically anywhere)

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2
Q

What is a carcinoma?

A

Malignancy of cells that make up epithelial lining of skin or tissue lining organs

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3
Q

What is an adenocarcinoma?

A

Malignancy of glandular cells in epithelial tissue

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4
Q

When is an adenoma?

A

Benign tumour formed from glandular structures in epithelial tissue

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5
Q

Incidence of GI cancer

A

Breast/prostate is top (then lung)
Bowel - large
Pancreas
Oesophagus
Stomach
Liver

(in order of incidence) BOWELS PROTECT OUR SILLY LIVES

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6
Q

Oesophageal cancer types

A

Most common: squamous cell carcinoma

Adenocarcinoma from columnar epithelia (following barretts oesophagus)

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7
Q

What part of oesophagus do these cancers affect?

A

Squamous cell carcinoma - upper 2/3rd

Adenocarcinoma - lower 1/3, nearer stomach and reflux

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8
Q

Clinical presentation of oesophageal cancer

A

Progressive dysphagia - solids more difficult first then eventually liquids

Odynophagia - pain on swallowing

Unexplained weight loss

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9
Q

Red flags for oesophageal cancer

A

Progressive dysphagia and ALARM:
A - anaemia (loss of blood)
L - loss of weight
A - anorexia
R - recent onset of progressive symptoms
M - malaena (or mass)

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10
Q

Risk factors for squamous cell carcinoma oesophageal cancer

A

Smoking
Alcohol abuse
Dietary intake - HOT beverages (in some cultural rituals)

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11
Q

Risk factors for adenocarcinomas of oesophagus

A

Obesity
Reflux disease
Most arise after Barrett’s Oesophagus

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12
Q

Prognosis for oesophageal cancer

A

Poor - 5% survival rate

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13
Q

Investigations for oesophageal cancer

A

Bloods - anaemia?

Oesophagogastroduodenoscopy (OGD) with biopsy - benign or cancerous

CT thorax and abdomen - staging, size of primary, local invasion/metastases?

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14
Q

Treatment for oesophageal cancer

A

If early and limited disease - endoscopic therapy

Oesophagectomy - removal of oesophagus and translocation of stomach to replace

Chemoradiotherapy - mix of both

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14
Q

Gastric cancer histology type

A

Adenocarcinoma (can get lymphoma, leiomyosarcoma or neuroendocrine tumours)

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15
Q

Where are gastric adenocarcinomas commonly found?

A

Gastric cardia - 31%
Antrum - 26%
Body of stomach - 14%

(CABS like imagine a gastric cancer in a taxi)

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16
Q

Classifying gastric cancer

A

Location - cardia gastric cancer or non-cardia gastric cancer

Lauren classification - type eg diffuse (poorly differentiated) or intestinal

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17
Q

In who do diffuse gastric cancers commonly occur?

A

More in young patients, have worse prognosis than intestinal

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18
Q

Gastric cancer risk factors

A

Age - 50-70
Male
(general)

Pernicious anaemia
H-pylori
N-nitroso compounts (in processed meats)
(strong)

Family history
High salt - weakens gastric mucosa, enhances -ve effects of N-nitroso compounds
Smoking
(weak)

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19
Q

Clinical presentation of gastric cancer

A

Unexplained weight loss

Epigastric abdo pain

Lymphadenopathy - Virchows node in supraclavicular fossa

Dysphagia (if around cardia)

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20
Q

What does cardiac gastric cancer usually present like?

A

Very similar to oesophageal cancer - dysphagia etc

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21
Q

Prognosis for gastric cancer

A

70% 5 year survival rate if local

5% if distant metastasis

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22
Q

Investigations for gastric cancer

A

Bloods - iron deficiency anaemia?

Upper GI endoscopy with biopsy - diagnosis

CT CAP (chest abdomen and pelvis) - stage, determine extent

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23
Q

Management of gastric cancer

A

Superficial - endoscope mucosal resection (cut out)

Localised - remove part or all of stomach (gastrectomy), if not surgery then chemoradiation

Advanced/mets - chemotherapy, immunotherapy and supportive care

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24
Q

Pancreatic cancer prevalance

A

8th leading cause of cancer deaths worldwide

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25
Q

Histology of pancreatic cancer

A

Pancreatic ductal adenocarcinoma

Neuroendocrine are rare and originate from endocrine cells in pancreas

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26
Q

Types of neuroendocrine cancers of pancreas

A

Non-functional
Functional - secrete hormones eg insulinoma

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27
Q

Risk factors for pancreatic cancer

A

Smoking
Chronic pancreatitis
Inherited mutations - BRCA1, BRCA2, PALB2 and familial syndromes
Men>women
Older age

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28
Q

Presentation of pancreatic cancer

A

Painless jaundice
Unexplained weight loss
Abdominal/back pain (radiates to back)

NEW ONSET of T2DM in adult over 50 with no obesity related risk factors

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29
Q

Why can chronic pancreatitis lead to pancreatic cancer?

A

ANY chronic inflammation can increase chance of malignancy

= increased cell turnover and increased cell cycles and divisions
More likely for mutation to occur and multiply

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30
Q

Why can pancreatic cancer cause painless jaundice?

A

If cancer affects head of pancreas this lies close to biliary system (common bile duct)
Can cause obstructive post hepatic jaundice

This is less likely to happen if cancer is in tail

31
Q

Symptoms of pancreatic cancer (campaign atm)

A

Indigestion
Tummy/back pain
Changes to poo
Unexplained weight loss/loss of appetite
Jaundice (yellow sclera/skin, itchy skin too)

32
Q

Investigations for pancreatic cancer

A

Bloods - LFT’s if jaundiced, CA 19-9 (tumour marker for pancreatic cancer)

CT - focused on pancreas can diagnose and assess resectability (can we operate?)

USS - detect cancer in head but not body/tail

33
Q

Tumour marker for pancreatic cancer

A

CA 19-9

34
Q

Hepatocellular carcinoma histology

A

Primary cancer arising from hepatocytes (usually with background of cirrhosis)

35
Q

Risk factors for hepatocellular carcinoma

A

Underlying cirrhosis
Eg any risk factors for this: Hepatits B&C, alcohol excess, drug use

36
Q

Presentation of hepatocellular carcinoma

A

As most pts have underlying liver disease, symptoms of this can mask the malignancy - eg ascites, fatigue, jaundice

Acute hepatic decompensation - sudden worsening symptoms or RUQ pain

37
Q

Prognosis for heaptocellular carcinoma

A

50% 5 year survival rate with complete surgical resection or liver transplant

Advanced - 1year survival rate post diagnosis

38
Q

Investigations for hepatcellular carcinoma

A

Bloods - LFTs, prothrombin/INR (check synthetic function), viral hepatitis panel

USS - non invasive, screen high risk

CT/MRI abdo - stage

Liver biopsy - diagnose and confirm

39
Q

Treatment for hepatocellular carcinoma

A

Ablation - burning
Resection
Transplantation

If not suitable for above, chemo/immunotherapy slows tumour growth

40
Q

Other cause of cancer in liver

A

Liver metastases

41
Q

How can cancer spread to liver

A

Haematological - eg via portal spread from GI viscera

Lymphatic

Transcoelomic - through peritoneal cavity

42
Q

Cancers spreading to liver

A

Colorectal
Pancreatic
Gastric
Breast
Melanoma
Small cell/non small cell lung cancer

Liver (lung) Metastatic (melanoma) Cancer (colorectal) gets (gastric) pretty (pancreatic) bad (breast)

43
Q

What is a bile duct cancer called?

A

Cholangiocarcinoma

44
Q

Histology of cholangiocarcinoma

A

Adenocarcinoma majority
Can be extrahepatic or intrahepatic

45
Q

Risk factors for cholangiocarcinoma

A

Liver/bile duct disease - cirrhosis, gallstones, primary sclerosing cholangitis, alcoholic liver disease

Infections - liver fluke, HepB/C

High alcohol consumption

Exposure to toxins/medications

46
Q

Clinical presentation of cholangiocarcinoma

A

Painless jaundice
Pruritus
Dark urine + light stool - obstructive pattern of biliary tree (stercobilin absent)

47
Q

Prognosis of cholangiocarcinoma

A

Poor - 2% survival rate in pts with metastatic disease

48
Q

Histology of colorectal cancer

A

Adenocarcinoma which progress from normal epithelia in sequence

49
Q

Risk factors for colorectal cancer

A

Dietary - high fat, lots of red meat, low fibre, lots alcohol

History of inflammatory bowel disease

Genetic - familial adenomatous polyposis (FAP), hereditary nonpolyposis colorectal cancer (HNPCC, lynch syndrome)

50
Q

Common presentation of colorectal cancer

A

Blood in stool
Altered bowel habits

Advanced - bowel obstruction, perforation, hepatic/peritoneal metastases symptoms - abdo pain/ascites

51
Q

Prognosis for colorectal cancer

A

BEST - non metastatic 50-95% 5 year survival rate

52
Q

Colorectal cancer red flags

A

Blood in stool/rectal bleeding
Change in bowel habits
Iron def anaemia
Unexplained weight loss
Tenesmus - feeling of incomplete emptying bowel
Mass on rectal exam

53
Q

What do you have to consider when asking about blood in stool/rectal bleeding?

A

CONTEXT: Fresh blood vs mixed in stool vs melaena

Fresh, little and pain - haemorrhoids likely

Melaena - upper GI bleed?

54
Q

What to take into account when asking about bowel habits?

A

CONTEXT: Age, frequency consitency

Older age = more concern for malignancy

If alternating between feeling constipation and diarrhoea bowel may still be obstructed as fluidy diarrhoea is forced around obstruction when pressure gets higher (cycle of this)

55
Q

Right sided colon cancer vs left - what do they both have

A

Both - weight loss, bleeding

56
Q

What does right sided colon cancer have?

A

Right:
- occult bleeding (not visible to naked eye, had time to be mixed in with faeces)
- less likely to present with obstruction
- mass in RIF
- more advanced disease on presentation
- Late change to bowel habits
- Fungating (ulcerations)

57
Q

What does left sided colon cancer have?

A

Left:
- Rectal bleeding - redder, less time digesting
- bowel obstruction more likely
- mass in LIF
- less advanced at presentation
- early change to bowel habits
- Stenosing - stricture/narrowing

58
Q

Right colon cancer affects

A

Ascending colon

59
Q

Left colon cancer affects

A

Descending/sigmoid colon

60
Q

Radiological sign for colorectal cancer

A

Apple core deformity - tumour narrows lumen of bowel looks like apple core

61
Q

Adenocarcinoma sequence simple- 3 points

A
  1. Normal glandular epithelia
  2. Adenomas (benign neoplasm)
  3. Invasive carcinoma
62
Q

What causes progression of adenoma carcinoma sequence?

A

Genetic and epigentic mutations =

Activation of oncogenes eg HER2

Inactivation of tumour supressor genes - p53

63
Q

Colorectal cancer investigations

A

Stool test - FIT (faecal immunochemical test for blood)

Blood tests - anaemia? CEA (carcinoembryonic antigen)

Colonoscopy + biopsy - diagnose

Imaging - MRI/CT

64
Q

Management of colorectal cancer

A

Largely dependent on stage

Surgery with pre/post op chemo/immunotherapy (neoadjuvant is before surgery)

Chemo/immunotherapy if no surgery

65
Q

Tumour marker for colorectal cancer

A

CEA

66
Q

Ages for FIT test screening

A

Age 60 - 74 (every 2 years)

NHS is expaning to 50-59 too soon

67
Q

Barriers to FIT screen

A

Gender - males less likely to take part
Fear/denial around outcome
Someone perceives themselves as low risk
No apparent symptoms
Ethnic minority
Lower socioeconomic groups
Practicalities and cleanliness of test

68
Q

Anal cancer histology

A

Squamous cell carcinoma

69
Q

Risk factors for anal cancer

A

Human papillomavirus (HPV)

HIV - more likely to get HPV if immunocompromised

Anal receptive intercourse

Chronic local inflammation from IBD/anal fissures recurring

70
Q

Anal cancer presentation

A

Perianal pruritus
Perianal pain
Bleeding
Discharge
Mass like sensation

71
Q

Prognosis for anal cancer

A

70% cured with chemoradiation

72
Q

Lowering incidence of anal cancer

A

Cervical smears in high risk
Prevention and treatment of HIV

73
Q

How is GI cancer staged?

A

TNM system

T - size of primary tumour
N - extent of regional lymph node involvement
M - metastatic spread?

Stage 1,2,3 or 4

74
Q

Colorectal cancer staging

A

Dukes staging

75
Q

Dukes stages of colorectal cancer

A

A - confined to inner lining of bowel

B - grown through muscle layer of bowel

C - spread to at least 1 lymph node close to bowel

D - metastasised and spread to another part of body eg lungs, liver or bones

GI (32 decks)

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