5 - Upper GI Malignancy Flashcards

Question

What are the signs and symptoms of peritoneal carcinomatosis?

Answer 1

CA-125 = ovarian cancer CEA = colon cancer α fetoprotein = hepatocellular cancer CA 19-9 = pancreatic or bile duct cancers

Answer 2

CT Can indicate cause due to the density of the fluid. - Similar to water = transudate - Higher than water = exudate - Really high = blood (hemoperitoneum)

Answer 3

Nephrotic syndrome Protein losing enteropathy (not being absorbed by the gut) Malnutrition Reduced production (liver failure, poor health)

Answer 4

Antioxidant and immunomodulation Regulation of colloid oncotic pressure Transporter of hormones, drugs etc Endothelial stabilisation

Answer 5

Hypoalbuminemia = loss of intravascular oncotic pressure = oedema in legs, ascites and effusions in lungs and heart. Less BV = activates RAAS - causes water and salt retention.

Answer 6

Clear or straw coloured

Answer 7

Excessive renal protein loss --> hypoalbuminemia, hyperlipidaemia and oedema. Glomeruli are affected by inflammation - allows protein to pass through and be excreted. Oedema then forms due to reduced vascular oncotic pressure.

Answer 8

Fluid and salt restriction, diuretics and ACEIs (reduce protein loss as reduce intraglomerular pressure and hyperfiltration)

Answer 9

Transudative Exudative Light's criteria can determine which it is.

Answer 10

Prehabilitation (prehab) means getting ready for cancer treatment in whatever time you have before it starts. It is a programme of support and advice that some NHS hospitals are using. It covers three particular parts of your health: what you're eating and your weight physical activity or exercise mental wellbeing Stopping smoking and cutting down on alcohol can also help. It helps while you're having treatment, with your recovery, as well as improving your overall health

Answer 11

Inc depth is linked to increased risk of lymph node spread (N) and distant organ spread (M). This impacts prognosis and treatment options.

Answer 12

Has gradually increased incidence - tumours at the GOJ have steadily increased.

Answer 13

Squamous Cell Carcinoma - Asia Adenocarcinoma - West

Answer 14

Macroscopic = what it looks like with the naked eye Microscopic = what it looks like under a microscope

Answer 15

Far East - Japan & Korea

Answer 16

Direct Haematogenous to other viscera Lymphatic

Answer 17

Adenocarcinoma - most common and most aggressive GIST (gastrointestinal stromal tumours) Lymphoma Neuroendocrine tumours - less common and less aggressive, treated differently

Answer 18

Trans-peritoneal spread - mets to the peritoneum

Answer 19

Dyspepsia complicated by dysphagia, weight loss and anorexia

Answer 20

Gastroscopy (OGD) and biopsy first Then you can do - CT (for staging) PET CT + Contrast (better for oesophageal as more radioisotope taken up, less taken up by gastric cancer) EUS (endoscopic US) Staging Laparoscopy - looking for peritoneal spread

Answer 21

Early disease = endoscopic surgery or primary surgery Locally advanced - Adenocarcinioma = perioperatvie chemo / chemo radio + surgery Oesophageal SCC = chemoradiotherapy Metastatic disease - palliative (chemo, radio, immune), supportive (stents for dysphagia). Median survival = 8-10m

Answer 22

Operative mortality = 5% Operative morbidity = 50% - cardio-respiratory complications, anastomic leak (causing sepsis abscess), mediastinitis

Answer 23

Anatomical reflux Early satiety Physiological - nutritional, weight loss, diarrhoea, vitamin deficiency, dumping Psychological - major life impacts, esp surrounding food and social life

Answer 24

Because they have similarities between them - Uncommon - Locally advanced a presentation - Poor prognosis

Answer 25

- Abdominal pain - Nausea / anorexia - Weight loss Can get extra-hepatic obstructive jaundice

Answer 26

Deep jaundice Pale stools Dark urine Pruritus

Answer 27

1st line - USS - may show biliary duct dilatation CT - extent of disease MRCP - detailed images of biliary duct obstruction ERCP +/- Stent

Answer 28

Cirrhosis = biggest RF - 3-5% annual risk of developing HCC - Alcohol excess - Chronic viral hepatitis - NAFLD (DM and metabolic syndrome) - Haemochromatosis / Wilsons - rare

Answer 29

Liver mass on clinical exam Incidental mass on CT / MRI / US

Answer 30

AFP - α fetoprotein

Answer 31

In the head - most common - turns Ps yellow because the tumour blocks the bile duct Or in the body or tail - less common -doesn't turn Ps yellow

Answer 32

Adenocarcinoma Mucinous Cystic Tumour Neuroendocrine Tumour

Answer 33

Recent onset diabetes Obstructive jaundice Couvoisier's sign Pancreatitis Abdominal mass

Answer 34

Courvoisier's sign Usually caused by malignant biliary obstruction

Answer 35

Removal of the head of the pancreas and the duodenum - used for Tx of cancer of the head of the pancreas

Answer 36

Distal pancreatectomy and splenectomy

Answer 37

Very rare - <1% of all cancer diagnoses. F>M 6:1

Answer 38

Obesity Age FHx Gallstone Hx Gallbladder polyps Porcelain GB

Answer 39

Usually asymptomatic until late presentation Usually incidental finding at surgery for gallstones

Answer 40

CEA CA19-9

Answer 41

Cholangiocarcinoma

Answer 42

Liver flukes Primary sclerosing cholangitis Choledochal cysts (biliary cysts) Bile duct stones

Answer 43

As an incidental finding when imaging the biliary tree

Answer 44

CEA CA19-9

Answer 45

Depends on site of cancer - whether intra or extra hepatic bile duct Local resection (bile ducts) Partial liver resection Whipple Liver transplantation

Answer 46

Pemigatinib

Answer 47

Rare = only 3-5% of all GI malignancies in the West despite making up 90% of the GIT

Answer 48

Adenocarcinoma

Answer 49

When P has a neuroendocrine tumour that secretes hormones such as serotonin which causes sx in Ps.

Answer 50

5-HIAA levels (primary metabolite of serotonin) Helps detect serotonin secreting tumours

Answer 51

The rate of complications after gastrectomy and oeophagectomy is 50% overall. Wound healing and abdominal sepsis do occur but are not as common as described. The commonest complication is respiratory infection. It is important to understand the need to undertake a careful assessment of any comorbidity preoperatively, particularly cardiovascular and respiratory. Students should recognise the need for a prehabilitation programme if necessary which includes physiotherapy exercises, weight loss and stopping smoking advice and psychological support.

Answer 52

All of these investigations could be considered for a patient presenting with obstructive jaundice. An US of the abdomen may show a dilated common bile duct with filling defects consistent with stones. US can be difficult to interpret because of overlying bowel gas. CT does show bile duct dilatation and can give a clue to diagnosis particularly if there is a tumour mass as in head of the pancreas cancers. PET-CT is not particularly used in HPB cancers for diagnosis but may have a role for assessment of metastatic disease. MRCP is the investigation of choice as it gives excellent detail of the anatomy of the biliary tree. ERCP can be used and has the advantage of allowing biopsy or cytology brushings from the bile duct lumen (targeted biopsy of pancreatic lesions can be undertaken with endoscopic ultrasound) and enabling stent placement but carries significant morbidity such as a risk of post ERCP pancreatitis.

Answer 53

In the UK the commonest histological type is adenocarcinoma which is increasing in incidence particularly of the oesophago-gastric junction. Men are more commonly affected and increasingly it affects middle aged obese men. There is a familial risk particularly with Barrett’s oesophagus which is columnar cell change associated with gastro-oesophageal reflux. Haematemesis can occur as presentation but it is not common – may be the presenting complaint for a gastric cancer.

Answer 54

Although all of these are associated with the development of gastric cancer H pylori is the only WHO designated cause of gastric cancer. It is particularly responsible for distal gastric cancer. Because HP is commonly diagnosed in investigation for dyspepsia, eradication with antibiotics (clarithromycin, amoxicillin and metronidazole) and proton pump inhibitors is recommended. There are parts of the world particularly in lower socio-economic groups which have a very prevalence in young people with HP who have a high risk of getting gastric cancer.

Answer 55

The commonest associated condition is diabetes. In an elderly patient with a recent diagnosis of diabetes investigations with cross sectional imaging are indicated to exclude a pancreatic cancer. Occasionally a patient may present with acute pancreatitis and have an underlying cancer. Such patients may have a chronic course and the acute becomes a chronic pancreatitis. They frequently develop a mass which can look very suspiciously like a cancer and the diagnosis is only confirmed once the lesion is resected. Gall stones are not associated but a patient may have a palpable gall bladder (Courvoisier’s sign) when they present with jaundice and pancreatic cancer. Gastric ulcer is not associated. Irritable bowel syndrome is not associated but many patients with pancreatic cancer have been treated for IBS because of the non-specific nature of their abdominal discomfort - this is why many patients present late with pancreatic cancer.

Answer 56

Dumping syndrome is caused by the rapid transition of hyperosmolar food into the small intestine caused by the lack of a stomach which usually would begin digestion and only allow small amounts of material at a time to enter the small bowel. Without this, undigested food rapidly enters the small bowel and leads to physiological disturbance which can be significant. It can be separated into two categories – early or late, the features of which are as follows: Early dumping syndrome * Rapid deposition of poorly digested food into small bowel * Extracellular fluid shift from small bowel in response to hyperosmolar load * Abdominal pain, nausea, vomiting, bloating, diarrhoea Reactive hypoglycaemia (late dumping) * Approx. 2 hours after food * Flushing and hypoglycaemia symptoms * High levels of insulin produced due to excessive carbohydrate in small bowel Treatment of dumping usually requires diet/lifestyle advice only such as not drinking at the same time as eating or eating smaller meals at a time. Dumping is referred to in the lecture but not expanded upon, but is discussed in more detail in the associated reading material.

Answer 57

Small bowel tumours are rare, making up only <5% of all GI tumours and most are asymptomatic. They are sometimes seen as incidental findings on imaging for other reasons and are very rare as a cause of iron deficiency anaemia. The most common presentation is, however, with an acute episode such as obstruction, perforation or acute bleeding and surgery is often required to deal with the problem. Carcinoid syndrome occurs from the systemic release of biologically active polypeptides, amines or prostaglandins from neuroendocrine tumours and can lead to symptoms such as flushing, wheezing, diarrhoea, fatigue and sometimes cardiac problems. This most often occurs when there are liver metastases from a GI NET as these substances are otherwise usually inactivated in the liver. This is a rare presentation (only approx. 10% patients with NETs).

Answer 58

The correct answer is ulcerative colitis. The incidence of cholangiocarcinoma increases with primary sclerosing cholangitis which is associated with UC (but this is not the only cause of PSC). Coeliac increases the risk of small bowel lymphoma and both Crohn’s and Ulcerative colitis can increase the risk of colorectal cancer. Hirschsprung’s disease is a congenital absence of nerves from part of the bowel, most often the colon, leading to constipation and narrowing. It occurs in around 5,000 live births but is not associated with cholangiocarcinoma.