cancers

Question 1

what type of cancer is pancreatic CA?

Answer 1

adenocarcinoma

Question 2

what are the risk factors pancreatic CA ?

Answer 2

increasing age
smoking 
high fat diet 
DM 
alcoholism 
chronic pancreatitis

Question 3

what are the clinical features of pancreatic CA in the head of the pancreas (65%) ?

Answer 3

• Obstructive jaundice (90%). Due to compression or invasion of the CBD. Gall bladder is typically palpable.
• Pain (70%). Epigastric or left upper quadrant, often vague and radiates to the back.
• Hepatomegaly. Due to metastases.
• Anorexia, nausea and vomiting, fatigue, malaise, dyspepsia, and pruritus.
• Acute pancreatitis. Occasionally the first presenting feature.
• Thrombophlebitis migrans (10%). Presents as emboli; splenic vein thrombosis may lead to splenomegaly in 10% of patient

Question 4

what are the clincal features of pancreatic CA in the body (25%) and tail (10%)

Answer 4

• Usually asymptomatic in the early stages.
• Weight loss and back pain (60%).
• Epigastric mass.
• Jaundice suggests spread to hepatic hilar lymph nodes or metastases.
• Thrombophlebitis migrans (7%).
• Diabetes mellitus (15%)

Question 5

What InV should be done in pancreatic CA?

Answer 5

Abdo US
- pancreatic mass, dilated bile ducts, liver mets

Pancreatic protocol CT

• mass in pancreas,
• given to all patients with suspected disease on US

LFTs
- increased bilirubin, alk phos, GGT

CA 19-9 elevated

PET-CT
- Mets

FNA and cytology

Question 6

what is the treatment for pancreatic CA?

Answer 6

For patients with tumours of the head of the pancreas, the most common surgery with curative intent is pancreaticoduodenectomy, also known as a Whipple’s procedure
Pylorus-preserving resections can be attempted in certain cases

For patients with tumours of the body or tail of pancreas, a distal pancreatectomy can often be performed
- complications of anastomotic leak, fistula, adhesions, delayed gastric emptying and DM

Question 7

what palliative options are used in pancreatic CA?

Answer 7

relief of jaundice via ERCP biliary stenting
Pain relief
Percutaneous coeliac nerve block

Question 8

what are the types of oesophageal CA?

Answer 8

Squamous cell carcinoma

• middle and upper third
• smoking and alcohol

adenocarcinoma

• lower third
• barretts oesophagus and GORD

Question 9

what are the S&S of oesophageal CA?

Answer 9

dysphagia 
odynophagia 
weight loss 
hoarseness 
post prandial cough 
haematemesis 
cervical lymphadenopathy

Question 10

what are the symptoms of local invasion in oesophageal CA?

Answer 10

Dysphonia in recurrent laryngeal nerve
palsy

cough and haemoptysis in tracheal invasion

neck swelling in superior vena cava (SVC) obstruction,

Horner’s syndrome in sympathetic chain invasion.

Question 11

what InV are done in oesophageal CA?

Answer 11

OGD with biopsy

comprehensive metabolic profile (decreased K+ and increased urea and creatinine)

CT CAP + PET-CT

FNA lymph nodes

Question 12

what is the management of oesophageal CA ?

Answer 12

endoscopic resection with/without ablation

oesophagectomy

chemo/radio

dysphagia can be treated with stenting

nutritional support

PEG feed

Question 13

what is the main type of gastric cancer?

Answer 13

mostly adenocarcinomas

Question 14

what is the aetiology of gastric CA?

Answer 14

nitrosamine rich diet (smoked fish and pickled fruit)

H. Pylori

Smoking and alcohol

increased age

Question 15

what are the S&S of gastric malignancy?

Answer 15

dyspepsia (new onset >45 should be considered adenocarcinoma until proven otherwise)

early satiety

weight loss, anorexia and lethargy

anaemia

acute upper GI bleed

palpable gastric mass

palpable supraclavicular lymph nodes

Question 16

what are the InV for gastric CA?

Answer 16

OGD with biopsy. Biopsy sent for;

• Histology – for classification and grading of any neoplasia present
• CLO test – for the presence of H. Pylori
• HER2/neu protein expression – this will allow for targeted monoclonal therapies if present

CT CAP

Laparoscopy to look for peritoneal mets

Question 17

what are the treatments for gastric malignancy?

Answer 17

proximal tumours = total gastrectomy

distal tumours = subtotal gastrectomy

The most commonly used method in reconstructing the alimentary anatomy is the Roux-en-Y reconstruction as it gives the best functional result, in particular with less bile reflux. Post-gastrectomy, distal oesophagus is end-to-end anastomosed directly to the small bowel, and the proximal small bowel is end-to-side anastomosed also to the small bowel

adjunct chemo

Question 18

what are the complications of gastrectomy?

Answer 18

death (3-5%)
anastomotic leak (5-10%)
re-operation
dumping syndrome
vitamin B12 deficiency (patients need 3-monthly vitamin B12 injections).

Question 19

what is gastric dumping syndrome

Answer 19

Gastric dumping syndrome is a common complication of gastric bypass surgery and can occur as an early and late phenomena:

Early (10-30 minutes post-prandial)
– Sudden and large passage of hypertonic gastric contents into the small intestine, resulting in an intraluminal fluid shift and subsequent intestinal distention. This causes symptoms of nausea, vomiting, diarrhoea, and hypovolaemia – leading to a sympathetic response, predominating with tachycardia and diaphoresis.

Late (1-3 hours post prandial)
– The surge in insulin production following the ‘dumping’ of food results in hypoglycaemia.
Gastric dumping syndrome can usually be managed by small volume and more frequent meals, avoidance of simple carbohydrates, and separation of eating and drinking (to avoid heavy loads on the stomach). These patients should be referred to a dietitian.