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GASTROENTEROLOGY 2 > GASTROINTESTINAL CANCERS > Flashcards

GASTROINTESTINAL CANCERS Flashcards

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1
Q

Which cancers arise from epithelial cells?

A

Squamous cell carcinoma - squamous epithelium

Adenocarcinoma - glandular metaplastic columnar epithelium

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2
Q

Which cancers arise from neuroendocrine cells?

A 
Neuroendocrine tumours (NETs) - enteroendocrine cells
Gastrointestinal stromal tumours (GISTs) - interstitial cells of Cajal
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3
Q

Which cancers arise from connective tissue?

A

Leiomyoma/leiomyosarcomas - smooth muscle

Liposarcomas - adipose tissue

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4
Q

How does alcohol increase risk of oesophageal cancer?

A

Via the acetaldehyde pathway (metabolism of alcohol which produces acetaldehyde - a carcinogen)

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5
Q

What part of the oesophagus does SSC affect?

A

upper 2/3

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6
Q

What part of the oesophagus does adenocarcinoma affect?

A

lower 1/3

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7
Q

What is oesophageal adenocarcinoma related to?

A

Acid reflux

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8
Q

Describe the steps from acid reflux to oesophageal adenocarcinoma

A

Oesophagitis - inflammation from GORD
Barrett’s - metaplasia 5% of GORD population
Adenocarcinoma - neoplasia

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9
Q

What are the stages of progression of Barrett’s oesophagus to adenocarcinoma which can be seen on biopsy?

A

Dysplasia (low grade)
Dysplasia (high grade)
Adenocarcinoma

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10
Q

How often do the different stages of dysplasia for Barrett’s need to be surveilled?

A

No dysplasia - every 2/3 years
LGD - every 6 months
HGD - intervention (likely invasive cancer)

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11
Q

What population does oesophageal cancer affect?

A

elderly with adenocarcinoma 10:1 male:female

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12
Q

How does oesophageal cancers present?

A

Late presentation with dysphagia and weight loss

Palliation is difficult and must rely on stents

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13
Q

What is the prognosis for oesophageal cancer patients?

A

High morbidity and a complex surgery
65% of patients palliative

5-year survival < 20% even with surgery

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14
Q

How are oesophageal cancers diagnosed?

A

Endoscopy then biopsy to confirm

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15
Q

What procedures can you undertake to stage oesophageal cancers?

A

CT scan
Laparoscopy - check metastases

Maybe endoscopic ultrasound if cancer is submucosal/not in visible in lumen

Maybe PET scan to pick up on metastases that aren’t seen by other imaging

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16
Q

How are oesophageal cancers treated?

A

Curative:
Squamous cell carcinoma- radiotherapy usually
Adenocarcinomas - neo-adjuvant chemo then surgery

Palliative (65%):

  • Chemo
  • DXT
  • Stent
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17
Q

What is a surgical procedure for oesophageal adenocarcinomas?

A

2 stage Ivor Lewis oesophagectomy:

  • Remove upper part of stomach
  • Open chest and resect malignant oesophagus
  • Rejoin stomach and oesophagus
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18
Q

What is the most common GI cancer in western societies?

A

Colorectal cancer

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19
Q

What age group does colorectal cancer tend to affect?

A

> 50 years

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20
Q

What is the lifetime risk for men and women

A

1/10 for men
1/14 for women

3rd most common cancer death

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21
Q

What are the 3 forms of colorectal cancer?

A

Sporadic - acquired, older population, isolated lesion

Familial - genetics (relative is usually close), more risk if < 50 years

Hereditary syndrome - genetics, younger age of onset, specific gene defects.

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22
Q

What are some examples of hereditary syndrome colorectal cancer?

A

Familial adenomatous polyposis (FAP)

Hereditary nonpolyposis colorectal cancer (Lynch syndrome)

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23
Q

What is the histopathology of colorectal cancer?

A

Adenocarcinoma

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24
Q

What are the risk factors for colorectal cancer?

A

Past history of colorectal cancer, adenoma, ulcerative colitis, radiotherapy

Family history
Diet/Environmental - smoking, obesity etc.

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25
How does a left sided and sigmoid colorectal carcinoma present?
``` PR bleeding and mucus Thin stool (late) Bowel obstruction (late) ```
26
How does a rectal colorectal carcinoma present?
PR bleeding and mucus Tenesmus (wanting to poop but nothing comes out) Anal/perineal/sacral pain (late) Bowel obstruction (late)
27
How does a caecal and right sided carcinoma present?
Iron deficiency anaemia - tumour more likely to bleed Change of bowel habit (diarrhoea) ``` Distal ileum obstruction (late) Palpable mass (late) ```
28
How will a late local invasion of colorectal cancer present?
Bladder symptoms | Female genital tract symptoms
29
How will a late metastasis of colorectal cancer present?
``` Liver (hepatic pain, jaundice, hepatomegaly) Lung (cough, monophonic wheeze) Regional lymph nodes Peritoneum (sister Mary Joseph nodule) Bone pain ```
30
What are some signs that a colorectal cancer is primary?
``` Abdominal mass (late) < 12 cm from pectinate/dentate line Abdominal tenderness and distention - large bowel obstruction ```
31
List the tests that can be done to investigate colorectal cancer
Faecal occult blood (blood invisible in poo)tests: - Guaiac test - Faecal immunochemical test (FIT) Blood tests: - FBC (anaemia, haematinics, ferritin) - Tumour markers (not diagnosis tool) e.g. CEA for monitoring
32
Describe the guaicac test
Test for colorectal cancer based on pseudoperoxidase activity of haematin Must avoid red meat, melons, horse-radish, vitamin C and NSAIDs for 3 days before test
33
What imaging can be done to investigate colorectal cancer?
Colonoscopy CT colonoscopy/colonography Pelvic MRI for rectal cancer CT chest/abdo/pelvis
34
Why is colonoscopy done for colorectal cancer patients?
Can see lesions < 5mm Small polyps can be removed to reduce cancer incidence Performed under sedation
35
Why is CT colonoscopy/colonography done for colorectal cancer patients?
Can see lesions > 5mm No need for sedation and less invasive/better tolerated than normal colonoscopy However if lesions are identified patient will still nee colonoscopy for diagnosis
36
Why is pelvic MRI done for rectal cancer patients?
Check depth of invasion and mesorectal lymph node involvement. No bowel prep or sedation Helps to choose between preoperative chemo/radiotherapy or straight to surgery
37
Why is CT chest/abdo/pelvis done for rectal cancer patients?
Staging prior to treatment
38
How is colorectal cancer managed?
Primarily surgery Stent/radiotherapy/chemotherapy to give time to plan surgery
39
How would an obstructing colon carcinoma in the right and transverse colon be treated?
Resection and primary anastomosis
40
How would a left sided obstructing colon carcinoma be treated?
Hartmann's procedure with/out reversal in 6 months Primary anastomosis with intraoperative bowel lavage (occasionally done) - might first do defunctioning ileostomy to allow colon to heal after resection Palliative stent
41
What is Hartmann's procedure?
Resect away tumour and surrounding colon then join proximal bowel to abdominal skin forming proximal end colostomy
42
List the surgical procedures for resection of a right sided cancer and the parts resected
Right hemicolectomy - caecum and ascending colon | Extended right hemicolectomy - portion of transverse colon too
43
Name the surgical procedure for resection of a left sided cancer and the parts resected
Left hemicolectomy - descending colon
44
If a patient has rectal cancer what is resected?
Part of rectum and part of sigmoid colon
45
What is the most common form of pancreatic cancer?
Pancreatic ductal adenocarcinoma (PDA)
46
Why should pancreatic cancer be taken seriously?
80-85% have late presentation and 5 year survival is 0.4-5% Only 15-20% have a resectable disease and virtually all patients are dead with 7 years of surgery
47
What are the risk factors for pancreatic cancer?
``` Chronic pancreatitis (inflammation, healing cycle) T2DM Cholelithiasis Previous gastric surgery Pernicious anaemia Diet Occupation (insecticides...) Smoking Family history ```
48
What are some inherited syndromes associated with increased pancreatic cancer risk?
``` Hereditary pancreatitis Familial atypical multiple mole melanoma Familial breast-ovarian cancer syndrome Peutz-Jeghers syndrome HNPCC (lynch syndrome) FAP ```
49
How does pancreatic ductal adenocarcinoma (PDA) evolve?
PDAs evolve through non-invasive neoplastic precursor lesions called pancreatic intraepithelial neoplasias (PanIN 1/2/3) These are similar to colorectal polyps and are microscopic
50
What is the PanIN progression model?
PanIN 1 PanIN 2 PanIN 3 (step before pancreatic cancer)
51
How would a carcinoma of the head of the pancreas present?
Jaundice (invasion or compression of common bile duct) Weight loss (malabsorption, diabetes) Pain (sign of locally invasive) ``` Acute atypical attack pancreatitis (rare) Vomiting (advanced - duodenal obstruction) GI bleeding (duodenal invasion/varices secondary to portal/splenic vein occlusion) ```
52
What does pain radiating to the back in a patient with pancreatic cancer signify?
Basically inoperable since it is now extraperitoneal due to posterior capsule invasion
53
How would a carcinoma of the body and tail of the pancreas present?
Develops insidiously and asymptomatic in early stages When diagnosed much more advanced than pancreatic head lesions Marked weight loss Back pain Vomiting (late stage invasion of DJ flexure) Most unresectable at time of diagnosis
54
What are the investigations for pancreatic cancer?
``` Tumour marker CA19-9 Ultrasonography Dual-phase CT MRI MRCP ERCP EUS Laparoscopy + laparoscopic ultrasound PET ```
55
What does a tumour marker CA19-9 test show?
Falsely elevated in pancreatitis, hepatic dysfunction and obstructive jaundice. Concentrations > 200 U/ml = 90% sensitivity
56
What is the purpose of ultrasonography in pancreatic cancer?
Identifies: - Pancreatic tumours - Dilated bile ducts - Liver metastases
57
What is the purpose of dual-phase CT in pancreatic cancer?
Predicts resectability, looks at: - Contiguous organ invasion - Vascular invasion - Different metastases
58
What is the purpose of MRI in pancreatic cancer?
Detects and predicts resectability - similar to CT
59
What is the purpose of MRCP in pancreatic cancer?
Provides ductal images without complications of ERCP
60
What is the purpose of ERCP in pancreatic cancer?
Confirms typical 'double duct' sign Aspiration/brushing of bile duct system Therapeutic modality Allows you to take biopsies to confirm diagnosis
61
What is the purpose of EUS in pancreatic cancer?
Detection of small tumours Assessing vascular invasion Fine needle aspirations to look at cells
62
What is the purpose of laparoscopy + laparoscopic ultrasound in pancreatic cancer?
Detect radiologically occult metastatic lesions of liver and peritoneal cavity
63
What is the purpose of PET in pancreatic cancer?
Mainly for demonstrating occult metastases
64
If a tumour is present at the head of the pancreas what is the surgical procedure?
Whipple's resection - head of pancreas, gall bladder, duodenum, distal bile duct
65
If a tumour is present at the tail of the pancreas what is the surgical procedure?
Distal pancreatectomy - tail of pancreas, splenic artery and spleen
66
What are 4 cancers that can affect the liver?
Hepatocellular cancer (HCC) (primary liver cancer) Colorectal cancer liver metastases Cholangiocarcinoma Gall bladder cancer
67
Name two potential causes of hepatocellular carcinoma
Cirrhosis (70-90%) | Aflatoxin
68
What is the median survival for hepatocellular carcinoma without treatment?
4-6 months
69
List the treatments for hepatocellular carcinoma
Liver transplant Transcatheter arterial chemoembolisation (TACE) Radiofrequency ablation (RFA) Surgical excision (optimal curative)
70
Why are only 5-15% of hepatocellular carcinoma patients suitable for surgery?
Most patients have cirrhosis which limits the amount of liver you can take away as they still need some functioning organ
71
What are the causes for gallbladder cancer?
Aetiology unknown but associated with... Gall stones: - porcelain GB (chronic inflammation - calcification) - chronic typhoid infection
72
What is the median survival for gallbladder cancer without treatment?
5-8 months
73
List the treatments for gallbladder cancer
Surgical excision 5 year survival: stage II 64%, stage III 44%, stage IV 8% Systemic chemotherapy ineffective
74
What are some potential causes for cholangiocarcinoma?
Primary sclerosing cholangitis (PSC) Ulcerative collitis Liver fluke (worms) Coledochal cyst
75
What is the median survival for cholangiocarcinoma without treatment?
< 6 months
76
List the treatments for cholangiocarcinoma
Surgical excision 5 year survival rate 20-40% Systemic chemotherapy ineffective
77
What is cholangiocarcinoma and where is it usually found?
Cancer of bile duct an cells most commonly found at bifurcation of common hepatic duct
78
What is the survival rate of secondary liver metastases e.g. colorectal cancer without treatment?
< 1 year
79
List the treatments for secondary liver metastases e.g. colorectal cancer
Surgical excision | 5 year survival rate 20-50%

GASTROENTEROLOGY 2 (7 decks)

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