Gastrointestinal Cancers

Question 1

Define cancer

Answer 1

A term for diseases in which abnormal cells divide without control and can invade nearby tissues

Question 2

What is a primary cancer?

Answer 2

A cancer arising directly from cells in the organ

Question 3

What is a secondary cancer?

Answer 3

A cancer that spreads from another organ, directly or by other means (blood or lymph)

Question 4

What are the 6 main hallmarks of cancer?

Answer 4

Sustaining proliferative signalling
Evading growth suppressors
Activating invasion and metastasis
Enabling replicative immortality
Inducing angiogenesis
Resisting cell death

Question 5

What are the epithelial cell GI cancers?

Answer 5

Squamous cell carcinoma

Adenocarcinoma

Question 6

What are the neuroendocrine GI cancers?

Answer 6

Neuroendocrine tumours

Gastrointestinal stromal tumours

Question 7

What are the connective tissue GI cancers?

Answer 7

Leiomyoma/leiomyosarcoma

Liposarcoma

Question 8

Where in the GI tract do neuroendocrine tumours occour?

Answer 8

Anywhere along the tract

Question 9

Define cancer screening

Answer 9

Testing of asymptomatic individuals to identify cancer at an early stage

Question 10

What criteria is used to decide if it is useful to screen for a disease?

Answer 10

Wilson Junger criteria

Question 11

How is screening for colorectal cancer carried out?

Answer 11

FIT= faecal immunochemical test which detects haemoglobin in the faeces
One off sigmoidoscopy

Question 12

How is screening for oesophageal cancer carried out? And for which patients?

Answer 12

Regular endoscopy for patients with Barrett’s oesophagus, low or high grade dysplasia

Question 13

How is screening for pancreatic and gastric cancer carried out?

Answer 13

No test currently as it doesn’t meet the W & J criteria

Question 14

How is screening for hepatocellular cancer carried out?

Answer 14

Regular ultrasound and AFP for high risk patients and those with cirrhosis

Question 15

What is the first step in a cancer journey?

Answer 15

Presenting to the GP with symptoms or being identified via a screening programme

Question 16

What happens after cancer is initially suspected?

Answer 16

Patients are referred via 2 week wait pathway

Question 17

In the cancer MDT what is role of pathologist?

Answer 17

Confirm cancer diagnosis using biopsy samples
Provide histological typing eg where does the cancer come from
Provide molecular typing eg what mutations does the cancer have
Provide the tumour grade

Question 18

In the cancer MDT what is role of radiologist?

Answer 18

Review scans
Suggest other imaging to clarify diagnosis
Decide if a biopsy needs to be performed and where
Provide tumour stage
Re staging after treatment

Question 19

In the cancer MDT what is role of surgeon?

Answer 19

Decide if surgery is appropriate

Perform operation and care for patient after the operation

Question 20

In the cancer MDT what is role of gastroenterologist?

Answer 20

Endoscopy, either diagnostic or therapeautic

Question 21

In the cancer MDT what is role of oncologist?

Answer 21

Decides on whether chemotherapy, radiotherapy or other systemic therapy is appropriate
Co ordinates overall treatment plan

Question 22

What is the major driver for gastric adenocarcinoma?

Answer 22

Chronic gastritis due to chronic acid overproduction

Question 23

Describe the pathogenesis of gastric adenocarcinoma

Answer 23

Chronic gastritis, intestinal metaplasia, dysplasia and malignancy

Question 24

What is the main symptom gastric adenocarcinoma presents with?

Answer 24

Dyspepsia (upper abdominal discomfort after eating or drinking)

Question 25

What acronym is used to remember red flags of gastric adenocarcinoma and what does it stand for?

Answer 25

``` ALARMS55 Anaemia Loss of weight or appetite Abdominal mass on examination Recent onset of progressive symptoms Melaena or haematemesis Swallowing difficulty 55 years and above ```

Question 26

How is gastric adenocarcinoma diagnosed?

Answer 26

Via endoscopy or biopsy

Question 27

How is gastric adenocarcinoma treated if the tumour is close to the OG junction?

Answer 27

Total gastrectomy (the sphincter mechanism cannot be saved)

Question 28

How is gastric adenocarcinoma treated if the tumour is at the OG junction?

Answer 28

Oesophago-gastrectomy

Question 29

How is gastric adenocarcinoma treated if the tumour is far from the OG junction?

Answer 29

Subtotal gastrectomy

Question 30

What types of chemotherapies can be used for gastric adenocarcinoma?

Answer 30

``` Neoadjuvant= to shrink tumour before surgery Adjuvant= needed in advanced tumours to reduce risk of relapse ```

Question 31

Where do neuroendocrine tumours arise from?

Answer 31

The gastreoenteropancreatic tract (stomach, bowel, pancreas) or from the bronchopulmonary system

Question 32

How do NETs present?

Answer 32

Most are asymptomatic and found incidentally

Question 33

What may NETs detrimentally secrete?

Answer 33

Hormones (and their metabolites), mainly serotonin

Question 34

What syndrome occurs when NETs secrete serotonin?

Answer 34

Carcinoid syndrome

Question 35

What is required for carcinoid syndrome to arise?

Answer 35

Liver mets as without these the liver would metabolise the excess serotonin

Question 36

What occurs in carcinoid syndrome?

Answer 36

``` Vasodilation causing face flushing Bronchoconstriction Increased intestinal motility causing diarrhoea Endocardial fibrosis (particularly right sided) ```

Question 37

What are the 2 results of a pancreatic cancer?

Answer 37

Insulinoma | Glucagonoma

Question 38

What are clinical features of insulinoma?

Answer 38

Hypoglycaemia | Whipples triad

Question 39

What is Whipple's triad?

Answer 39

A set of criteria that indicates someone is suffering from hypogylcaemia: Has symptoms of hypoglycaemia Symptoms are relieved by giving IV glucose Fasting hypoglycaemia

Question 40

What are clinical features of glucagonoma?

Answer 40

Diabetes mellitus | Erythema

Question 41

What is insulinoma often misdiagnosed as?

Answer 41

Epilepsy because when blood sugar is low they faint and have seizures, their partners may also think they are drinking as hypoglycaemia makes you act like you are drunk

Question 42

How are NETs diagnosed?

Answer 42

Biochemical assessment | Imaging eg CT/MRI

Question 43

How are NETs graded?

Answer 43

By their mitoses and Ki-67 index

Question 44

Where do GEP NETs most commonly metastasise?

Answer 44

Small intestine, pancreas and colon

Question 45

How are NETs treated?

Answer 45

Mainly via resection May need liver transplant if their are mets Embolisation, medical therapy, targeted therapy or biotherapy may also be done

Question 46

What are structural causes of upper dysphagia?

Answer 46

Pharyngeal cancer | Pharyngeal pouch

Question 47

What are neurological causes of upper dysphagia?

Answer 47

Parkinson’s Stroke Motor neuron disease

Question 48

What are structural causes of lower dysphagia?

Answer 48

Inside (mural and luminal): oesophageal or gastric cancer, stricture, Schatzki ring (hypertrophy of mucosa) Outside (extrinsic compression): lung cancer

Question 49

What are neurological causes of lower dysphagia?

Answer 49

Achalasia | Diffuse oesophageal spasm

Question 50

How can we differentiate between angina and dysphagia?

Answer 50

Angina can occour after meals but will also usually occour after exertion Dysphagia will also cause discomfort seconds after swallowing

Question 51

How do you differentiate between upper or lower oesophageal dysphagia?

Answer 51

If food is painful on swallowing its upper | If food is easy to swallow but feels stuck seconds later its lower

Question 52

How do you differentiate between mechanical and neurological causes of dysphagia?

Answer 52

If both liquids and solids are hard to swallow its likely neurological

Question 53

What can you ask to determine if the patient is at risk of strictures?

Answer 53

History of reflux

Question 54

What happens to albumin levels in anorexia?

Answer 54

May be low/slightly low

Question 55

What are causes of microcytic anaemia?

Answer 55

Iron deficiency Anaemia of chronic disease Thalassaemia Sideroblastic anaemia

Question 56

What are causes of normocytic anaemia?

Answer 56

``` ABCDE: Aplastic anaemia Bleeding Chronic disease Destruction (haemolysis) Endocrine disorders (hypo or hyperthyroidism) ```

Question 57

What are causes of macrocytic anaemia?

Answer 57

``` FAT RBC Foetus (pregnancy) Alcohol excess Thyroid disorders Reticulocytosis B12/folate deficiency Cirrhosis ```

Question 58

What are some common GI causes of iron deficiency anaemia?

Answer 58

Aspirin/ NSAID use Colonic adenocarcinoma Gastric carcinoma Benign gastric ulcer

Question 59

What symptoms suggest colorectal cancer?

Answer 59

Change in bowel habit Blood or mucus in stool Faecal incontinence Tenesmus

Question 60

What is done to ensure the patient hasn't missed blood in stool or urine?

Answer 60

Digital rectal exam | Urine dipstick test

Question 61

How are cancers of the colon treated?

Answer 61

Via surgery to do resection | Accompanied by aggressive chemo and aggressive treatment in general as there are high rates of survival