GI Cancers Flashcards

Question

Colorectal cancer management

Answer 1

Colon cancer is primarily managed by surgery ? Stent/Radiotherapy/Chemotherapy Obstructing colon carcinoma Right & transverse colon – resection and primary anastomosis Left sided obstruction Hartmann’s procedure Proximal end colostomy (LIF) +/- Reversal in 6 months Primary anastomosis Intraoperative bowel lavage with primary anastomosis (10% leak) Defunctioning ileostomy Palliative stent

Answer 2

Aetiology - 70-90% have underlying cirrhosis - Aflatoxin (toxin made by certain fungi) Median survival without Rx 4-6 m 5yr survival <5% Systemic chemotherapy ineffective (RR <20%) Other effective Rx options - OLTx:liver transplant if you have less than 3 cancers in liver and they’re <3cm - TACE:transarterial chemo embolisation (put small catheter in blood dull,T of tumour then embolism blood supply - RFA:radio frequency ablation, stick a needle into tumour and burn it Optimal Rx surgical excision with curative intent - 5yr survival >30% 5-15% suitable for surgery

Answer 3

Aetiology unknown - GS - porcelain GB - chronic typhoid infection Median survival without Rx 5-8 m 5yr survival <5% Systemic chemotherapy ineffective No other effective Rx options Optimal Rx surgical excision with curative intent - 5yr survival: stage II 64%; stage III 44%; stage IV 8% Stage II-transmural invasion of cancer going through mucosa to muscle we can remove some liver and lymph nodes Stage III-begins to invade liver Stage IV-invaded liver >2cm and distal metastasis <15% suitable for surgery

Answer 4

Aetiology - Primary sclerosing cholangitis& Ulcerative colitis - liver fluke (clonorchis sinesis) - choledochal cyst Median survival (depends on site) without Rx <6 m 5yr survival <5% Systemic chemotherapy ineffective GEMCIS - median overall survival 11.7 months* No other effective Rx options (OLTx) Optimal Rx surgical excision with curative intent - 5yr survival 20-40% 20-30% suitable for surgery

Answer 5

15-20% synchronous discovered at the same time, 25% metachronous discovered at different time median survival without Rx <1yr 5yr survival 0% Systemic chemotherapy improving Other effective Rx options (RFA & SIRT) Optimal Rx surgical excision with curative intent - 5yr survival rates of 25-50% 25% suitable for surgery

Answer 6

Best supportive care 4-6 months 5-FU/LV 12-14 months IFL OR FOLFIRI 15-16 months 5 FU/LV and bevacuzimab 18.3 months FOLFOX4 or CAPEOX 19-20 months IFL AND BEVACIZUMAB 20.3 months FOLFOX6 20.6 IFL+BV to OX 25.1 months

Answer 7

IRelatively common & highly lethal: Commonest form of panc CA is pancreatic ductal adenocarcinoma (PDA) 80-85% have late presentation Overall median survival <6 months 5-year survival 0.4 - 5% Incidence ↑er in Western/industrialised countries Rare before 45 years, 80% occur between 60 & 80 years of age Men > women (1.5 - 2:1) UK & USA annual incidence panc CA 100 per million popn 4th commonest cause of cancer death Incidence & mortality roughly equivalent – UK in 2015 9,921 new cases of PDA 9263 deaths from PDA 2nd commonest cause of cancer death – in USA 2030 - 48,000 deaths 15-20% have resectable disease Median survival 11-20 months 5-year survival 20–25% Virtually all pts dead within 7 years of surgery

Answer 8

Chronic pancreatitis → 18-fold ↑er risk Type II diabetes mellitus → relative risk 1.8 Cholelithiasis, previous gastric surgery & pernicious anaemia – WEAK Diet (↑fat & protein, ↓fruit & veg, coffee & EtOH) - WEAK Occupation (insecticides, aluminium, nickel & acrylamide) Cigarette smoking → causes 25-30% PDAs 7-10% have a family history Relative risk of PDA increased by: 2, 6 & 30-fold with: 1, 2 & 3 affected first degree relatives

Answer 9

Heridatery pancreatitis (genes PRSS1,SPINK1,CFTR) genes cause cationic trypsinogen,panc secretory trypsin inhibitors,CFTR prtone Familial atypical mutltiple mole melanoma (gene CDKN2A) which is a tumour suppressor Familial breast ovarian syndrome (BRAC1,BRACW,PALB2) are tumiur suppressors Peutz jeghers syndrome (STK11) tumiur suppressor HNPCC (lynch syndrome) and FAP mismatch repair and tumour support (MLH1,MSH2,MSH6,PMS2)APC

Answer 10

Pancreatic Intraepithelial Neoplasias (PanIN) are precancerous lesions found in pancreatic ducts PDAs evolve through non-invasive neoplastic precursor lesions PanINs are microscopic (<5 mm diameter) & not visible by pancreatic imaging Acquire clonally selected genetic & epigenetic alterations along the way

Answer 11

Normal PANIN-1A (ERBB2 KRAS MUTATION) PANIN-1B PANIN-2 (CDKN2A) OANIN-3 (TP53,SMAD4,BRCA2) Minimal changes in 1 to moderate dysplasia

Answer 12

Carcinoma of the head of the pancreas At least two-thirds of PDAs arise in the head • Jaundice >90% due to either invasion or compression of CBD - often painless - palpable gallbladder (Courvoisier’s sign) • Weight loss - anorexia - malabsorption (secondary to exocrine insufficiency) - diabetes. • Pain 70% at the time of diagnosis - epigastrium - radiates to back in 25% - back pain usually indicates posterior capsule invasion and irresectability. • 5% atypical attack of acute pancreatitis. • In advanced cases, duodenal obstruction results in persistent vomiting. • Gastrointestinal bleeding - duodenal invasion or varices secondary to portal or splenic vein occlusion.

Answer 13

Develop insidiously and are asymptomatic in early stages At diagnosis they are often more advanced than lesions located in the head There is marked weight loss with back pain in 60% of patients. Jaundice is uncommon Vomiting sometimes occurs at a late stage from invasion of the DJ flexure Most unresectable at the time of diagnosis

Answer 14

Tumour marker CA19-9 - falsely elevated in pancreatitis, hepatic dysfunction & obstructive jaundice. - concentrations > 200 U/ml confer 90% sensitivity - concentrations in the thousands associated with high specificity • Ultrasonography - can identify pancreatic tumours - dilated bile ducts - liver metastases • Dual-phase CT accurately predicts resectability in 80–90% of cases - contiguous organ invasion - vascular invasion (coeliac axis & SMA) - distant metastases

Answer 15

MRI imaging detects and predicts resectability with accuracies similar to CT MRCP provides ductal images without complications of ERCP • ERCP - confirms the typical ‘double duct’ sign - aspiration/brushing of the bile-duct system - therapeutic modality → biliary stenting to relieve jaundice EUS - highly sensitive in the detection of small tumours - assessing vascular invasion - FNA • Laparoscopy & laparoscopic ultrasound - detect radiologically occult metastatic lesions of liver & peritoneal cavity PET mainly used for demonstrating occult metastases

Answer 16

Arise from the gastroenteropancreatic (GEP) tract (or bronchopulmonary system) Diverse group of tumours Regarded as common entity as arise from secretory cells of the neuroendocrine system Sporadic tumours in 75% Associated with a genetic syndrome in 25% Multiple Endocrine Neoplasia Type 1 (MEN1) Parathyroid tumours Pancreatic tumours Pituitary tumours

Answer 17

Most NETs are asymptomatic & incidental findings Secretion of hormones & their metabolites in 40% serotonin, tachykinins (substance P) & other vasoactive peptides < 10% of NETs produce symptoms Can result in a variety of debilitating effects Carcinoid syndrome Vasodilatation Bronchoconstriction ↑ed intestinal motility Endocardial fibrosis (PR & TR)

Answer 18

Pancreatic: Insulinoma-hypoglycaemua,whipples triad Glucagonoma-diabetes mellitus,necrolytic migratory erythema Pancreatic/duodenal: Gastrinoma-zollinger ellison syndrome Entire GIT VIPoma-vernor morrison syndrome,watery diarrhea Somatostatinima-gallstones,diabetes,steatorrhea Midgut-most are non functioning some may develop carcinoid syndrome Hindgut-usually non functioning

Answer 19

Biochemical Assessment Chromogranin A is a secretory product of NETs Other gut hormones: insulin, gastrin, somatostatin, PPY Measured in fasting state Other screening: Calcium, PTH, prolactin, GH 24 hr urinary 5-HIAA (serotonin metabolite) Imaging Cross-sectional imaging (CT and/or MRI) Bowel imaging (endoscopy, barium follow through, capsule endoscopy) Endoscopic ultrasound Somatostatin receptor scintigraphy 68Ga-DOTATATE PET/CT most sensitive

Answer 20

G1-mitosis <2-10 HPF, ki67 <=2 G2-mitosis 2-20 HPF,ki67 3-20% G3->20/10 HPF ki67 >20% High grade (poorly differentiated)Neuroendocrine carcinoma

Answer 21

Curative resection (R0) Cytoreductive resection (R1/R2) Liver transplantation (OLTx) RFA, microwave ablation Embolisation (TAE), chemoembolisation (TACE) Selective Internal RadioTherapy (SIRT) 90Y-Microspheres Somatostatin receptor radionucleotide therapy 90Y-DOTA 177 Lu-DOTA Medical therapy, targeted therapy, biotherapy Octreotide, Lanreotide, SOM203 PK-inhibitors, mTOR-inhibitors ⍺-Interferon

Answer 22

head of pancreas and tail of pancreas surgical removement

GI Cancers Flashcards

(46 cards)