LGI

Question 1

A tumour is CK20 positive- this suggests which primary?

Answer 1

Adenocarcinoma of large bowel origin

Question 2

How do you treat early and late onset irinotecan diarrhoea?

Answer 2

Early (24 hrs) high dose loperamide

Question 3

Taking which drugs reduces risk of rectal cancer?

Answer 3

NSAIDs

Question 4

What is the most common molecular abnormality in rectal cancer?

Answer 4

Chromosomal instability

MSI is rare

Question 5

What is the frequency of BRAF mutations like in rectal cancer?

Answer 5

Low- unlike colon cancer

Question 6

Indications post op DXT in a pt who has upfront surgery for rectal cancer?

Answer 6

Involved CRM

Question 7

Indications post op chemo in a pt who has upfront surgery for rectal cancer?

Answer 7

Positive nodes

Tumour perforation

Question 8

How long should oxali be given over to prevent pharyngolaryngeal dysethesia from recurring?

Answer 8

6 hours

Question 9

The highest lymph node in the chain closest to the surgical tie is involved. What is it called and what Duke’s stage does it make it?

Answer 9

The high tie node

DUKE’s C2

Question 10

Most common gene mutation in Lynch syndrome?

Answer 10

MSH2

Others MLH1 and MSH6

Question 11

In what percent of anal SCC is HPV16 and 18 found?

Answer 11

90%

Question 12

Is there screening for anal cancer in the UK?

Answer 12

Not currently

Question 13

What is Gardasil?

Answer 13

Quatravalent vaccine against HPV 6, 11, 16 and 18
Protects against genital warts and cancer of the anus vagina and vulva
Boys not currently vaccinated

Question 14

What percent of AIN 3 will progress to invasive anal cancer?

Answer 14

5%

Question 15

What is the dentate line?

Answer 15

Line where below it the epithelium is squamous (it’s near the internal anal sphincter)

Question 16

What percent of palpable inguinal nodes in anal cancer work up turn out to be malignant?

Answer 16

Only 50%- need FNA to confirm

Question 17

Is PET useful for anal cancer staging?

Answer 17

Yes to pick up distant mets and is high sensitivity for nodes

Question 18

How is the T stage in anal cancer worked out?

Answer 18

Size related 
T1 up to 2cm
T2 up to 5cm
T3 more than 5cm 
T4 any size invading adjacent organ (subcut tissue or sphincter doesn't count)

Question 19

What percent of anal cancer is node positive at presentation? What does this mean for survival?

Answer 19

40% node positive

5 year survival 45%

Question 20

Tell me about nodal staging anal cancer?

Answer 20

It's based on LOCATION of nodes 
N0 none 
N1 peri rectal
N2 unilateral internal iliac or inguinal 
N3 bilat inguinal

Question 21

What is the management of anal cancer?

Answer 21

Majority of patients definitive chemoradiotherapy

Only a v few T1 are suitable for excision biopsy (IE less than 2cm) - if leaves residual disease then give them chemoRT

Question 22

What is the regimen of chemo RT for anal SCC?

Answer 22

DXT 50.4 Gy in 28# to primary and nodes
Chemo 5FU pumps (or cap) in two four day blocks
Mitomycin C bolus day 1 only

Question 23

What is the complete response rate for definitive CRT for anal SCC?

Answer 23

80% (impressive!)

Question 24

How long does it take for a tumour to regress completely after CRT for anal SCC?

Answer 24

6 months- don’t over biopsy

If patient fails then for salvage surgery- AP resection with stoma

Question 25

What are the side effects of Mitomycin C?

Answer 25

Myelosupression- check weekly FBC Dermatitis Pulmonary fibrosis Haemolytic uraemic syndrome

Question 26

What changes have to be made if a patient with HIV has treatment for anal SCC with chemo RT?

Answer 26

None if CD4>400 | If CD4

Question 27

What is first line chemo for metastatic anal cancer?

Answer 27

Cis 5FU

Question 28

Should you resect oligo met anal SCC?

Answer 28

No evidence for it but there are some case reports of successful liver met resections

Question 29

Are polyps a big deal?

Answer 29

Well ALL colorectal cancer originally arises within precursor polyps so you could say so

Question 30

What kind of polyp is the most risky in terms of CRC?

Answer 30

Pedunculated

Question 31

What is the 10 year risk of a > 1cm polyp progressing to cancer?

Answer 31

15%

Question 32

Name the three main molecular patterns of CRC?

Answer 32

(1) Chromosome unstable (80%) lots of chromosomal stuff (2) DNA mismatch repair (15%) 1000's of point mutations, small del, ins (3) "serrated" CpG island hypermethylation. BRAF Mutant. RIGHT Sided.

Question 33

RR of CRC if longstanding UC?

Answer 33

X10

Question 34

% CRC familial

Answer 34

5%

Question 35

Two main types familial CRC

Answer 35

FAP (APC gene) HNPCC (Lynch syndrome) DNA mismatch repair (MSH2 most common)

Question 36

Which familial CRC syndrome get tumours youngest?

Answer 36

FAP - have to start annual colonoscopy age 10! | In HNPCC start colonoscopy age 30

Question 37

Management of risk in APC?

Answer 37

100% risk of CRC by age 40 so it's intensive Annual colonoscopy from age 10 OGD age 25 NSAIDS Prophylactic colectomy and monitor rectal stump

Question 38

What kind of gene is APC?

Answer 38

Gatekeeper TSG- controls wnt signalling pathway

Question 39

Common mutations in CRC (4)

Answer 39

APC KRAS P53 PIK3CA

Question 40

Two prognostic molecular biology factors in CRC:

Answer 40

Poorer prognosis 18q alleli can loss | MSI/MMR may identify patients at lower risk of recurrence

Question 41

Describe the UK bowel screening program

Answer 41

Part 1 Age 60-74 faecal occult blood every 2 years reduces CRC mortality by 15% In in 10 of those with positive FOBT will turn out to have cancer Part 2 one off flexi sig age 55 NNTS 300 to pick up one CRC (ESMO don't recommend a one off sigi)

Question 42

Adverse signs in a colorectal polyp - unfavourable histology meaning operative resection needed

Answer 42

``` Invasion into stalk Grade 3 LVI Involved margin Invades sub mucosa ```

Question 43

What structure do malignant cells have to cross in the bowel wall for them no longer to be in situ but become invasive?

Answer 43

Lamina propria

Question 44

What is the significance of an elevated pre op CEA?

Answer 44

CEA>5 worse prognosis | Should normalise by 1 month post operative

Question 45

How many nodes should be examined in CRC surgery?

Answer 45

At least 12

Question 46

What is Dukes C1 disease in CRC?

Answer 46

Node positive but the highest node IE nearest surgical tie is negative

Question 47

Who gets adjuvant treatment in CRC?

Answer 47

``` YES Node positive (stage 3 or dukes C) PLUS High risk Dukes B (t3 or t4) plus high risk features like Less than 12 LN sampled Poorly diff LVI Perf/obstr ```

Question 48

What is the evidence for not giving oxaliplatin to patients over age 70?

Answer 48

MOSAIC trial sub analysis >70 did not benefit from adding oxaliplatin

Question 49

What proximal and distal margins are needed with surgery for CRC?

Answer 49

5cm

Question 50

Where is the cut off between rectal cancer and colon cancer?

Answer 50

15 cm from the anal margin

Question 51

What is T2 and T3 rectal cancer?

Answer 51

T2 is in the muscularis propria | T3 is in the subserosal/ perirectal tissue

Question 52

If rectal cancer has reached the serosal surface what stage is that?

Answer 52

T4a invasion of the visceral peritoneum

Question 53

What is the impact on prognosis in CRC if a patient has BRAF mutation?

Answer 53

Adverse prognostic indicator | No consistent data on impact of EGFR treatment

Question 54

Describe TNM anal scc

Answer 54

T1 up to 2cm T2 up to 5cm T3 more than 5cm T4 any size invades adj organ N1 perirectal N2 unilat int iliac or unilat inguinal N3 bilat inguinal

Question 55

Indications for post Op RT in rectal cancer And indications for post op chemo

Answer 55

Involved CRM Tumour perf Chemo: Positive nodes Tumour perforation

Question 56

A rectal tumour extends 1mm from rectal wall what T stage is that?

Answer 56

T3a

Question 57

Age a first degree relative has to be diagnosed with bowel cancer to make you at increased risk?

Answer 57

Below age 50