1b GI Cancer Flashcards
1
Q
What is a cancer?
A
A disease caused by an uncontrolled division of abnormal cells in a part of the body
2
Q
What is the difference between primary and secondary cancer?
A
Primary = arising directly from cells in an organ
Secondary = Spread from another organ, directly or by other means (blood and lymph)
3
Q
What are cancers from squamous epithelium called?
A
Squamous Cell Carcinoma (SCC)
4
Q
What are cancers of glandular epithelium called?
A
Adenocarcinoma
5
Q
What are cancers of enteroendocrine cells called?
A
Neuroendocrine tumours (NETs)
6
Q
What are cancers of the interstitial cells of Cajal called?
A
Gastrointestinal Stromal Tumours (GISTs)
7
Q
What are cancers of the smooth muscle called?
A
Leiomyoma / leiomyosarcomas
8
Q
What are cancers of the adipose tissue called?
A
Liposarcomas
9
Q
What are the three forms of colorectal cancer?
A
Sporadic
Familial
Hereditary syndrome
10
Q
Describe the histopathology of colorectal cancer?
A
Adenocarcinoma
11
Q
Which type of colorectal cancer is present in older populations, with an absence of family history and generally an isolated lesion?
A
Sporadic
12
Q
Which type of colorectal cancer is present with patients with a family history, younger age of onset and specific gene defects?
A
hereditary syndrome
13
Q
What can PREVENT the normal epithelium to become hyperproliferative epithelium?
A
Aspirin and other NSAIDs
Folate
Calcium
14
Q
Which mutation is involved with the formation of hyperproliferative epithelium?
A
APC mutation
15
Q
Which mutation is involved with the formation of A large adenoma?
A
K-Ras mutation
16
Q
What STOPS the formation of a large adenoma from a small adenoma?
A
Oestrogen
Aspirin and other NSAIDs
17
Q
Which two genetic events result in the formation of a colon carcinoma from a large adenoma?
A
Loss of 18q
p53 mutation
18
Q
What are the past history risk factors for colorectal cancer?
A
Adenoma, ulcerative colitis, radiotherapy
19
Q
Having which condition in your family history will increase the risk of colorectal cancer?
A
Peutz-Jegher’s syndrome - rare disorder in which growths called polyps form in the intestines, HNPCC, FAP
20
Q
What are the diet and environmental risk factors for colorectal cancer?
A
Smoking
Obesity
Socioeconomic status
carcinogenic foods?
21
Q
What are the clinical presentations of caecal and right sided cancer?
A
Iron deficiency anaemia (most common)
Change of bowel habit (diarrhoea)
Distal ileum obstruction (late)
Palpable mass (late)
22
Q
What are some clinical presentations of left sided and sigmoid carcinoma?
A
PR bleeding, mucus
Thin stool - late sign
23
Q
What are some symptoms of a rectal carcioma?
A
PR bleeding, mucus
Tenesmus - continutally needing to empty bowels
Anal, perineal, sacral pain (late)
24
Q
What are some signs of a local invasion?
A
Bladder symptoms
Female genital tract symptoms
25
What are some signs of a metastasized colorectal cancer ?
Liver (hepatic pain, jaundice)
Lung (cough)
Regional lymph nodes
Peritoneum - Sister Marie Joseph nodule
26
What are signs of primary cancer?
Abdominal mass
DRE: most <12cm dentate and reached by examining finger
Rigid sigmoidoscopy
Abdominal tenderness and distension – large bowel obstruction
27
What are some signs of metastasis of colorectal cancer which involve other body systems?
Hepatomegaly (mets)
Monophonic wheeze – lung metastasis
Bone pain
28
What is the FIT test?
FIT (Faecal Immunochemical Test) - detects minute amounts of blood in faeces (faecal occult blood).
29
Which tumour marker is a good indicator of colorectal cancer?
Tumour markers: CEA which is useful for monitoring
30
What is the difference between colonoscopy and FlexiSigmoid?
colonoscopy goes the whole way around, flexi is only in the sigmoid colon
31
what are the benefits of a colonoscopy?
- visualise lesions <5mm
- remove small polyps
- reduce incidence of cancer
32
Which imaging / investigations is used to visualise lesions that are > 5mm in size?
CT colonoscopy/colonography
33
What is the benefit of an MRI of the pelvis?
You are able to visualise the depth of invasion, no bowel prep or sedation is involved
34
What is used to stage colorectal cancer?
CT chest / Abdo / Pelvis
35
What is the primary management of colorectal cancer?
Surgery
Sometimes stent / radiotherapy / chemotherapy
36
How is an obstructing colon carcinoma of the right and transverse colon managed?
Resection and primary anastomosis
Extended right hemicolectomy = right colon and portion of the transverse colon is also removed
37
What is the management of a left sided bowel obstruction?
Hartmann’s procedure
Primary anastomosis
Palliative Stent
38
Why is there a difference in the right sided and left sided colorectal cancer management principles?
Right sided recieves a good blood supply from the middle colic artery, right colic artery and ileocolic artery,, therefore can resect and anastomose
Left sided blood supply is less good, therefore Hartmann's procedure needs to be done, along with anastamosis
39
What type of resection is done when the tumour is in the cecum?
Right hemicolectomy
40
What procedure is done when the tumour is in the ascending colon - right side?
Right and transverse portion of the colon removed in an extended right hemicolectomy
41
What procedure is done when the cancer is left sided, in the descending colon?
left side resected
42
What procedure is done when the cancer is in the rectum?
Formation of a J pouch - join the colon to the anus
43
What is a HCC?
hepatocellular carcinoma
The primary liver cancer
44
What causes HCC?
(cirrhosis, hepatits, alcoholic liver disease, aflatoxin)
45
What is the optimal treatment for HCC?
surgical excision
46
What are other treatments for HCC?
OLTx (orthotic liver transplant)
TACE (transarterial chemoembolisation)
RFA (radiofrequency ablation)
47
What is the survival rate for HCC with different treatment options?
Median survival without treatment is 5-6m
5 year survival <5%
With surgical excision, 5 year survival >30%
-Only 5-15% suitable for surgery6
48
What causes gall bladder cancer?
- Gallstones
- porcelain GB (gallbladder wall encrusted in calcum)
- chronic typhoid infection
49
Survival Rate and treatment options for Gallbladder Cancer?
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%
<15% suitable for surgery
50
What is a ChCA?
Cholangiocarcinomaa
type of cancer that forms in the slender tubes (bile ducts) that carry the digestive fluid bile.
51
What causes a ChCA?
- PSC (Primary sclerosing cholangitis) & Ulcerative Colitis
- liver fluke (clonorchis sinesis)
- choledochal cyst
52
Survival Rate and treatment options for ChCA?
-Median survival (depends on site) without Rx <6 m
- 5yr survival <5%
-Systemic chemotherapy ineffective
-GEMCIS (chemotherapy) - 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
53
What is RFA?
Radiofrequency ablation
a minimally invasive technique that shrinks the size of tumors, nodules or other growths in the body.
54
Survival rate and treatment options for secondary liver metastases?
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
55
What is the most common cause of pancreatic cancer?
pancreatic ductal adenocarcinoma
56
Risk factors for pancreatic cancer?
chronic pancreatitis -18x risk
T2DM -1.8X
Cholelithiasis, previous gastric surgery & pernicious anaemia – WEAK
Diet (↑fat & protein, ↓fruit & veg, coffee & EtOH) - WEAK
Occupation (insecticides, aluminium, nickel & acrylamide)
Cigarette smoking
Family History
57
Describe the pathogenesis of pancreatic cancer?
PDAs evolve through non-invasive neoplastic precursor lesions, which acquire clonally selected genetic and epigenetic alterations along the way.
The pathogenesis involves Pancreatic Intraepithelial Neoplasias (PanIN)
58
What PanIN?
Pancreatic intraepithelial neoplasia (PanIN) is considered a precursor for invasive pancreatic cancer.
PanIN is defined as a microscopic papillary or flat and noninvasive epithelial neoplasm arising from the pancreatic ductal epithelium.
59
What are the clinical presentations of pancreatic cancer of the head of the pancrea?
Jaundice
Weight Loss
Pain
Gastrointestinal Bleeding
60
What is the name of the sign where you have a palpable gall bladder?
Courvoisier Sign
61
What are the causes of weight loss seen in pancreatic cancer?
anorexia
malabsorption
diabetes
62
Why does gastrointestinal bleeding occur in pancreatic cancer?
duodenal invasion or varices secondary to portal or splenic vein occlusion.
63
Cancer of which part of the pancreas is asymptomatic in early stages?
carcinoma or the body and tail of the pancreas
64
What do 60% of patients with pancreatic cancer of the body and tail present with?
Marked weight loss with back pain - no jaundice
65
Which tumour marker is used to indicate pancreatic cancer?
Tumour marker CA19-9
66
Which condition is CA19-9 falsely elevated in?
pancreatitis, hepatic dysfunction and obstructive jaundice
67
What investigation is used to accurately predict the resectability of a pancreatic tumour?
Dual-phase CT
68
What is ultra sonography?
- can identify pancreatic tumours
- dilated bile ducts
- liver metastases
69
What imaging techniques are used for pancreatic cancer?
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
70
Which imaging technique is used to see the double duct sign?
ERCP
71
What is the double duct sign?
A double-duct sign is the combined dilatation of the common bile duct and pancreatic duct, often caused by cancer of the pancreas.
72
Which imaging technique should be used for small tumour detection?
EUS
73
What does laparoscopy and laparoscopic ultra sound detect?
- detect radiologically occult metastatic lesions of liver & peritoneal cavity
74
What are NETs?
neuroendocrine tumours which arise from the gastroenteropancreatic tract
75
Which condition are NETs associated with?
Multiple Endocrine Neoplasia Type 1 (MEN1)
Parathyroid tumours
Pancreatic tumours
Pituitary tumours
76
What are secreted in NETs?
Secretion of hormones & their metabolites in 40%
serotonin, tachykinins (substance P) & other vasoactive peptides
77
What dermatological condition arises from NETs?
carcinoid syndorme
78
What are the symptoms of carcinoid syndrome?
Vasodilatation
Bronchoconstriction
↑ed intestinal motility
Endocardial fibrosis (PR & TR)
79
What are the clinical features of insulinoma?
Hypoglycaemia, Whipple’s triad
Whipples - symptoms of low glucose, low glucose and resolved when glucose in ingested
80
What are the clinical features of glucagonoma?
Diabetes mellitus, necrolytic migratory erythema
ALpha cells
81
What are the clinical features of a gastrinoma?
Zollingere-Ellison syndrome
82
What are the clinical features of a VIPoma?
Verner-Morrison syndrome, watery diarrhoea
83
What are the clinical features of a somatostatinoma?
Gallstones, diabetes mellitus, steatorrhoea
Steatorrhoea = faeces with fat in it
84
What is a secretory product of NETs?
Chromogranin A
85
What are the othwe biochemical assessments for NETs?
- insulin, gastrin,
somatostatin, PPY
-Measured in fasting state
Other screening: Calcium, PTH, prolactin, GH
24 hr urinary 5-HIAA (serotonin metabolite)
86
What imaging is done to diagnose NETs?
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
87
What is the mitoses requirement for G1-G3 cancer?
G1 - <2/10 H.P.F
G2 - 2-20/10 H.P.F
G3 - >20/10 H.P.F
88
What is Ki-67? what are levels in each grade?
Marker of proliferation
less than or equal to 2% = G1
3-20% = G2
> 20% = G3
89
How differentiated is a high grade neuroendocrine carcinoma?
Poorly differentiated
90
What is the most common / effective treatment for NETs?
Curative resection
91
What are the four types of liver cancers?
Hepatocellular cancer
Gallbladder cancer
Cholangiocarcinoma
Colorectal cancer liver metastases
92
What are the cardiac causes of dysphagia?
Post-prandial angina
93
What are the Abdominal causes of upper dysphagia?
Structural causes: Pharyngeal cancer, pharyngeal pouch
Neurological causes: Parkinson’s, stroke, motor neuron disease
94
What are the abdominal causes of lower dysphagia?
Structural causes:
Inside (mural and luminal): oesophageal or gastric cancer, stricture, Schatzki ring
Outside (extrinsic compression): lung cancer
Neurological causes: Achalasia, diffuse oesophageal spasm
95
How to differentiate between dysphagia and angina?
unusual for angina to occur only after eating
Discomfort seconds after swallowing is unusual and suggestive more of dysphagia
96
How to determine whether the pain is of upper or lower oesophageal origin?
Painful on swallowing - upper
Food easy to swallow but feels like it is getting stuck seconds later - lower
97
How to determine if the cause of dysphagia is neurological or not?
if both solids and liquids are hard to swallow - neurological
98
What would blood in the stool suggest?
GI malignanct
99
What are the causes of microcytic anaemia?
1. Iron deficiency anaemia
2. Anaemia of chronic disease
3. Thalassaemia
4. Sideroblastic anaemia
100
What are the causes of normocytic anaemia? ABCDE
ABCDE
Aplastic anaemia
Bleeding
Chronic disease
Destruction (haemolysis)
Endocrine disorders
Hypothyroidism
Hypoadrenalism
101
What is the MCV for normocytic cells?
80-96
102
What are the causes of Macrocytic anaemia?
FAT RBC
Foetus (pregnancy)
Alcohol excess
Thyroid disorders
Reticulocytosis
B12/Folate deficiency
Cirrhosis
103
What is the MCV for macrocytic cells?
96
104
Which GI cancers can cause iron deficiency anaemia?
2. Colonic adenocarcinoma
3. Gastric carcinoma
105
What are the generic symptoms of malignancy?
Weight loss, anorexia, malaise
106
What are some symptoms which might suggest colorectal cancer?
Change in bowel habit
Blood or mucus in stool
Faecal incontinence
Feeling of incomplete emptying of bowels (tenesmus)
107
What should you do to determine whether there is blood in the stool which the patient hasn't noticed?
Perform a digital rectal examination.
Dip the urine to check for blood.
