4- Abdominal cancer

Question 1

Colorectal (bowel) cancer background

Answer 1

• 4th most prevalent cancer in UK (behind breast, prostate and lung)
• Anywhere from colon to rectum
• Small bowel and anal cancers less common

Question 2

types of colorectal cancer

Answer 2

Types
- Adenocarcinomas (rarer types inc lymphoma, carcinoid (think flushing) and sarcoma)
- Adenomas may be present for 10 years before becoming cancerous

Question 3

risk factors for colorectal cancer

Answer 3

Hereditary factors

• Family history of bowel cancer
• Familial adenomatous polyposis (FAP)
• Hereditary nonpolyposis colorectal cancer (HNPCC), also known as Lynch syndrome
• Inflammatory bowel disease (Crohn’s or ulcerative colitis)
• Increased age

Modifiable

• Diet (high in red and processed meat and low in fibre)
• Obesity and sedentary lifestyle
• Smoking
• Alcohol

Protective

• aspirin or NSAIDS
• HRT
• statin use
• physical activirty
• whole grains
• dietary fibre
• fish intake
• tree nuts
• vitamins D,C and others
• calcium supplements

Question 4

presentation of colorectal cancer

Answer 4

• Change in bowel habit (usually to more loose and frequent stools)
• Unexplained weight loss
• Rectal bleeding
• Unexplained abdominal pain
• Iron deficiency anaemia (microcytic anaemia with low ferritin)
• Abdominal or rectal mass on examination
• Presenting with obstruction
  o Tumour blocks passage through bowel- surgical emergency
• Right side colon cancer: abdominal pain, iron def anaemia, palpable mass in RIF or on PR exam
• Left side colon cancer: rectal bleeding, change in bowel habit, tenesmus, palpable mass in LIF

Question 5

Red flags for colorectal cancer

Answer 5

• Change in bowel habit (usually to more loose and frequent stools)
• Unexplained weight loss
• Rectal bleeding
• Unexplained abdominal pain
• Iron deficiency anaemia (microcytic anaemia with low ferritin)
• Abdominal or rectal mass on examination

Question 6

referral for colorectal cancer

Answer 6

2- week wait
- Over 40 years with abdominal pain and unexplained weight loss
- Over 50 years with unexplained rectal bleeding
- Over 60 years with a change in bowel habit or iron deficiency anaemia

Question 7

Familial adenomatous polyposis (FAP)

Answer 7

• Autosomal dominant condition involving malfunctioning of the tumour suppressor genes called adenomatous polyposis coli (APC).
• It results in many polyps (adenomas) developing along the large intestine.
• These polyps have the potential to become cancerous (usually before the age of 40).

Management
- Patients have their entire large intestine removed prophylactically to prevent the development of bowel cancer (panproctocolectomy).

Question 8

Hereditary nonpolyposis colorectal cancer (HNPCC)

Answer 8

• Lynch syndrome.
• Autosomal dominant condition that results from mutations in DNA mismatch repair (MMR) genes.
• Patients are at a higher risk of a number of cancers, but particularly colorectal cancer.
• Unlikely FAP, it does not cause adenomas and tumours develop in isolation.

Question 9

people with FAP or Lynch are offered

Answer 9

These patients offered FIT screening at regular intervals

Question 10

classification for bowel cancer

Answer 10

Dukes’ Classification
Dukes’ classification is the system previously used for bowel cancer. It has now been replaced in clinical practice by the TNM classification, but you may come across it in older textbooks or question banks. A brief summary is:
* Dukes A – confined to mucosa and part of the muscle of the bowel wall
* Dukes B – extending through the muscle of the bowel wall
* Dukes C – lymph node involvement
* Dukes D – metastatic disease

Question 11

Investigations for colorectal cancer

Answer 11

• Bloods- FBC (microcytic – iron def anaemia), LFTs, clotting, carcinoembryonic antigen (CEA)- tumour marker
  o CEA tumour marker for bowel cancer
  o Not helpful in screening, but can be used for predicting relapse
• Colonoscopy with biopsy- gold standard- biopsy if lesion found
• Sigmoidoscopy (if only features of rectal bleeding)

- CT colonography- pts less fit for colonoscopy- less detailed doesn’t allow for biopsy

- Staging CT scan
o CT thorax, abdomen and pelvis (CT TAP)

Question 12

management of colorectal cancer

Answer 12

MDT approach
* Surgeons
* Oncologists
* Radiologists
* Histopathology
* Specialist nurse

Choice of managed depends on
* Clinical condition
* General health
* Stage
* Histology
* Patient wishes

Options (in any combination)
* Surgical resection
* Chemotherapy
* Radiotherapy
* Palliative care- stenting

Question 13

Screening for colorectal cancer

Answer 13

Faecal Immunochemical Test (FIT) for asymptomatic
- Ages 60-74yo every 2 years
- If results positive –>colonoscopy

Question 14

how does FIT testing work

Answer 14

• Faecal immunochemical tests (FIT) look very specifically for the amount of human haemoglobin in the stool.
• FIT replaced the older stool test called the faecal occult blood (FOB) test, which detected blood in the stool but could give false positives by detecting blood in food (e.g., from red meats).

Question 15

how are FIT tests also used in GP

Answer 15

• FIT tests can be used as a test in general practice to help assess for bowel cancer in specific patients who do not meet the criteria for a two week wait referral, for example:
• Over 50 with unexplained weight loss and no other symptoms
• Under 60 with a change in bowel habit

Question 16

surgical resection of colorectal cancer

Answer 16

Ideal to surgically remove entire tumour – potentially curative. Can also be used palliatively- reduce size of tumour and improve symptoms
- Laparoscopic surgery gives better recovery and few complications than open surgery
- Robotic surgery used increasingly

Question 17

what does colorectal cancer surgery involve

Answer 17

• Identify tumour (may have been tattooed in endoscopy)
• Remove section of bowel containing tumour
• Creating an end-to- end anastomosis (sewing the remaining ends back together)
• Creating a stoma if end to end not possible

Question 18

Complications of colorectal bowel resection

Answer 18

There is a long list of potential complications of surgery for bowel cancer:

• Bleeding, infection and pain
• Damage to nerves, bladder, ureter or bowel
• Post-operative ileus
• Anaesthetic risks
• Laparoscopic surgery converted during the operation to open surgery (laparotomy)
• Leakage or failure of the anastomosis
• Requirement for a stoma
• Failure to remove the tumour
• Change in bowel habit
• Venous thromboembolism (DVT and PE)
• Incisional hernias
• Intra-abdominal adhesions

Question 19

Right hemicolectomy

Answer 19

involves removal of the caecum, ascending and proximal transverse colon.

Question 20

left hemicolectomy

Answer 20

involves removal of the distal transverse and descending colon.

Question 21

High anterior resection

Answer 21

involves removing the sigmoid colon (may be called a sigmoid colectomy).

Question 22

Low anterior resection

Answer 22

involves removing the sigmoid colon and upper rectum but sparing the lower rectum and anus.

Question 23

Abdomino-perineal resection (APR)

Answer 23

involves removing the rectum and anus (plus or minus the sigmoid colon) and suturing over the anus. It leaves the patient with a permanent colostomy.

Question 24

Hartmann’s procedure

Answer 24

is usually an emergency procedure that involves the removal of the rectosigmoid colon and creation of an colostomy. The rectal stump is sutured closed. The colostomy may be permanent or reversed at a later date.

Common indications are acute obstruction by a tumour, or significant diverticular disease.

Question 25

Hartmann’s procedure

Answer 25

is usually an emergency procedure that involves the removal of the rectosigmoid colon and creation of an colostomy. The rectal stump is sutured closed. The colostomy may be permanent or reversed at a later date. Common indications are acute obstruction by a tumour, or significant diverticular disease.

Question 26

Low Anterior Resection Syndrome

Answer 26

Low anterior resection syndrome may occur after resection of a portion of bowel from the rectum, with anastomosis between the colon and rectum. It can result in a number of symptoms, including: * Urgency and frequency of bowel movements * Faecal incontinence * Difficulty controlling flatulence

Question 27

Follow-Up for colorectal cancer

Answer 27

Patients will be followed up for a period of time (e.g., 3 years) following curative surgery. This includes: * Serum carcinoembryonic antigen (CEA) * CT thorax, abdomen and pelvis

Question 28

Stomach (gastric) cancer background

Answer 28

- 5th most common cancer globally - Presents with advanced disease - Majority of gastric cancers arise from gastric mucosa as adenocarcinomas. - The rest are a mixture of connective tissue, lymphoid or neuroendocrine malignancies

Question 29

RF for gastric cancer

Answer 29

rate has improved in the west due to H.pylori eradication therapy and improved diet - H.pylori - Male - Age - Smoking - Alcohol - Positive family history - Pernicious anaemia

Question 30

presentation of gastric cancer

Answer 30

- Vague and non-specific – pts present at advanced stage - Dyspepsia - Dysphagia - Early satiety - Vomiting (haematemesis - Melaena **Non-specific cancer SYMPTOMS** - ANOREXIA - WEIGHT LOSS - ANAEMIA - Clinical signs usually absent - Epigastric mass in late disease - Troisiers sign- palpable left supraclavicular node (Virchow node)- metastatic abdominal malignancy **Metastatic signs** - Hepatomegaly - Ascites - Jaundice - Acanthosis nigricans (hyper pigmentation of skin creases e.g. axilla)

Question 31

sign assoicated with gastric cancer

Answer 31

palpable left supraclavicular node (Virchow node)- metastatic abdominal malignancy

Question 32

investigations for gastric cancer

Answer 32

**Bloods**: FBC, LFT **Imaging** - Urgent upper GI endoscopy (OGD) with biopsy- any patients presenting with new-onset dysphagia or aged >55 years presenting with weight loss and either upper abdominal pain, reflux, or dyspepsia.- signet ring cells - CT may show thickening of gastric wall but does not allow direct visualisation or biopsy hence OGD **Biopsy** - Histology- neoplasia classification and grading - CLO test- H.pylori - HER2/neu protein expression (targeted monoclonal therapies) **Staging- CT** chest-abdomen-pelvis and staging laparoscopy (looking for peritoneal metastases)- TNM staging

Question 33

Management of gastric cancer

Answer 33

- MDT approach - Adequate nutrition e.g. NG, RIG may be needed Curative treatment: **surgery** - Peri-operative chemotherapy - 3 cycles neoadjuvant and 3 cycles adjuvant - Palliative care

Question 34

Endoscopic Mucosal Resection (EMR)

Answer 34

- Patients with early T1a tumours (tumours confined to the muscularis mucosa) may be offered an Endoscopic Mucosal Resection (EMR). This has the advantage of a greatly reduced morbidity, mortality, and quality of life impact, however is only used in early tumours therefore current use in clinical practice is rare.

Question 35

surgery for gastric cancer

Answer 35

**Gastrectomy** The aim of surgery is to achieve loco-regional control by removing the tumour and its local lymph nodes. The type of operation performed depends on the region of the malignancy: * Proximal gastric cancers – total gastrectomy * Distal gastric cancers (antrum or pylorus) – subtotal gastrectomy

Question 36

reconstruction after gastrectomy

Answer 36

**Roux-en-Y reconstruction** gives the best functional result, in particular with less bile reflux. - Post-gastrectomy, distal oesophagus is end-to-end anastomosed directly to the small bowel, and the proximal small bowel is end-to-side anastomosed also to the small bowel

Question 37

Palliative management of gastric cancer

Answer 37

Most patients will be offered only a palliative approach due to the extent of disease at time of presentation. This may include : - Chemotherapy - Best supportive care - Stenting (for patients who have gastric outlet obstruction secondary to an obstructing cancer). **Palliative surgery **(usually distal gastrectomy or bypass surgery (a gastro-jejunostomy)) can be used when stenting fails or is not available. It can also be used cautiously in the palliation of bleeding gastric tumours.

Question 38

pancreatic cancer background

Answer 38

- 4th most common cause of cancer-related deaths - Rare in <40s - Diagnosed late and very poor prognosis due to late presentation

Question 39

types of pancreatic cancer

Answer 39

vast majority adenocarcinomas **Ductal carcinoma (most common)** - From exocrine portion **Pancreatic cystic carcinoma** - From exocrine protion **Endocrine tumours** Derived from islet cells of the pancreas (better prognosis)

Question 40

Location of pancreatic cancer

Answer 40

- Most occur in head of pancreas (as opposed to body or tail) - Once large enough will press on bile duct- obstructive jaundice - Tumours located in the body and tail are diagnosed later due to obstructive symptoms occurring later

Question 41

metastasis in pancreatic cancer

Answer 41

Metastasis (early) - Liver - Peritoneum - Lungs - Bones

Question 42

Risk factors for pancreatic cancer

Answer 42

- Age (60-80) - Male - Smoking - Obesity, diet (red meat, low fruit), alcohol - Diabetes - Fx

Question 43

presentation of pancreatic cancer

Answer 43

**RED FLAG: Painless obstructive jaundice** is a key presenting feature that should make you immediately consider pancreatic cancer (the key differential is cholangiocarcinoma) * Yellow skin and sclera * Pale stools * Dark urine * Generalised itching **The other presenting features for pancreatic cancer can be vague:** * Non-specific upper abdominal or back pain * Unintentional weight loss * Palpable mass in the epigastric region * Change in bowel habit * Nausea or vomiting * New onset diabetes or worsening of type 2 diabetes

Question 44

examination findings of someone with pancreatici cancer

Answer 44

- Cachetic, malnourished, jaundiced - Abdominal mass in epigastric region

Question 45

pancreatic cancer investigations

Answer 45

**Initial bloods** - FBC and LFTs **CA 19-9 (carbohydrate antigen)** is a tumour maker raised in pancreatic cancer (also raised in cholangiocarcinoma) **Imaging** - Abdominal US - Staging CT- CT TAP (Looks for metastasis and other cancers) - Magnetic resonance cholangial pancreatography (MRCP)- assess biliary system - Endoscopic retrograde cholangial-pancreatography (ERCP)- stent to relieve obstruction and biopsy tumour - Endoscopic US for staging **Biopsy** - Through skin under US OR CT guidance

Question 46

refferal for pancreatic cancer

Answer 46

Referral * Over 40 with jaundice – referred on a 2 week wait referral * Over 60 with weight loss plus an additional symptom (see below) – referred for a direct access CT abdomen The NICE guidelines suggest a GP referral for a direct access CT abdomen (or ultrasound if not available) to assess for pancreatic cancer if a patient has weight loss plus any of: * Diarrhoea * Back pain * Abdominal pain * Nausea * Vomiting * Constipation

Question 47

management of pancreatic cancer

Answer 47

- HPB MDT meeting - Surgery - Palliative

Question 48

surgery for pancreatic cancer

Answer 48

- Only curative procedure is **radical resection** (only 20% have resectable tumours) - More likely to be considered with small tumours isolated in the head of the pancreas --> Total pancreatectomy --> Distal pancreatectomy -->Pylorus-preserving pancreaticoduodenectomy (PPPD) (modified Whipple procedure) -->Radical pancreaticoduodenectomy (Whipple procedure) **Adjuvant chemotherapy** e.g. gemcitabine or 5-fluorouracil (5-FU)

Question 49

whipples procedure

Answer 49

A Whipple procedure (pancreaticoduodenectomy) is a surgical operation to remove a tumour of the head of the pancreas that has not spread. A Whipple procedure is a massive operation so patients need to be in good baseline health. It involves the removal of the: * Head of the pancreas * Pylorus of the stomach * Duodenum * Gallbladder * Bile duct * Relevant lymph nodes

Question 50

Prognosis of pancreatic cancer

Answer 50

- 6 months from diagnosis - High metastatic capacity even in small tumours - 5 year survival of 10%

Question 51

named signs for pancreatic cancer/ cholangiocarcinoma

Answer 51

- Courvoisiers law - Trousseaus sign of malignancy

Question 52

Courvoisier’s law

Answer 52

states that a palpable, painless gallbladder along with jaundice is unlikely to be gallstones. The cause is usually cholangiocarcinoma or pancreatic cancer

Question 53

Trousseau’s sign of malignancy

Answer 53

refers to migratory thrombophlebitis as a sign of malignancy, particularly pancreatic adenocarcinoma. - **Thrombophlebitis** is where blood vessels become inflamed with an associated blood clot (thrombus) in that area. - **Migratory** refers to the thrombophlebitis reoccurring in different locations over time.

Question 54

management of secondary liver cancer

Answer 54

Management - Due to nature of metastasis surgery is more diff and less useful- resection not particularly useful - Surgery may be considered if metastasis confined to the liver and the primary tumour is under control - Oncological and palliative input important - Alternatives o Transarterial chemoembolization o Selective interval radiotherapy

Question 55

carcinoid colon cancer

Answer 55

Gastrointestinal (GI) neuroendocrine tumors (also called gastrointestinal carcinoid tumors) form from a certain type of neuroendocrine cell (a type of cell that is like a nerve cell and a hormone-making cell). These cells are scattered throughout the chest and abdomen but most are found in the GI tract. presentation * a tumour in the bowel may cause tummy pain, a blocked bowel (diarrhoea, constipation, feeling sick or being sick) and bleeding from the bottom (rectal bleeding) * Facial flushing * a tumour in the lung may cause a cough, which may make you cough up blood, and cause wheezing, shortness of breath, chest pain and tiredness * a tumour in the stomach may cause pain, weight loss, tiredness and weakness