4- Abdominal cancer Flashcards
Colorectal (bowel) cancer background
- 4th most prevalent cancer in UK (behind breast, prostate and lung)
- Anywhere from colon to rectum
- Small bowel and anal cancers less common
types of colorectal cancer
Types
- Adenocarcinomas (rarer types inc lymphoma, carcinoid (think flushing) and sarcoma)
- Adenomas may be present for 10 years before becoming cancerous
risk factors for colorectal cancer
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
presentation of colorectal cancer
- 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
Red flags for colorectal cancer
- 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
referral for colorectal cancer
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
Familial adenomatous polyposis (FAP)
- 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).
Hereditary nonpolyposis colorectal cancer (HNPCC)
- 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.
people with FAP or Lynch are offered
These patients offered FIT screening at regular intervals
classification for bowel cancer
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
Investigations for colorectal cancer
-
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)
management of colorectal cancer
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
Screening for colorectal cancer
Faecal Immunochemical Test (FIT) for asymptomatic
- Ages 60-74yo every 2 years
- If results positive –>colonoscopy
how does FIT testing work
- 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).
how are FIT tests also used in GP
- 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
surgical resection of colorectal cancer
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
what does colorectal cancer surgery involve
- 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
Complications of colorectal bowel resection
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
Right hemicolectomy
involves removal of the caecum, ascending and proximal transverse colon.
left hemicolectomy
involves removal of the distal transverse and descending colon.
High anterior resection
involves removing the sigmoid colon (may be called a sigmoid colectomy).
Low anterior resection
involves removing the sigmoid colon and upper rectum but sparing the lower rectum and anus.
Abdomino-perineal resection (APR)
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.
Hartmann’s procedure
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.
Hartmann’s procedure
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.
Low Anterior Resection Syndrome
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
Follow-Up for colorectal cancer
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
Stomach (gastric) cancer background
- 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
RF for gastric cancer
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
presentation of gastric cancer
- 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)
sign assoicated with gastric cancer
palpable left supraclavicular node (Virchow node)- metastatic abdominal malignancy
investigations for gastric cancer
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
Management of gastric cancer
- 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
Endoscopic Mucosal Resection (EMR)
- 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.
surgery for gastric cancer
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
reconstruction after gastrectomy
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
Palliative management of gastric cancer
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.
pancreatic cancer background
- 4th most common cause of cancer-related deaths
- Rare in <40s
- Diagnosed late and very poor prognosis due to late presentation
types of pancreatic cancer
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)
Location of pancreatic cancer
- 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
metastasis in pancreatic cancer
Metastasis (early)
- Liver
- Peritoneum
- Lungs
- Bones
Risk factors for pancreatic cancer
- Age (60-80)
- Male
- Smoking
- Obesity, diet (red meat, low fruit), alcohol
- Diabetes
- Fx
presentation of pancreatic cancer
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
examination findings of someone with pancreatici cancer
- Cachetic, malnourished, jaundiced
- Abdominal mass in epigastric region
pancreatic cancer investigations
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
refferal for pancreatic cancer
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
management of pancreatic cancer
- HPB MDT meeting
- Surgery
- Palliative
surgery for pancreatic cancer
- 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)
whipples procedure
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
Prognosis of pancreatic cancer
- 6 months from diagnosis
- High metastatic capacity even in small tumours
- 5 year survival of 10%
named signs for pancreatic cancer/ cholangiocarcinoma
- Courvoisiers law
- Trousseaus sign of malignancy
Courvoisier’s law
states that a palpable, painless gallbladder along with jaundice is unlikely to be gallstones.
The cause is usually cholangiocarcinoma or pancreatic cancer
Trousseau’s sign of malignancy
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.
management of secondary liver cancer
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
carcinoid colon cancer
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
