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Cancer care (Y4) > 4- Abdominal cancer (2/2) > Flashcards

4- Abdominal cancer (2/2) Flashcards

1
Q

cholangiocarcinoma background

A
  • Cancer originating in bile duct (biliary system)
  • Majority adenocarcinomas
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2
Q

location of cholangiocarcinomas

A
  • Intrahepatic ducts (bile ducts in the liver)
  • Extrahepatic (outside liver)
  • Most common sit= perihilar region – where the right and left hepatic ducts have joined to become the common hepatic duct just after leaving the liver (Klatskin tumour)
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3
Q

metastasis for cholangiocarcinoma

A

Metastasis
- Lymph nodes
- Liver
- Peritoneum
- Bone

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4
Q

Risk factors for cholangiocarcinoma

A
  • Primary sclerosing cholangitis (pt with UC at risk)
  • Liver flukes (parasitic infection)
  • Intraductal gallstone formation
  • Liver cirrhosis
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5
Q

presentation of cholangiocarcinoma

A
  • Obstructive jaundice(Courvoisiers law)
  • Pale stools
  • Dark urine
  • Generalise itching

Non-specific signs and symptoms
* Unexplained weight loss
* Right upp quadrant pain
* Palpable gallbladder
* Hepatomegaly

Courvoisiers law states that a palpable gallbladder along with jaundice is unlikely to be gallstone
- Cholangiocarcinoma
- Pancreatic cancer

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6
Q

Investigations for cholangiocarcinoma

A

Bloods
- LFTs elevated
- Tumour markers CEA and CA19-9
- CA 19-9 (carbohydrate antigen) is a tumour marker that may be raised in cholangiocarcinoma. It is also raised in pancreatic cancer and a number of other malignant and non-malignant conditions.

Diagnosis is based on imaging (CT or MRI) plus histology from a biopsy.
- Staging CT scan involves a full CT thorax, abdomen and pelvis (CT TAP). This is used to look for metastasis and other cancers.
- Magnetic resonance cholangio-pancreatography (MRCP) may be used to assess the biliary system in detail to assess the obstruction.
- Endoscopic retrograde cholangio-pancreatography (ERCP) can be used to put a stent in and relieve the obstruction, and also obtain a biopsy from the tumour.

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7
Q

management of cholangiocarcinoma

A

Management

1) Curative surgery (may be possible in early cases) +- radio and chemo
- Complete surgical resection
- Normally palliative care e.g. stents inserted to relieve the biliary obstruction
- Surgery to improve symptoms (e.g., bypassing the biliary obstruction)

2) Palliative chemotherapy

3) Palliative radiotherapy
4) End of life care with symptom control

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8
Q

Prognosis for cholangiocarcinoma

A
  • Poor
  • Treatment should be aimed at good symptom relief and palliative care
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9
Q

oesophageal cancer background

A

Squamous cell carcinoma
- More common in developing world
- Middle and upper thirds of the oesophagus
Adenocarcinoma
- More common in developed world
- Lower third of oesophagus
- Consequence of metaplastic epithelium (Barretts oesophagus)

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10
Q

Metastasis for oesophageal cancer

A
  • Liver
  • Lung
  • Distant lymph nodes
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11
Q

risk factors for oesophageal cancer

A

Male x3
Squamous cell carcinoma
- Smoking
- Excessive alcohol consumption
- Chronical achalasia
- Low vitamin A

Adenocarcinoma
- Barretts oesophagus
- GORD
- Obesity
- High fat intake

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12
Q

oesophageal cancer presentation

A

Presentation
- Early stage lacks well defined symptoms
- Dysphagia – progressive in nature
- Weight loss
- Odynophagia
- Hoarseness
- Weight loss or cachexia
- Dehydration
- Supraclavicular lymphadenopathy
- Metastatic disease signs

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13
Q

Referral for oesophageal cancer

A

Criteria for Upper GI Endoscopy
Red-flag symptoms for a suspected oesophageal malignancy requiring urgent endoscopy are:

  • Any patient with dysphagia
  • Any patient >55yrs with weight loss and upper abdominal pain, dyspepsia, or reflux

Dysphagia DD

  • Anyone with dysphagia should be treated as cancer until proven otherwise
  • Neuromuscular
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14
Q

investigations for oesophageal cancer

A

Investigations

  • Upper GI endoscopy- (OGD) within 2 weeks – biopsy and sent for histology
  • CT CAP and PET-CT scan to investigate metastases
  • Endoscopic US (measure penetration into oesophageal wall)
  • Staging laparoscopy- intra peritoneal metastases
  • Fine needle aspiration of palpable cervical lymph nodes
  • Bronchoscopy for hoarseness or haemoptysis
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15
Q

anatomy of the thorax

A

Vena cava (T8)
- 8 letters
Oesophagus (T10)
- 10 letters
Aortic hiatus (T12)
- 12 letters

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16
Q

management of oesophageal cancer

A
  • MDT approach
  • CPEX test for fitness for surgery
  • Mostly treated palliatively due to late presentation
  • Curative management - surgery

Depends on
- Tumour type,
- Site
- Patient factors e.g. patient co-morbidities

17
Q

surgery for oesophageal cancer

A

Inc surgery with or without neoadjuvant chemotherapy or chemoradiotherapy

Squamous cell carcinoma- upper oesophagus is difficult to operate on.
- Definitive chemo-radiotherapy is treatment of choice

Adenocarcinoma- neoadjuvant chemotherapy or chemoradiotherapy
- Oesophageal resection = definitive treatment

18
Q

oesphagectomy surgery

A

MAJOR undertaking:
- Both abdominal and chest cavities opened
- One lung deflated for 2 hours during surgery
- 30 day mortality at 4%
- 6-9 months to recover pre-op QoL

General approach
- Removal of tumour, top of stomach, surrounding lymph nodes
- Stomach is then made into a tube (conduit) and brought up into the chest to replace the oesophagus
- Specific approaches include
–> Right thoracotomy (a surgical procedure in which a cut is made between the ribs to see and reach the lungs or other organs in the chest or thorax) with laparotomy (termed an Ivor-Lewis procedure)
–> **Right thoracotomy with abdominal and neck incision **(termed a McKeown procedure)
–> **Left thoracotomy with or without neck incision
–> Left thoraco-abdominal **incision (one large incision starting above the umbilicus and extending round the back to below the left shoulder blade)

19
Q
A

Endoscopic mucosal resection (EMR)-> removal of just the mucosal layer of oesophagus

20
Q

complications of oesphagectomy

A
  • Anastomotic leak
    High rate- any deterioration in an oesophagectomy pt should be considered an anastomotic leak until proven otherwise
  • Re-operation
  • Pneumonia
  • Death
21
Q

Post-operative nutrition

A
  • Major problem for these patients as they lose the reservoir function of the stomach.
  • Many centres will routinely insert a feeding tube into the small bowel (a “feeding jejunostomy”) to aid nutrition.
  • However, most patients will need to eat 5-6 small meals per day to meet their nutritional requirement
22
Q

palliaitive management of oesophageal cancer

A

Palliative management
Pts too unfit or unsuitable for curative therapy
- Oesophageal stent (if difficulty swallowing

  • Radiotherapy/and or chemo
    To reduce tumour sizw and bleeding

Nutritional support
- Thickened fluids
- Nutritional supplements
- Radiologically inserted gastrotomy (RIG) if dysphagia too bad to tolerate enteral feeds

23
Q

Liver cancer background

A
  • Can either be metastatic (90%) or primary (10%)
  • Primary cause is hepatocellular carcinoma
    –>Other cholangiocarcinoma
  • 2nd leading cause of cancer
  • Due to chronic inflammation in the liver e.g. hep B/C
24
Q

liver cancer risk factors

A

Risk factors
- Viral hepatitis
o Hepatitis B virus and Hepatitis C virus are the most common causative organisms
- Liver cirrhosis
- High alcohol intake
- Smoking
- Advanced age (>70yrs)
- Aflatoxin exposure
- Hereditary haemochromatosis
- Fx

25
Q

presentation of liver cancer

A

Risk factors
- Viral hepatitis
o Hepatitis B virus and Hepatitis C virus are the most common causative organisms
- Liver cirrhosis
- High alcohol intake
- Smoking
- Advanced age (>70yrs)
- Aflatoxin exposure
- Hereditary haemochromatosis
- Fx

26
Q

investigaitons for liver cancer

A

Bloods

  • FBC
  • Liver function test (ALP, ALT, AST, bilirubin)
  • If AST:ALT ratio >2, likely alcoholic liver disease; if AST:ALT around 1, likely viral hepatitis
  • Low platelets
  • Prolonged clotting
  • Alphafetoproetin (AFP)
    (Also used to monitor treatment response and recurrence )

Imaging

  • US
    If mass >2cm found with AFP- virtually diagnostic
  • Staging CT
  • Patients with rising AFP and suggestive US nodules – MRI liver scanning

If diagnosis still in doubt- biopsy or percutaneous fine-needle aspiration

27
Q

staging for liver cancer

A

**
Barcelona clinic liver cancer staging system (BCLC)**
Provides guidance on which treatment is most suitable
- Tumour stage
- Liver function
- Physical status
- Cancer related symptoms

28
Q

risk assessment scores for liver cancer

A

Risk assessment score
Child-Pugh
- Uses serum bilirubin, albumin, INR, degree of ascites, evidence of encephalopathy
- Calculates prognosis of patient with liver cirrhosis

MELD score- better predictor or morality
- Creatinine, bilirubin, INR, sodium and use of dialysis
- Used to predict likelihood of patient tolerating potential liver transplant

29
Q

management of liver cancer

A

MDT approach
- surgical management
- non-surgical mangeemnt
- metastatic

30
Q

surigical management of liver cancer

A

resection vs transplanation

31
Q

liver cancer: resection

A
  • Treatment of choice in pt without cirrhosis and with good baseline health status
  • High recurrence rate 50-60%
  • With lymphadectomy
  • Mainly unifocal disease
32
Q

liver cancer: transplantation

A

Can be considered in pt that fulfils Milan Criteria
* One lesion is smaller than 5cm or three lesions smaller than 3cm
* No extrahepatic manifestation
* No vascular infiltration

33
Q

non surgical management of liver cancer

A

Image-guided ablation
- For early HCC
- US probes are placed in the tumour mass to induce necrosis
- Alcohol ablation

Transarterial chemoembolization (TACE)
- High conc of chemo are injected directly into hepatic artery and an embolising agent is then added to induce ischaemia
- Radiology used to visualise hepatic artery supplying tumour- preserving majority of liver

34
Q

management of metastatic liver cancer

A

Anti-angiogenic agents such as sorafenib and Atezolizumab

35
Q

Prognosis of primary HCC

A

depends on cirrhosis. Median survival time form diagnosis 6 months

36
Q

Secondary liver malignancy

A

Most common underlying cause of death in patients with cancer. Typically picked up on during staging

Cause
- Bowel- colorectal primary tumourl (via portal circulation)
- Breast
- Pancreas
- Stomach and lung

37
Q

Presentation of secondary liver malignancy

A
  • Hepatomegaly
  • Ascites
  • Jaundice upper
  • Abdominal pain
38
Q

investigations for secondary liver malignancy

A

Similar to HCC
Bloods
- Derangement of LFTS (ALPs most raised)
Imaging
- US imaging of choice
Staging
- CT
- Biopsy not advice if tumour is operable- needle tract may lead to seeding of tumour

Cancer care (Y4) (30 decks)

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