4- Abdominal cancer (2/2) Flashcards
cholangiocarcinoma background
- Cancer originating in bile duct (biliary system)
- Majority adenocarcinomas
location of cholangiocarcinomas
- 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)
metastasis for cholangiocarcinoma
Metastasis
- Lymph nodes
- Liver
- Peritoneum
- Bone
Risk factors for cholangiocarcinoma
- Primary sclerosing cholangitis (pt with UC at risk)
- Liver flukes (parasitic infection)
- Intraductal gallstone formation
- Liver cirrhosis
presentation of cholangiocarcinoma
- 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
Investigations for cholangiocarcinoma
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.
management of cholangiocarcinoma
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
Prognosis for cholangiocarcinoma
- Poor
- Treatment should be aimed at good symptom relief and palliative care
oesophageal cancer background
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)
Metastasis for oesophageal cancer
- Liver
- Lung
- Distant lymph nodes
risk factors for oesophageal cancer
Male x3
Squamous cell carcinoma
- Smoking
- Excessive alcohol consumption
- Chronical achalasia
- Low vitamin A
Adenocarcinoma
- Barretts oesophagus
- GORD
- Obesity
- High fat intake
oesophageal cancer presentation
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
Referral for oesophageal cancer
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
investigations for oesophageal cancer
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
anatomy of the thorax
Vena cava (T8)
- 8 letters
Oesophagus (T10)
- 10 letters
Aortic hiatus (T12)
- 12 letters
management of oesophageal cancer
- 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
surgery for oesophageal cancer
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
oesphagectomy surgery
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)
Endoscopic mucosal resection (EMR)-> removal of just the mucosal layer of oesophagus
complications of oesphagectomy
- Anastomotic leak
High rate- any deterioration in an oesophagectomy pt should be considered an anastomotic leak until proven otherwise - Re-operation
- Pneumonia
- Death
Post-operative nutrition
- 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
palliaitive management of oesophageal cancer
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
Liver cancer background
- 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
liver cancer risk factors
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
presentation of liver cancer
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
investigaitons for liver cancer
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
staging for liver cancer
**
Barcelona clinic liver cancer staging system (BCLC)**
Provides guidance on which treatment is most suitable
- Tumour stage
- Liver function
- Physical status
- Cancer related symptoms
risk assessment scores for liver cancer
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
management of liver cancer
MDT approach
- surgical management
- non-surgical mangeemnt
- metastatic
surigical management of liver cancer
resection vs transplanation
liver cancer: resection
- Treatment of choice in pt without cirrhosis and with good baseline health status
- High recurrence rate 50-60%
- With lymphadectomy
- Mainly unifocal disease
liver cancer: transplantation
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
non surgical management of liver cancer
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
management of metastatic liver cancer
Anti-angiogenic agents such as sorafenib and Atezolizumab
Prognosis of primary HCC
depends on cirrhosis. Median survival time form diagnosis 6 months
Secondary liver malignancy
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
Presentation of secondary liver malignancy
- Hepatomegaly
- Ascites
- Jaundice upper
- Abdominal pain
investigations for secondary liver malignancy
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
