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YEAR 4 CANCER CARE > Abdo + Gastric Cancers > Flashcards

Abdo + Gastric Cancers Flashcards

1
Q

What are the red flag symptoms for colorectal cancer?

A
  • Change in bowel habit
  • Rectal bleeding
  • Weight loss
  • Iron deficiency anaemia
  • Tenesmus
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2
Q

What is the APC gene?

A

It is present in FAP (familial Adenomatous polyposis) and is a tumour suppressor gene, results in the growth of polyps

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3
Q

What is HNPCC gene?

A

It is a mismatch repair gene, giving you Lynch syndrome and increases your chance of colorectal cancer

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4
Q

Risk factors for colorectal cancer?

A
  • Male
  • increasing age
  • family hx
  • low fibre diet
  • increased processed meat intake
  • smoking
  • alcohol excess
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5
Q

How does colorectal cancer present?

A
  • Weight loss
  • change in bowel habit
  • PR bleeding
  • abdominal pain
  • iron deficiency anaemia.
  • mass in abo
  • sister Mary Joseph’s node
  • PE
  • LARGE BOWEL OBSTRUCTION
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6
Q

How does right sided colon cancer present?

A
  • Ascending colon
  • Fungating
  • Change in bowel habit- more common in Right side- HAPPENS LATER ON
  • Abdo pain
  • Iron deficiency anaemia
  • Palpable mass in RIF
  • Presents later at diagnossi
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7
Q

How does left-sided colon cancer present?

A
  • Descending colon
  • Stenosing
  • Change in bowel habit (less common than right side)- stool becomes pellety/ ribbony early on
  • Rectal bleeding
  • Palpable mass in LIF
  • tenesmus
  • Presents earlier
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8
Q

What are the referral guidelines for ?colorectal cacncer?

A

NICE recommend a FIT is used to guide referral in the following scenarios:
* with an abdominal mass, or
* with a change in bowel habit, or
* with iron-deficiency anaemia, or

  • aged 40 and over with unexplained weight loss and abdominal pain, or
  • aged under 50 with rectal bleeding and either of the following unexplained symptoms:
    abdominal pain
    weight loss, or
  • aged 50 and over with any of the following unexplained symptoms:
    rectal bleeding
    abdominal pain
    weight loss, or
  • aged 60 and over with anaemia even in the absence of iron deficiency
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9
Q

How many people are diagnosed with colorectal ca a year?
How many people die of it?

A
  • 150,000 new cases
  • 50,000 deaths from the disease
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10
Q

Aside from screening, when do you use the FIT test?

NICE updated their referral guidelines in 2023 to make increased use of Faecal Immunochemical Test (FIT) testing, instead of always doing a colonoscopy first-line.

A

NICE recommend a FIT is used to guide referral in the following scenarios:
* with an abdominal mass, or
* with a change in bowel habit, or
* with iron-deficiency anaemia, or

  • aged 40 and over with unexplained weight loss and abdominal pain, or
  • aged under 50 with rectal bleeding and either of the following unexplained symptoms:
    abdominal pain
    weight loss, or
  • aged 50 and over with any of the following unexplained symptoms:
    rectal bleeding
    abdominal pain
    weight loss, or
  • aged 60 and over with anaemia even in the absence of iron deficiency.
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11
Q

What LAB investigations do you do for a suspected colorectal cancer?

A

In ORDER OF IMPORTANCE

  • FBC- microcytic (iron deficiency) anaemia
  • U&E—> for contrast for staging CT
  • Ferritin/ haemanitics for iron deficiency
  • clotting—> if thinking of doing a liver biopsy
  • bone profile—> some cancers can get hypercalcaemia
  • CEA is used to monitor DISEASE PROGRESSION
  • LFTs- used for pancreatic and liver ca
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12
Q

What is your first line imaging do you do in ?colon cancer

A

Colonoscopy with biopsy
If unable to do a colonoscopy, CT colongraphy

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13
Q

What other imaging do you do for colon cancer?

A
  • CT TAP with contrast - for diagnosis and staging, and distant mets
  • if cannot tolerate contrast: CT CAP with USS Liver
  • MRI rectum for rectal tumours- to see tumour depth
  • Endo-anal USS for T1/2 rectal tumours to determine suitability for trans-anal resection
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14
Q

How do you approach management of colon cancer?

A

Discussion with the MDT

Very small tumours may be suitable for endoscopic resection

Surgery is the main curative treatment

R.Sided tumour- right hemicolectomy
L.Sided tumour- left hemicolectomy
Sigmoid colon tumour- Sigmoidectomy
High Rectal tumour- Anterior resection with loop ileostomy
Low Rectal tumour- Abdominoperineal resection

CHEMO- used Neo-adjuvant or adjuvant, usually in patients with advanced disease
RADIOTHERAPY-used more in rectal cancer

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15
Q

What is the aim of palliation in colorectal cancer?

A
  • Reduce cancer growth
  • focus on symptom control
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16
Q

What type of tissue does colon cancer arise from?

A
  • Epithelial cells lining the colon or rectum
  • Most commonly adenocarcinoma
  • Rarer types incl lymphoma, carcinoid and sarcoma
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16
Q

What type of tissue does colon cancer arise from?

A
  • Epithelial cells lining the colon or rectum
  • Most commonly adenocarcinoma
  • Rarer types incl lymphoma, carcinoid and sarcoma
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17
Q

What is the progression from normal tissue to colorectal cancer?

A
  • Most colorectal cancers develop via a progression of normal mucosa to colonic adenoma (colorectal ‘polyps’)
  • to invasive adenocarcinoma (termed the “adenoma-carcinoma sequence”).
  • Adenomas may be present for 10 years or more before becoming malignant;
  • progression to adenocarcinoma occurs in approximately 10% of adenomas.
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18
Q

Screening for colorectal cancer?

A
  • Every 2 years to men and women aged 60-74
  • FIT testing is used
  • If samples are +ve, pts offered an apt with a specialist nurse and further investgation via colonscopy
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19
Q

What is Dukes Classification of colon cancer?

Not used as much- but still good to know

A

Dukes’ A Tumour confined to the mucosa 95%
Dukes’ B Tumour invading bowel wall 80%
Dukes’ C Lymph node metastases 65%
Dukes’ D Distant metastases 5%
(20% if resectable)

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20
Q

How does large bowel obstruction present?

A
  • Abdominal pain
  • Bloating
  • Absolute constipation
  • Nausea and vomiting
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21
Q

What is the most common type of gastric cancer?

A
  • Adenocarcinoma
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22
Q

What are RF for gastric cancer?

A
  • Male
  • H-pylori infection
  • Increasing age
  • Smoking
  • positive fhx
  • Alcohol consumption
  • increased dietary salt
  • pernicious anaemia
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23
Q

Presentation of gastric cancer?

A

Specific: Dyspepsia, early satiety, vomiting and dysphagia.

General cancer sx: anorexia, weight loss, anaemia

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24
Q

What signs would you expect in gastric cancer?

A
  • Trosiers sign
  • Hepatomegaly
  • Ascites
  • Jaundice
  • Acanthosis nigricans
  • Sister Mary Joseph’s node
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25
Q

What is trosier sign?

A
  • Presence of palpable left supraclavicular node- sign of metastatic abdominal cancer (usually gastric)
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26
Q

Early satiety Ddx?

A

Ovarian cancer, GORD, gastritis, peptic/duodenal ulcer, gastric cancer

27
Q

Why is gastric ca so hard to diagnose?

A
  • Vague and non-specific symptoms
28
Q

What is your first line imaging in gastric cancer?

A
  • Upper GI endoscopy
  • Visualisation and biopsy
29
Q

When do you refer a pt via 2ww for gastric ca?

A
  • anyone who has new onset dysphagia
  • or >55yrs with weight loss and either: upper abdo pain, reflux or dyspepsia
30
Q

What is the appearance of gastric cancer on histology?

A
  • Signet ring cells- very specific type of gastric ca
31
Q

Presentation of gastric cancer?

A
  • abdominal pain
  • typically vague, epigastric pain
  • may present as dyspepsia
  • weight loss and anorexia
  • nausea and vomiting
  • dysphagia: particularly if the cancer arises in the proximal stomach
  • overt upper gastrointestinal bleeding is seen only in a minority of patients
32
Q

Ddx for gastric cancer presentation (dyspepsia, abdo pain, weight loss)

A
  • peptic ulcer disease
  • GORD
  • gallstone disease
  • pancreatic cancer
33
Q

What tests do you run on biopsies from suspected gastric malignancies?

A
  • Histology-for classification and grading of any neoplasia present
  • CLO test – for the presence of H. Pylori
  • HER2/neu protein expression – this will allow for targeted monoclonal therapies if present
34
Q

What investigations do you do post endoscopy for gastric cancer?

A
  • CT CAP- for the size of the tumour, local and lymphatic spread
  • MRI for metastatic spread to the liver and if there is advanced local disease
35
Q

Management of early gastric cancer?

A
  • T1a- endoscopic mucosal resection is used
36
Q

What is the curative management of gastric cancer?

A
  • Surgery- offered to fit enough patient, with peri-operative chemo.
  • Proximal gastric cancer- total gastrectomy
  • Distal gastric cancer- subtotal gastrectomy
37
Q

Palliative treatment options for gastric ca?

A
  • May incl chemo, best supportive care and stenting
    Palliative surgery can be used when stenting fails
38
Q

Most common place colorectal ca metastises to?

A

Liver

39
Q

Where do most pancreatic cancers present?

A
  • 80% at the head of the pancreas
40
Q

Associations of pancreatic cancer?

A
  • increasing age
  • smoking
  • diabetes
  • chronic pancreatitis
  • hereditary non-polyposis colorectal carinoma
  • multiple endocrine neoplasia
  • BRCA2 gene
  • KRAS gene mutation
41
Q

A patient presents with painless jaundice- what is your differential?

A
  • PANCREATIC CANCER UNLESS PROVEN OTHERWISE
42
Q

Feature of pancreatic cancer?

A
  • classically painless jaundice: pale stools, dark urine, and pruritus, cholestatic liver function tests

the following abdominal masses may be found (in decreasing order of frequency)
* hepatomegaly: due to metastases
* gallbladder: Courvoisier’s law states that in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones
* epigastric mass: from the primary tumour

  • many patients present in a non-specific way with anorexia, weight loss, epigastric pain
  • loss of exocrine function (e.g. steatorrhoea)
  • loss of endocrine function (e.g. diabetes mellitus)
  • atypical back pain is often seen
  • migratory thrombophlebitis (Trousseau sign) is more common than with other cancers
43
Q

What is Courvoisier’s Law?

A

that in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones

44
Q

Investigations for suspected pancreatic cancer?

A

Bedside: BM- blood sugars
Lab: FBC- anaemia or thrombocytopenia and LFTs- raised bilirubin, raised ALP, gamma GT
CA19-9 to assess response to treatment
Imaging: Abdo USS- may show pancreatic mass or dilated biliary tress

High resolution CT- gold standard preliminary diagnosis

CT TAP- good for staging

Biopsy

45
Q

What is the management of pancreatic cancer?

A
  • less than 20% are suitable for surgery at diagnosis
  • a Whipple’s resection (pancreaticoduodenectomy) is performed for resectable lesions in the head of pancreas.
  • adjuvant chemotherapy is usually given following surgery
46
Q

Whipples side effects?

A

dumping syndrome and peptic ulcer disease

47
Q

What palliative treatment is offered in pancreatic cancer?

A
  • Stents inserted to relieve the biliary obstruction
  • Surgery to improve symptoms (e.g., bypassing the biliary obstruction)
  • Palliative chemotherapy (to improve symptoms and extend life)
    Palliative radiotherapy (to improve symptoms and extend life)
  • End of life care with symptom control
48
Q

When should you refer someone for suspected pancreatic cancer?

A
  • Over 40 with jaundice- referred on 2 WW referral
  • Over 60 with wieght loss + any of: diarrhoea, back pain, abdo pain, nausea, vomitting, constipation, new-onset diabetes : for DIRECT ACCESS CT ABDOMEN
49
Q

Whatare risk factors for having Cholangiocarcinoma?

A

Primary sclerosing cholangitis- main one

  • UC
  • Infective causes (liver flukes, HIV, hep)
  • Airplane and rubber fumes
  • Congential
  • Alcohol excess
  • DM
50
Q

Clinical features of cholangiocarcinoma?

A

usually asymptomatic until later stages
* post hepatic jaundice
* Persistent biliary colic symptoms
* pruritus
* pale stools and dark urine

*Less commonly- RUQ pain, early satiety, weight loss, anorexia and malaise

51
Q

How does cholangiocarcinoma present on examination?

A

*Jaundice
*Cachexia
*courvoisiers rule applies
* periumbilical lymphadenopathy (Sister Mary Joseph nodes) and left supraclavicular adenopathy (Virchow node) may be seen
* raised CA 19-9 levels
often used for detecting cholangiocarcinoma in patients with primary sclerosing cholangitis

52
Q

What do you expect to be present on LFTs in a cholangiocarcinoma?

A

Obstructive jaundice, elevated bilirubin, ALP, y gamma transferase

53
Q

What is the gold standard imaging for cholangiocarcinoma?

A

MRCP
ERCP can be used to obtain samples

54
Q

What is the most common aim of treatment with cholangiocarcinoma?

A

Palliative

55
Q

What is the definitive cure of cholangiocarcinoma?

A

Surgery

56
Q

What are the palliative treatment options for cholangiocarcinoma?

A
  • Stenting- to relieve the obstruction
  • Bypass surgery- to bypass the obstruction, stenting doesn’t work
  • Palliative radiotherapy- to prolong survival some chemo agents may be used with radiotherapy
57
Q

How common is hepatocellular carcinoma (HCC) ?

A
  • 3rd more commong cause of cancer worldwide
58
Q

What is the most common cause of hepatocellular carcinoma (HCC)?

A
  • Chronic hep B is the most cause worldwide
  • Chronic hep C is the most common cause in Europe
59
Q

Risk factors for developing HCC?

A
  • Main RF- liver cirrhosis this can be secondary to anything e.g. hep B & C, haemochromatosis and PBC.
  • alpha-1 antitrypsin deficiency
  • hereditary tyrosinosis
  • glycogen storage disease
  • aflatoxin
  • drugs: oral contraceptive pill, anabolic steroids
  • porphyria cutanea tarda
  • male sex
  • diabetes mellitus, metabolic syndrome
60
Q

Features of HCC?

A
  • tends to present late
  • features of liver cirrhosis may be seen: jaundice, asictes, RUQ pain, hepatomegaly, pruritus, splenomegaly
  • Raised AFP

Possible presentation: decompensation with chronic liver diease

61
Q

1) When should you consider screening for HCC?
2) What would you used to screen?

A

1) High risk groups e.g.
* patients with liver cirrhosis secondary to hep B C or haemochromatosis,
* men with liver cirrhosis secondary to alcohol
2) Screening with USS +/- alpha fetoprotein

62
Q

What is a Haemangioma?

A
  • Common benigh tumour of the liver
  • No symptoms
  • No malignant potential
  • No treatment or monitoring is needed
63
Q

What is the prognosis of HCC?

A

Very poor unless diagnosed early

64
Q

Managment of HCC?

A
  • Resection of early disease or transplant if HCC is isolated to the liver is likely to be curative
  • Kinase inhibtors: ihibit the proliferation of cancer cells e.g. sorafenib, regorafenib
  • Generally resistanct to chemo and radiotherapy- may be used as part of palliative treatment or clinical trials
65
Q

What is focal nodular hyperplasia?

A
  • Benign liver tumour made of fibrotic tissue
  • Asymptomatic and no malignant potential
  • Often related to oestrogen and so more commen in women and those on COCP
  • No treatment of monitoring is required
66
Q

Ddx for rectal bleeding?

A
  • haemorrhoids
  • anal fissure
  • Diverticular disease
  • IBD

YEAR 4 CANCER CARE (22 decks)

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