Cancer Flashcards
1
Q
GASTRIC CA risk factors?
A
- most common in what countries?
- male
- h pylori infection
- inc age
- smoking
- alcohol consumption
- inc salt in diet
- FHx
- pernicious anaemia
2
Q
GASTRIC CA clinical features?
A
- vague & non specific - so pts present at advanced stage
- common presenting symptoms: dyspepsia (when/why?), dysphagia, early satiety, vomiting or malaena
- non specific ca symptoms ie red flag (eg??x3) are markers of late stage disease
3
Q
GASTRIC CA on examination?
A
- usually absent, especially in early stage
- epigastric mass may be felt in late stage
- troisier sign is the presence of virchows node (what one? left or right?) - considered a sign of metastatic abdo malignancy
-> other sign of met disease inc hepatomegaly, ascites, jaundice or acanthosis nigricans
4
Q
GASTRIC CA differential diagnoses?
A
presents w non specific symptoms so what else presents similarly???
5
Q
GASTRIC CA lab tests?
A
any pt presenting w clinical features of gastric ca (inc haematemesis or malaena) - urgent bloods inc fbc & lfts
6
Q
GASTRIC CA imaging?
A
- urgent OGD - allows direct visulisation & biopsy taking
- staging CT CAP and staging laparoscopy (to look for?)
- TNM staging
7
Q
GASTRIC CA when does NICE reccomend an urgent OGD?
A
if pts present w either:
- new onset dysphagia
- aged > 55 yrs w weight loss & either upper abdo pain, reflux or dyspepsia
- new onset dyspepsia not responding to PPIs
8
Q
GASTRIC CA biopsies from suspected gastric malignancies should be sent for?
A
- histology - why?
- CLO test - why?
- HER2/neu protein expression - why?
9
Q
GASTRIC CA management?
A
- pt discussed at specialist upper GI CA MDT meeting for definitive managment plans (inc potential palliation decisions)
- nutritional status assessment. many pts need definitive nutritional support (pre & post treatment) via NG or RIG tube (what are these?)
10
Q
GASTRIC CA what is the curative treatment?
A
- pts who are fit enough should be offered peri op chemo (how many cycles of neoadjuvant & adjuvant?)
- main curative treatment = surgery. aim is to remove tumour & local nodes. type of op performed depends on region of the malignancy
– proximal gastric cas - ??
– distal gastric cas (antrum or pylorus) - ??
-
11
Q
GASTRIC CA palliative management?
A
- most pts will be offered this due to extent of disease at time of presentation
- this may include chemo, best supportive care or stenting (why?)
- palliative surgery (distal gastrectomy or bypass surgery) used when?? x2
12
Q
GASTRIC CA complications?
A
- gastric outlet obstruction
- iron deficiency anaemia
- perf
- malnutrition
13
Q
OESOPHAGEAL CA classification?
A
- squamous cell carcinoma (squamous cells - typical cells of the oesophagus). occurs in what thirds of the oesophagus? associated w what risk factors?
- adenocarcinoma (columnar cells - typical cells of the stomach). occurs in what third of the oesophagus? what causes it? risk factors?
14
Q
OESOPHAGEAL CA clinical features?
A
- early o ca lack well defined symptoms so many pts present in the later course of the disease
- progressive dysphagia - starts w solids and then liquids
- weight loss - due to dysphagia and cachexia
- odynophagia
- hoarseness of voice
15
Q
OESOPHAGEAL CA on examination?
A
- recemt weight loss or cachexia
- signs of dehydration
- supraclavicular lymphadenopathy
- signs of mets (eg? x3)
16
Q
OESOPHAGEAL CA differential diagnoses?
A
dysphagia must be classified as mechanical or neuromuscular disorder — there are many causes for dysphagia but any pt presenting w it should be assumed to have o ca until proven otherwise
17
Q
OESOPHAGEAL CA initial investigations?
A
- urgent OGD within 2 weeks. any malignancy will be biopsied and sent for histology
18
Q
OESOPHAGEAL CA further investigations?
A
staging investigations:
- CT CAP & PET-CT for mets
- endoscopic US - why?
- staging laparoscopy - why?
- any palpable cervical lymph nodes may be investigated via fine needle aspiration
- any hoarseness or haemoptysis may warrant bronchoscopy
19
Q
OESOPHAGEAL CA curative management?
A
depends on tumour type. tumour site & patient factors (eg fitness & comorbidities)
- squamous cell carcinoma - hard to operate on so definitve chemo radiotherapy
- adenocarcinoma - neoadjuvant chemo or chemo-radiotherapy followed by oesophageal resection
20
Q
OESOPHAGEAL CA surgical treatment?
A
many approaches - one to note: right thoracotomy w laparotomy (ivor lewis)
21
Q
OESOPHAGEAL CA surgical complications?
A
anastomotic leak, re-op, pneumonia & death
22
Q
OESOPHAGEAL CA post op nutrition?
A
major problem due to pts losing the reservoir function of the stomach
- feeding JEJ
- or pts need to eat 5-6 small meals per day to meet requirements
23
Q
OESOPHAGEAL CA palliative management?
A
- dysphagia? oesophageal stent
- radio & chemo therapy to reduce tumour size & bleeding - temporarily improves pts symptoms
** nutritional support essential for this pt group as disease progression leads to dysphagia & cachexia. thickened fluid & nutritional supplements should be offered - dysphagia too severe? RIG tube
24
Q
COLORECTAL CA aetiology?
A
- originate from the epithelial cells lining the colon or rectum. most commonly adenocarcinoma. rarer types?x3
- progression: normal mucosa -> colonic adenoma (polyps) -> invasive adenocarcinoma
25
COLORECTAL CA predisposing genetic mutations?
- APC - tumour suppressor gene mutation of the APC gene results in growth of adenomatous tissue eg FAP
- HNPCC - a dna mismatch repair gene leads to defects in DNA repair eg lynch syndrome
26
COLORECTAL CA risk factors ?
75% sporadic
- inc age, m, fhx, ibd, low fibre diet, high processed meat intake, smoking, xs alcohol
- acromegaly
- ileal conduit
27
COLORECTAL CA clinical features
- most common: change in bowel habit (can be due to meds eg opiates, ezetimibe, metformin) , rectal bleeding, wt loss, abdo pains, sx of anaemia
- r sided colon ca: abdo pain, iron deficiency anaemia, palpable mass in RIF - LATER PRESENTATION
- l sided colon ca: rectal bleeding, chnage in bowel habit, tenesmus, palpable mass in LIF or on PR exam
28
COLORECTAL CA 2ww nice guidance ?
see tms
29
COLORECTAL CA differentials ?
ibd, haemorrhoids
30
COLORECTAL CA screening?
- m & f aged 60 - 75 yrs - FIT test every 2 yrs
- +ve? colonoscopy
31
COLORECTAL CA investigations ?
- bloods - ?
- tumour marker CEA not diagnostic but instead to monitor progression
- imaging - gold standard is colonoscopy w biopsy
- biopsy sent for histology & assessed using ?? x6
- diagnosis made? for staging: CT CAP (?), MRI rectum (for rectal CA only, ?), endo anal USS (early rectal cas only, ?)
32
COLORECTAL CA management?
** discuss w MDT. only cure= surgery but chemo & radiotherapy. are important s neoadjuvant & adjuvant therapy
- surgical:right/extended right hemicoloectomy, left colectomy, sigmoidcolectomy, anterior resection, abdominoperineal resection
- colorectal ca presenting w bowel ob? relieved by decompressing colostomy or endoscopic stenting
- chemo for pts w advanced disease
- radiotherapy in rectal ca (why not colon?) most often as a new adjuvant treatment
- v advanced ca? palliative care
33
COLORECTAL CA right hemi/extended right hemi more info
- for which CA? caecal, ascending colon. extended=transverse colon
- what vessels removed w their mesenteries? ileocolic, right colic, right branch of middle colic
34
COLORECTAL CA left hemi more info
- for which CA? descending colon
- what vessels removed w their mesenteries? left branch of middle colic, inferior mesenteric vein, left colic
35
COLORECTAL CA sigmoidcolectomy more info
- for which CA? sigmoid colon
- IMA removed to ensure adequate margins obtained
36
COLORECTAL CA anterior resection more info
- for which CA? high rectal tumours - typically is >5cm from anus
- preferred as rectal sphincter intact if anastomosis is performed
- temporary defunctioning loop ileostomy to protect anastamosis & reduce comps in case of a leak. reversed electively 4-6 m later
37
COLORECTAL CA AP resection more info
- for which CA? low rectal tumours - <5cm from anus
- excision of distal colon, rectum & anal sphincters -> permanent colostomy
38
CHOLANGIOCARCINOMA what is it?
CA of the biliary system. @ any site along biliary tree - normally extrahepatic biliary system ** most common @ the bifurcation of the r & l hepatic ducts. typically slow growing & invade locally & met to local lymph nodes before spreading distally to peritoneal cavity, lung & liver
39
CHOLANGIOCARCINOMA risk factors?
PSC, UC, infective (eg hiv), toxins (air craft industry), congenital, alcohol xs, dm
40
CHOLANGIOCARCINOMA clinical features
asymptomatic until later stage of disease
sx: post hepatic jaundice, pruritus, pale stools w dark urine. less common: ruq pain, early satiety, wt loss, anorexia, malaise
41
CHOLANGIOCARCINOMA OE?
jaundice
cachexia
courvoisiers law can be applied - what is this
42
CHOLANGIOCARCINOMA differentials
anything that causes post hepatic jaundice eg????
43
CHOLANGIOCARCINOMA investigations?
- bloods that show obstructive jaundice ??
- tumour markers may be raised - CEA & CA19-9
- radiology - MRCP optimal. ERCP for biopsy. CTCAP for staging
44
CHOLANGIOCARCINOMA management ?
cure=surgical resection.
- intrahepatic tumour? partial hepatectomy & reconstruction of biliary tree
- distal common duct tumour? whipple
- radiotherapy as an adjunct or neoadjunct
-palliative = ercp stenting to relieve sx, surgical bypass, palliative radiotherapy
45
CHOLANGIOCARCINOMA comps?
- biliary tract sepsis
- 2 biliary cirrhosis
- long term survival is poor
46
LIVER CA pathophysiology?
hepatocellular carcinoma (HCC) arises as a result of a chronic inflammatory process affecting the liver. 90% metastatic and 10% primary
47
LIVER CA causes?
- viral hepatitis (most common)
- chronic alcoholism
- haemochromatosis
- pbc
- aflatoxin (?)
48
LIVER CA risk fax?
- viral hep - c & b
- high alcohol intake
- smoking
- >70 yrs
- aflatoxin exposure
- fhx
49
LIVER CA sx?
same as liver cirrhosis
vague non specific sc eg fatigue, wt loss, lethargy
** dull ruq ache is UNCOMMON but should raise suspicions in pts w known cirrhosis
advanced disease? sx of liver failure eg ascites or jaundice
50
LIVER CA OE?
irregular, enlarged, craggy and tender liver
51
LIVER CA differentials ?
- cardiac failure (smooth hepatomegaly)
- infectious hep (specific serology seen)
- other causes of liver cirrhosis
- benign hepatocellular adenoma
52
LIVER CA investigations?
labs:
- lfts - deranged
- low platelets & prolonged clotting - associated w liver failure (why?)
- alpha feta protein (AFP) raised in many cases
imaging:
- uss - mass >2cm + ^afp = diagnostic -> CT CAP
- ^ afp + suggestive uss nodules = MRI for further assessment
- still unsure? biopsy or fine needle aspiration (why is it a last resort?)
53
LIVER CA staging system used?
barcelona clinic liver cancer staging system (BCLC)
54
LIVER CA mgmt?
surgical
- surgical resection
- transplant - in pts that fulfill the milan criteria ??? x3
non surgical
- image guided ablation (early hcc) - what is this?
- TACE (large multimodal hcc) - what is this?
55
LIVER CA prognosis?
depends on underlying cirrhosis and this determines how aggressive the CA is. 6 months from diagnosis
56
LIVER CA what CAs commonly met to liver?
bowel (via?), brest, pancreas, stomach, lung
57
LIVER CA it is a met from elsewhere - investigations ?
- ^ alp due to biliary obstruction
- uss
- ct cap
- NO BIOPSY - why?
58
PANCREATIC CA types?
- ductal - most common - arises from exocrine part
- exocrine tumours (eg pancreatic cystic carcinoma)
- endocrine tumours (from islet cells)
59
PANCREATIC CA where in the pancreas?
- 60-70% in head
- 20-25% in body and tail - diagnosed at advanced stage- why??
- 10-20% diffusely involve the pancreas
60
PANCREATIC CA risk fax?
smoking, chronic pancreatitis, dietary fax (eg? x3), fhx, late onset dm
61
PANCREATIC CA clinical features?
depends on site of tumour :
- obstructive jaundice - why? typically…
- wt loss - why?
- abdo pain (non specific )- why?
- less common presentations: acute pancreatitis, thrombophlebitis migrans (???), upper gastroduodenal obstruction (if ca invades)
62
PANCREATIC CA OE?
cachectic, malnourished, jaundiced
abdo mass in epigastrium region may be felt
enlarged gb (? law)
63
PANCREATIC CA differentials?
- for causes of obstructive jaundice - ?? x2
- for causes of epigastrium abdo pain - ?? x4
64
PANCREATIC CA investigations?
labs
- fbc (anaemia or thrombocytopenia)
- lfts (^ bili, alp & ggt)
- ca19-9 to assessing response to treatment
imaging
- abdo uss - shows pancreatic mass or dilated biliary tree
- ct CAP
- unclear? pet-ct scan or mrcp
- endoscopic us for adenocarcinoma staging
65
PANCREATIC CA mgmt?
radical resection but only <20% are resectable.
** pancreatic ca defined as resectable, borderline resectable or locally advanced (ie unresectable) depending on degree of contact between tumour and surrounding vessels (eg x5) and mets
- head of pan ca - whipple w regional lymphadenectomy
- body or tail of pan ca - distal pancreatectomy +/- splenectomy w regional lymphadenectomy
all should receive adjuvant chemo - what drugs? x2
66
PANCREATIC CA comps of surgery?
high morbidity
pancreatic fistula, delayed gastric emptying, pancreatic insufficiency
67
PANCREATIC CA non resectable disease?
chemo - gemcitabine
mets? palliative chemo -> FOLFIRINOX regime or gemcitabine
poor performance status? symptomatic mgmt only eg ob jaundice & pruritus relief w biliary stent, exocrine insufficiency enzyme replacements to stop malabsorption ad steatorrhoea
68
PANCREATIC CA prognosis?
very poor. high metastatic capacity
69
PANCREATIC CA endocrine tumours - functional vs non functional
functional - actively secrete hormones so signs & sx related to this
non functional - don’t secrete active hormones so signs & sx related purely to their malignant spread
70
PANCREATIC CA endocrine tumours what syndrome are they associated w?
MEN1
71
PANCREATIC CA endocrine tumours - G cells:
- Hormones secreted
- CA name
- Normal physiological function of hormone
- Features of functional tumours
- Hormones secreted: gastrin
- CA name: gastrinoma
- Normal physiological function of hormone: stimulates gastri acid release
- Features of functional tumours: zollinger ellison syndrome -> pud (refractory to med) + diarrhoea & steatorrhea
72
PANCREATIC CA endocrine tumours - alpha cells:
- Hormones secreted
- CA name
- Normal physiological function of hormone
- Features of functional tumours
- Hormones secreted: glucagon
- CA name: glucagonoma
- Normal physiological function of hormone: inc [blood glucose]
- Features of functional tumours: hyperglycaemia, dm, necrolytic migratory erythema
73
PANCREATIC CA endocrine tumours - beta cells:
- Hormones secreted
- CA name
- Normal physiological function of hormone
- Features of functional tumours
- Hormones secreted: insulin
- CA name: insulinoma
- Normal physiological function of hormone: decrease [blood glucose]
- Features of functional tumours: symptomatic hypoglycaemia eg sweating, changed mental state - improves w carbs
74
PANCREATIC CA endocrine tumours - delta cells:
- Hormones secreted
- CA name
- Normal physiological function of hormone
- Features of functional tumours
- Hormones secreted: somatostatin
- CA name: somatostatinoma
- Normal physiological function of hormone:inhibits GH, TSH & prolactin release from apg & gastrin
- Features of functional tumours: dm, steatorrhoea, gallstones (ckk inhibition), wt loss, achlorhydria (bc of gastrin inhibition)
75
PANCREATIC CA endocrine tumours - non islet cells:
- Hormones secreted
- CA name
- Normal physiological function of hormone
- Features of functional tumours
- Hormones secreted: vasoactive intestinal peptide
- CA name: VIPoma
- Normal physiological function of hormone: secretion of water & electrolytes into gut, enteric sm relaxation
- Features of functional tumours: profuse watery diarrhoea, severe hypokalaemia & dehydration (? syndrome)
76
PANCREATIC CA endocrine tumours investigation & mgmt?
- ct, mri & eus
- <1cm - observe
- bigger? resection (same for mets)
- somatostatin analogues to control hyper secretion effects
77
GEP-NETs what are they?
gastroenteropancreatic neuroendocrine tumoura are nets originating from the neuro endocrine cells in the gi tract or pancreas (aka carcinoid tumour) all of which have malignant potential . majority in si, rectum or stomach
78
GEP-NETs risk fax?
may occur as part of complex familial endocrine cancer syndromes eg MEN1, MEN2
fhx
female
79
GEP-NETs clincial features
either functioning or non functioning (most)
all present w non specific sx: vague abdo pain, n&v, abdo distension, maybe bowel ob
if functioning + sx due to peptide hormone release - many w carcinoid syndrome
80
GEP-NETs whats carcinoid syndrome ?
functional GEP-NETs can present w this. it occurs following metastasis of a function GEP-NETs(ie carcinoid tumour) whereby the metastasised cells begin to OVERsecrete bio active mediators g seratonin, prostaglandins & gastrin into the blood. sx: flushing, palps, intermittent abdo pain, diarrhoea. RESISTANT SEVERE HYPOTENSION in CARCINOID CRISIS (overwhelming release of hormones from NET) - give pre op prophylactic somatostatin analogues (edge ocreotide) to prevent this
81
GEP-NETs investigations
labs
- chromogranin A - only general marker for NETs found in high concs whether tumour is functional or non functional - normal ? test chromogranin b
- pancreatic polypeptide checked where cga and cgb are normal . high for many GEP-NETs
- 5-HIAA - breakdown product of serotonin
imaging
- ct
- endoscopy
- mets w/o known primary? whole body ssrs
82
GEP-NETs surgical mgmt
gastric NETs: endoscopic resection due to low met potential. more aggressive? gastrectomy w lymph node clearance
SI NETs: almost always malignant. tumour resection w mesenteric lymph node c learnce
appendiceal NETs: found incidentally following appendicectomy. right hemi in certain circumstances (??)
colonic NETs: worst prog. segmental colectomy w regional lymph node clearance . rectal are benign so endoscopic if small or ap resection if large
