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🕺🏽gen surg > Cancer > Flashcards

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
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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
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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
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4
Q

GASTRIC CA differential diagnoses?

A

presents w non specific symptoms so what else presents similarly???

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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

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6
Q

GASTRIC CA imaging?

A
  • urgent OGD - allows direct visulisation & biopsy taking
  • staging CT CAP and staging laparoscopy (to look for?)
  • TNM staging
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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

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8
Q

GASTRIC CA biopsies from suspected gastric malignancies should be sent for?

A
  • histology - why?
  • CLO test - why?
  • HER2/neu protein expression - why?
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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?)
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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) - ??
    -
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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
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12
Q

GASTRIC CA complications?

A
  • gastric outlet obstruction
  • iron deficiency anaemia
  • perf
  • malnutrition
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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?
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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
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15
Q

OESOPHAGEAL CA on examination?

A
  • recemt weight loss or cachexia
  • signs of dehydration
  • supraclavicular lymphadenopathy
  • signs of mets (eg? x3)
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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

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17
Q

OESOPHAGEAL CA initial investigations?

A
  • urgent OGD within 2 weeks. any malignancy will be biopsied and sent for histology
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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

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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

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20
Q

OESOPHAGEAL CA surgical treatment?

A

many approaches - one to note: right thoracotomy w laparotomy (ivor lewis)

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21
Q

OESOPHAGEAL CA surgical complications?

A

anastomotic leak, re-op, pneumonia & death

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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

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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
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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
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25
Q

COLORECTAL CA predisposing genetic mutations?

A
  • 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
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26
Q

COLORECTAL CA risk factors ?

A

75% sporadic
- inc age, m, fhx, ibd, low fibre diet, high processed meat intake, smoking, xs alcohol
- acromegaly
- ileal conduit

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27
Q

COLORECTAL CA clinical features

A
  • 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
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28
Q

COLORECTAL CA 2ww nice guidance ?

A

see tms

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29
Q

COLORECTAL CA differentials ?

A

ibd, haemorrhoids

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30
Q

COLORECTAL CA screening?

A
  • m & f aged 60 - 75 yrs - FIT test every 2 yrs
  • +ve? colonoscopy
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31
Q

COLORECTAL CA investigations ?

A
  • 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, ?)
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32
Q

COLORECTAL CA management?

A

** 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

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33
Q

COLORECTAL CA right hemi/extended right hemi more info

A
  • for which CA? caecal, ascending colon. extended=transverse colon
  • what vessels removed w their mesenteries? ileocolic, right colic, right branch of middle colic
34
Q

COLORECTAL CA left hemi more info

A
  • for which CA? descending colon
  • what vessels removed w their mesenteries? left branch of middle colic, inferior mesenteric vein, left colic
35
Q

COLORECTAL CA sigmoidcolectomy more info

A
  • for which CA? sigmoid colon
  • IMA removed to ensure adequate margins obtained
36
Q

COLORECTAL CA anterior resection more info

A
  • 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
Q

COLORECTAL CA AP resection more info

A
  • for which CA? low rectal tumours - <5cm from anus
  • excision of distal colon, rectum & anal sphincters -> permanent colostomy
38
Q

CHOLANGIOCARCINOMA what is it?

A

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
Q

CHOLANGIOCARCINOMA risk factors?

A

PSC, UC, infective (eg hiv), toxins (air craft industry), congenital, alcohol xs, dm

40
Q

CHOLANGIOCARCINOMA clinical features

A

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
Q

CHOLANGIOCARCINOMA OE?

A

jaundice
cachexia
courvoisiers law can be applied - what is this

42
Q

CHOLANGIOCARCINOMA differentials

A

anything that causes post hepatic jaundice eg????

43
Q

CHOLANGIOCARCINOMA investigations?

A
  • bloods that show obstructive jaundice ??
  • tumour markers may be raised - CEA & CA19-9
  • radiology - MRCP optimal. ERCP for biopsy. CTCAP for staging
44
Q

CHOLANGIOCARCINOMA management ?

A

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
Q

CHOLANGIOCARCINOMA comps?

A
  • biliary tract sepsis
  • 2 biliary cirrhosis
  • long term survival is poor
46
Q

LIVER CA pathophysiology?

A

hepatocellular carcinoma (HCC) arises as a result of a chronic inflammatory process affecting the liver. 90% metastatic and 10% primary

47
Q

LIVER CA causes?

A
  • viral hepatitis (most common)
  • chronic alcoholism
  • haemochromatosis
  • pbc
  • aflatoxin (?)
48
Q

LIVER CA risk fax?

A
  • viral hep - c & b
  • high alcohol intake
  • smoking
  • > 70 yrs
  • aflatoxin exposure
  • fhx
49
Q

LIVER CA sx?

A

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
Q

LIVER CA OE?

A

irregular, enlarged, craggy and tender liver

51
Q

LIVER CA differentials ?

A
  • cardiac failure (smooth hepatomegaly)
  • infectious hep (specific serology seen)
  • other causes of liver cirrhosis
  • benign hepatocellular adenoma
52
Q

LIVER CA investigations?

A

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
Q

LIVER CA staging system used?

A

barcelona clinic liver cancer staging system (BCLC)

54
Q

LIVER CA mgmt?

A

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
Q

LIVER CA prognosis?

A

depends on underlying cirrhosis and this determines how aggressive the CA is. 6 months from diagnosis

56
Q

LIVER CA what CAs commonly met to liver?

A

bowel (via?), brest, pancreas, stomach, lung

57
Q

LIVER CA it is a met from elsewhere - investigations ?

A
  • ^ alp due to biliary obstruction
  • uss
  • ct cap
  • NO BIOPSY - why?
58
Q

PANCREATIC CA types?

A
  • ductal - most common - arises from exocrine part
  • exocrine tumours (eg pancreatic cystic carcinoma)
  • endocrine tumours (from islet cells)
59
Q

PANCREATIC CA where in the pancreas?

A
  • 60-70% in head
  • 20-25% in body and tail - diagnosed at advanced stage- why??
  • 10-20% diffusely involve the pancreas
60
Q

PANCREATIC CA risk fax?

A

smoking, chronic pancreatitis, dietary fax (eg? x3), fhx, late onset dm

61
Q

PANCREATIC CA clinical features?

A

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
Q

PANCREATIC CA OE?

A

cachectic, malnourished, jaundiced
abdo mass in epigastrium region may be felt
enlarged gb (? law)

63
Q

PANCREATIC CA differentials?

A
  • for causes of obstructive jaundice - ?? x2
  • for causes of epigastrium abdo pain - ?? x4
64
Q

PANCREATIC CA investigations?

A

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
Q

PANCREATIC CA mgmt?

A

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
Q

PANCREATIC CA comps of surgery?

A

high morbidity
pancreatic fistula, delayed gastric emptying, pancreatic insufficiency

67
Q

PANCREATIC CA non resectable disease?

A

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
Q

PANCREATIC CA prognosis?

A

very poor. high metastatic capacity

69
Q

PANCREATIC CA endocrine tumours - functional vs non functional

A

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
Q

PANCREATIC CA endocrine tumours what syndrome are they associated w?

A

MEN1

71
Q

PANCREATIC CA endocrine tumours - G cells:
- Hormones secreted
- CA name
- Normal physiological function of hormone
- Features of functional tumours

A
  • 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
Q

PANCREATIC CA endocrine tumours - alpha cells:
- Hormones secreted
- CA name
- Normal physiological function of hormone
- Features of functional tumours

A
  • Hormones secreted: glucagon
  • CA name: glucagonoma
  • Normal physiological function of hormone: inc [blood glucose]
  • Features of functional tumours: hyperglycaemia, dm, necrolytic migratory erythema
73
Q

PANCREATIC CA endocrine tumours - beta cells:
- Hormones secreted
- CA name
- Normal physiological function of hormone
- Features of functional tumours

A
  • 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
Q

PANCREATIC CA endocrine tumours - delta cells:
- Hormones secreted
- CA name
- Normal physiological function of hormone
- Features of functional tumours

A
  • 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
Q

PANCREATIC CA endocrine tumours - non islet cells:
- Hormones secreted
- CA name
- Normal physiological function of hormone
- Features of functional tumours

A
  • 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
Q

PANCREATIC CA endocrine tumours investigation & mgmt?

A
  • ct, mri & eus
  • <1cm - observe
  • bigger? resection (same for mets)
  • somatostatin analogues to control hyper secretion effects
77
Q

GEP-NETs what are they?

A

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
Q

GEP-NETs risk fax?

A

may occur as part of complex familial endocrine cancer syndromes eg MEN1, MEN2
fhx
female

79
Q

GEP-NETs clincial features

A

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
Q

GEP-NETs whats carcinoid syndrome ?

A

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
Q

GEP-NETs investigations

A

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
Q

GEP-NETs surgical mgmt

A

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

🕺🏽gen surg (8 decks)

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