Cancers of the GI tract Flashcards
LO:
- Gastrooesophageal disorders: Describe the clinical features and treatment options of gastrooesophageal disorders
- Intestinal disorders: Describe the clinical features and treatment options of small and large intestine disorders
Cancers of the GI Tract – Case 1
HR, pulse and BP-all normal
Right basal crepitatons
What is the differential diagnosis?
Think about his recent history and current examination, get into the habit of organising your differential diagnoses into categories.
-Main complaint was dysphasia-so think of causes. Pharyngeal cancer is rare. Pharyngeal pouch is rare-defect in muscle and mucosa can pop out through hole.
GORD if persistent can cause strictures
Schatzki ring-ring of mucosal tissue which causes narrowing of lower oesophagus
Outside-smoker in past so could be lung cancer growing and pressing on oesophagus.
Neurological causes-nut cracker oesophagus (doesn’t sound like this though in this case), achalasia
Other-globus sensation-feeling they have a lump in their throat but actually there is nothing there, it is to do with anxiety.
What else would you ask or do in clinic?
Shift through the differentials with additional history and examination.
Cardiac pain being confused with dysphagia. Ask about exertional chest pain as unusual to get just after eating.
History sounds very oesophageal in origin-hard in reality to distinguish between upper and lower.
People with mechanical problems usually have problems with solid food first and then progresses to liquid. If neurological tends to be both from start.
Ask if blood in stool-would suggest GI malignancy. Perform a Digital rectum exam always if in doubt (if don’t put finger in it, put foot in it)
What is the differential diagnosis now?
=all potentiall correct
Oesophageal spasm doesn’t fit in as described with nut cracker oesophagus
What investigations would you request?
Be organised-think of all these categories:
Bedside-ECG, very straightforward and still worried about cardiac issue
Chronic GI bleed often associated with GI cancer
Basal crepitations noticed in right lower lobe so do chest X-ray
Patients get to MDTs via GPs who put them in an urgent 2 week wait pathway.
Although no microbiology tests done, urine is good as UTIs can manifest in many ways
Hb on low side
Albumin is on low side, so that fits in with malnutrition
ECG-fine
Chest X-ray-aspiration pneumonia so even though no symptoms of vomiting, when people have dysphagia, you can regurgitate and aspirate fluid, so this explains lower lobe creptitations. Lower lobe is fuzzy-coming into right bronchus
Can see a lesion in oespohagus
=all of the above (need all info before deciding how to go forward, but that is presuming the patient is fit and are looking to do op on patient)
PET scan looks for distant metastases that cannot be picked up on CT
Stging laproscopy-puts camera in abdomen and picks up small lesions that can’t be picled up on PET scans
Top left is CT-oesophagus is usually small little tube with air, but can see quite significant oesophageal tumour here.
PET is on right. Top arrow is where tumour is, these are functional scans so big means more active
Local involved lymph node seen. But still is all local
T3, lymph node positive, no metastases
Really questions are is surgery right for this cancer? In most cases this is the right choice to get best outcome. This uses TNM staging. T3 tumour so yes that is operable, but actually take these ot during operation so still possible. If have liver or peritoneal metastases wouldn’t do surgery.
Second question is surgery right for patient-are they fit enough for this? ECOG-eastern cooperative oncology group-Performance status-measures patient fitness (0=best, 5=dead)
This is the treatment our patient had:
Cancers of the GI Tract – Case 2
What do these blood test results mean?
Hb-low
WCC-okay
Creatinine-up a little bit
MCV is size of red blood cells so low=microcytic anaemia
She isn’t managing diabetes so well.
Anaemia causes by mean corpuscular volume (MCV)
Microcytic-PINT
Normocytic-bleeding that is not chronic
Commonest cause of macrocytic is b12/folate deficiency
Iron deficiency anaemia
Angiodysplasia-which acquires AV-arterious venal mutations
A week later the patient has her follow-up GP appointment.
What would you ask and what would you do to narrow down your differential?
What else would you ask or do in clinic?
Generic symptoms of malignancy: FLAW
=colorectal cancer is most likely with history
All possible but coeliac disease is less likely
What investigations would you request?
Be organised, put your things into categories:
- Bedside tests
- Blood tests
- Imaging
- Microbiology
- Special/Invasive
anti-tissue transglutaminase antibody
OGD then colonoscopy if problems stem from oesophagus, ie do tests other way around.
=with colorectal cancer, first test is staging CT of abdomen and pelvis as they metastasise rapidly to liver and lung. PET wouldn’t do routinely unlike oesophageal cancer.
pet scan pick up rate is low for colorectal cancer and wouldn’t do Staging laprascopy as unusual to get peritoneal deposits
dilated proximal bowel, not yet occluding but there is possibility
Microcytic anaemia is most often associated with right sided lesion eg ascending colonic or caecal cancer, so this is unusual that patient has a left sided lesion with microcytic lesion.
Palative care-no treatment
Pallative chemotherapy-therapy to extend life, not save it
palative chemo-possibe esp if no access to liver surgery, fit enough so not pallative care, large colon and large liver operation together don’t go well, but a large liver and small colon or vice versa go well together.
=Resect primary colonic tumour, followed by neoadjuvant chemo followed by liver resecrtion.
What patient had:
Resect tumour first as that is where metastases came from and so want to prevent further tumours arising and also don’t want blockage as this would require surgery which would disrupt chemotherapy.
