Colorectal Cancer Flashcards
What is the incidence (new cases) of colon cancer/year in the UK?
1 - 4000
2 - 40,000
3 - 400,000
4 - 4 million
2 - 40,000
64 cases per 100,000
- 10 year survival is 53%
What age is colorectal cancer rare?
1 - <50
2 - <65
3 - <70
4 - <85
1 - <50
- becomes more common in >50 y/o
Colon cancer is more likely in white than black populations, especially in the western world. What is the most likely cause of this?
1 - more pollutants
2 - westernised diet
3 - smoking
4 - obesity
2 - westernised diet
- low in dietary fibre
There are lot of risk factors for colorectal cancer, which of the following is NOT a risk factor for colorectal cancer?
1 - high BP
2 - low dietary fibre
3 - obesity/sedentary lifestyle
4 - red meat consumption
5 - smoking and alcohol
6 - genetics (Lynch, FAP)
7 - IBD (specifically Ulcerative colitis)
8 - T2DM
1 - high BP
- in IBD risk is increased due to chronic inflammation causing DNA damage and cancer
The colon has multiple layers. One of these is the mucosa, which itself has 3 separate layers. Which of the following is not one of the mucosa layers?
1 - epithelium
2 - muscularis mucosae
3 - serosa
4 - lamina propria
3 - serosa
Arrange the layers of the colon from the lumen outwards using the labels below:
1 - serosa (intraperitoneal) or adventia (retroperitoneal)
2 - submucosa
3 - mucosa
4 - muscularis
3 - mucosa
2 - submucosa
4 - muscularis
1 - serosa (intraperitoneal) or adventia (retroperitoneal)
Colorectal cancers can occur anywhere in the GIT, including all of the following. But which is most common?
1 - rectal
2 - sigmoid
3 - descending colon
4 - transverse colon
5 - ascending colon and caecum
1 - rectal
Accounts for 40%, closely followed by the sigmoid and then the caecum
Colon cancer can be sporadic or hereditary. Which is most common?
1 - sporadic
Accounts for 95% of colon cancers
- hereditary non-polyposis colorectal carcinoma (HNPCC, 5%)
- familial adenomatous polyposis (FAP, <1%)
There are different types of colorectal cancers. Which of the following is most common?
1 - adenocarcinomas /
adenomatuous
2 - hyperplastic polyps
3 - sessile serrated polyps
4 - non-neoplastic polyps
1 - adenocarcinomas /
adenomatuous
- tumour comes from tissue of the colon
- accounts for 70% of colon cancer
All of the following are classifications of bowel cancer based on histology. Which type accounts for >90% of colon cancer?
1 - Squamous cell
2 - Adenosquamous type
3 - Neuroendocrine
4 - Spindle cell
5 - Adenocarcinoma
5 - Adenocarcinoma
adeno” meaning ‘pertaining to a gland’ and “carcinoma” meaning cancer.
Which 2 of the following would we find sqaumous cells in the lower GI?
1 - transverse colon
2 - ascending colon
3 - anus
4 - rectum
5 - descending colon
3 - anus
4 - rectum
- this is where we could find any squamous cell carcinomas
What are adenocarcinomas?
1 - tumours formed in squamous cells
2 - tumours formed in lamina propria
3 - tumours formed in glandular tissues
4 - all of the above
3 - tumours formed in glandular tissues
- in colon glandular cells are crypts
Adenocarcinomas can be:
- well differentiated
- moderately differentiated
- poorly differentiated
Which of these resembles normal tissue and an increase in glandular tissue?
- well differentiated
- grow slowly
Adenocarcinomas can be:
- well differentiated
- moderately differentiated
- poorly differentiated
Which of these have the worst prognosis?
- poorly differentiated
Adenoma-carcinoma progress in a stepwise progression from a normal bowel mucosa to an adenomatous polyp and bowel cancer. The first step of this stepwise progression is when normal bowel tissue undergoes hyperplasia and becomes an early adenoma. Which of the following occurs here?
1 - Kirsten RAt Sarcoma virus (KRAS) mutation
2 - Adenomatous polyposis coli (APC) inactivation
3 -18q loss
4 -Tumour protein 53 (TP53) mutation and/or loss
2 - Adenomatous polyposis coli (APC) inactivation
- APC gene = tumour suppressor gene
- APC gene normally suppressor tumour growth
- abnormal APC gene means adenocarcinoma can begin to develop
Adenoma-carcinoma progress in a stepwise progression from a normal bowel mucosa to an adenomatous polyp and bowel cancer. The second step is the development of an early adenoma to an intermediate adenoma due to dysplasia. Which of the following occurs to allow this?
1 - Kirsten RAt Sarcoma virus (KRAS) mutation
2 - Adenomatous polyposis coli (APC) inactivation
3 -18q loss
4 -Tumour protein 53 (TP53) mutation and/or loss
1 - Kirsten RAt Sarcoma virus (KRAS) mutation
- KRAS is a proto-oncogene involved in cell division
- mutation of proto-oncogene into an oncogene gene leads to uncontrolled cell division
Adenoma-carcinoma progress in a stepwise progression from a normal bowel mucosa to an adenomatous polyp and bowel cancer. The development from a later adenoma to a carcinoma is commonly caused by what?
1 - Kirsten RAt Sarcoma virus (KRAS) mutation
2 - Adenomatous polyposis coli (APC) inactivation
3 -18q loss
4 -Tumour protein 53 (TP53) mutation and/or loss
4 -Tumour protein 53 (TP53) mutation and/or loss
- TP53 normally acts as a tumour suppressor
- Loss of the tumour supressor leads to adenocarcinoma growth
Adenoma have the potential to become malignant. Over what time period could it become malignant and progress to invasive cancer?
1 - 1-2 years
2 - 2-4 years
3 - 5 years
4 - 5-10 years
4 - 5-10 years
- early diagnosis prevents adenomas become adenocarcinomas
Which patients are monitored due to an increased risk of colorectal cancer?
1 - patients with colorectal polyps
2 - patients >65 y/o
3 - patients with previous surgery
4 - patients with >3 risk factors
1 - patients with colorectal polyps
- screened between 1-5 years to monitor polyps
- aspirin 600mg has shown some preventative effects
Why has aspirin at doses of 600mg been used in treatment for patients with colorectal cancer?
1 - inhibits tumour growth
2 - inflammatory effects
3 - induces hypoxia in tumours
4 - all of the above
2 - inflammatory effects
There is a screening programme for colorectal cancer. How do they screen patients?
1 - undertake colonoscopy
2 - laparoscopic surgery
3 - faecal immunochemical test (FIT)
4 - change in bowel habits for >6months
3 - Faecal Immunochemical Test (FIT)
qFIT may be used to quantify the amount of blood rather than just the presence of blood
- measures microscopic blood in stool
Patients who are eligible will have a qFIT every 2 years. What is the current screening age?
1 - 30-40 y/o
2 - 40-60 y/o
3 - 54-74 y/o
4 - >65 y/o
3 - 54-74 y/o
- likely to be reduced to 50 y/o
Which of the following conditions increases the risk of colorectal cancer?
1 - IBS
2 - coeliac disease
3 - IBD
4 - diverticulosis
3 - IBD
- both crohns and ulcerative colitis
A small proportion of colorectal carcinomas can be due to familial inheritance. Polyposis syndromes is where patients develop a large number of polyps early in life, that can then become malignant. Which of the following is the most important?
1 - Familial adenomatous polyposis
2 - MUTYH-associated polyposis
3 - Serrated polyposis syndrome
4 - Peutz-Jeghers syndrome
1 - Familial adenomatous polyposis
- inevitable that patients will develop colon cancer if untreated by 40 y/o
- 100-1000s of polyps form in teens
- subtotal colectomy and/or rectum removal with ileostomy is curative
Autosomal dominant genetic condition, meaning only 1 copy of mutated gene is required
A small proportion of colorectal carcinomas can be due to familial inheritance. Polyposis syndromes is where patients develop a large number of polyps early in life, that can then become malignant. One of these is peutz-jeghers syndrome. Which of the following is NOT a common effect of this syndrome?
1 - polyps in just the colon
2 - freckles around the mouth
3 - freckles on hands, feet and genitls
4 - hyperpigmented macules on the lips
1 - polyps in just the colon
Polyps can form anywhere in the GIT
Peutz Jeghers syndrome (PJS) is an autosomal dominant genetic condition, meaning only 1 copy of mutated gene is required
A small proportion of colorectal carcinomas can be due to familial inheritance. Polyposis syndromes is where patients develop a large number of polyps early in life, that can then become malignant. One of these is hereditary nonpolyposis colorectal cancer (HNPCC) syndrome, also known as Lynch syndrome. Which of the following is NOT true about this syndrome?
1 - defect in mismatch repair gene
2 - 70-80% lifetime risk of colorectal cancer
3 - most common cause of hereditary colorectal (colon) cancer
4 - tumours form anywhere in the GIT
5 - median age is 44-61 y/o
4 - tumours form anywhere in the GIT
- typically occur on the right side of the colon
- if confirmed with HNPCC syndrome then need screening every 2 years after >25y/o
Autosomal dominant genetic condition, meaning only 1 copy of mutated gene is required
Hereditary nonpolyposis colorectal cancer (HNPCC) syndrome, also known as Lynch syndrome is the most common cause of hereditary bowel cancer. If a patient has Lynch syndrome, the risk of which of the following cancers is also increased the most?
1 - gastric cancer
2 - endometrial cancer
3 - ovarian
4 - small intestines
2 - endometrial cancer
- 60% risk
Which of the following is NOT a characteristic of hereditary nonpolyposis colorectal cancer (HNPCC) syndrome, also known as Lynch syndrome?
1 - mostly left sided in colon
2 - mucinous adenocarcinomas
3 - poorly differentiated medullary type
4 - signet ring cells present in biopsy
5 - infiltrating lymphocytes present in tumour
1 - mostly left sided in colon
- predominantly found on the right side of colon
What is the transmission type of hereditary nonpolyposis colorectal cancer (HNPCC) syndrome, also known as Lynch syndrome?
1 - autosomal dominant
2 - autosomal recessive
3 - Y linked recessive
4 - X lnked recessive
1 - autosomal dominant
Which genes are mutated in the hereditary nonpolyposis colorectal cancer (HNPCC) syndrome, also known as Lynch syndrome?
1 - TP53 (tumour suppressor gene)
2 - P53 (tumour suppressor gene)
3 - DNA mismatch genes
4 - all f the above
3 - DNA mismatch genes
- can include PMS2, MLH-1, MSH-2 and MSH-6
Although colorectal cancer can go unoticed for some time, there are a number of key symptoms that patients present with. Which of the following is NOT a common symptom?
1 - change in bowel habits
2 - hematuria
3 - iron deficiency anaemia
4 - mass (abdo or rectal)
5 - weight loss
2 - hematuria
- blood in urine
- rectal bleeding is common
The Amsterdam criteria is a diagnostic criteria used by doctors to help identify families who are likely to have Lynch syndrome. Which if the following is NOT one of the criteria?
1 - a single relative with aLynch syndrome
2 - one relative with Lynch syndrome must be a 1st degree relative
3 - 2 successive generations affected
One is a first-degree relative of the other two
More than one relative is diagnosed younger than age 50
4 - No evidence of Familial Adenomatous Polyposis (FAP)
1 - a single relative with aLynch syndrome
- there must be >3 relatives with Lynch syndrome
The Revised Bethesda Guidelines is also is a diagnostic criteria used by doctors to help identify families who are likely to have Lynch syndrome. Which if the following is NOT one of the criteria?
1 - colorectal cancer diagnosed >65y/o
2 - synchronous or metachronous, colorectal, or otherLynch syndrome-related tumors, regardless of age
3 - colorectal cancer withmicrosatellite instability-highhistology
4 - colorectal cancer diagnosed in a patient with one or more first-degree relatives with aLynch syndrome-related cancer
5 - colorectal cancer diagnosed in a patient with two or more first- or second-degree relatives withLynch syndrome-related cancers regardless of age
1 - colorectal cancer diagnosed >65y/o
- typically this is <50 y/o
Familial Adenomatosis Polyposis Coli 1 (FAP) refers to:
- familial = inherited
- adenomatosis = growth of glandular tissue
- polyposis = lots of polyps
Which lost/mutated gene is lost in patients that causes FAP?
1 - TP53 (tumour suppressor gene)
2 - P53 (tumour suppressor gene)
3 - DNA mismatch genes
4 - APC gene (tumour suppressor gene)
4 - APC gene (tumour suppressor gene)
- APC = Adenomatous polyposis coli
- abnormal growth of glandular cells (endothelial) grow unchecked forming 100s of polyps
Typically the first step of this stepwise progression is when normal bowel tissue undergoes hyperplasia and becomes an early adenoma. Which of the following occurs here?
What is the transmission type of Familial Adenomatosis Polyposis Coli 1 (FAP)?
1 - autosomal dominant
2 - autosomal recessive
3 - Y linked recessive
4 - X lnked recessive
1 - autosomal dominant
- second most common cause of hereditary colon cancer behind Lynch syndrome
Which of the following pathologies is Familial Adenomatosis Polyposis Coli 1 (FAP) NOT associated with?
1 - congenital hypertrophic retinal pigment epithelium
2 - bony osteomas
3 - sebaceous cysts
4 - benign desmoid tumours
5 - gastric – duodenal malignancy/ hepatoblastoma / Thyroid cancers.
6 - anal cancer
6 - anal cancer
- rare if at all
FAP Typically causes left sides cancers
In a patient with Familial Adenomatous Polyposis (FAP) by the time they are 30 they are at a 100% risk of developing bowel cancer. What is therefore the treatment?
1 - steroids and NSAIDs
2 - sulindac medication
3 - regular colonscopy to remove polyps
4 - total proctocolectomy
4 - total proctocolectomy
- complete removal of colon and rectum
- patient may take sulindac (pain medication), COX-2 inhibitor and NSAIDs can be used but surgery is required
In a patient with colorectal cancer there is the risk of metastasis through the lymphatics. Where is the first site the metastasis typically spread to?
1 - para-aortic nodes
2 - mesenteric nodes
3 - iliac nodes
4 - splenic nodes
2 - mesenteric nodes
All of the following are common metastatic sites in colonrectal cancer, but which is most common?
1 - brain
2 - bone
3 - liver
4 - lungs
3 - liver
Due to portal blood flow draining the GIT
Iron deficiency anaemia is common in colorectal cancer and generally in cancer. There are a number of reasons causing this, which one of the following is NOT a common cause?
1 - increased iron absorption
2 - tumour-induced anorexia
3 - malnutrition
4 - occult blood loss
1 - increased iron absorption
- malabsorption normally occurs due to damage to the mucosa of the colon
Although colorectal cancer can go noticed for some time, it can present in an emergency manner. Which of the following is NOT common?
1 - bleeding and mucus
2 - perforation
3 - obstruction
4 - ileus
4 - ileus
Lack of peristalsis with no sign of mechanical obstruction
If a patient has a mass in the right side of the colon, they rarely have obstruction unless the ileocaecal valve is involved. Why is this?
1 - less likely for tumours to develop
2 - more tumour suppressor genes here
3 - wider part of colon
4 - mucus is thicker here so more difficult for tumours to grow
3 - wider part of colon
- only causes obstruction if the ileocaecal valve is involved
If a patient has a mass in the left side of the colon, they could experience an obstruction. Why is this?
1 - narrower so smaller tumours can obstruct
2 - less tumour suppressor genes here
3 - more likely to cause constipation
4 - increased intraluminal pressure
4 - increased intraluminal pressure
Perforation can occur in patients with colorectal cancer. Which of the following is NOT true about perforations in colorectal cancer?
1 - pericolic abscess
2 - peritonitis
3 - ileus
4 - fistula
3 - ileus
In a patient with suspected colon cancer what technique is used to diagnose patients?
1 - qFIT
2 - colonoscopy
3 - CT scan
4 - MRI
2 - colonoscopy
- also allows for biopsy as well
Following a colonoscopy for diagnosis, how can we stage colorectal cancer?
1 - qFIT
2 - sigmoidoscopy
3 - CT scan
4 - MRI
3 - CT scan
- Dukes classification may also be used alongside TNM
- image thorax abdomen and pelvis
- MRI if liver or rectum is involved)
What is the tumour specific marker for colorectal cancer?
1 - Carbohydrate antigen 19-9 (CA19-9)
2 - Breast cancer type 1 (BRCA1)
3 - Carcinoembryonic antigen (CEA)
4 - Alpha-fetoprotein (AFP)
3 - Carcinoembryonic antigen (CEA)
If the rectum is involved in colorectal cancer, what treatment must only be used here?
1 - chemotherapy
2 - immunotherapy
3 - surgery
4 - radiotherapy
4 - radiotherapy
- downstages local response
Surgery for colorectal cancer can be curative or palliative, including stents and stomas.
What is the difference between adjuvant and neo-adjuvant?
- adjuvant given after main treatment
- neo-adjuvant given prior to the main treatment
If a patient has surgery and requires a right hemicolectomy, which 2 of the following blood vessels must be ligated?
1 - middle colic artery
2 - right colic artery
3 - ilio-colic artery
4 - inferior mesenteric artery
2 - right colic artery
3 - ilio-colic artery
If a patient has surgery and requires a left hemicolectomy, which 2 of the following blood vessels must be ligated?
1 - middle colic artery
2 - left colic artery
3 - ilio-colic artery
4 - inferior mesenteric artery
1 - middle colic artery
2 - left colic artery
If a patient has surgery and requires a transverse colectomy, which of the following blood vessels must be ligated?
1 - middle colic artery
2 - left colic artery
3 - ilio-colic artery
4 - inferior mesenteric artery
1 - middle colic artery
- part would be left if possible
If a patient has surgery and requires a sigmoid colectomy, which of the following blood vessels must be ligated?
1 - middle colic artery
2 - left colic artery
3 - lower left colic and sigmoid arteries
4 - inferior mesenteric artery
3 - lower left colic and sigmoid arteries
The primary aim of any surgery in cancer is always curative. The following steps are followed fr surgery:
1 - tumour dissection with clear margins
2 - lymph node removal
3 - maintain intestinal continuity where possible
4 - palliative surgery (stoma/stents)
What is the overall 5 year survival following surgery with no lymph involvement?
1 - 35%
2 - 50%
3 - >85%
4 - 100%
3 - >85%
-nodal involvement is 65%
- metastatic is 20%
If a patient does not have metastatic cancer, what would the treatment be?
1 - surgery to remove the tumour
2 - chemotherapy and radiotherapy
3 - total proctocolectomy surgery
4 - radio frequency oblation and chemotherapy
1 - surgery to remove the tumour
- could be open laparotomy or laparoscopic surgery to remove the tumour
- adjuvant chemotherapy may be offered alongside
Liver cancer a key location where metastatic cancer can spread to. How do metastasis travel to the liver?
1 - superior vena cava
2 - portal system
3 - femoral and iliac veins
4 - all of the above
2 - portal system
A 45 year old male patient has presented with sudden onset rectal bleeding . He gives a family history of malignancy ie his sister was diagnosed with endometrial cancer in her 30s. He cannot recall any other family history
What is the most likely diagnosis
1 - Lynch syndrome
2 - Familial adenomatosis Polyposis
3 - Gardners syndrome
4 - Gorlins Syndrome
1 - Lynch syndrome
- endometrial cancer is high risk in this group of patients
74 year old man presents to his GP and complains of haemorrhoids (piles), enlarged blood vessels around the anus.
- rectal bleeding for 3 months
- change in bowel habit for 5 months
- alternating constipation/diarrhoea
- o/e – abdomen- soft and non tender/ - no suspicious findings on DRE
What would the 1st test be in this patient if you suspect colon cancer?
1 - qFIT
2 - colonoscopy
3 - pelvic abdomen
4 - ultrasound of abdomen
1 - qFIT
Abnormal = 10 µg of blood per gram of stool
This patient has 150 µg and FBC shows microcytic anaemia
74 y/o M no family history of cancer
3/12 rectal bleeding
QFIT positive
Colonoscopy shows a suspicious mass in the rectum and a polyp in the descending colon
Rectal biopsies confirm adenocarcinoma of colorectal origin
The descending colon biopsy shows a benign adenoma only. Which of the following can be used to stage the patients colon cancer?
1 - CEA levels
2 - CT TAP
3 - colonoscopy with biopsy
4 - all of the above
4 - all of the above
Patient is staged as T3d N1 M0 adenocarcinoma of the rectum
MRI and PET scan used in specific cases
74 y/o M no family history of cancer
3/12 rectal bleeding
QFIT positive
Colonoscopy shows a suspicious mass in the rectum and a polyp in the descending colon
Rectal biopsies confirm adenocarcinoma of colorectal origin staged as T3d N1 M0. Which of the following is typically 1st line treatment?
1 - radiotherapy
2 - brachiatherapy
3 - surgery
4 - chemotherapy
3 - surgery
Aim is to remove all the cancer with clear resection margin
May involve multivisceral resection
Remove lymph nodes to allow N staging
+/- restore intestinal continuity (if possible)
Palliative surgery – defunctioning stomas/bypass
In a patient with rectal cancer, is surgery always used?
- no
Typically, patients staged using MRI if cancer is operable
Then patient given neoadjuvant chemo/ RT prior to surgery in selected cases
In a patient with inoperable rectal cancer, which of the following treatment is typically used?
1 - chemotherapy followed by radiotherapy
2 - chemotherapy and radiotherapy together
3 - radiotherapy followed by chemotherapy
2 - chemotherapy and radiotherapy together
Has an 80% response rate
Oligometastatic cancer describes an intermediate stage of cancer between localized and widely spread disease. We classify oligometastatic as a subclass of stage IV cancer. If you have oligometastatic cancer, that means cancer has spread to fewer than five sites in your body. Typically the patient will have an MRI and/or PET scan. The patient may then receive which of the following?
1 - metastectomy
2 - radioablation
3 - stereotactic ablative radiotherapy
4 - microwave ablation
5 - all of the above
5 - all of the above
If a patient has widespread metastatic disease, which of the following should be initiated?
1 - metastectomy of metastasis
2 - surgery for removal of metastasis
3 - palliative chemotherapy
4 - all of the above
3 - palliative chemotherapy
Not possible to cure, so symptom treat
In the image below, which one is a thrombosed haemorrhoid?
Far left
Colour is blue ish as this is venous blood that has pooled
If a patient develops neutropenic sepsis due to the cancer treatment, in addition to initiating the sepsis 6, what can be given in an attempt to increase the neutrophil count?
1 -dexamethasone
2 - granulocyte colony stimulating factors (GCSF)
3 - blood transfusion
4 - frozen WBCs
2 - granulocyte colony stimulating factors (GCSF)
