Colorectal + pancreatic cancer Flashcards
colorectal, pancreatic
Cancer
What is a cancer?
A disease caused by an uncontrolled division of abnormal cells in a part of the body
Cancer
What is a primary cancer?
Arising directly from the cells in an organ
Cancer
What is a secondary cancer / metastasis?
Spread from another organ, directly or by other means (blood or lymph)
Cancer
What is a CUP?
Carcinoma of unknown primary (CUP) is a rare disease in which malignant (cancer) cells are found in the body but the place the cancer began is not known
GI Cancer
What kind of epithelial cells do we have in the GI tract?
squamous
glandular epithelium
GI Cancer
What kind of neuroendocrine cells do we have in the GI tract?
enteroendocrine cells
interstitial cells of Cajal
GI Cancer
What kind of connective tissue do we have in the GI tract?
smooth muscle
adipose tissue
GI cancer
What kind of cancer do squamous cells of the GI tract make?
squamous cell carcinoma (SCC)
GI cancer
What kind of cancer do the glandular epithelium of the GI tract make?
adenocarcinoma
GI cancer
What kind of cancer do enteroendocrine cells of the GI tract make?
neuroendocrine tumours (NETs)
GI cancer
What kind of cancer do interstitial cells of Cajal of the GI tract make?
gastrointestinal stromal tumours (GISTs)
GI cancer
What kind of cancer does smooth muscle of the GI tract make?
leiomyoma / leiomyosarcomas
GI cancer
What kind of cancer does adipose tissue of the GI tract make?
liposarcomas
GI cancer
What is the most common GI cancer in western societies?
colorectal
Colorectal cancer
At the start of what age do colorectal cancers start occurring?
Generally affects patients > 50 years (>90% of
cases)
Colorectal cancer
The majority colorectal polyps are ____. The majority of colorectal adenocarcinomas arise from ____.
The majority colorectal polyps are adenomas. The majority of colorectal adenocarcinomas arise from existing adenomas.
Colorectal cancer
What familial syndromes predispose people to colorectal cancer?
- Familial adenomatous polyposis (FAP)
- hereditary nonpolyposis colorectal cancer (HNPCC or Lynch syndrome)
- Peutz-Jegher’s syndrome
Colorectal cancer
What is FAP?
- full name
- mutation involved
- how it presents
- Familial adenomatous polyposis
- Autosomal dominant mutation in chromosome 5 of the APC gene
- Hundreds of polyps within the large intestine and rectum
- Inevitable development of colorectal cancer without total colectomy
Colorectal cancer
What is HNPCC?
- full name
- mutation involved
- how it presents
- Hereditary non-polyposis colorectal cancer
- Autosomal dominant mutation in DNA mismatch repair genes (variable penetration)
- Type 1: hereditary colorectal cancer
- Type 2: as above, with the addition of extra-colonic adenocarcinomas – particularly endometrial carcinoma
Colorectal cancer
What is Peutz-Jegher’s syndrome?
- mutation involved
- how it presents
- Autosomal dominant mutation in STK11 gene
- Multiple hamartomatous polyps throughout the gastrointestinal tract
Colorectal cancer
What histology does colorectal cancer have?
adenocarcinoma
Colorectal cancer
Colorectal cancers develop throughan accumulation of mutations.
Describe the progression from a normal epithelium to a colon carcinoma and the mutations that cause this progression
- normal cell -> APC gene mutation
- hyperproliferative cell -> K-ras mutation
- adenoma -> DCC gene mutation / p53 gene inactivation
- carcinoma
Colorectal cancer
What is an alternative staging system to TNM?
Duke’s classification
Colorectal cancer
How does TNM staging work for colorectal cancer?
(every t passes through a new layer)
Colorectal cancer
What local complications are associated?
Local complications include obstruction, perforation and fistula formation.
Colorectal cancer
How do they spread?
lymphatic, hematogenous or transcoelomic.
Colorectal cancer
Name some risk factors for colorectal cancer:
- past history
- family history
- diet / environmental
Colorectal cancer
The clinical presentation of a colorectal cancer is dependent on its location. Where do colorectal cancers usually occur?
Colorectal cancer
If a colorectal cancer is on the caecal & right side what clinical presentations may there be?
- Iron deficiency anaemia (most common)
- Change of bowel habit (diarrhoea)
- Distal ileum obstruction (late)
- Palpable mass (late)
Colorectal cancer
If the cancer is on the left side & sigmoid carcinoma what clinical presentations may there be?
PR bleeding, mucus
thin stool (late)
Colorectal cancer
If the cancer is a rectal carcinoma what clinical presentations may there be?
- PR bleeding, mucus
- Tenesmus
- Anal, perineal, sacral pain (late)
Colorectal cancer
What is Tenesmus?
The feeling that you need to pass stools, even though your bowels are already empty.
Colorectal cancer
If there is local invasion of the colorectal cancer, what clinical presentations may there be?
- Bladder symptoms
- Female genital tract symptoms
Colorectal cancer
If there is metastasis of the colorectal cancer, what clinical presentations may there be?
- Liver (hepatic pain, jaundice)
- Lung (cough)
- Regional lymph nodes
- Peritoneum (Sister Marie Joseph nodule)
Colorectal cancer
What is this? Why does it appear?
Sister Marie Joseph nodule
an intraperitoneal cancer: tumour metastasised to umbilicus
Colorectal cancer
How can we examine for signs of a primary colorectal cancer?
- Abdominal mass
- DRE
- Rigid sigmoidoscopy
- Abdominal tenderness and distension – large bowel obstruction
Colorectal cancer
What are some signs of metastatic colorectal cancer?
- Hepatomegaly (mets)
- Monophonic wheeze
- Bone pain
Colorectal cancer
What are some faecal occult blood investigations for colorectal cancer?
- Guaiac test (Hemoccult)
- FIT (Faecal Immunochemical Test)
Colorectal cancer
What is a FIT test and what is it used for?
Faecal Immunochemical Test
detects minute amounts of blood in faeces (faecal occult blood)
Colorectal cancer
What is Guaiac test (Hemoccult)?
How sensitive and specific is it as a test?
What are some restrictions patients must follow before having the test done?
based on pseudoperoxidase activity of haematin
Sensitivity of 40-80%; Specificity of 98%
Dietary restrictions – avoid red meat, melons, horse-radish, vitamin C & NSAIDs for 3 days before test
Colorectal cancer
What kinds of blood tests can we do to investigate for colorectal cancers?
- FBC: anaemia, haematinics – low ferritin
- Tumour markers: CEA which is useful for monitoring, but it is not a diagnostic tool!
Colorectal cancer
What imaging investigations may we do to investigate for colorectal cancer?
- colonoscopy
- CT colonoscopy / colonography
- MRI pelvis
- CT chest / abdo / pelvis
Colorectal cancer
What size of lesions can colonoscopies and CT colonoscopies visualise?
- colonoscopy: <5cm
(small polyps can we removed during procedure) - CT: >5cm
Colorectal cancer
Which requires sedations and which is more invasive:
colonoscopy / CT colonoscopy?
colonoscopy more invasive and requires sedation
Colorectal cancer
When may we use an MRI pelvis for colorectal cancer?
for rectal cancer: investigate depth of invasion
to choose between preoperative chemo or straight into surgery
Colorectal cancer
Why would we use a CT Chest/Abdo/pelvis for colorectal cancer?
to stage prior to treatment
Colorectal cancer
How do we manage colorectal cancer?
primarily managed by surgery
? stent/radiotherapy/chemo
Colorectal cancer
How would we manage an obstructing colon carcinoma of the right and transverse colon?
resection and primary anastomosis
Colorectal cancer
How would we manage a left sided obstructing colon carcinoma?
-
Colorectal cancer
What is Hartmann’s procedure?
- Proximal end colostomy (LIF)
- +/- Reversal in 6 months
Colorectal cancer
On what side does the colon have a better blood supply?
right side
Colorectal cancer
Label
Colorectal cancer
What ways can we try to remove the rectum?
J pouch
W pouch
GI cancer
Carcinoids arise from ____ cells and are less common than adenocarcinomas, usually occurring in the ____ and ____.
Carcinoids arise from enterochromaffin cells and are less common than adenocarcinomas, usually occurring in the small bowel and appendix.
Colorectal cancer
How would you manage this pt?
positive faecal occult blood, >40yrs with abdominal pain and weight loss
options:
- urgent referal
- consider urgent referal
- faecal occult test
urgent referral
Colorectal cancer
How would you manage this pt?
> 50yrs with rectal bleeding of unknown source
options:
- urgent referal
- consider urgent referal
- faecal occult test
urgent referal
Colorectal cancer
How would you manage this pt?
> 60yrs with iron-deficient anaemia or change in bowel habit
options:
- urgent referal
- consider urgent referal
- faecal occult test
urgent referal
Colorectal cancer
How would you manage this pt?
Rectal/abdominal mass, anal ulceration
options:
- urgent referal
- consider urgent referal
- faecal occult test
consider urgent referal
Colorectal cancer
How would you manage this pt?
<50yrs with rectal bleeding plus lower GI symptoms or weight loss or iron-deficiency anaemia
options:
- urgent referal
- consider urgent referal
- faecal occult test
consider urgent referal
Colorectal cancer
How would you manage this pt?
> 50yrs with abdominal pain or weight loss
options:
- urgent referal
- consider urgent referal
- faecal occult test
faecal occult
Colorectal cancer
How would you manage this pt?
<60yrs with change in bowel habit or iron-deficiency anaemia
options:
- urgent referal
- consider urgent referal
- faecal occult test
faecal occult
Colorectal cancer
How would you manage this pt?
> 60yrs with anaemia
options:
- urgent referal
- consider urgent referal
- faecal occult test
faecal occult
GI cancer
What is carcinoid syndrome? What is it caused by?
syndrome characterised by flushing, diarrhoea, bronchoconstriction and pulmonary stenosis
It occurs as a result of serotonin release from tumours that have metastasized to the liver.
Colorectal cancer
If not surgical, what other management options are there?
Adjuvant chemotherapy has proven beneficial for stage 3 disease
can be considered in individual cases for stage 2 disease and in palliative care of metastatic disease.
Colorectal cancer
What is the FOLFOX regimen?
fluorouracil, folinic acid and oxaliplatin
the recommended standard adjuvant chemotherapy
Cancer
What does it mean if a secondary cancer is metachronous?
cancer appears after primary cancer is removed surgically
Cancer
Systemic chemotherapy is improving…what other effective treatment options are there?
RFA (Radiofrequency ablation)
SIRT (selective internal radiation therapy)
GI cancer
What guides surgeons when it comes to surgical excision of the colon? and of the liver?
colon: blood supply (anatomical)
liver: non-anatomical, just try and take away bit with cancer
Pancreatic cancer
____% of pancreatic cancers are adenocarcinomas and a further ____% are neuroendocrine.
95%
5%
Pancreatic cancer
What is the most common adenocarcinoma?
pancreatic ductal adenocarcinoma (PDA)
(90% of cases)
Cancer
What type of cancer is the 2nd commonest cause of cancer death?
pancreatic cancer
(incidence and mortality are roughly equivalent)
Pancreatic cancer
What are some risk factors for pancreatic cancer?
- chronic pancreatitis
- type 2 diabetes mellitus
- occupation
- smoking, obesity, diet (red meat, alcohol)
- 7-10% have family history
Pancreatic cancer
What familial cancer syndromes increase risk of pancreatic cancer?
5
- BRCA1
- BRCA2
- FAP
- Peutz-Jeghers syndrome
- Multiple Endocrine Neoplasia type 1 (neuroendocrine pancreatic cancer)
Pancreatic cancer
What is PDA in regards to pancreatic cancer?
pancreatic ductal adenocarcinoma
Pancreatic cancer
Symptoms are often of late-onset and non-specific.
The most common symptoms are:
- Abdominal pain (epigastric with radiation to the back)
- Jaundice (Head of pancreas).
- Anorexia.
- Ascites
- Nausea and Vomiting
- Generalised malaise
Pancreatic cancer
Where in the pancreas do 2/3rd of PDAs arise in?
the head
Pancreatic cancer
How come is jaundice one of the clinical presentations of pancreatic cancer?
The carcinoma puts pressure on or invades the common bile duct, blocking bilirubin excretion from the liver.
May cause dark urine, pale stools, pruritus.
https://www.youtube.com/watch?v=gIACp5js4MU
Pancreatic cancer
Why might ascites occur as a sign?
fluid in the abdomen due to physical pressure or invasion of portal system caused by carcinoma or liver metastasis
Pancreatic cancer
Due to the several different types of pancreatic cancer, these cancers may have a wide range of symptoms.
Other symptoms may include, just as paraneoplastic syndrome.
Give an example:
thromboembolic disease
Pancreatic cancer
Due to the several different types of pancreatic cancer, these cancers may have a wide range of symptoms.
Other symptoms may include, just as Neuroendocrine presentations.
Give 4 examples.
- Insulinoma
- Gastrinoma
- Glucagonoma
- Somatostatinoma
Pancreatic cancer
How might a neuroendocrine presentation of insulinoma present?
confusion, hypoglycaemia, unconsciousness
These are benign in 90% of cases.
Pancreatic cancer
How might a neuroendocrine presentation of gastrinoma present?
Zollinger-Ellison syndrome of severe peptic ulceration
Pancreatic cancer
How might a neuroendocrine presentation of Glucagonoma present?
Necrolytic migratory erythema, a type of dermatitis. Hyperglucagonaemia.
Pancreatic cancer
How might a neuroendocrine presentation of Somatostatinoma present?
Associated with diabetes and anaemia. Postprandial fullness, relative biliary stasis.
Pancreatic cancer
What is Courvoisier’s sign?
It means that you have jaundice and a gallbladder that is enlarged but is not painful
Pancreatic cancer
What is the term used to describe jaundice and a gallbladder that is enlarged but is not painful.
Courvoisier’s sign
Pancreatic cancer
What is Virchow’s node?
enlarged supraclavicular node, late sign
Pancreatic
How might we distinguish cancer of the head vs cancer of the body/tail only using symptoms?
patients with tumors originating in the head often present with jaundice
whereas pain and weight loss are typical symptoms of body/tail cancers
Pancreatic cancer
How come vomiting is sometimes a clinical presentation of carcinoma of the body and tail of the pancreas?
vomiting at late stages due to invasion of the DJ flexure
Pancreatic cancer
What might we see in the LFTs of?
- Hyperbilirubinaemia (carcinoma head of pancreas, liver metastasis)
- raised ALP and GGT (obstructive picture)
- raised alanine aminotransferase
Pancreatic cancer
What tumour marker might we test for and why?
CA19-9 tumour marker may be used to guide treatment and follow-up. Limited value as a diagnostic test.
Pancreatic cancer
How effective is Tumour marker CA19-9 as a diagnostic examination for pancreatic cancer?
doesn’t have good diagnostic value
- falsely elevated in pancreatitis, hepatic dysfunction & obstructive jaundice.
- concentrations > 200 U/ml confer 90% sensitivity
- concentrations in the thousands associated with high specificity
Pancreatic cancer
What can US be used to visualise in regards to pancreatic cancer?
- can identify pancreatic tumours
- dilated bile ducts
- liver metastases
Pancreatic cancer
What can dual-phase CT be used for in regards to pancreatic cancer investigations?
can accurately predict resectability in 80–90% of cases
can scan for:
- contiguous organ invasion
- vascular invasion (coeliac axis & SMA)
- distant metastases
Pancreatic cancer
What can MRI be used to visualise in regards to pancreatic cancer?
detects and predicts resectability with accuracies similar to CT
Pancreatic cancer
What can MRCP be used to visualise in regards to pancreatic cancer?
provides ductal images without complications of ERCP
Pancreatic cancer
What can ERCP be used to visualise in regards to pancreatic cancer?
can be investigative and therapeutic
- confirms the typical ‘double duct’ sign
- aspiration/brushing of the bile-duct system
- therapeutic modality → biliary stenting to relieve jaundice
Cancer
What is PET in regards to imaging?
Positron Emission Tomography
Pancreatic cancer
How can we use EUS to investigate for pancreatic cancer?
- highly sensitive in the detection of small tumours
- assessing vascular invasion
- FNA (fine needle aspiration)
Pancreatic cancer
Describe the TNM system. What is it used for?
STAGING
T
* T1A cancer <0.5cm.
* T1B 0.5cm-1cm
* T1C 1-2cm
- T2 2-4cm
- T3 >4cm
- T4 Tumour involves coeliac axis or superior mesenteric artery
N
* N0 (no regional lymph nodes)
* N1 (regional lymph nodes)
M
* M0 (no distant metastasis)
* M1 (distant metastasis, non-resectable)
Pancreatic cancer
How are exocrine pancreatic cancers graded?
G1 - G4
G1 - similar to normal cells
G4 - most poorly differentiated, most aggressive
Pancreatic cancer
How do we manage it?
- chemo + radiotherapy prescribed from specialist team
- 2 week wait referral
- surgical resection if possible
Pancreatic cancer
What can we add to surgery to improve survival rate at 5ys?
adjuvant chemo
Pancreatic cancer
What are the surgical procedure options?
3
Whipple’s procedure: pancreaticoduodenectomy with antrectomy
Modified Whipple’s: With pylorus preservation
Distal pancreatectomy (tumours of body and tail of pancreas)
Pancreatic cancer
How do we treat unresectable disease?
Surgical bypass or biliary stenting may improve symptoms related to obstructive jaundice and pruritus
Cancers
Where do NETs arise form?
gastroenteropancreatic (GEP) tract
(or bronchopulmonary system)
Cancer
What is MEN1 and what types of tumours is this associated with?
a genetic syndrome
Multiple Endocrine Neoplasia Type 1
- NETs
- Parathyroid tumours
- Pancreatic tumours
- Pituitary tumours
Cancer
Usually NETs are asymptomatic and in late stages can cause a variety of debillitating effects.
One of these is Carcinoid syndrome. What does this syndrome do to the body?
- Vasodilatation
- Bronchoconstriction
- ↑ed intestinal motility
- Endocardial fibrosis (PR & TR)
GI Cancer
Name the cell types that these come from.
GI cancer
What is Zollinger-Ellison syndrome? What type of NET can cause this?
a rare digestive disorder that results in too much gastric acid
gastrinoma (g cells in antrum)
GI cancer
What kind of scan is this?
CT Scan (arterial phase)
GI cancer
What is GEP-NETs?
Gastroenteropancreatic neuroendocrine tumors
Pancreatic cancer
What are pNETs?
pancreatic neuroendocrine tumours
Cancer
What is R0, R1 and R2 in surgical resection?
- R0 corresponds to resection for cure or complete remission
- R1 to microscopic residual tumor
- R2 to macroscopic residual tumor.
