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Y3 Conditions > Colorectal + pancreatic cancer > Flashcards

Colorectal + pancreatic cancer Flashcards

colorectal, pancreatic

1
Q

Cancer

What is a cancer?

A

A disease caused by an uncontrolled division of abnormal cells in a part of the body

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2
Q

Cancer

What is a primary cancer?

A

Arising directly from the cells in an organ

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3
Q

Cancer

What is a secondary cancer / metastasis?

A

Spread from another organ, directly or by other means (blood or lymph)

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4
Q

Cancer

What is a CUP?

A

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

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5
Q

GI Cancer

What kind of epithelial cells do we have in the GI tract?

A

squamous
glandular epithelium

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6
Q

GI Cancer

What kind of neuroendocrine cells do we have in the GI tract?

A

enteroendocrine cells
interstitial cells of Cajal

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7
Q

GI Cancer

What kind of connective tissue do we have in the GI tract?

A

smooth muscle
adipose tissue

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8
Q

GI cancer

What kind of cancer do squamous cells of the GI tract make?

A

squamous cell carcinoma (SCC)

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9
Q

GI cancer

What kind of cancer do the glandular epithelium of the GI tract make?

A

adenocarcinoma

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10
Q

GI cancer

What kind of cancer do enteroendocrine cells of the GI tract make?

A

neuroendocrine tumours (NETs)

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11
Q

GI cancer

What kind of cancer do interstitial cells of Cajal of the GI tract make?

A

gastrointestinal stromal tumours (GISTs)

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12
Q

GI cancer

What kind of cancer does smooth muscle of the GI tract make?

A

leiomyoma / leiomyosarcomas

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13
Q

GI cancer

What kind of cancer does adipose tissue of the GI tract make?

A

liposarcomas

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14
Q

GI cancer

What is the most common GI cancer in western societies?

A

colorectal

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15
Q

Colorectal cancer

At the start of what age do colorectal cancers start occurring?

A

Generally affects patients > 50 years (>90% of
cases)

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16
Q

Colorectal cancer

The majority colorectal polyps are ____. The majority of colorectal adenocarcinomas arise from ____.

A

The majority colorectal polyps are adenomas. The majority of colorectal adenocarcinomas arise from existing adenomas.

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17
Q

Colorectal cancer

What familial syndromes predispose people to colorectal cancer?

A
  • Familial adenomatous polyposis (FAP)
  • hereditary nonpolyposis colorectal cancer (HNPCC or Lynch syndrome)
  • Peutz-Jegher’s syndrome
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18
Q

Colorectal cancer

What is FAP?
- full name
- mutation involved
- how it presents

A
  • 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
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19
Q

Colorectal cancer

What is HNPCC?
- full name
- mutation involved
- how it presents

A
  • 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
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20
Q

Colorectal cancer

What is Peutz-Jegher’s syndrome?
- mutation involved
- how it presents

A
  • Autosomal dominant mutation in STK11 gene
  • Multiple hamartomatous polyps throughout the gastrointestinal tract
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21
Q

Colorectal cancer

What histology does colorectal cancer have?

A

adenocarcinoma

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22
Q

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

A
  1. normal cell -> APC gene mutation
  2. hyperproliferative cell -> K-ras mutation
  3. adenoma -> DCC gene mutation / p53 gene inactivation
  4. carcinoma
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23
Q

Colorectal cancer

What is an alternative staging system to TNM?

A

Duke’s classification

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24
Q

Colorectal cancer

How does TNM staging work for colorectal cancer?

A

(every t passes through a new layer)

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25
Q

Colorectal cancer

What local complications are associated?

A

Local complications include obstruction, perforation and fistula formation.

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26
Q

Colorectal cancer

How do they spread?

A

lymphatic, hematogenous or transcoelomic.

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27
Q

Colorectal cancer

Name some risk factors for colorectal cancer:
- past history
- family history
- diet / environmental

A
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28
Q

Colorectal cancer

The clinical presentation of a colorectal cancer is dependent on its location. Where do colorectal cancers usually occur?

A
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29
Q

Colorectal cancer

If a colorectal cancer is on the caecal & right side what clinical presentations may there be?

A
  • Iron deficiency anaemia (most common)
  • Change of bowel habit (diarrhoea)
  • Distal ileum obstruction (late)
  • Palpable mass (late)
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30
Q

Colorectal cancer

If the cancer is on the left side & sigmoid carcinoma what clinical presentations may there be?

A

PR bleeding, mucus
thin stool (late)

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31
Q

Colorectal cancer

If the cancer is a rectal carcinoma what clinical presentations may there be?

A
  • PR bleeding, mucus
  • Tenesmus
  • Anal, perineal, sacral pain (late)
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32
Q

Colorectal cancer

What is Tenesmus?

A

The feeling that you need to pass stools, even though your bowels are already empty.

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33
Q

Colorectal cancer

If there is local invasion of the colorectal cancer, what clinical presentations may there be?

A
  • Bladder symptoms
  • Female genital tract symptoms
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34
Q

Colorectal cancer

If there is metastasis of the colorectal cancer, what clinical presentations may there be?

A
  • Liver (hepatic pain, jaundice)
  • Lung (cough)
  • Regional lymph nodes
  • Peritoneum (Sister Marie Joseph nodule)
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35
Q

Colorectal cancer

What is this? Why does it appear?

A

Sister Marie Joseph nodule

an intraperitoneal cancer: tumour metastasised to umbilicus

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36
Q

Colorectal cancer

How can we examine for signs of a primary colorectal cancer?

A
  • Abdominal mass
  • DRE
  • Rigid sigmoidoscopy
  • Abdominal tenderness and distension – large bowel obstruction
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37
Q

Colorectal cancer

What are some signs of metastatic colorectal cancer?

A
  • Hepatomegaly (mets)
  • Monophonic wheeze
  • Bone pain
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38
Q

Colorectal cancer

What are some faecal occult blood investigations for colorectal cancer?

A
  • Guaiac test (Hemoccult)
  • FIT (Faecal Immunochemical Test)
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39
Q

Colorectal cancer

What is a FIT test and what is it used for?

A

Faecal Immunochemical Test

detects minute amounts of blood in faeces (faecal occult blood)

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40
Q

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?

A

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

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41
Q

Colorectal cancer

What kinds of blood tests can we do to investigate for colorectal cancers?

A
  • FBC: anaemia, haematinics – low ferritin
  • Tumour markers: CEA which is useful for monitoring, but it is not a diagnostic tool!
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42
Q

Colorectal cancer

What imaging investigations may we do to investigate for colorectal cancer?

A
  • colonoscopy
  • CT colonoscopy / colonography
  • MRI pelvis
  • CT chest / abdo / pelvis
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43
Q

Colorectal cancer

What size of lesions can colonoscopies and CT colonoscopies visualise?

A
  • colonoscopy: <5cm
    (small polyps can we removed during procedure)
  • CT: >5cm
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44
Q

Colorectal cancer

Which requires sedations and which is more invasive:

colonoscopy / CT colonoscopy?

A

colonoscopy more invasive and requires sedation

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45
Q

Colorectal cancer

When may we use an MRI pelvis for colorectal cancer?

A

for rectal cancer: investigate depth of invasion

to choose between preoperative chemo or straight into surgery

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46
Q

Colorectal cancer

Why would we use a CT Chest/Abdo/pelvis for colorectal cancer?

A

to stage prior to treatment

47
Q

Colorectal cancer

How do we manage colorectal cancer?

A

primarily managed by surgery

? stent/radiotherapy/chemo

48
Q

Colorectal cancer

How would we manage an obstructing colon carcinoma of the right and transverse colon?

A

resection and primary anastomosis

49
Q

Colorectal cancer

How would we manage a left sided obstructing colon carcinoma?

50
Q

Colorectal cancer

What is Hartmann’s procedure?

A
  • Proximal end colostomy (LIF)
  • +/- Reversal in 6 months
51
Q

Colorectal cancer

On what side does the colon have a better blood supply?

A

right side

52
Q

Colorectal cancer

Label

53
Q

Colorectal cancer

What ways can we try to remove the rectum?

A

J pouch
W pouch

54
Q

GI cancer

Carcinoids arise from ____ cells and are less common than adenocarcinomas, usually occurring in the ____ and ____.

A

Carcinoids arise from enterochromaffin cells and are less common than adenocarcinomas, usually occurring in the small bowel and appendix.

55
Q

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

A

urgent referral

56
Q

Colorectal cancer

How would you manage this pt?

> 50yrs with rectal bleeding of unknown source

options:
- urgent referal
- consider urgent referal
- faecal occult test

A

urgent referal

57
Q

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

A

urgent referal

58
Q

Colorectal cancer

How would you manage this pt?

Rectal/abdominal mass, anal ulceration

options:
- urgent referal
- consider urgent referal
- faecal occult test

A

consider urgent referal

59
Q

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

A

consider urgent referal

60
Q

Colorectal cancer

How would you manage this pt?

> 50yrs with abdominal pain or weight loss

options:
- urgent referal
- consider urgent referal
- faecal occult test

A

faecal occult

61
Q

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

A

faecal occult

62
Q

Colorectal cancer

How would you manage this pt?

> 60yrs with anaemia

options:
- urgent referal
- consider urgent referal
- faecal occult test

A

faecal occult

63
Q

GI cancer

What is carcinoid syndrome? What is it caused by?

A

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.

64
Q

Colorectal cancer

If not surgical, what other management options are there?

A

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.

65
Q

Colorectal cancer

What is the FOLFOX regimen?

A

fluorouracil, folinic acid and oxaliplatin

the recommended standard adjuvant chemotherapy

66
Q

Cancer

What does it mean if a secondary cancer is metachronous?

A

cancer appears after primary cancer is removed surgically

67
Q

Cancer

Systemic chemotherapy is improving…what other effective treatment options are there?

A

RFA (Radiofrequency ablation)
SIRT (selective internal radiation therapy)

68
Q

GI cancer

What guides surgeons when it comes to surgical excision of the colon? and of the liver?

A

colon: blood supply (anatomical)

liver: non-anatomical, just try and take away bit with cancer

69
Q

Pancreatic cancer

____% of pancreatic cancers are adenocarcinomas and a further ____% are neuroendocrine.

70
Q

Pancreatic cancer

What is the most common adenocarcinoma?

A

pancreatic ductal adenocarcinoma (PDA)

(90% of cases)

71
Q

Cancer

What type of cancer is the 2nd commonest cause of cancer death?

A

pancreatic cancer

(incidence and mortality are roughly equivalent)

72
Q

Pancreatic cancer

What are some risk factors for pancreatic cancer?

A
  • chronic pancreatitis
  • type 2 diabetes mellitus
  • occupation
  • smoking, obesity, diet (red meat, alcohol)
  • 7-10% have family history
73
Q

Pancreatic cancer

What familial cancer syndromes increase risk of pancreatic cancer?

5

A
  • BRCA1
  • BRCA2
  • FAP
  • Peutz-Jeghers syndrome
  • Multiple Endocrine Neoplasia type 1 (neuroendocrine pancreatic cancer)
74
Q

Pancreatic cancer

What is PDA in regards to pancreatic cancer?

A

pancreatic ductal adenocarcinoma

75
Q

Pancreatic cancer

Symptoms are often of late-onset and non-specific.

The most common symptoms are:

A
  • Abdominal pain (epigastric with radiation to the back)
  • Jaundice (Head of pancreas).
  • Anorexia.
  • Ascites
  • Nausea and Vomiting
  • Generalised malaise
76
Q

Pancreatic cancer

Where in the pancreas do 2/3rd of PDAs arise in?

77
Q

Pancreatic cancer

How come is jaundice one of the clinical presentations of pancreatic cancer?

A

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
78
Q

Pancreatic cancer

Why might ascites occur as a sign?

A

fluid in the abdomen due to physical pressure or invasion of portal system caused by carcinoma or liver metastasis

79
Q

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:

A

thromboembolic disease

80
Q

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.

A
  • Insulinoma
  • Gastrinoma
  • Glucagonoma
  • Somatostatinoma
81
Q

Pancreatic cancer

How might a neuroendocrine presentation of insulinoma present?

A

confusion, hypoglycaemia, unconsciousness

These are benign in 90% of cases.

82
Q

Pancreatic cancer

How might a neuroendocrine presentation of gastrinoma present?

A

Zollinger-Ellison syndrome of severe peptic ulceration

83
Q

Pancreatic cancer

How might a neuroendocrine presentation of Glucagonoma present?

A

Necrolytic migratory erythema, a type of dermatitis. Hyperglucagonaemia.

84
Q

Pancreatic cancer

How might a neuroendocrine presentation of Somatostatinoma present?

A

Associated with diabetes and anaemia. Postprandial fullness, relative biliary stasis.

85
Q

Pancreatic cancer

What is Courvoisier’s sign?

A

It means that you have jaundice and a gallbladder that is enlarged but is not painful

86
Q

Pancreatic cancer

What is the term used to describe jaundice and a gallbladder that is enlarged but is not painful.

A

Courvoisier’s sign

87
Q

Pancreatic cancer

What is Virchow’s node?

A

enlarged supraclavicular node, late sign

88
Q

Pancreatic

How might we distinguish cancer of the head vs cancer of the body/tail only using symptoms?

A

patients with tumors originating in the head often present with jaundice

whereas pain and weight loss are typical symptoms of body/tail cancers

89
Q

Pancreatic cancer

How come vomiting is sometimes a clinical presentation of carcinoma of the body and tail of the pancreas?

A

vomiting at late stages due to invasion of the DJ flexure

90
Q

Pancreatic cancer

What might we see in the LFTs of?

A
  • Hyperbilirubinaemia (carcinoma head of pancreas, liver metastasis)
  • raised ALP and GGT (obstructive picture)
  • raised alanine aminotransferase
91
Q

Pancreatic cancer

What tumour marker might we test for and why?

A

CA19-9 tumour marker may be used to guide treatment and follow-up. Limited value as a diagnostic test.

92
Q

Pancreatic cancer

How effective is Tumour marker CA19-9 as a diagnostic examination for pancreatic cancer?

A

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
93
Q

Pancreatic cancer

What can US be used to visualise in regards to pancreatic cancer?

A
  • can identify pancreatic tumours
  • dilated bile ducts
  • liver metastases
94
Q

Pancreatic cancer

What can dual-phase CT be used for in regards to pancreatic cancer investigations?

A

can accurately predict resectability in 80–90% of cases

can scan for:
- contiguous organ invasion
- vascular invasion (coeliac axis & SMA)
- distant metastases

95
Q

Pancreatic cancer

What can MRI be used to visualise in regards to pancreatic cancer?

A

detects and predicts resectability with accuracies similar to CT

96
Q

Pancreatic cancer

What can MRCP be used to visualise in regards to pancreatic cancer?

A

provides ductal images without complications of ERCP

97
Q

Pancreatic cancer

What can ERCP be used to visualise in regards to pancreatic cancer?

A

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
98
Q

Cancer

What is PET in regards to imaging?

A

Positron Emission Tomography

99
Q

Pancreatic cancer

How can we use EUS to investigate for pancreatic cancer?

A
  • highly sensitive in the detection of small tumours
  • assessing vascular invasion
  • FNA (fine needle aspiration)
100
Q

Pancreatic cancer

Describe the TNM system. What is it used for?

A

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)

101
Q

Pancreatic cancer

How are exocrine pancreatic cancers graded?

A

G1 - G4

G1 - similar to normal cells
G4 - most poorly differentiated, most aggressive

102
Q

Pancreatic cancer

How do we manage it?

A
  • chemo + radiotherapy prescribed from specialist team
  • 2 week wait referral
  • surgical resection if possible
103
Q

Pancreatic cancer

What can we add to surgery to improve survival rate at 5ys?

A

adjuvant chemo

104
Q

Pancreatic cancer

What are the surgical procedure options?

3

A

Whipple’s procedure: pancreaticoduodenectomy with antrectomy

Modified Whipple’s: With pylorus preservation

Distal pancreatectomy (tumours of body and tail of pancreas)

105
Q

Pancreatic cancer

How do we treat unresectable disease?

A

Surgical bypass or biliary stenting may improve symptoms related to obstructive jaundice and pruritus

106
Q

Cancers

Where do NETs arise form?

A

gastroenteropancreatic (GEP) tract
(or bronchopulmonary system)

107
Q

Cancer

What is MEN1 and what types of tumours is this associated with?

A

a genetic syndrome

Multiple Endocrine Neoplasia Type 1

  • NETs
  • Parathyroid tumours
  • Pancreatic tumours
  • Pituitary tumours
108
Q

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?

A
  • Vasodilatation
  • Bronchoconstriction
  • ↑ed intestinal motility
  • Endocardial fibrosis (PR & TR)
109
Q

GI Cancer

Name the cell types that these come from.

110
Q

GI cancer

What is Zollinger-Ellison syndrome? What type of NET can cause this?

A

a rare digestive disorder that results in too much gastric acid

gastrinoma (g cells in antrum)

111
Q

GI cancer

What kind of scan is this?

A

CT Scan (arterial phase)

112
Q

GI cancer

What is GEP-NETs?

A

Gastroenteropancreatic neuroendocrine tumors

113
Q

Pancreatic cancer

What are pNETs?

A

pancreatic neuroendocrine tumours

114
Q

Cancer

What is R0, R1 and R2 in surgical resection?

A
  • R0 corresponds to resection for cure or complete remission
  • R1 to microscopic residual tumor
  • R2 to macroscopic residual tumor.

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