Gastric Cancer Flashcards
T1 - GASTRIC CANCER
Invasion of mucosa and submucosa (a/b)
T2 - GASTRIC CANCER
Invasion of tunica muscualaris
T3- GASTRIC CANCER
Invasion of subserosa
T4a- GASTRIC CANCER
Penetrates into visceral peritoneum
T4b- GASTRIC CANCER
Invades surrounding tissue
N1- GASTRIC CANCER
1-2 LN
N2 - GASTRIC CANCER
3-6 LN
N3 - GASTRIC CANCER
More than 7 LN
M1- GASTRIC CANCER
Distant metastases
T1- ESOPHAGEAL CANCER
Invasion of mucosa and submucosa (a/b)
T2 - ESOPHAGEAL CANCER
Invasion of tunica muscularis
T3 - ESOPHAGEAL CANCER
Invades beyond muscularis into adventitia
T4 - ESOPHAGEAL CANCER
Invades surrounding tissue (a/b)
N1 - ESOPHAGEAL CANCER
2-3 LN
N2 - ESOPHAGEAL CANCER
4-6 LN
N3 - ESOPHAGEAL CANCER
More than 7 LN
M1 - ESOPHAGEAL CANCER
Visceral metastases
What the risk factors of esophageal cancer?
- obesity
- smoking and alcohol
- GERD
- Barrett’s Esophagus
What are the clinical features of EC?
- dysphagia and odynophagia
- pain in tumour location
- weight loss
- loss of appetite
Diagnosis of EC?
- EGD with biopsy
Treatment of EC?
- Limited disease = resection (T1-T2N0.M0)
Locally advanced
SCC
- either neoadj or definitive chemo
- resection after restaging
OR
- FU and salvage resection
ADC
- periop or neoadj chemo
- restage
- resection
ESMO treatment of metastatic disease?
- assess its operability
- inoperable = palliative chemo and check if HER2 +/- (trastuzumab)
Operable depends on stage
- varies from endoscopic resection
or
- surgery then adj chemo/chemradio
- pre-op chemo, surgey, post-op chemo
What are the risk factors of gastric carcinoma? Mention types?
90% adenocarcinoma
- smoking
- H.pyori
- atrophic gastritis
-male
Distal (asian) : h.pylori, low fruit and veg, high red meat and salt
Gastric - fundus (non-asian): GERD, Obesity and Barrett’s
What are the clinical features of gastric cancer?
- early = asymptomatic
- stomach pain
- anemia
- dyspepsia
- weight loss
- vomiting
How do you diagnose gastric cancer?
- EGD and biopsy
How can gastric cancer present as metastases?
- virchow’s node
- krukenburg tumour
Treatment of gastric cancer?
Operable (T1N0) - resection
Operable (> T1N0)
- surgery and adj chemo/chemoradio tx
- Preop chemo, surgery and postop chemo
Inoperable or Metastatic
- palliative
- check for HER2 +/- (Trastuzumab)
- CF/CX
-Platinum + fluoropyramindine based double/triple regimen
What are the risk factors of colorectal cancer?
- familial adenomatous polyposis (FAP)
- Lynch syndrome
- Peutz Jeghers Syndrome
- Obesity
- High red meat intake
- Smoking
- Hx of IBD
What are the do tests of colorectal cancer?
- fecal occult blood test
- recommended age 50-74 at 2 year intervals
- fecal immunochem test
What are the clinical features of colorectal cancer?
- sideropenic anemia
- emptying rhythm changes
- mucous and blood in stool
- sudden onset of ileus
- right sided is more severe than left
*right is more common in females, has poorer outcomes , gives rise to M1c and is more chemoresistant
How do you diagnose colorectal cancer?
- colonoscopy and biopsy
- Fecal immunohisto test is more sensitive (FIT)
- Other emerging Dx using DNA from stool
TNM staging of colon cancer?
T1: invades submucosa
T2: invades muscularis propriae
T3: penetrates pericolorectal tissue
T4: viscera peritoneum and surround organ involvement
N1: 1-4 LN
N2: 4-7 LN
M1
a: 1 organ
b: more organs
c: peritoneal dissemination
Types of colon cancer?
- adenocarcinoma : grade 1, 2, 3
- mucinous
- signet cell
- neuroendocrine
ESMO treatment of primary colorectal cancer?
- colectomy: total, subtotal or hemi L or R
- assess for Ras or BRAF mutation
- Adj Tx stage II high risk or III
FOLFOX 4/6 12 CYCLES and FU
folfox4/6 = oxaplatin, leucovorin, fluoruracil
ESMO treatment of metastatic colorectal cancer?
- cytotoxic doublet (oxaplatin and fluoropyramdine)
- bevacizuamb
EGFR antibody may be given instead of bevacizumab (use aflibercept)
Why is FU important in colorectal cancer?
- 30-50% relapse
- focus on CEA monitoring
- US of liver or MCST
- 50% relapses occur in liver, 20% in lungs and other organs
What is rectal cancer?
- defined as a tumour 15cm from anocutaneous line
- can be low (5cm), medium (10cm) and high (15cm)
- rectal cancer differ biologically and via etiology from Colorectal cancer
What are the risk factors of rectal cancer?
- obesity
- abdominal obesity
- T2DM
- Crohn’s disease
- High red meat and processed food consumption
- Smoking
- High intake of alcohol
TNM staging of rectal cancer?
T1: submucosa
T2: muscularis propia
T3: subserosa/pericolic/perirectal fat tissue
T4: perforation of visceral peritoneum and organ invasion
N0
N1: 1-3 LN
N2: more than 4 LN
M0
M1
a: 1 organ
b: more than 1 organ
c: peritoneal metastases w or w/o visceral organs
How do you diagnose rectal cancer?
- DRE
- Endoscopy
*if distal extension < 15 cm from anal margin = rectal cancer - if distal extension > 15 cm from anal margin = colon cancer
Treatment of rectal cancer?
- depends on stage
Transanal excision Microsurgery - local
Low anterior resection
Abdominoperineal resection
Plus radiotherapy and chemo e.g. FOLFOX
Treatment of metastatic rectal cancer?
Curative:
- systemic Chemo
- short course preop radiotherapy (SCPRT)
- metastasectomy
Palliative:
- SCPRT
- Systemic chemo +/- targeted agents
Facts about pancreatic cancer?
- 4th leading cause of death with 5-OS 5%
- same treatment for the past 20 years
- median age 71-74
- most are locally advanced, unresectable cancer
Risk factors of pancreatic cancer?
Hereditary:
-BRCA2 mutation
- Li fraumeni syndrome
- familial pancreatic carcnioma syndrome
Non-hereditary:
- tobacco smoking
- heavy alcohol usage
- DM
- High intake of red meat
Types of pancreatic cancer?
- 95% adenocarcinoma (85% are ductal adenocarcinoma with very rich stroma = barrier against chemo
- acinar cell carcinoma
- adenosquamous carcinoma
- neuroendocrine
- undifferentiated carcinoma with osteoclast like cells
Diagnosis of pancreatic cancer
- CA19-9 not useful for primary diagnosis
- preop ca19-19 high indicates poor outcome
- CT scan
- endoscopy and US biopsy
- if metastatic = biopsy of metastasis
TNM staging of pancreatic cancer?
T1: limited to pancreas, size < 2cm
T2: limited to pancreas, size > 2cm
T3: extended beyond pancreas w/o invasion of SM artery or celiac axis
T4: extended beyond pancreas w invasion of SMA or celiac axis
N1: regional metastasis of LN
M1: distant metastases
ESMO treatment recommendation for pancreatic cancer?
resectable (potentially curative) stage I
- resection and adj chemo tx
borderline resectable (potentially curative) stage II
- neoadj tx followed by resection
locally advanced (usually palliative) stage III
- combination chemo tx e.g. gemcitabine
metastatic (palliative) - stage IV
- combination chemo tx e.g. gemcitabine r FOLFIRINOX
*FOLFIRINOX
folinic acid (leucovorin), fluorouracil, irinotecan
What are the risk factors for liver cancer?
- chronic active HBV and HCV infection
- liver cirrhosis
- Aflatoxin A1
- alcoholic/non-alcoholic liver disease
Diagnosis of liver cancer?
- CT/MRI of abdomen
- ESR, CBC, LFT
- AFP
- Liver biopsy
Hepatocellular carcinoma CC grades?
HCC Grade: 1, 2, 3
*important to distinguish HCC from intraductal cholangiocarcinoma or liver metastases originating from other tumours
- Fibrolamelar carcinoma
TNM staging of HCC?
T1: tumour 2cm w/o vascular invasion
T2: solitary tumour > 2cm w vascular invasion
T3: multiple tumours (at least 1 is > 5cm)
T4: multiple tumours of varying size invading portal vein or hepatic vein or infiltrates surrounding tissue
N1: 1 LN positive at least
M1: distant metastases
What is the Barcelona Clinic Liver Staging?
BCLS connects clinical stages and functional liver capacity with treatment modalities
(0, A, B, C, D)
ESMO treatment HCC?
BCLC 0-A
- resection or liver transplant then radiotherapy
BCLC B
- liver transplant or resection
- or transarterial chemoembolisation (TACE) with systemic therapy and radiotherapy
BCLC C
- sorafenib
- pembrolizumab
BCLC D
- best supportive care
What are the biliary carcinomas?
- very rare < 1% of human cancers
- Cholangiocarcinoma
intrahepatic or extrahepatic: perihilar (Klatskin tumor) and distal - Gallbladder carcinoma
Risk factors of biliary carcinoma?
Cholangiocarcinoma:
- primary sclerosing cholangitis
- liver fluke infection
Gallbladder Carcinoma:
- cholelithiasis (Chronic)
- Chronic cholecystitits
- Gallbladder polyps
- primary sclerosing cholangitis
- porcelain gallbladder
- obesity
Clinical features of cholangiocarcinoma and gallbladder carcinoma?
Cholangiocarcinoma:
- signs of cholestasis e.g. jaundice, pruritus, dark urine, pale stool
- Courvoisier sign: painless obstructive jaundice, non-tender gallbladder
Gallbladder carcinoma:
- no specific symptoms
- mostly asymptomatic diagnosed incidentally
Diagnosis of biliary carcinoma?
- US
- Biopsy
- CT/MRI
- Raised CA19-9 and CEA
- MRCP for definitive diagnosis
Biliary carcinoma local and systemic disease treatment recommendation by ESMO?
Early stage: surgery, adj chemoradio tx, adj chemo, surveillance
* <10% cases are resectable
Locally advanced & Metastatic: systemic chemotherapy and radiotherapy
e.g. gemcitabin based or fluoropyramidine based regimen
What is GIST?
Gastrointestinal Stromal Tumour
- very rare
- 60% affects stomach 30% duodenum
- 60-65 years of age onset
- mainly men
ESMO treatment of localised GIST?
R0 with no expected major complications: surgery and follow
R0 with expected major complications not feasible:
- imatinib 6-12 months
- then either surgery or follow metastatic protocol
ESMO treatment for metastatic GIST?
Imatinib
- Exon 11 mutation then 400mg
- Exon 9 mutation then 800mg
follow up with this treatment and reassess for potential surgery of residual disease or no response, then change to sunitinib
What the histological types of Esophageal cancer and where are they located?
SCC (90%): proximal and thoracal
AdC: distal
Rare tumours: small cell carcinoma, neuroendocrine, signet-ring cell
What are the PH types of gastric cancer?
90% AdC: intestinal type (well differentiated) and diffuse type (poorly differentiated)
“Signet-ring cell poorly cohesive”
Mucinoous adenocarcinoma
Anaplastic carcinoma
Neuroendocrine carcinoma
10% other tumors (lymphoma, plasmocytoma, GIST, sarcoma)
What is anal carcinoma?
- mostly SCC with HPV infection
- Rarely adenocarcinoma, melanoma, lymphoma or sarcoma
- chemo-radiation with with 5FU or Mitomycin C is preferred method of treatment
- Tx also to enable anal sphincter preservation
- 10-20% disseminate
What is the Child Pugh Staging?
- HCC
- a tool for functional assessment of cirrhotic liver
- albumine, Total bilirubin, PT, ascites and hepatic encephalopathy
